Initial care of the pressure ulcer involves debridement, wound cleansing, the application of dressings, and possibly adjunctive therapy. In some cases, operative repair will be required (see Chapter 6). In all cases, specific wound care strategies should be consistent with overall patient goals.

Figure 4 depicts the procedural flow, decision points, and preferred management path for ulcer care. The four basic components of an effective ulcer care plan are (1) debridement of necrotic tissue as needed on initial and subsequent assessments (Node 1); (2) cleansing the wound initially and with each dressing change (Node 2); (3) prevention, diagnosis, and treatment of infection (Node 3) (see recommendations in Chapter 5, Managing Bacterial Colonization and Infection, and see Figure 5); and (4) using a dressing that keeps the ulcer bed continuously moist and the surrounding intact tissue dry (Node 4).

Ulcer healing should be assessed at least weekly and the efficacy of the basic ulcer care plan evaluated (Node 5). If the ulcer is healing, it should be monitored (Skip to Node 13). If the ulcer is not healing, the treatment plan should be reassessed and the level of adherence to the plan evaluated. The plan and implementation strategy should be modified as necessary (Node 6).

Electrical stimulation therapy may be considered for patients with Stage III or IV pressure ulcers that are refractory to more conventional treatments. To date, this therapy has been limited to a small number of research centers. Clinicians considering electrical stimulation therapy should ensure that they have proper equipment and trained personnel who are following protocols shown to be effective and safe in appropriately designed and properly conducted clinical trials.

If the ulcer is still not healing (Node 7), selected patients may be candidates for operative repair (Node 8). Information regarding available operative procedures and the anticipated benefits and harms of each procedure should be part of patient counseling and decisionmaking (Node 9). If surgery is preferred, the operative repair procedure most appropriate for the individual should be used (Node 10). Vigilant postoperative followup care is essential to successful operative repair (Node 11). (See Chapter 6, Operative Repair of Pressure Ulcers, for specific recommendations.)

All pressure ulcers that are managed medically should be evaluated at least weekly. All patients with an operative repair should be evaluated at least daily (Node 12). Healing ulcers and surgical wounds should be monitored regularly to ensure continued progress toward the goal of complete healing (Node 13). The frequency of monitoring should be determined by the clinician based on the condition of the patient, the condition of the ulcer, the rate of healing, and the type of health care setting. If progress in healing cannot be demonstrated, the treatment plan must be reassessed and the level of adherence to that plan evaluated. The plan and implementation strategy should be modified as necessary (Node 14).

Moist, devitalized tissue supports the growth of pathological organisms. Therefore, the removal of such tissue favorably alters the healing environment of a wound. Although debridement is a time-honored modality for treating pressure ulcers, it has not been studied in a randomized trial.

Remove devitalized tissue in pressure ulcers when appropriate for the patient's condition and consistent with patient goals. (Strength of Evidence = C.)

Removal of devitalized tissue is considered necessary for wound healing (Agren and Stromberg, 1985;Black and Black, 1987;Boxer, Gottesman, Bernstein, et al., 1969). Moist, necrotic tissue provides a medium for infection (Galpin, Chow, Bayer, et al., 1976;Reuler and Cooney, 1981), initiates an inflammatory response (Longe, 1986;Mummery and Richardson, 1979), places a phagocytic demand on the wound, and retards wound healing. Because these devitalized tissues are avascular, systemic antibiotics are of limited value.

Select the method of debridement most appropriate to the patient's condition and goals. Sharp, mechanical, enzymatic, and/or autolytic debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalized tissue. If there is urgent need for debridement, as with advancing cellulitis or sepsis, sharp debridement should be used. (Strength of Evidence = C.)

Sharp debridement involves the use of a scalpel, scissor, or other sharp instrument to remove devitalized tissue. The use and benefits of sharp debridement are based on expert opinion (Bale and Harding, 1990;Barrett and Klibanski, 1973;Longe, 1986;Michocki and Lamy, 1976). Sharp debridement should be used to remove areas of thick, adherent eschar and devitalized tissue in extensive ulcers. As the most rapid form of debridement, sharp debridement is urgently indicated when there are signs of advancing cellulitis or sepsis.

