Essential Treatment Tips For Decubitus Ulcers

By Farah Siddiqui, DPM, and John Steinberg, DPM, FACFAS

Given the prevalence and problematic nature of decubitus ulcers in at-risk patients, these authors review proper staging, keys to debridement and other principles for facilitating successful wound closure.

Over the last decade, the prevalence of pressure sores in hospitalized patients has reportedly ranged between 14 to 21 percent.1 With the costs to heal a single full-thickness pressure sore soaring as high as $70,000 and overall annual costs estimated between $5 billion and $8.5 billion, it is not only an unnecessary and preventable complication but also a costly epidemic.1,2

   Furthermore, the costs of treating National Pressure Ulcer Advisory Panel (NPUAP) stage IV ulcers are reported to be about 10 times more than the cost of treating stage II ulcerations.3 The most effective method to reducing these costs is early recognition and treatment to prevent progression. Understanding the mechanism of insult is key not only for early recognition but, more importantly, prevention.

   Decubitus ulcers develop when there is prolonged pressure on the skin, soft tissue, muscle and bone above capillary filling pressure (approximately 32 mmHg). Pressure, shear forces and friction cause microcirculatory occlusion, resulting in ischemia, inflammation and tissue anoxia, which can eventually lead to cell death, necrosis and ulceration. Irreversible damage may occur in as little as two hours of uninterrupted pressure. The skin itself can withstand ischemia from direct pressure for up to 12 hours but the underlying muscle, which has higher metabolic requirements for oxygen, may have already had significant damage by the time the skin shows any signs of injury.4

   While we know prolonged, uninterrupted pressure causes the ulcers, impaired mobility and sensation are what predispose patients to developing the ulcers. Accordingly, the first step is acknowledging that every patient with limited mobility is at risk for developing pressure ulcerations. At-risk patients also include those with decreased neurological sensations or those on certain medications that decrease or eliminate stimuli for repositioning and pressure relief.5 Skin integrity can also be compromised by malnutrition and systemic diseases that affect skin turgor and make skin more susceptible to breakdown.

A Guide To Assessing The Patient

In developing a treatment plan, the clinician should not only assess the wound but the patient as well. This includes obtaining a complete history and physical, identifying comorbidities and the potential for complications, nutritional assessment and assessing the risk for additional pressure ulcers. Pay special attention to identifying and facilitating the management of illnesses that might impede healing. Such illnesses include peripheral vascular disease, diabetes, collagen vascular diseases, malignancies and depression. Physicians may control contractures or spasticity pharmacologically with benzodiazepines or other muscle relaxants.

   Nutritional status assessment and management are essential to the successful treatment of pressure ulcers. One must ensure that patients have an adequate intake of protein and calories. Not only have researchers demonstrated that malnutrition increases the risk of development of new pressure ulcers, a recent meta-analysis showed positive effects of oral nutritional supplementation on pressure ulcer healing as well as risk reduction.6,7

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