Pressure ulcers: Current understanding and newer modalities of treatment

 

 Permissions and Reprints

ABSTRACT

This article reviews the mechanism, symptoms, causes, severity, diagnosis, prevention and present recommendations for surgical as well as non-surgical management of pressure ulcers. Particular focus has been placed on the current understandings and the newer modalities for the treatment of pressure ulcers. The paper also covers the role of nutrition and pressure-release devices such as cushions and mattresses as a part of the treatment algorithm for preventing and quick healing process of these wounds. Pressure ulcers develop primarily from pressure and shear; are progressive in nature and most frequently found in bedridden, chair bound or immobile people. They often develop in people who have been hospitalised for a long time generally for a different problem and increase the overall time as well as cost of hospitalisation that have detrimental effects on patient’s quality of life. Loss of sensation compounds the problem manifold, and failure of reactive hyperaemia cycle of the pressure prone area remains the most important aetiopathology. Pressure ulcers are largely preventable in nature, and their management depends on their severity. The available literature about severity of pressure ulcers, their classification and medical care protocols have been described in this paper. The present treatment options include various approaches of cleaning the wound, debridement, optimised dressings, role of antibiotics and reconstructive surgery. The newer treatment options such as negative pressure wound therapy, hyperbaric oxygen therapy, cell therapy have been discussed, and the advantages and disadvantages of current and newer methods have also been described.

• REFERENCES

• 1 Gebhardt KS. Part 1. Causes of pressure ulcers. Nurs Times 2002; 98: 4
  PubMedGoogle Scholar
• 2 Gefen A. Reswick and Rogers pressure-time curve for pressure ulcer risk. Part 1. Nurs Stand 2009; 23: 64-66 , 68
  PubMedGoogle Scholar
• 3 Gefen A. Reswick and Rogers pressure-time curve for pressure ulcer risk. Part 2. Nurs Stand 2009; 23: 40-4
  CrossrefPubMedGoogle Scholar
• 4 Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: Extent of the problem and provision of care. Br Med J (Clin Res Ed) 1985; 290: 1855-6
  CrossrefPubMedGoogle Scholar
• 5 Krouskop TA, Reddy NP, Spencer WA, Secor JW. Mechanisms of decubitus ulcer formation - An hypothesis. Med Hypotheses 1978; 4: 37-9
  CrossrefPubMedGoogle Scholar
• 6 Reddy NP, Patel K. A mathematical model of flow through the terminal lymphatics. Med Eng Phys 1995; 17: 134-40
  CrossrefPubMedGoogle Scholar
• 7 Leblebici B, Turhan N, Adam M, Akman MN. Clinical and epidemiologic evaluation of pressure ulcers in patients at a university hospital in Turkey. J Wound Ostomy Continence Nurs 2007; 34: 407-11
  CrossrefPubMedGoogle Scholar
• 8 Vasconez LO, Schneider WJ, Jurkiewicz MJ. Pressure sores. Curr Prob Surg 1977; 62: 1-62
  Google Scholar
• 9 Cannon BC, Cannon JP. Management of pressure ulcers. Am J Health Syst Pharm 2004; 61: 1895-905
  CrossrefPubMedGoogle Scholar
• 10 Dodd KT, Gross DR. Three-dimensional tissue deformation in subcutaneous tissues overlying bony prominences may help to explain external load transfer to the interstitium. J Biomech 1991; 24: 11-9
  CrossrefPubMedGoogle Scholar
• 11 Jay R. Pressure and shear: Their effects on support surface choice. Ostomy Wound Manage 1995; 41: 36-8 , 40