Those performing sharp debridement should have demonstrated the necessary clinical skills and should meet licensing requirements. Small wounds can be debrided at the bedside, whereas extensive wounds are usually debrided in the operating room or in a special procedures room. Extensive Stage IV wounds often require debridement in the operating room. When such is required, the surgeon should consider a bone biopsy during the same procedure to determine whether osteomyelitis is present. The need to control pain should be considered.

Mechanical debridement includes the use of wet-to-dry dressings at prescribed intervals, hydrotherapy, wound irrigation, and dextranomers. All these methods can be used as the initial form of debridement, while the patient is being prepared for surgery, or as the sole form of debridement. Because no studies have addressed the benefits, risks, or efficacy of any of the forms of mechanical debridement, these recommendations are based on expert opinion.

Wet-to-dry dressings adhere to devitalized tissue. Once the dressings are dry -- usually within 4 to 6 hours -- they can be removed and the devitalized tissue will be removed along with them. The debriding function of the dressing is at least partly defeated if the dressing is moistened prior to removal. One disadvantage of wet-to-dry dressings is that they are nonselective; they remove both nonviable and viable tissues and are therefore potentially traumatic to granulation tissue and especially to new epithelial tissue (Alvarez, Mertz, and Eaglstein, 1983;Longe, 1986;Torrance, 1983). Adequate analgesia should be provided when this method is used (Black and Black, 1987). Once the wound is clean and granulating, moist dressings can be used to promote healing by secondary intention (see recommendations on dressings in this chapter) or the wound can be repaired surgically (see Chapter 6, Operative Repair of Pressure Ulcers).

Hydrotherapy and wound irrigation can be used to debride wounds and soften eschar (Salyer, 1988). Wound irrigation with a safe and effective device such as a 35-mL syringe with a 19-gauge angiocatheter attached to it will provide enough force to remove eschar, bacteria, and other debris (Stevenson, Thacker, Rodeheaver, et al., 1976). A bulb syringe may produce too little pressure for this purpose, whereas some irrigation devices produce too much pressure, damaging healthy tissue. See the cleansing section of this chapter for irrigation pressures delivered by various devices.

Dextranomers are beads that are placed into a wound bed to absorb exudate, bacteria, and other debris. One disadvantage of their use is that they may be difficult to apply if the patient cannot be positioned so that they can be poured into the wound. In addition, the beads are expensive. Further-more, if dextranomer beads spill onto the floor, a slick surface is created that may be hazardous to both patients and caregivers. In one study of the use of dextranomers, healing time did not appear to decrease greatly (from 25 to 21 days) (Shand and McClemont, 1979).

Enzymatic debridement is accomplished by applying topical debriding agents to devitalized tissues on the wound surface. This option should be considered when individuals cannot tolerate surgery or are in long-term care facilities or receiving care at home, and when the ulcer does not appear to be infected. If infection spreads beyond the ulcer (e.g., advancing cellulitis, sepsis), there is urgent need for sharp debridement. Collagenase, an FDA-licensed biologic, is an example of such a product. Research findings indicate that collagenase promotes debridement and growth of granulation tissue within 3 to 30 days (Boxer, Gottesman, Bernstein, et al., 1969;Lee and Ambrus, 1975;Rao, Sane, and Georgiev, 1975;Varma, Bugatch, and German, 1973). Enzymes can be used alone to break down the eschar, after sharp debridement, or in conjunction with mechanical debridement. Health care providers should refer to specific product information regarding their use.

Autolytic debridement involves the use of synthetic dressings to cover a wound and allow devitalized tissue to self-digest from enzymes normally present in wound fluids. Research supporting the use of autolytic debridement is limited to one animal study (Lydon, Hutchinson, Rippon, et al., 1989) and a small, uncontrolled clinical trial (Carr and Lalagos, 1990). Although autolytic debridement takes longer than other methods, expert clinical opinion indicates that it is an appropriate choice for patients who cannot tolerate other forms of debridement and who are not likely to become infected if their wound is not debrided by other, more rapid means. Autolytic debridement is contraindicated if the ulcer is infected.

Use clean, dry dressings for 8 to 24 hours after sharp debridement associated with bleeding; then reinstitute moist dressings. Clean dressings may be used in conjunction with mechanical or enzymatic debridement techniques. (Strength of Evidence = C.)

