Decubitus ulcers

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Decubitus ulcers or pressure ulcers are preventable injuries frequently encountered in older, malnourished, and immobilized individuals, especially those with multiple comorbidities. These injuries typically develop over bony prominences when local pressure-induced hypoperfusion and necrosis can lead to the loss of several or all skin layers. Diagnosis is primarily clinical but laboratory studies and imaging are required to evaluate for complications or risk factors that may delay healing (e.g., uncontrolled blood sugars, hypoalbuminemia). Treatment includes adequate analgesia, pressure relief (e.g., regular position changes, alternating pressure mattresses), frequent wound dressings, and nutritional support. Infectious complications (e.g., osteomyelitis, sepsis) should be treated with appropriate antibiotic therapy. Large, deep ulcers may require surgical debridement, especially if there is an inadequate response to conservative management. Preventive measures should be taken for all at-risk individuals and include pressure relief, rigorous skin care, and treatment of comorbidities and other risk factors such as malnutrition and systemic infection.

A decubitus ulcer or pressure injury is a focal area of unrelieved pressure resulting in ischemia, cell death, and necrotic injury of the epidermis and soft tissue.

The development of decubitus ulcers is multifactorial. Decubitus ulcers are prone to secondary infection, which is often polymicrobial.

Predisposing factors [2][3]

• Old age
• Cachexia or malnourishment
• Multimorbidity
• Diabetes mellitus
• Prolonged reduction in any of the following:
  • Mobility (e.g., secondary to illness, frailty, or paralysis)
  • Perception of pain (e.g., due to polyneuropathy, cognitive impairment, or anesthesia)
  • Skin perfusion (e.g., in peripheral artery disease, heart failure, vasoconstriction, or shock)
• Skin breakdown (maceration) due to urinary or fecal incontinence
• Certain medications (e.g., immunosuppressants, steroids, or vasopressors) [2][4]
• Prolonged pressure from medical devices such as feeding tubes, oxygen delivery devices, or tracheostomy tubes [2][4]

Pressure ulcers can develop within hours in an immobilized individual. Critically ill patients are at especially high risk and must be monitored carefully. [3]

Microbiology [5]

The most commonly isolated bacteria include:

• Staphylococcus aureus
• Proteus mirabilis
• Pseudomonas aeruginosa
• Enterococcus faecalis

Mechanical stress → local hypoperfusion → ischemic necrosis [3]

• Typical location: over bony prominences, such as the sacrum, ischium, heel, greater trochanter, lateral malleolus, elbows
• Initial presentation
  • Focal area of nonblanchable erythema with/without edema
  • Evidence of decreased skin perfusion (increased capillary refill time)
  • Painful, unless there is sensory loss (e.g., due to spinal cord injury) [6]
• Advanced ulcers: loss of several or all skin layers and/or subcutaneous tissue
  • Eschar and/or slough may cover the wound bed.
  • Exposure of underlying tissue, including muscle and bone
  • Signs of wound infection (e.g., purulent drainage or unpleasant odor) may be present.
• See also “Etiology” for predisposing factors and “Staging of decubitus ulcers” for further information.

Reference [4]

• Decubitus ulcers should be staged in order to plan management. [4]
• The wound bed should be cleaned before staging to ensure accurate assessment.
• The stage is determined by the deepest extent of the ulcer.

Initial assessment

• Identify predisposing factors (see “Etiology”) and assess nutritional status and skin condition, especially in other at-risk areas.
• Confirm that the injury is secondary to prolonged focal pressure. [4]
• Determine the onset of the ulcer and if it has changed in size or depth.
• Assess for undermining and tunneling into surrounding tissue, as well as the presence of necrotic tissue and drainage.
• Document the stage of the decubitus ulcer.
• Consider differential diagnoses of decubitus ulcers that may need additional workup.

Diagnostics

• Evaluate for predisposing factors, such as:
  • Blood glucose and HbA1C to assess for diabetes
  • Serum albumin to assess for malnutrition
• Screen for complications
  • CBC, CRP: Leukocytosis and ↑ CRP suggest an infectious complication.
  • Wound swab: not routinely recommended ; consider in patients with suspected MRSA infection/colonization. [7]
  • Blood cultures: Consider in patients with deep ulcers and signs of sepsis.
  • Imaging (e.g., x-ray, CT, or MRI): Consider if osteomyelitis or an underlying bony involvement is suspected.
  • For further information see “Skin and soft tissue infections” and “Diagnosis of osteomyelitis”.

• Venous ulcer
• Arterial ulcer
• Malum perforans
• Ulcerated skin tumor (e.g., basal cell carcinoma)

The differential diagnoses listed here are not exhaustive.

