Treatment strategies
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Perform a complete assessment of patients with pressure ulcers | Level of Evidence 5 |
| Address Patient-Centered Concerns | ||
|---|---|---|
| 2 | Assess and control pain, and assist with psychosocial needs | Level of Evidence 5 |
| Provide Local Wound Care | ||
|---|---|---|
| 3 | Stage the ulcer using the National Pressure Ulcer Advisory Panel (NPUAP) staging system. | Level of Evidence 1a |
| 4 | Assess local wound status and healing on an ongoing basis. | Level of Evidence Not Assessed |
| 5 | Create an optimal wound healing environment through use of suitable local wound care strategies, management of mechanical forces and maintenance of skin integrity. | Level of Evidence Not Assessed |
| 6 | Consider use of adjunctive therapies for chronic pressure ulcers that fail to heal despite provision of an optimal wound healing environment. | Level of Evidence Not Assessed |
| 7 | Consider surgical intervention in carefully selected younger patients where quality of life is an important factor. | Level of Evidence Not Assessed |
| 8 | Prevent ulcer progression through early treatment and frequent assessment of progress towards healing. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 9 | Develop an interprofessional team to meet the patient’s specific management needs | Level of Evidence Not Assessed |
Background
The treatment of pressure ulcers involves initial and ongoing assessment and management of risk factors and related problems; pressure ulcer staging; development of a realistic treatment plan; provision of an optimal environment for wound healing, including addressing the cause of the ulcer; and use of advanced therapies and surgical intervention as appropriate.• Assessment:
Complete assessment of a patient with a pressure ulcer includes a thorough history; a limited general physical examination; nutritional assessment and management; pain assessment and management; and psychosocial assessment and management, including evaluation of tobacco and alcohol use and support systems. Assessment of the pressure ulcer involves staging, ongoing assessment of healing and assessment of the local wound status.
• Staging:
The National Pressure Ulcer Advisory Panel (NPUAP) staging system should be used to stage the ulcer. Progress towards healing over time should be assessed by a tool designed for that purpose, such as the NPUAP Pressure Ulcer Scale for Healing (PUSH) and not by reverse staging. The MEASURE mnemonic (Measure, Exudate, Appearance, Suffering, Undermining, Re-evaluate, Edge) captures important wound parameters that should be monitored.
• Wound healing environment:
Creating an optimal wound healing environment includes the following:
o Local wound care strategies: debride nonviable tissue, assess and manage bacterial burden, manage exudate through selection of appropriate dressings, and manage undermining and dead space by gently filling with absorbent materials. If the risk of contamination from urine or feces exists, use occlusive antimicrobial dressings.
o Redistribution of pressure and prevention of friction and shear.
o Maintenance of skin integrity: ensure adequate nutrition and stratum corneum hydration and prevent damage due to excessive moisture.
• Advanced therapies:
Adjunctive therapies may be considered for chronic pressure ulcers that fail to heal despite provision of an optimal wound healing environment. Evidence supports the use of the following therapies:
o Electrical stimulation therapy (EST): Randomized controlled trials (RCTs) indicate that EST significantly accelerates healing compared with controls.
o Platelet-derived growth factor (PDGF): One large multicentre trial demonstrated a significant increase in healing with use of PDGF.
o Normothermia: At least one RCT shows beneficial results in healing pressure ulcers.
o Ultraviolet light C: At least one RCT shows beneficial results in healing pressure ulcers.
o Larval debridement therapy: At least one RCT shows beneficial results in healing pressure ulcers.
Trials assessing electromagnetic fields and therapeutic ultrasound have produced inconsistent results.
• Surgical intervention:
Surgical management of deep, non-healing ulcers is associated with a high failure rate. Success rates are improved when rehabilitation is implemented before and after surgery. Surgical intervention may be considered in carefully selected younger patients where quality of life is an important factor.
Early intervention is critical in preventing ulcer progression. Frequent reassessment of healing enables rapid adjustment of the treatment plan to address stalled healing or worsening of the ulcer.