  PubMedGoogle Scholar
• 12 Kuffler DP. Techniques for wound healing with a focus on pressure ulcers elimination. Open Circ Vasc J 2010; 3: 72-84
  Google Scholar
• 13 Goossens RH, Snijders CJ, Holscher TG, Heerens WC, Holman AE. Shear stress measured on beds and wheelchairs. Scand J Rehabil Med 1997; 29: 131-6
  Google Scholar
• 14 Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med 1997; 13: 421-36
  PubMedGoogle Scholar
• 15 Bliss MR. Hyperaemia. J Tissue Viability 1998; 8: 4-13
  CrossrefPubMedGoogle Scholar
• 16 Kaveeshwar SA, Cornwall J. The current state of diabetes mellitus in India. Australas Med J 2014; 7: 45-8
  CrossrefPubMedGoogle Scholar
• 17 Premalatha G, Shanthirani S, Deepa R, Markovitz J, Mohan V. Prevalence and risk factors of peripheral vascular disease in a selected South Indian population: The Chennai Urban Population Study. Diabetes Care 2000; 23: 1295-300
  CrossrefPubMedGoogle Scholar
• 18 Langemo D, Anderson J, Hanson D, Hunter S, Thompson P, Posthauer ME. Nutritional considerations in wound care. Adv Skin Wound Care 2006; 19: 297-8 , 300, 303
  CrossrefPubMedGoogle Scholar
• 19 Scivoletto G, Fuoco U, Morganti B, Cosentino E, Molinari M. Pressure sores and blood and serum dysmetabolism in spinal cord injury patients. Spinal Cord 2004; 42: 473-6
  CrossrefPubMedGoogle Scholar
• 20 Keast DH, Fraser C. Treatment of chronic skin ulcers in individuals with anemia of chronic disease using recombinant human erythropoietin (EPO): A review of four cases. Ostomy Wound Manage 2004; 50: 64-70
  PubMedGoogle Scholar
• 21 Narsete TA, Orgel MG, Smith D. Pressure sores. Am Fam Physician 1983; 28: 135-9
  PubMedGoogle Scholar
• 22 Ferrell BA, Josephson K, Norvid P, Alcorn H. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000; 48: 1042-7
  CrossrefPubMedGoogle Scholar
• 23 Berlowitz DR, Brandeis GH, Anderson J, Brand HK. Predictors of pressure ulcer healing among long-term care residents. J Am Geriatr Soc 1997; 45: 30-4
  CrossrefPubMedGoogle Scholar
• 24 Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes. Diabetes Care 1998; 21: 2161-77
  CrossrefPubMedGoogle Scholar
• 25 Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: A randomised controlled trial. Clin Nutr 2005; 24: 979-87
  CrossrefPubMedGoogle Scholar
• 26 Mosher BA, Cuddigan J, Thomas DR, Boudreau DM. Outcomes of 4 methods of debridement using a decision analysis methodology. Adv Wound Care 1999; 12: 81-8
  PubMedGoogle Scholar
• 27 Ramundo J, Gray M. Enzymatic wound debridement. J Wound Ostomy Continence Nurs 2008; 35: 273-80
  CrossrefPubMedGoogle Scholar
• 28 Mumcuoglu KY, Lipo M, Ioffe-Uspensky I, Miller J, Galun R. Maggot therapy for gangrene and osteomyelitis. Harefuah 1997; 132: 323-5 , 382
  PubMedGoogle Scholar
• 29 Sherman RA. Maggot versus conservative debridement therapy for the treatment of pressure ulcers. Wound Repair Regen 2002; 10: 208-14
  CrossrefPubMedGoogle Scholar
• 30 Moore ZE, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst Rev 2005; 3: CD004983
  Google Scholar
• 31 Ramundo J, Gray M. Is ultrasonic mist therapy effective for debriding chronic wounds?. J Wound Ostomy Continence Nurs 2008; 35: 579-83
  CrossrefPubMedGoogle Scholar
• 32 Kavros SJ, Liedl DA, Boon AJ, Miller JL, Hobbs JA, Andrews KL. Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: A retrospective analysis. Adv Skin Wound Care 2008; 21: 416-23
  CrossrefPubMedGoogle Scholar