The use of dry dressings for the first 8 to 24 hours after sharp debridement tends to limit bleeding. Thereafter, a moist environment should be recreated to support healing. For a rationale supporting the use of clean (as opposed to sterile) dressings, see Chapter 5, Managing Bacterial Colonization and Infection.

Heel ulcers with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement (e.g., edema, erythema, fluctuance, drainage). (Strength of Evidence = C.)

Stable heel ulcers with a protective eschar covering are considered an exception to the recommendation that all eschar be debrided. Literature is not available on this subject; however, it is the panel's opinion that a wound is stable if it is clean, dry, nontender, nonfluctuant, nonerythematous, and nonsuppurative. The eschar provides a natural protective cover. If any signs of complications appear, however, debridement is usually mandatory.

Prevent or manage pain associated with debridement as needed. (Strength of Evidence = C.)

Although formal studies on this subject are lacking, clinicians report anecdotally that patients complain of pain during debridement. Until such research can be carried out, clinicians should institute measures to prevent, assess, and manage debridement-associated pain. Readers are referred to Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline, No. 1, and to Chapter 2 of this document for specific approaches to this problem.

Wound healing is optimized and the potential for infection is decreased when all necrotic tissue, exudate, and metabolic wastes are removed from the wound. The process of cleansing a wound involves selecting both a wound-cleansing solution and a mechanical means of delivering that solution to the wound. The benefits of obtaining a clean wound must be weighed against the potential trauma to the wound bed as a result of such cleansing. Routine wound cleansing should be accomplished with a minimum of chemical and mechanical trauma.

Cleanse wounds initially and at each dressing change. (Strength of Evidence = C.)

Optimal healing cannot proceed until all inflammatory foreign material is removed from the wound. Materials on the wound surface such as foreign bodies, residual topical agents, dressing residue, wound exudate, and metabolic wastes can be removed by careful wound cleansing (Jones and Shires, 1974;Westaby, 1987).

Use minimal mechanical force when cleansing the ulcer with gauze, cloth, or sponges. (Strength of Evidence = C.)

Traumatized wounds are more susceptible to infection and are slower to heal. Coarse wound-cleansing materials elicit more friction trauma and wound infection than do less coarse ones (Rodeheaver, Smith, Thacker, et al., 1975).

Do not clean ulcer wounds with skin cleansers or antiseptic agents (e.g., povidone iodine, iodophor, sodium hypochlorite solution [Dakin's solution], hydrogen peroxide, acetic acid). (Strength of Evidence = B.)

Antiseptic agents are reactive chemicals that are cytotoxic to normal tissue. Betadine, Hibiclens, pHisoHex, benzalkonium chloride, and Granulex& have been found to be toxic to human fibroblasts (Custer, Edlich, Prusak, et al., 1971;Johnson, White, and McAnalley, 1989;Rodeheaver, Kurtz, Kircher, et al., 1980;Rydberg and Zederfeldt, 1968).

Skin cleansers contain chemicals that are cytotoxic to wound tissue and should not be used as wound cleansers. Studies have shown that most wound cleansers need to be diluted to maintain cell viability (Burkey, Weinberg, and Brenden, 1993;Foresman, Payne, Becker, et al., 1993).Foresman, Payne, Becker, et al. (1993) studied the required amounts of dilution needed for various skin and wound cleansers to maintain white blood cell viability and phagocytic function. They found a wide range of toxicities among available skin and wound-cleansing agents (see Table 2).

Use normal saline for cleansing most pressure ulcers. (Strength of Evidence = C.)

Normal saline is the preferred cleansing agent because it is physiologic, will not harm tissue, and adequately cleanses most wounds. Wounds with adherent materials may benefit from the use of those commercial wound cleansers that do not contain harmful chemicals. Available wound cleansers range widely from safe to toxic. Commercial wound cleansers contain surfactants and other chemicals intended to enhance their efficacy, and some of these chemicals may have deleterious effects on wound cells (Bryant, Rodeheaver, Reem, et al., 1984;Foresman, Payne, Becker, et al., 1993). Commercial wound cleansers do not require FDA approval for distribution.