References
| Essential Publications |
|---|
| 1 | Electromagnetic therapy in the treatment of pressure ulcers |
Quality Indicator
|
Type: Systematic review |
| Olyaee Manesh A, Flemming K, Cullum NA. Electromagnetic therapy for treating pressure ulcers. Cochrane Database Syst.Rev., 2006, 2 | |||
| The literature was systematically reviewed in an attempt to determine the effectiveness of electromagnetic therapy in the treatment of pressure ulcers. Three RCTs showed that electromagnetic therapy is a useful strategy in the treatment of pressure ulcers. The limitations on the number and size of studies, however, indicates that further research is necessary before the results of the study can be treated as sound clinical recommendations | |||
| 2 | Therapeutic ultrasound in the treatment of pressure ulcers |
Quality Indicator
|
Type: Systematic review |
| BabaAkbari Sari A. Flemming K. Cullum NA. Therapeutic ultrasound for pressure ulcers. Cochrane Database Syst.Rev., 2006, 3 | |||
| Three RCTs examining the effect of therapeutic ultrasound on pressure ulcer healing were reviewed, yielding no results that were statistically significant. This paper demonstrates that not enough research has been conducted to be able to evaluate the benefits or risks of therapeutic ultrasound in the healing of pressure ulcers. It is evident that this area must be addressed in future studies | |||
| 3 | Management of pediatric pressure ulcers |
Quality Indicator
|
Type: Systematic review |
| Baharestani MM, Ratliff CR. Pressure ulcers in neonates and children: an NPUAP white paper. Adv Skin Wound Care. 2007 Apr;20(4):208, 210, 212, 214, 216, 218-20. Review. | |||
| This paper highlights the fact that pediatric patients do develop pressure ulcers, and that prevention and treatment strategies should be tailored specifically to pediatric patients. It would be more effective if it provided some sort of direction as to how this could be achieved | |||
| 4 | Dressings and topical agents in treatment of chronic wounds |
Quality Indicator
|
Type: Systematic review |
| Bradley M, Cullum N, Nelson EA. Systematic reviews of wound care management: (2) dressings and topical agents used in the healing of chronic wounds. Health Technol.Assess., 1999, 3, 17 II, 126 | |||
| The objective of this systematic review (to determine the optimal dressing) is worthy of extensive research. Unfortunately, no statistical evidence promoting one dressing over another was found, and further research was recommended. In the absence of statistical evidence of an advantage of one dressing over another, clinicians are advised to use their judgment, experience and knowledge to select appropriate dressings. | |||
| 5 | Evaluation of techniques used in wound cleansing for pressure ulcers |
Quality Indicator
|
Type: Systematic review |
| Moore ZEH, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst.Rev., 2005, 4 | |||
| This publication demonstrates that Aloe, silver chloride and decyl glucoside are effective in treatment of pressure ulcers. The study addressed a wide range of questions, however, and this caused its analysis of the aforementioned products to be limited. The other topics addressed did not demonstrate any statistically significant results | |||
| 6 | Monochromatic phototherapy as a treatment strategy for pressure ulcers |
Quality Indicator
|
Type: RCT |
| Dehlin O, Elmstahl S, Gottrup F. Monochromatic phototherapy: effective treatment for grade II chronic pressure ulcers in elderly patients. Aging Clin.Exp.Res., 2007, 19, 6, 478-483 | |||
| The results of this study indicate that monochromatic phototherapy results in a greater normalized reduction in wound size compared to placebo light. These findings are useful because they statistically demonstrates that monochromatic phototherapy is effective in treating pressure ulcers in senior citizens. Its findings can be effectively implemented into practice | |||
| 7 | Honey dressings for treatment of pressure ulcers |
Quality Indicator
|
Type: RCT |
| Gunes UY, Eser I. Effectiveness of a honey dressing for healing pressure ulcers. J.Wocn, 2007, 34, 2, 184-190 | |||
| This study compared honey dressings vs. a placebo for the treatment of pressure ulcers. Ulcer surface area decreased at a greater rate in the honey group than in the control group. This study is the first randomized clinical trial to evaluate the effects of honey dressings on healing of pressure ulcers. While more evidence is necessary, this study suggests that honey dressings are a viable treatment option for pressure ulcers. | |||
