Management of Pressure Sores in Surgical Wards
Guidelines for the Management of Pressure Sores in Surgical Wards
Wound coverage and other surgical issues
Admission to hospital and psychosocial support
This guideline is aimed at surgical staff, and is not an overall review of the condition.
The primary focus must always be on prevention in high risk individuals.
- significantly limited mobility (for example, people with a spinal cord injury)
- significant loss of sensation
- a previous or current pressure ulcer
- nutritional deficiency
- the inability to reposition themselves
- significant cognitive impairment.
Such individuals must be identified by the nursing staff, and pressure prevention strategies implemented immediately, according to hospital protocols.
- pressure reduction= egg-shell or memory foam type mattress
- control of all moisture in the patients immediate environment (linen savers are not breathable and add to the risk if not changed regularly).
- 2 hour turning and massage in patients with impaired mobility or consciousness.
- Bean bag / gel pad pressure reduction for extremities.
- Electronic position adjusting devices are effective, but not widely available
Pressure ulcers that develop in hospital are considered an adverse event and should be reported via a protocolled reporting pathway in your institution or ward.
Introduction
A pressure sore is a localised area of damage to the skin and/or underlying tissue usually over a bony prominence; it occurs a result of pressure, or pressure in combination with shear (e.g. sacrum, calcaneus, ischium).
Pressure ulcers are typically related to immobility (i.e. bed-bound/ chair-bound individual), but can also result from poorly fitting casts or other medical equipment or devices.
A patient who develops a decubitus ulcer has a 2-3 times increase in mortality.
When faced with a patient with a pressure sore the key questions a surgeon should address are:
- is this a decubitus ulcer or something else?
- How bad is it?
- Why has it occurred?
- What is the underlying cause for immobility, and is it going to get better?
- Is there associated sepsis?
- What dressing is best suited to this circumstance?
- Is there need for surgical intervention?
- What clinical facility should care for the patient?
Differential diagnosis
The diagnosis is obvious at typical pressure sites (calcaneous and pre-sacral) but at other sites ulcers related to diabetes, arterial or venous insufficiency must be identified.
Many wounds, particularly in the lower extremity, have a multifactorial etiology.
Pressure ulcers may also be confused with other conditions that cause skin erythema, such as cellulitis, pilonidal sinus/ abscess and perianal sepsis.
Clinical features and staging
The patient must be thoroughly assessed, and the wound examined. Photographs of all wounds are helpful. The pressure ulcer can then be measured and staged.
The most commonly used system is from the National Pressure Ulcer Advisory Panel.
| 1 | Skin intact but with non-blanchable redness for >1 hour after relief of pressure. |
| 2 | Blister or other break in the dermis with partial thickness loss of dermis, with or without infection. |
| 3 | Full thickness tissue loss. Subcutaneous fat may be visible; destruction extends into muscle with or without infection. Undermining and tunnelling may be present. |
| 4 | Full thickness skin loss with involvement of bone, tendon, or joint, with or without infection. Often includes undermining and tunnelling. |
| Unstageable | Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. |
Most ulcers that require surgical opinion are stages 3-4, or unstageable.
General care principles
- Control pain — particularly at dressing changes
- Providing pressure redistribution with proper positioning and support surfaces, patients should be re-positioned at least 2-hourly.
- Provide appropriate local wound care
- Treat infection
- Give nutritional support routinely, and correct deficiencies
- Provide appropriate psychosocial support to the patient and family.
Sepsis and antibiotics
Systemic antibiotic therapy is reserved for those cases where an alternative source has been excluded and the patient remains systemically ill.
- Antibiotic stewardship principles should prevail and only culture directed organism specific antibiotics should be used.
- If there is significant local surrounding cellulitis, an antibiotic can be considered but the mainstay of therapy remains antimicrobial wound care.
- Wounds without local or systemic complications should be managed with locally available products and do not warrant antibiotic use even if there is significant slough or purulent exudate present
Wound management
This is according to general principles of wound care, which includes debridement of necrotic tissue, and appropriate dressings or wound packing to promote healing of the wound bed, and wound coverage, when indicated.
Wound dressings
Dressings serve to protect the wound from contamination, and facilitate healing by absorbing exudate and protecting healing surfaces. Excess fluid causes wound maceration, while desiccation will slow epithelial cell migration.
Dressings are selected based on wound characteristics, including the presence of heavy exudate, desiccation, or necrotic tissue. Many different types of dressings are available and no dressing has been shown to be consistently superior to another in clinical trials.
Avoid gauze dressings, unless treating actively infected wounds.
Rely on dressing types that require less frequent changes and the local experience of the nursing staff.
| Stage 1 | Transparent film for protection. A stage 1 ulcer should be taken as an indication that the patient is at high risk for more serious ulcer development |
| Stage 2 | Semi-occlusive (transparent film) or occlusive dressings (hydro-colloids or hydrogels) Aim to maintain a moist wound environment . These wounds generally require little debridement Hydro-colloid dressings are not a substitute for pressure care. They should be labelled or marked with a date and changed at a minimum every 7 days |
| Stage 3/4 | Debridement of necrotic tissue and coverage with appropriate dressings Treatment of infection If minor tissue slough and exudate use nonsurgical debridement (e.g. mechanical, enzymatic, biologic) excessive exudate =absorptive dressings (e.g. sorbact, charcoal compounds, kaltostat and gel matrix products) significant necrosis and malodour= use highly absorbent dressing underneath an occlusive dressing such as granuflex or tegaderm or comfeel. Protect surrounding skin with barrier creams such as zinc and castor oil Surgical debridement for areas of extensive tissue necrosis or thick eschar, EXCEPT: Do not debride or remove maggots if present Do not remove thick eschar overlying the heel in the absence of signs of sepsis |
Wound coverage and other surgical issues
Most pressure induced ulcers are managed using the basic principles of wound care and dressings described above.
Surgical wound coverage (by means of a skin graft, skin flap, or myocutaneous flap) may benefit some patients, particularly good risk surgical candidates.
Consider referral to plastic surgery in the following patients
- young
- paraplegic
- non smoker
- absence of systemic disease (no CCF/ DM /CVS disease/ organ failure/ malignancy/ HIV-ve)
- good nutritional baseline
Faecal diversion by means of a colostomy may be a consideration in a very select group of patients.
Admission to hospital and psycho-social support
Admission to hospital needs to be considered in light of the patient’s overall medical condition, and psychosocial issues. A decubitus ulcer is seldom the primary reason for admission.
A decubitus ulcer is not a surgical condition, rather it is a complication of significant co-morbid illness, and logistics of hospital admission are to be viewed in this context.
Pressure sores are frequently a marker of a pre-terminal state. It is not appropriate to subject patients with incurable or irreversible disease to surgical debridement. In this scenario, analgesia, control of the wound exudate and malodour and analgesia are paramount.
A surgical consult, and intervention with surgical debridement may assist in patient care, but a patient with a decubitus ulcer will not be admitted to a surgical ward, unless the primary underlying cause for immobility is “surgical” in origin- i.e. a post-operative complication.
Early multi-disciplinary management, and discharge planning must take place to avoid prolonged hospitalisation. The patient and their family must at all time be actively involved in decision making.