• 33 Graham JS, Schomacker KT, Glatter RD, Briscoe CM, Braue Jr EH, Squibb KS. Efficacy of laser debridement with autologous split-thickness skin grafting in promoting improved healing of deep cutaneous sulfur mustard burns. Burns 2002; 28: 719-30
  CrossrefPubMedGoogle Scholar
• 34 Webb LX. New techniques in wound management: Vacuum-assisted wound closure. J Am Acad Orthop Surg 2002; 10: 303-11
  CrossrefPubMedGoogle Scholar
• 35 Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev 2008; 4: CD002106
  Google Scholar
• 36 Fletcher J. The benefits of using hydrocolloids. Nurs Times 2003; 99: 57
  PubMedGoogle Scholar
• 37 Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 2006; 5: 40-54
  CrossrefPubMedGoogle Scholar
• 38 Toy LW, Macera L. Evidence-based review of silver dressing use on chronic wounds. J Am Acad Nurse Pract 2011; 23: 183-92
  CrossrefPubMedGoogle Scholar
• 39 Leaper DJ. Silver dressings: Their role in wound management. Int Wound J 2006; 3: 282-94
  CrossrefPubMedGoogle Scholar
• 40 Lorée S, Dompmartin A, Penven K, Harel D, Leroy D. Is Vacuum Assisted Closure a valid technique for debriding chronic leg ulcers?. J Wound Care 2004; 13: 249-52
  CrossrefPubMedGoogle Scholar
• 41 Al Fadhli A, Alexander G, Kanjoor JR. Versatile use of vacuum-assisted healing in fifty patients. Indian J Plast Surg 2009; 42: 161-8
  CrossrefPubMedGoogle Scholar
• 42 Payne WG, Ochs DE, Meltzer DD, Hill DP, Mannari RJ, Robson LE. et al. Long-term outcome study of growth factor-treated pressure ulcers. Am J Surg 2001; 181: 81-6
  CrossrefPubMedGoogle Scholar
• 43 Marston WA. Dermagraft, a bioengineered human dermal equivalent for the treatment of chronic nonhealing diabetic foot ulcer. Expert Rev Med Devices 2004; 1: 21-31
  CrossrefPubMedGoogle Scholar
• 44 González Sarasúa J, Pérez López S, Álvarez Viejo M, Pérez Basterrechea M, Fernández Rodríguez A, Ferrero Gutiérrez A. et al. Treatment of pressure ulcers with autologous bone marrow nuclear cells in patients with spinal cord injury. J Spinal Cord Med 2011; 34: 301-7
  CrossrefPubMedGoogle Scholar
• 45 Kamata Y, Takahashi Y, Iwamoto M, Matsui K, Murakami Y, Muroi K. et al. Local implantation of autologous mononuclear cells from bone marrow and peripheral blood for treatment of ischaemic digits in patients with connective tissue diseases. Rheumatology (Oxford) 2007; 46: 882-4
  CrossrefPubMedGoogle Scholar
• 46 Robson MC, Hill DP, Smith PD, Wang X, Meyer-Siegler K, Ko F. et al. Sequential cytokine therapy for pressure ulcers: Clinical and mechanistic response. Ann Surg 2000; 231: 600-11
  CrossrefPubMedGoogle Scholar
• 47 Fischer BH. Topical hyperbaric oxygen treatment of pressure sores and skin ulcers. Lancet 1969; 2: 405-9
  PubMedGoogle Scholar
• 48 Chen L, Tredget EE, Wu PY, Wu Y. Paracrine factors of mesenchymal stem cells recruit macrophages and endothelial lineage cells and enhance wound healing. PLoS One 2008; 3: e1886
  CrossrefPubMedGoogle Scholar
• 49 Bhutani S, Vishwanath G. Hyperbaric oxygen and wound healing. Indian J Plast Surg 2012; 45: 316-24
  Article in Thieme ConnectPubMedGoogle Scholar
• 50 Schönfeld M, Moll I, Maier K, Jung EG. Keratinocytes from cell culture for therapy of skin defects. Review and personal results. Hautarzt 1993; 44: 281-9
  PubMedGoogle Scholar
• 51 Kuroyanagi Y, Yamada N, Yamashita R, Uchinuma E. Tissue-engineered product: Allogeneic cultured dermal substitute composed of spongy collagen with fibroblasts. Artif Organs 2001; 25: 180-6