| 8 | Intravenous Semelil in the treatment of pressure ulcers |
Quality Indicator
|
Type: RCT |
| Shamimi Nouri K, Heshmat R, Karimian R. Intravenous Semelil (ANGIPARS[trademark]) as a novel therapy for pressure ulcers: A randomized clinical trial. Daru, 2008, 16, 1, 49-53 | |||
| This study compares intravenous semelil to a placebo in the treatment of pressure ulcers, and the results indicate that intravenous semelil facilitates pressure ulcer healing. The study is not particularly useful due to one significant error in the analysis. The treatment group had an average baseline ulcer size of 57.2 cm^2, while the control group had an average baseline size of 20.0 cm^2. Due to this discrepancy, the results of the study do not categorically demonstrate the effectiveness of intravenous ANGIPARS™ in the treatment of pressure ulcers | |||
| 9 | Topical Semelil in the treatment of pressure ulcers |
Quality Indicator
|
Type: RCT |
| Shamimi Nouri K, Karimian R. Nasli E. Topical application of Semelil (ANGIPARS[trademark]) in treatment of pressure ulcers: A randomized clinical trial. Daru, 2008, 16, 1, 54-57 | |||
| This study compares topical semelil to a placebo in the treatment of pressure ulcers, and the results indicate that topical semelil facilitates pressure ulcer healing. This study is not particularly useful due to one significant error in the analysis. The treatment group had an average baseline ulcer size of 56.1 cm^2, while the control group had an average baseline size of 20.0 cm^2. Due to this discrepancy, the results of the study do not categorically demonstrate the effectiveness of intravenous ANGIPARS™ in the treatment of pressure ulcers | |||
| 10 | Electrical Therapy in the treatment of pressure ulcers |
Quality Indicator
|
Type: RCT |
| Ullah MO. A study to detect the efficacy of Micro-current Electrical Therapy on decubitus wound. Journal of Medical Sciences, 2007, 7, 8, 1320-1324 | |||
| This study created a scoring system to standardize pressure ulcer healing based on reduction in area, percentage reduction in area and rate of healing. The end results show that Micro-current Electrical Therapy is effective in treating pressure ulcers, but a more transparent rationale for this conclusion would have increased the study's value. Further research is necessary to give this study any true merit | |||
| 11 | Collagen protein hydrolysate in the treatment of pressure ulcers |
Quality Indicator
|
Type: RCT |
| Lee SK, Posthauer ME, Dorner B. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial.Adv Skin Wound Care 2006;19:92, 94-6. | |||
| This well-conducted study was done to determine if concentrated, fortified collagen protein hydrolysate supplement is useful in the treatment of pressure ulcers. It compared the supplement to a placebo, and measured percentage reduction in ulcer area. The results demonstrated that the supplement is very effective in treatment of pressure ulcers. | |||
| 12 | Phenytoin Solution in the treatment of pressure ulcers |
Quality Indicator
|
Type: RCT |
| Subbanna PK, Margaret Shanti FX, George J. Topical phenytoin solution for treating pressure ulcers: a prospective, randomized, double-blind clinical trial. Spinal Cord, 2007, 45, 11, 739-743 | |||
| The study is intended to examine the effect of phenytoin solution on the treatment of pressure ulcers by comparing it with a saline placebo. The results do not show any statistically significant difference between the two groups. This demonstrates an important area for future research. | |||
| 13 | Continuous Quality Improvement (CQI), and its ability to facilitate implementation of best practice recommendations for pressure ulcer treatment in nursing homes |
Quality Indicator
|
Type: Systematic review |
| Berlowitz DR, Frantz RA. Implementing best practices in pressure ulcer care: the role of continuous quality improvement. J.Am.Med.Dir.Assoc., 2007, 8, 3): Supplement 1, S37-41 | |||
| This paper suggests that the use of CQI can improve implementation of best practice recommendations for treatment of pressure ulcers in nursing homes. The study does not, however, provide any detail or instructions on how this can be achieved. | |||