Once a pressure injury (pressure ulcer) has developed, immediate treatment is required. [10] Commonly used treatments over the years have included innovative mattresses, ointments, creams, solutions, dressings, ultrasonography, ultraviolet heat lamps, sugar, and surgery. In choosing a treatment strategy, consideration should be given to the stage of the wound and the purpose of the treatment (eg, protection, moisture, or removal of necrotic tissue). An algorithm for assessment and treatment is available. [57, 76, 77]
General principles of wound assessment and treatment are as follows:
- Wound care may be broadly divided into nonoperative and operative methods
- For stage 1 and 2 pressure injuries, wound care is usually conservative (ie, nonoperative)
- For stage 3 and 4 lesions, surgical intervention (eg, flap reconstruction) may be required, though some of these lesions must be treated conservatively because of coexisting medical problems [3]
- Approximately 70-90% of pressure injuries are superficial and heal by second intention
With thorough and comprehensive medical management, many pressure injuries may heal completely without the need for surgical intervention. Successful medical management of pressure ulcers relies on the following key principles:
- Reduction of pressure
- Adequate débridement of necrotic and devitalized tissue
- Control of infection
- Meticulous wound care
If surgical reconstruction of a pressure injury is indicated, it cannot be emphasized too strongly that medical management must be optimized before reconstruction is attempted; otherwise, reconstruction is doomed to failure. That is, spasticity must be controlled, nutritional status must be optimized, and the wound must be clean and free of infection. If there is significant fecal soiling into the injury, diverting colostomy should be considered before reconstruction. If there is a urethral fistula, it should be diverted and healed before reconstruction.
Wound reconstruction can be considered once the bacterial load has been sufficiently minimized to reduce the risk of infectious complications. Furthermore, the patient’s social situation and nutritional status must be optimized (albumin level >3.5 g/mL) to reduce the risk of an adverse outcome.
Because the complication rate after pressure injury reconstruction can be extremely high, patients who are poor surgical candidates in general should not undergo this procedure. Those who do not have a proper support network and a pressure-release bed at home also are not good candidates for pressure injury reconstruction, because of the risk of recurrence or other complications. Patients who do not comply with nonoperative measures used to promote healing by secondary intention are poor reconstruction candidates as well.
Treatment options of unproven efficacy that are currently being studied include hyperbaric oxygen therapy, electrotherapy, growth factors, and negative-pressure wound therapy (NPWT). Initial studies of electrotherapy seem promising, and topical application of the recombinant human growth factor becaplermin has been approved for use in patients with diabetic neuropathic ulcers of the lower extremity. However, not enough evidence is available to permit these treatments to be recommended for the treatment of pressure injuries.
Discharge planning begins early in the hospital stay and requires an interdisciplinary approach. Knowledge of available resources facilitates smooth transitions through all levels of care. With more care being conducted in the home environment, education of the patient and caregiver in preventing and treating pressure injuries becomes increasingly important. Various methods can be used to facilitate the educational process, including charts, diagrams, photographs, and videos. This comprehensive approach can positively influence outcome. [77]
As a final note, some consideration should be given to the ethics of treating pressure injuries. For some individuals with pressure injuries, such as acutely hospitalized patients with a recoverable illness, aggressive treatment, as outlined in this article, is certainly indicated.
For other persons, however, such as chronically or terminally ill patients with long-standing or recurrent ulceration, aggressive treatment may not be in their best interests. In such instances, the wishes of the patient or the patient’s family should be weighed carefully. It may prove to be the case that the patient’s interests are better served by providing medical care and maintaining patient comfort than by instituting major invasive procedures.
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