Decubitus Ulcer

See Also

Epidemiology

Incidence: 17-35% in Nursing Home residents
Prevalence: 3 Million treated patients in U.S. per year
Estimated to cost $11 to 26 Billion per year in U.S.

Pathophysiology

External localized pressure exceeds capillary Blood Flow to affected region
Results ischemia and injury to local tissue, skin and mucosa
Shearing forces add to the degree of Pressure Injury

Risk Factors

Key risk factors
1. Non-Ambulatory Patients or limited mobility
2. Decreased perfusion
3. Local tissue edema
4. Pre-existing Stage 1 Pressure Sore
5. Excessive moisture (e.g. bowel or bladder Incontinence, wound drainage, excessive sweating)
Other risk factors
1. Underweight, malnourished or Cachexia
2. Cognitive Impairment or Dementia
3. Incontinence (and other causes of excessive moisture)
4. Advanced age
5. Device-induced pressure (e.g. Nasogastric Tube, Nasal Cannula, casts or splints)
Higher risk medical conditions
1. Diabetes Mellitus
2. Congestive Heart Failure
3. Peripheral Vascular Disease
4. Neurologic disorders (e.g. Dementia, Multiple Sclerosis, Parkinsonism, Spinal Injury, Stroke)

Signs
Distribution

See Comprehensive Skin Integrity Assessment
Most common in regions of bony prominences
Common
1. Heel
2. Sacrum
3. Coccyx
4. Ischial tuberosity
5. Buttock
Other
1. Ear
2. Occiput
3. Shoulder
4. Scapula
5. Elbow
6. Pelvis
7. Greater Trochanter
8. Lateral Malleolus

Exam
Pressure Injury Characterization

See Comprehensive Skin Integrity Assessment
Basic description
1. Include images and diagrams in EHR
2. Location
3. Size (Length x Width x Depth)
4. Timing (onset and progression)
Stage (Types 1-4)
1. See Decubitus Ulcer Grade
2. Staging precautions
  1. Accurate grading requires Debridement of necrosis first
  2. Use other grading schemes for staging of Diabetic Foot Ulcers and Venous Stasis Ulcers
  3. Macerated skin (moisture induced wounds) are not staged
3. Stage 1: Nonblanchable erythema of intact skin (pink skin, not purple)
4. Stage 2: Superficial or partial thickness skin loss (no slough or eschar)
5. Stage 3: Full thickness skin loss with subcutaneous damage (crater to fascia)
6. Stage 4: Full thickness skin loss with extensive deep damage to Muscle, bone, tendon
Additional findings
1. Sinus tracts, skin undermining or tunneling
2. Exudate or sloughing
3. Necrotic tissue
4. Granulation tissue
5. Wound discharge
6. Wound odor
7. Signs of Wound Infection or Cellulitis
8. Skin base quality and surrounding skin integrity
9. Wound bed color
Wound Healing Assessment Tools
1. Pressure Ulcer Scale for Healing
  1. https://www.sralab.org/sites/default/files/2017-06/push3.pdf
2. DESIGN-R (depth, exudates, size, inflammation, granulation, necrosis, rating)
  1. https://www.researchgate.net/figure/Assessment-table-for-the-DESIGN-R-tool-The-table-is-reproduced-from-the-DESIGN-R-scoring_fig1_316832231
3. Bates-Jensen Wound Assessment Tool
  1. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/388243/22.-Bates-Jensen-wound-assessment-tool-BWAT.pdf

Labs

Wound culture
1. Typically not indicated except to identify MRSA
2. Levine Technique is preferred
  1. Rotate culture swab over a 1 cm patch of wound
  2. Apply enough pressure for fluid to collect in wound site for 5 seconds
  3. Reddy (2012) JAMA 307(6): 605-11 [PubMed]

Differential Diagnosis

See Leg Ulcer Causes
Stasis ulcer
1. Venous Insufficiency
2. Lymphedema
Ischemic ulcer (Peripheral Vascular Disease)
Vasculitic ulcer