Use enough irrigation pressure to enhance wound cleansing without causing trauma to the wound bed. Safe and effective ulcer irrigation pressures range from 4 to 15 psi. Table 3 indicates the irrigation pressure delivered by various clinically available devices. (Strength of Evidence = B.)

If irrigation pressures are too low (below 4 psi), they will not cleanse the wound adequately. Several investigators found that pressurized irrigation more effectively removed wound bacteria and debris than did gravity or bulb syringe irrigation (Brown, Shelton, Bornside, et al., 1978;Green, Carlson, Briggs, et al., 1971;Gross, Cutright, and Bhaskar, 1972;Hamer, Robson, Krizek, et al., 1975). An irrigation pressure of 8 psi effectively cleanses the wound and reduces the risk of trauma and wound infection. A 35-mL syringe with a 19-gauge needle or angiocatheter delivers saline to the wound at 8 psi and was found to be significantly more effective in removing bacteria and preventing infection than was a bulb syringe (Stevenson, Thacker, Rodeheaver, et al., 1976). Irrigation at 13 psi was significantly superior to a bulb syringe in reducing wound inflammation in traumatic wounds (Longmire, Broom, and Burch, 1987). Wound irrigation pressures of 10 and 15 psi were superior to those of 1 or 5 psi (Rodeheaver, Pettry, Thacker, et al., 1975). Irrigation pressures that exceed 15 psi may cause trauma to the wound and drive bacteria into the tissue (Bhaskar, Cutright, and Gross, 1969;Wheeler, Rodeheaver, Thacker, et al., 1976). Such high pressures lead to fluid dispersion and extensive penetration of irrigation fluid into the wound tissue.

Consider whirlpool treatment for cleansing pressure ulcers that contain thick exudate, slough, or necrotic tissue. Discontinue whirlpool when the ulcer is clean. (Strength of Evidence = C.)

Increasing the length of time a wound surface is in contact with water during whirlpool therapy may enhance the removal of debris from the pressure ulcer. Feedar and Kloth (1990) recommend twice-daily whirlpool cleansing to remove debris and residue. Neiderhuber, Stribley, and Koepke (1975) and Bohannon (1982) found in separate studies that whirlpool treatment followed by a clean pressurized rinse was more effective in removing bacteria than was whirlpool alone. Wound trauma can occur, however, if the wound is positioned too close to the high-pressure water jets in the whirlpool. Whirlpool treatment should be discontinued when the ulcer is considered clean, because the benefits of wound cleansing are outweighed by the potential for trauma to the regenerating tissue as a result of the agitating water (Feedar and Kloth, 1990).

Pressure ulcers require dressings to maintain their physiologic integrity. An ideal dressing should protect the wound, be biocompatible, and provide ideal hydration. The condition of the ulcer bed and the desired dressing function determine the type of dressing needed. The cardinal rule is to keep the ulcer tissue moist and the surrounding intact skin dry.

Use a dressing that will keep the ulcer bed continuously moist. Wet-to-dry dressings should be used only for debridement and are not considered continuously moist saline dressings. (Strength of Evidence = B.)

Several investigators studied pressure ulcer healing outcomes by comparing dry wound healing techniques with moist ones. Kurzuk-Howard, Simpson, and Palmieri (1985) compared heat lamp treatments with film dressings, and Saydak (1990) compared dry gauze dressings with absorptive powder treatment. Several investigators compared wet-to-dry gauze dressings with various moist wound-healing alternatives (Fowler and Goupil, 1984;Gorse and Messner, 1987;Sebern, 1986). The results of these studies suggest that the rate of healing is better with the moist wound-healing treatment than with dressings or treatments that dry the wound bed.

Use clinical judgment to select a type of moist wound dressing suitable for the ulcer. Studies of different types of moist wound dressings showed no differences in pressure ulcer healing outcomes. (Strength of Evidence = B.)

In five controlled trials in which moist saline gauze and other types of moist wound dressings were compared, no significant differences were noted in pressure ulcer healing outcomes (Alm, Hornmark, Fall, et al., 1989;Colwell, Foreman, and Trotter, 1992;Neill, Conforti, Kedas, et al., 1989;Oleske, Smith, White, et al., 1986;Xakellis and Chrischilles, 1992). On the basis of these results, clinicians may select a suitable dressing that supports moist wound healing.

