Monday, January 30, 2017

Management Of Pressure Ulcers



A 85-year-old debilitated nursing home resident was found to have pressure ulcers. He has no evidence of bacteremia or osteomyelitis. Which of the following is an acceptable treatment?
A) Application of povidone-iodine gauze two times per day
B) Application of hydrogen peroxide 3 times per day
C) Systemic antibiotics for 7 to 10 days
D) Keeping the area clean and dry until granulation tissue forms
E) Surgical debridement

The answer is
E. (Surgical debridement)

Discussion: When treating pressure ulcers, it is important to maintain a moist environment while keeping the surrounding skin dry. This can be accomplished by loosely packing the ulcer with saline-moistened gauze. Topical antimicrobials such as silver sulfadiazine cream may be helpful in ulcers that appear infected. Topical antiseptics such as povidone-iodine or hydrogen peroxide should not be
used in the treatment of pressure ulcers. Systemic antibiotics should be reserved for serious infections (e.g., bacteremia, osteomyelitis). A 2-week trial of topical antimicrobials may be considered for ulcers that do not appear infected but are not improving. Although most patients are successfully managed without surgery, procedures may be appropriate in patients whose quality of life would be markedly improved by rapid wound closure. Stage 3 and 4 ulcers with necrotic tissue should be debrided. Ulcers with minimal exudate that are not infected can be covered with an occlusive dressing to promote autolytic debridement. Ulcers with thick exudate, slough, or loose necrotic tissue should undergo mechanical debridement. Options include wet-to-dry dressings, hydrotherapy, wound
irrigation, and scrubbing the wound with gauze. Ulcers with evidence of cellulitis or deep infection should undergo sharp debridement with a scalpel or scissors. Ulcers with a thick eschar or extensive necrotic tissue should undergo sharp debridement as well. However, a thick, dry eschar covering a
heel ulcer should generally be left intact. Patients without access to surgical interventions (such as in a long-term care setting) or those who may not be acceptable surgery candidates can be treated with enzymatic debriding agents. Wound debridement should stop once necrotic tissue has been
removed and granulation tissue is present.

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