A patient recovering from a prolonged admission to ICU has developed a new sacral pressure ulcer. Outline your management of this problem.

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College Answer

Assessment-

Severity of ulcer-superficial/deep The ulcer presents clinically as an
abrasion, blister, or shallow crater.

Signs of infection (systemic and local), contributing devices (eg splints, etc) Serial photographs          ·

Management-

Continue preventative strategies-

a) pressure relief through posture and regular (two hourly) turns and pressure relief devices (range of devices but can include foam/gel pads, special mattresses
b) Aim to mobilize (reduce/minimize any sedation) adequate analgesia for painful ulcers. Alert as high risk within ICU and determine tailored team approach.
c) Also treat/manage diarrhea and urinary incontinence.                  ·
d) Avoid·friction
e) Review unit protocols

Specific treatment

1) Dressings-occlusive or semipermeable dressing that will maintain a moi&t wound environment for superficial ulcers.
2) Infection-identify and treat accordingly
3) Surgery-ranging from minor removing infected granulation and necrotic tissue to major debridement
4) Adequate nutrition

Discussion

This question resembles a part of Question 2 from the first paper of 2003.

In the interest of revision, the answer is reproduced below. Additionally, LITFl have a nice section on pressure areas.

A structured approach would resemble the following:

Risk factors for pressure ulcers in ICU

A good article from 2000 has an exhaustingly long table (Table 1).

Highlights from this article include the following:

  • Prolonged immobility
  • Use of neuromuscular junction blockers
  • Age over 60
  • Severe illness (APACHE II score over 13)
  • Hemodynamic instability preventing pressure area care
  • Diabetes
  • Incontinence
  • Low albumin
  • Poor nutrition
  • Oedema
  • Peripheral vascular disease
  • Steroid use

Prevention of pressure ulcers in ICU

  • Risk assessment and monitoring
  • Mobility (may be unreasonable in this context)
  • Minimise sedation and restraints to allow for self-repositioning (may not be relevan in this context)
  • Management of incontinence
  • 2 hourly repositioning
  • Air mattress or specialised foam (evidence is not strong)
  • Adequate skin care

Management of pressure ulcers in the ICU

  • Engagement of a multidisciplinary wound care team
  • Debridement
  • Antibacterial (silver sulfadiazine) dressings
  • Frequent dressing changes
  • Exudate-absorbing dressings
  • Promote wound healing:
    • Adequate nutritional supplementation, particularly of protein (2g/kg/day)
    • Control of diabetes
    • Avoidance of corticosteroids
    • Optimisation of tissue perfusion
    • Avoidance of oedema

References

References

Keller, Paul B., et al. "Pressure ulcers in intensive care patients: a review of risks and prevention." Intensive care medicine 28.10 (2002): 1379-1388.

 

Cullum, N., et al. "Beds, mattresses and cushions for pressure sore prevention and treatment." The Cochrane Library (2000).

 

REULER, JAMES B., and THOMAS G. COONEY. "The pressure sore: pathophysiology and principles of management." Annals of Internal Medicine94.5 (1981): 661-666.

 

Health Quality Ontario. "Pressure Ulcer Prevention: An Evidence-Based Analysis." Ontario health technology assessment series 9.2 (2009): 1.

 

Stratton, Rebecca J., et al. "Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis." Ageing research reviews 4.3 (2005): 422-450.

 

Henzel, M. Kristi, et al. "Pressure ulcer management and research priorities for patients with spinal cord injury: consensus opinion from SCI QUERI Expert Panel on Pressure Ulcer Research Implementation." J Rehabil Res Dev 48.3 (2011): xi-xxxii.

 

Theaker, C., et al. "Risk factors for pressure sores in the critically ill."Anaesthesia 55.3 (2000): 221-224.