• Soft tissue infection (e.g., cellulitis, abscess)
• Osteomyelitis
• Bacteremia, sepsis
• Marjolin ulcer [8]

Reference [9]

We list the most important complications. The selection is not exhaustive.

Approach

• Ensure adequate analgesia (see “Pain management” for details on drugs and dosages).
• Consult a wound care specialist, general surgery, and/or plastic surgery.
• Urgently consult surgery for advanced and/or infected ulcers, especially if they are suspected to be the source of sepsis.
• Initiate treatment depending on the stage of the ulcer and whether an infection is present.
  • Superficial, clean wound: supportive care alone may be appropriate
  • Extensive and/or infected wound, wet eschar: debridement, antibiotic therapy, and/or surgical management in addition to supportive care
• Optimize management of comorbidities that may affect healing (e.g., uncontrolled diabetes mellitus).
• Ensure proper follow-up. [10]
  • The wound should be cleaned and freshly dressed regularly.
  • Repeated debridements might be necessary.

Supportive care [2][10][11]

The following are also important preventive measures for patients at risk of developing a decubitus ulcer.

Redistribute pressure

Pressure relief over the affected or vulnerable area is one of the most important aspects of management.

• Immobile patients and patients with several or refractory ulcers: [3]
  • Frequent position changes (every 2 hours)
  • Pad all pressure points.
  • Alternating pressure mattress
• Mobile patients
  • Optimize bedding with a foam mattress or overlay.
  • Assist with movement for patients with limited mobility.
• All at-risk patients: pad pressure points on devices such as CPAP masks and physical restraints.

Rigorous skin care

• Keep the skin clean and moisturized in order to prevent skin erosion and laceration.
• Advise caregivers to regularly inspect other at-risk areas to identify early stages of decubitus ulcers.
• Catheterization, bowel programs, and/or highly absorbent incontinence products (e.g., diapers, pads) may be helpful for patients with incontinence.

Nutrition

• Ensure adequate hydration and nutrition in all patients, preferably in consultation with a nutritionist.
• Protein supplementation is recommended. [12]
• Consider increasing daily calorie requirement and supplementing micronutrients to facilitate healing.

Pressure relief and regular skin care are the most important steps for the prevention and treatment of decubitus ulcers.

Wound management [2][10][12]

• Cleaning
  • Perform frequently to reduce the bacterial load.
  • Normal saline is a suitable cleaning agent.
  • Limit the use of antiseptic fluids, because they inhibit the formation of granulation tissue. [10]
• Dressings (e.g., hydrocolloids, foam dressings ): Perform frequently to absorb excess exudate while keeping the wound moist
• Debridement
  • Used to remove devitalized tissue or biofilms to prevent or treat infection and enable healing
  • Modalities: sharp (surgical), mechanical, biological, enzymatic, and autolytic
  • In patients with suspected infection, obtain a swab or tissue for culture following debridement.
• Adjunctive treatment options: electrical stimulation, negative pressure wound therapy, and administration of platelet-derived growth factor [12]

Systemic antibiotic treatment [2]

• Indication: evidence of localized or systemic infection (e.g., cellulitis, underlying osteomyelitis, sepsis)
• Options
  • The choice of antibiotic should be directed by local microbiological guidance or, if a wound swab was obtained, by the culture results.
  • See “Empiric antibiotic therapy for skin and soft tissue infections”, “Treatment of osteomyelitis”, or "Antibiotics for sepsis” as needed.

Surgical management [2][10]

• Indications and options
  • Surgical debridement, ulcer/eschar excision
    • Extensive ulcers with undermining of adjacent tissue, cavity formation, or large necrotic areas
    • Management of associated infection (e.g., extensive cellulitis, abscess, or osteomyelitis)
    • Stage 3 or 4 wounds refractory to conservative management
  • Secondary closure (e.g., tissue flap reconstruction): clean, healing ulcers.
• Important consideration: Conservative management may be more appropriate for patients who are not good candidates for surgery (e.g., multiple comorbidities, limited life-expectancy).

• Identify patients at high risk of developing a decubitus ulcer (e.g., use scoring systems such as the Braden scale and Norton scale).
• Initiate measures to prevent decubitus ulcers from forming, such as pressure relief, skin care, regular skin inspection of at-risk areas, and good nutrition. (see “Supportive care” in “Treatment” for details).

Ensure regular screening and preventative measures in high-risk care settings (e.g., overcrowded emergency departments) where pressure ulcer incidence is high and development can be rapid. [13][14]