  CrossrefPubMedGoogle Scholar
• 52 Ichioka S, Ohura N, Sekiya N, Shibata M, Nakatsuka T. Regenerative surgery for sacral pressure ulcers using collagen matrix substitute dermis (artificial dermis). Ann Plast Surg 2003; 51: 383-9
  CrossrefPubMedGoogle Scholar
• 53 Mizuno H, Miyamoto M, Shimamoto M, Koike S, Hyakusoku H, Kuroyanagi Y. Therapeutic angiogenesis by autologous bone marrow cell implantation together with allogeneic cultured dermal substitute for intractable ulcers in critical limb ischaemia. J Plast Reconstr Aesthet Surg 2010; 63: 1875-82
  CrossrefPubMedGoogle Scholar
• 54 Tang YL, Zhao Q, Zhang YC, Cheng L, Liu M, Shi J. et al. Autologous mesenchymal stem cell transplantation induce VEGF and neovascularization in ischemic myocardium. Regul Pept 2004; 117: 3-10
  CrossrefPubMedGoogle Scholar
• 55 Ono I, Yamashita T, Hida T, Jin HY, Ito Y, Hamada H. et al. Local administration of hepatocyte growth factor gene enhances the regeneration of dermis in acute incisional wounds. J Surg Res 2004; 120: 47-55
  CrossrefPubMedGoogle Scholar
• 56 Caplan AI, Dennis JE. Mesenchymal stem cells as trophic mediators. J Cell Biochem 2006; 98: 1076-84
  CrossrefPubMedGoogle Scholar
• 57 Zuk PA, Zhu M, Ashjian P, De Ugarte DA, Huang JI, Mizuno H. et al. Human adipose tissue is a source of multipotent stem cells. Mol Biol Cell 2002; 13: 4279-95
  CrossrefPubMedGoogle Scholar
• 58 Strioga M, Viswanathan S, Darinskas A, Slaby O, Michalek J. Same or not the same? Comparison of adipose tissue-derived versus bone marrow-derived mesenchymal stem and stromal cells. Stem Cells Dev 2012; 21: 2724-52
  CrossrefPubMedGoogle Scholar
• 59 Jiang L, Dai Y, Cui F, Pan Y, Zhang H, Xiao J. et al. Expression of cytokines, growth factors and apoptosis-related signal molecules in chronic pressure ulcer wounds healing. Spinal Cord 2014; 52: 145-51
  CrossrefPubMedGoogle Scholar
• 60 Hurteau JE, Bostwick J, Nahai F, Hester R, Jurkiewicz MJ. V-Y advancement of hamstring musculocuataneous flap for coverage of ischial pressure sores. Plast Reconstr Surg 1981; 68: 539-42
  CrossrefPubMedGoogle Scholar
• 61 Tobin GR, Sanders BP, Man D, Weiner LJ. The biceps femoris myocutaneous advancement flap: A useful modification for ischial pressure ulcer reconstruction. Ann Plast Surg 1981; 6: 396-401
  CrossrefPubMedGoogle Scholar
• 62 International review. Pressure ulcer prevention: Pressure, shear, friction and microclimate in context. A consensus document. London: Wounds International; 2010
  Google Scholar
• 63 Hargest TS, Artz CP. A new concept in patient care: The air-fluidized bed. AORN J 1969; 10: 50-3
  PubMedGoogle Scholar
• 64 Allman RM, Laprade CA, Noel LB, Walker JM, Moorer CA, Dear MR. et al. Pressure sores among hospitalized patients. Ann Intern Med 1986; 105: 337-42
  Google Scholar
• 65 Bergstrom N, Bennett MA, Carlson CE. Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. Rockville, MD: AHCPR Publication 95-0652, Agency for Health Care Policy and Research; 1994
  Google Scholar
• 66 Ferguson RP, O’Connor P, Crabtree B, Batchelor A, Mitchell J, Coppola D. Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents. J Am Geriatr Soc 1993; 41: 545-9
  CrossrefPubMedGoogle Scholar
• 67 Friedman FJ, Campbell AJ, Caradoc-Davies TH. Hypoalbuminemia in the elderly is due to disease not malnutrition. Clin Exp Gerontol 1985; 7: 191-203
  Google Scholar
• 68 National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009
  Google Scholar