Essential Insights On Treating Pressure Ulcers

Clinical Editor: Kazu Suzuki, DPM, CWS

   Dr. Armstrong and his colleagues have just finished a large, multinational randomized study. He says the results seem to suggest that robust oral supplementation may help those who need it most: those with albumins less than 4 (which is the case with most of his admissions) and with ankle brachial indices less than 0.9.

   Dr. Suzuki does not recommend vitamin supplements. He says the evidence is not clear enough that vitamin supplements help wound healing or pressure ulcer prevention although he wouldn’t make patients stop taking them. On the other hand, Dr. Suzuki does recommend probiotic supplements for all of his wound patients, especially if they are on antibiotics, as the supplements may help in boosting the immune functions while preventing C. difficile and other antibiotic-associated diarrhea.


What kind of dressing do you use for pressure ulcers?


Dr. Armstrong has a “vertical” and “horizontal” philosophy for wound healing. He and his colleagues will treat exposed bone or hardware (i.e. the vertical component) most frequently with NPWT. Dr. Armstrong says the next step is to resolve the horizontal component either with split thickness skin grafting, which is often his first option, or bioengineered tissue to facilitate healing by secondary intention.

   Dr. Suzuki likes to use foam dressings (Mepilex, Molnlycke). He says they are soft and provide a little of bit of protection against friction and pressure. If his patients have a swollen limb along with pressure ulcers, Dr. Suzuki may apply a multilayer compression bandage (such as Comprifore, BSN Medical) to add more layers and cushioning to the wounded area while reducing the leg edema.

   After cleansing the wound, Dr. Sage dresses pressure ulcers with simple gauze or alginates. He will also use protective offloading devices, such as a Prevalon boot (Sage Products).


In what kind of situations do you use NPWT?


For any deep wounds that need assistance in building up granulation tissue in the wound bed, Dr. Suzuki would order NPWT (Vacuum Assisted Closure, KCI) right away. He will also prescribe NPWT for exposed bones or tendons and fascia, noting that one will want to cover those structures with granulation tissue as soon as possible, granted that one has ruled out osteomyelitis or osteomyelitis is under appropriate treatment with antibiotics. Dr. Suzuki also uses NPWT in the operating room after applying split-thickness skin grafts or performing a complex flap procedure.

   Dr. Sage uses NPWT after a calcanectomy when there is a large defect to fill.


Do you have any other pearls for the care of patients with pressure ulcers?


Dr. Sage emphasizes that offloading is the key to preventing and healing pressure wounds. “No amount of advanced wound care products, surgery or revascularization will work if the pressure is not relieved,” he advises.

   When one sees multiple pressure ulcers on one patient, Dr. Suzuki says it is a clear sign that either patients’ nutrition intake is not catching up with their metabolism or that they are suffering from major organ failures.

   “This does not mean you should give up on them but we should be aware of these frail patients and provide them with appropriate protection (heel boots and air bed) as well as appropriate palliation with palliative wound care, hydration and pain control,” says Dr. Suzuki.

   For some patients who are unlikely to walk — even around the house — Dr. Armstrong suggests asking yourself, “What are our goals?” He notes that “a decided minority” of patients are better off not with an expensive therapy but often just with what he refers to as “wound hospice.” Additionally, he notes some patients may benefit from an amputation earlier rather than later.

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