Choose a dressing that keeps the surrounding intact (periulcer) skin dry while keeping the ulcer bed moist. (Strength of Evidence = C.)

Moisture makes intact skin more susceptible to injury. Various techniques can be used to protect the skin from drainage resulting from incontinence and other sources of excessive moisture (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992). Patients with pressure ulcers have additional sources of moisture (wound drainage and wound treatment solutions) that may damage unprotected skin.

Choose a dressing that controls exudate but does not desiccate the ulcer bed. (Strength of Evidence = C.)

Exudative ulcers were found to heal more slowly than nonexudative ones (Gorse and Messner, 1987;Xakellis and Chrischilles, 1992). Although wounds heal better in a moist environment, excessive exudate can macerate surrounding tissue. According to expert opinion, excessive exudate should be absorbed away from the ulcer bed. Several case series report that some dressings work very well for highly exudative wounds. When absorptive dressings are used to remove excess exudate, care should be taken not to desiccate the ulcer bed.

Consider caregiver time when selecting a dressing. (Strength of Evidence = B.)

In five studies that compared the nursing time required to care for pressure ulcer patients treated with moist saline gauze dressings and patients treated with film or hydrocolloid dressings, the former approach took significantly more time than the latter (Alm, Hornmark, Fall, et al., 1989;Colwell, Foreman, and Trotter, 1992;Neill, Conforti, Kedas, et al., 1989;Sebern, 1986;Xakellis and Chrischilles, 1992). This difference relates to the fact that film or hydrocolloid dressings need to be changed less often. However, time spent in assessing whether the dressing remains intact between changes of film or hydrocolloid dressings was not studied. Whether the time taken to assess the dressing results in differences in the overall cost in the hospital or nursing home setting depends on the cost of the dressing materials versus the cost of nursing time. In the home setting, caregivers may choose more expensive dressing materials to reduce the frequency of dressing changes.

Eliminate wound dead space by loosely filling all cavities with dressing material. Avoid overpacking the wound. (Strength of Evidence = C.)

Wound cavities need to be filled so that areas do not wall off and become abscessed. Overpacking a wound may increase pressure on the tissue in the wound bed, potentially causing additional tissue damage (Maklebust and Sieggreen, 1991).

Monitor dressings applied near the anus, since they are difficult to keep intact. (Strength of Evidence = C.)

A number of investigators reported that both film and hydrocolloid dressings failed to remain intact near the anus, and thus their effectiveness was difficult to evaluate (Ahmed, 1982;Dobrzanski, Kelly, Gray, et al. 1990;Goren, 1989; Lingner, Rolstad, Wetherill, et al., 1984).Dobrzanski, Kelly, Gray, et al. (1990) also reported that hydrocolloid dressings over the sacral area tended to roll when the subject changed position. Clinicians report that picture-framing or taping the edges of the dressing may reduce this problem.

The roles of several adjunctive therapies in enhancing pressure ulcer healing have been investigated. The therapies considered by the panel included electrical stimulation; hyperbaric oxygen; infrared, ultraviolet, and low-energy laser irradiation; ultrasound; miscellaneous topical agents (including cytokine growth factors); and systemic drugs other than antibiotics. At this time, electrical stimulation is the only adjunctive therapy with sufficient supporting evidence to warrant recommendation by the panel.

Consider a course of treatment with electrotherapy for Stage III and IV pressure ulcers that have proved unresponsive to conventional therapy. Electrical stimulation may also be useful for recalcitrant Stage II ulcers. (Strength of Evidence = B.)

Data from five clinical trials, involving a total of 147 patients, support the effectiveness of electrotherapy in enhancing the healing rate of pressure ulcers that have been unresponsive to conventional therapy (Carley and Wainapel, 1985;Feedar, Kloth, and Gentzkow, 1991;Gentzkow, Pollack, Kloth, et al., 1991; Griffin, Tooms, Mendius, et al., 1991;Kloth and Feedar, 1988). This finding was consistent across a variety of electrical stimulation protocols. Adverse reactions were limited to minor uncomfortable tingling sensations in 15 percent of patients in one study. Most of the subjects enrolled in these studies had Stage III or IV ulcers.

