Decubitus ulcers

Last updated: January 6, 2022

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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 [1][2]

Pressure ulcers can develop within hours in an immobilized individual. Critically ill patients are at especially high risk and must be monitored carefully. [2]

Microbiology [4]

The most commonly isolated bacteria include:

Mechanical stress → local hypoperfusion ischemic necrosis [2]

Reference [3]

  • Decubitus ulcers should be staged in order to plan management. [3]
  • The wound bed should be cleaned before staging to ensure accurate assessment.
  • The stage is determined by the deepest extent of the ulcer.

Staging of decubitus ulcers

[3]

Stage Clinical features
1
  • Intact skin (i.e., no ulceration) with nonblanchable erythema
2
  • Partial-thickness skin loss
3
4
  • Full-thickness tissue loss
  • Exposure of muscle, fascia, tendons, or bone
Unstageable
  • The wound bed is fully covered with slough or eschar.

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. [3]
  • 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

The differential diagnoses listed here are not exhaustive.

Reference [8]

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.
  • Optimize management of comorbidities that may affect healing (e.g., uncontrolled diabetes mellitus).
  • Ensure proper follow-up. [9]
    • The wound should be cleaned and freshly dressed regularly.
    • Repeated debridements might be necessary.

Supportive care [1][9][10]

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: [2]
  • 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. [11]
  • 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 [1][9][11]

  • Cleaning
  • 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 [11]

Systemic antibiotic treatment [1]

Surgical management [1][9]

  • 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. [12][13]

  1. Gould L, Stuntz M, Giovannelli M, et al. Wound healing society 2015 update on guidelines for pressure ulcers. Wound Repair Regen. 2016; 24 (1): p.145-162. doi: 10.1111/wrr.12396 . | Open in Read by QxMD
  2. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. http://www.internationalguideline.com/static/pdfs/Quick_Reference_Guide-10Mar2019.pdf. Updated: March 10, 2019. Accessed: November 5, 2020.
  3. Qaseem A, Mir TP, Starkey M, Denberg TD. Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015; 162 (5): p.359. doi: 10.7326/m14-1567 . | Open in Read by QxMD
  4. Bansal C, Scott R, Stewart D, Cockerell CJ. Decubitus ulcers: A review of the literature. Int J Dermatol. 2005; 44 (10): p.805-810. doi: 10.1111/j.1365-4632.2005.02636.x . | Open in Read by QxMD
  5. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD. Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015; 162 (5): p.370. doi: 10.7326/m14-1568 . | Open in Read by QxMD
  6. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016; 43 (6): p.585-597. doi: 10.1097/won.0000000000000281 . | Open in Read by QxMD
  7. Khan K, Giannone AL, Mehrabi E, Khan A, Giannone RE. Marjolin's Ulcer Complicating a Pressure Sore: The Clock is Ticking.. The American journal of case reports. 2016; 17 : p.111-4. doi: 10.12659/ajcr.896352 . | Open in Read by QxMD
  8. Espejo E, Andrés M, et al. Bacteremia associated with pressure ulcers: a prospective cohort study. European Journal of Clinical Microbiology & Infectious Diseases. 2018; 37 (5): p.969-975. doi: 10.1007/s10096-018-3216-8 . | Open in Read by QxMD
  9. Raetz JG, Wick KH. Common Questions About Pressure Ulcers.. Am Fam Physician. 2015; 92 (10): p.888-94.
  10. Dana AN, Bauman WA. Bacteriology of pressure ulcers in individuals with spinal cord injury: What we know and what we should know.. J Spinal Cord Med. 2015; 38 (2): p.147-60. doi: 10.1179/2045772314Y.0000000234 . | Open in Read by QxMD
  11. Girouard K, Harrison MB, VanDenKerkof E. The symptom of pain with pressure ulcers: a review of the literature.. Ostomy Wound Manage. 2008; 54 (5): p.30-40, 42.
  12. Naccarato MK, Kelechi T. Pressure Ulcer Prevention in the Emergency Department. Advanced Emergency Nursing Journal. 2011; 33 (2): p.155-162. doi: 10.1097/tme.0b013e3182157743 . | Open in Read by QxMD
  13. Liu P, Shen WQ, Chen HL. The Incidence of Pressure Ulcers in the Emergency Department: A Metaanalysis.. Wounds. 2017; 29 (1): p.14-19.

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