Pressure Injuries (Sacral and Pelvic Region, Columella—From CPAP)

Pressure Injuries (Sacral and Pelvic Region, Columella—From CPAP)

David A. Billmire

Kim A. Bjorklund


  • Pressure injury formation is a complex process that involves numerous factors.2

    • Extrinsic contributing factors include pressure, friction, and shear.

    • Intrinsic factors include local tissue ischemia, decreased autonomic control, infection, loss of sensation, decreased mental status, fecal or urinary incontinence, anemia, and hypoproteinemia.3,4

  • As muscle is more sensitive to pressure than is skin, areas with a significant amount of muscle may be susceptible to an inverted cone pattern of injury, in which most of the necrosis is deep to the skin.5

  • Particular risk factors in the pediatric population have been identified1,6:

    • Paraplegia, sensory impairment

    • Cognitive impairment

    • Kyphoscoliosis or kyphosis

    • Chronic fecal or urinary soiling

    • Trauma

    • Immobility

    • Poor nutrition


  • Nonblanchable erythema may be observed within 30 minutes of unrelieved pressure and typically disappears within 1 hour after pressure is eliminated.

  • Ischemia develops after pressure is present for 2 to 6 hours.

  • Necrosis may occur if pressure is not relieved within 6 hours.

  • Ulceration tends to occur over bony prominences within 2 weeks after development of necrosis.


  • Determine factors contributing to the pressure injury (extrinsic and intrinsic) and whether they can be eliminated postoperatively.

    • Note any chronic medical conditions contributing to the pressure injury, such as myelodysplasia, cerebral palsy, paraplegia, and scoliosis.

    • Note any temporary conditions contributing to the pressure injury (prolonged immobility, repetitive trauma) that require resolution.

  • Ambulatory status

  • Previous pressure injuries

  • Compliance and motivation with treatment

  • Assess risk factors using Braden Scale, including mobility, activity, sensation, moisture, friction/shear, and nutrition.

  • Assess sensation and lower extremity motor function, including spasticity.

  • Palpate for any fluctuance or bony prominences.

  • Note any signs of infection such as warmth, erythema, tenderness, purulent drainage, and systemic signs of infection.

  • Assess ongoing factors that may be contributing to wound breakdown, such as items causing pressure, spasticity, and fecal or urinary incontinence.

  • Staging of pressure injuries based on the updated guidelines of National Pressure Ulcer Advisory Panel8:

    • Stage 1: Nonblanchable erythema of intact skin

    • Stage 2: Partial-thickness skin loss with exposed dermis

    • Stage 3: Full-thickness skin loss

    • Stage 4: Full-thickness skin and tissue loss

    • Unstageable pressure injury: Obscured full-thickness skin and tissue loss

    • Deep tissue pressure injury: Persistent nonblanchable deep red, maroon, or purple discoloration


  • Nutritional assessment (including albumin, prealbumin, electrolytes)

  • Wound cultures if concern for infection

  • WBC and ESR if concern for infection/osteomyelitis

  • MRI or CT scan may help in identification of osteomyelitis and communicating sinus tracts.

  • Bone biopsy and culture if concern for osteomyelitis prior to treatment with antibiotics


Feb 27, 2020 | Posted by in Pediatric plastic surgery | Comments Off on Pressure Injuries (Sacral and Pelvic Region, Columella—From CPAP)

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