Pressure area prevention and management

Questions about pressure areas have usually presented the candidates with pictures of decomposed sacral ulcers. The questions then ask the candidate to talk about risk factors, prevention and management. Previous such questions have included the following:

Generally, the best published resource for this is probably the 2015 article by Krupp and Monfre, which is a review and update on the current state of the art. Unfortunately, only the first two pages are available to the homeless and destitute- the rest you have to pay for.

Risk factors for pressure ulcers in ICU

Modifiable risk factors

  • Prolonged immobility
  • Use of neuromuscular junction blockers
  • Use of steroids
  • Hemodynamic instability preventing pressure area care
  • Incontinence with soiling
  • Low albumin
  • Poor nutrition
  • Oedema
  • Hypotension

Non-modifiable risk factors and comorbidities

  • Low BMI (no padding!)
  • Altered mental state
  • Peripheral vascular disease
  • Diabetes
  • Age over 60
  • Severe illness (APACHE II score over 13)

Associated disease states:

  • malignancy
  • stroke
  • pneumonia
  • sepsis
  • heart failure

Prevention of pressure ulcers in ICU

  • Use of a "skin integrity care bundle", for example the InSpPiRE protocol (Coyer et al, 2015)
  • Risk assessment and monitoring
  • Mobility
  • Minimise sedation and restraints to allow for self-repositioning
  • Management of incontinence (rectal pouches, IDC)
  • 2 hourly repositioning
  • Air mattress or specialised foam (evidence is not strong)
  • Adequate skin care (clean and dry)
  • Adequate nutrition
  • Control of modifiable risk factors (eg. hypotension, oedema, low albumin, steroids)

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


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

Krupp, Anna E., and Jill Monfre. "Pressure Ulcers in the ICU Patient: an Update on Prevention and Treatment." Current infectious disease reports 17.3 (2015): 1-6.

Coyer, Fiona, et al. "Reducing Pressure Injuries in Critically Ill Patients by Using a Patient Skin Integrity Care Bundle (Inspire)." American Journal of Critical Care 24.3 (2015): 199-209.