Management
General Approach

See TIME Principle of Chronic Wound Care
Monitoring
1. Weekly clinical assessment
2. Daily observation by Caregiver
Key point: Minimize moisture, friction and sheering
1. Control moisture and keep skin clean and dry, and with barrier creams applied
2. Without this, no Pressure Sore will heal
3. Consider modified beds or bed overlays (see Pressure Sore Positioning)
Protect normal skin at wound edges
1. Use Wound Dressings or Emollients to protect skin from moisture and irritation
Patient positioning to take pressure off wound
1. See Pressure Sore Positioning
2. See Decubitus Ulcer Prevention
3. Remove all pressure at the ulcer site
4. Frequent repositioning (every 2 hours)
5. Do not drag patient
Wound cleaning and Debridement
1. See Decubitus Ulcer Cleansing
2. See Decubitus Ulcer Debridement
3. Manage the microclimate
  1. Use a pH neutral skin cleanser
  2. Use barrier wipes and creams
4. Avoid removing a dry, non-inflamed, non-fluctuant intact eschar at heel
  1. Provides intact barrier to further injury
Nutrition
1. See Nutrition in Wound Healing
2. Ensure adequate hydration per day
3. Correct Malnutrition and specific deficiencies
  1. Supplement Protein 1.25 to 1.5 g/kg bodyweight
  2. Supplement calories 30 to 35 kcal/kg bodyweight
  3. Consider Vitamin Supplementation (e.g. Zinc, Arginine, Vitamin C)
Control sources of pain
1. Cover wounds
2. Adjust support surfaces
3. Reposition patient frequently
4. Provide analgesia with dressing changes and Debridement
5. Control moisture
  1. Contributes to maceration and skin breakdown
  2. Airflow surface may help keep area dry
  3. Do not use Incontinence briefs (impedes airflow)
Be alert for signs of infection
1. Delayed Wound Healing
2. Wound dehiscence
3. Local tissue necrosis
4. Increased exudate
5. Increased local warmth
6. Cellulitis
7. Osteomyelitis suspected (exposed bone or Probe-to-Bone Test positive)
8. Systemic signs (fever, Altered Mental Status, increased pain)
Other measures
1. Smoking Cessation
2. Caregiver Support and education
3. Psychosocial support for patient and Caregivers

Management
Wound Dressing

See Wound Dressing for complete list and selection criteria
Precautions
1. Cleanse wounds before each dressing change
  1. See Decubitus Ulcer Cleansing
2. Debride wounds with overlying slough or biofilm
  1. See Decubitus Ulcer Debridement
  2. Avoid Debridement of slough on the heels or ischemic limbs
3. Dressings should promote moist Wound Healing (without being wet)
4. Avoid Wet-to-Dry Dressings
  1. May slow healing and results in pain on removal
  2. Wet-to-Moist Dressing however may be used (see below)
5. Protect normal skin on wound edges to prevent progression
  1. See above
Decubitus Ulcer Grade 1 (red but intact skin)
1. Apply barrier protection
2. No dressing is typically needed
3. Consider Transparent Film Dressing (e.g. Tegaderm)
Decubitus Ulcer Stage 2 (superficial or partial thickness skin loss)
1. Light Exudate
  1. Hydrogel Dressing (provide moisture to dry wounds)
2. Heavy Exudate (absorbent dressing)
  1. Hydrocolloid Dressing (e.g. Duoderm CGF) with or without absorbent paste or powder
Decubitus Ulcer Stage 3 to 4
1. Shallow - Dry wounds
  1. Thin Hydrocolloid Dressing (e.g. Tegaderm Thin, Primacol Thin, Restore Extra Thin)
  2. Hydrogels (provide moisture to dry wounds)
  3. Transparent Film Dressing (e.g. Tegaderm)
  4. Wet-to-Moist Dressing
  5. Cover with nonadherent gauze wrap
2. Shallow - Wet wounds
  1. Hydrocolloid Dressing (e.g. Duoderm CGF) with or without absorbent paste or powder
  2. Cover with nonadherent gauze wrap
3. Shallow - Very Wet wounds
  1. Foam Dressing (e.g. Allevyn) - preferred
  2. Alginate Dressing
  3. Cover with nonadherent gauze wrap
4. Deep - Dry wounds
  1. Fill wound with damp gauze or Hydrogel Dressing
  2. Cover with Hydrocolloid Dressing
  3. Cover with Transparent Film Dressing (e.g. Tegaderm) or nonadherent gauze wrap
5. Deep - Wet wounds
  1. Foam Dressing (e.g. Allevyn)
  2. Consider filling with Alginate Dressing
  3. Cover with Transparent Film Dressing (e.g. Tegaderm)
Infected Wounds
1. Superficially Infected Wounds
  1. Topical antimicrobials or Antimicrobial Dressing
2. Spreading Wound Infection (e.g. Cellulitis)
  1. Perform Wound Debridement and send material for culture and sensitivity
  2. Start systemic antibiotics
  3. Consider underlying Osteomyelitis

