A patient recovering from a prolonged admission to ICU has developed a new sacral pressure ulcer. Outline your management of this problem.
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 ·
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. ·
e) Review unit protocols
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
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
- Low albumin
- Poor nutrition
- 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
- 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
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.