To date, this therapy has been limited to a small number of research centers. Clinicians considering electrical stimulation therapy should ensure that they have proper equipment and trained personnel who are following protocols shown to be effective and safe in appropriately designed and properly conducted clinical trials.

The therapeutic efficacy of hyperbaric oxygen; infrared, ultraviolet, and low-energy laser irradiation; and ultrasound has not been sufficiently established to permit recommendation of these therapies for the treatment of pressure ulcers. (Strength of Evidence = C.)

Studies of the efficacy of hyperbaric oxygen in pressure ulcer healing have been limited to case series employing topical hyperbaric oxygen (Fisher, 1969;Rosenthal and Schurman, 1971). The lack of controlled clinical trials, combined with in vitro evidence suggesting topical hyperbaric oxygen does not increase tissue oxygen tension beyond the superficial dermis (Gruber, Heitkamp, Billy, et al., 1970), precludes the panel from making any recommendation for the treatment of pressure ulcers. The use of various forms of light (infrared, ultraviolet, and low-energy laser) to promote wound healing has been reported in the literature (Freytes, Fernandez, and Fleming, 1965;Kahn, 1984;MacKinnon and Cleek, 1984; Mester, Mester, and Mester, 1985;Scott, 1983;Stillwell, 1971;Surinchak, Alago, Bellamy, et al., 1983;Wills, Anderson, Beattie, et al., 1983). Controlled clinical trials are generally lacking, however, and data specific to pressure ulcers are minimal. The efficacy of ultrasound for healing of pressure ulcers was evaluated in one controlled trial (McDiarmid, Burns, Lewith, et al., 1985), which showed an improved rate of healing for infected ulcers, but no difference for clean ulcers. The marginal benefit demonstrated in this study and the lack of additional controlled trials of pressure ulcers prevented formulation of any recommendation.

The therapeutic efficacy of miscellaneous topical agents (e.g., sugar, vitamins, elements, hormones, other agents), growth factors, and skin equivalents has not yet been sufficiently established to warrant recommendation of these agents at this time. (Strength of Evidence = C.)

Agents reviewed for this section included some that are very old and some that are new. Of the older agents, sugar, honey, zinc, magnesium, gold, aluminum, phenytoin, aloe vera gel, yeast extract, and insulin all have been popular for short periods of time. Some of these agents are currently being used and investigated. Zinc acetate and aluminum hydroxide ointment (Motta, 1991) and phenytoin (El Zayat, 1989) were evaluated in a controlled and blinded fashion. Many of the newer agents such as cytokine growth factors (e.g., recombinant platelet-derived growth factor-BB [rPDGF-BB] and basic fibroblast growth factor [bFGF]) and skin equivalents are currently being scrutinized in clinical trials. The use of rPDGF-BB (Robson, Phillips, Thomason, et al., 1992b) and bFGF (Robson, Phillips, Lawrence, et al., 1992) has been evaluated in a controlled and blinded fashion. All the studies listed above have shown encouraging results, but data that adequately address the efficacy of any of these agents in the treatment of pressure ulcers are limited. Therefore, for now, none of these agents can be recommended for this purpose. However, it should not be construed that these agents do not deserve further study or that an agent's efficacy might not be demonstrated in trials now under way.

The therapeutic efficacy of systemic agents other than antibiotics has not been sufficiently established to permit their recommendation for the treatment of pressure ulcers. (Strength of Evidence = C.)

The panel considered several nonantibiotic systemic drugs (i.e., vasodilators, hemorrheologics [pentoxiphylline], serotonin inhibitors, fibrolytic agents) as potential adjunctive therapies for pressure ulcer treatment. Preliminary reports suggest that systemic vasodilators may improve skin ulcer outcomes associated with scleroderma (Baron, Skrinskas, Urowitz, et al., 1982) and peripheral vascular disease (Olsson, 1980). A case series indicates that pentoxiphylline may be of benefit in the treatment of diabetic ulcers (Adler, 1991). No data, however, support the use of systemic vasodilators, hemorrheologics, serotonin inhibitors, or fibrolytic agents in treating pressure ulcers.