Management
Adjunctive Therapy for Grade 3 to 4 Ulcers

Electrotherapy (Electrical stimulation)
1. Direct electric, pulse current via electrodes applied to wound bed for 1 hour daily
2. Indicated in Grade 3-4 Pressure Ulcers refractory to other care
3. Contraindicated in cancer and Osteomyelitis
4. Kawasaki (2014) Wound Repair Regen 22(2): 161-73 [PubMed]
Ultrasound
Vacuum-Assisted Closure (negative pressure)
Collagen matrix dressing (bovine, porcine or avian)
Insufficient evidence to support use of other adjuncts
1. Topical and systemic agents
2. Hyperbaric treatment
3. Infared or ultraviolet light exposure

Course

Anticipate Wound Healing over 2 to 4 weeks

Complications

Osteomyelitis
1. Suspect if non-healing ulcer after 2 to 4 weeks
2. Presume Osteomyelitis when bone is exposed within wound site
3. Start with plain film, but typically requires bone scan or MRI
4. Consult infectious disease
Cellulitis (Bacterial superinfection) or Sepsis
1. Stage 2 and greater Pressure Ulcers are colonized with Bacteria
2. Adequate cleansing and Debridement prevents infection
3. Size and depth of ulcer does not distinguish need for antibiotics
4. Risk factors for infection
  1. Foreign bodies within ulcer
  2. Large or necrotic ulcers
  3. Repeatedly contaminated sites (e.g. stool at Sacrum)
  4. Diabetes Mellitus or Immunosuppression
  5. Diminished perfusion
5. Findings suggestive of infection
  1. Increasing pain is a a key indicator of Wound Infection
  2. Fever
  3. Leukocytosis
  4. Increased purulent or foul discharge
  5. New necrotic tissue
  6. Surrounding erythema
  7. Irregular or friable granulation tissue
6. Wound culture is typically not indicated
  1. Consider if determining presence of MRSA
  2. See Levine culture technique described above

Prevention

Resources

http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html

References

(2015) Presc Lett 22(5): 29
Vertanen (2017) Wound Care Update, Park Nicollet Conference, St Louis Park, MN (attended 9/15/2017)
Habif (1996) Clinical Derm, Mosby, p. 810-13
PUGP (1994) Pressure Ulcer Treatment, AHCPR 95-0653
PUGP (1995) Am Fam Physician 51(5):1207-22
Krasner (1995) Prevention Management Pressure Ulcers
Lewis (1996) Med-Surg Nursing, Mosby, p. 199-200
Lueckenotte (1996) Gerontologic Nurs., Mosby, p. 800-7
Way (1991) Current Surgical, Lange, p.95-108
Bello (2000) JAMA 283(6): 716-8 [PubMed]
Bowers (2020) Am Fam Physician 101(3):159-66 [PubMed]
Degreef (1998) Dermatol Clin 16(2): 365-75 [PubMed]
Findlay (1996) Am Fam Physician 54(5): 1519-28 [PubMed]
Knapp (1999) Pediatr Clin North Am 46(6):1201-13 [PubMed]
Raetz (2015) Am Fam Physician 92(10): 888-94 [PubMed]
Stotts (1997) Clin Geriatr Med 13(3): 565-73 [PubMed]
Qaseem (2015) Ann Intern Med 162:359-9 [PubMed]
Visconti (2023) Am Fam Physician 108(2): 166-74 [PubMed]