Pressure ulcer

Bed sores, also known as pressure ulcers, are a serious health concern for residents in nursing homes and long-term care facilities. These painful wounds develop when sustained pressure on the skin limits blood flow, leading to tissue damage and necrosis. Bedsores are preventable with proper care, yet they remain alarmingly common in understaffed or negligent facilities.^[1]

Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised

Pressure ulcers occur due to pressure applied to

The rate of pressure ulcers in hospital settings is high; the prevalence in European hospitals ranges from 8.3% to 23%, and the prevalence was 26% in Canadian healthcare settings from 1990 to 2003.[5] In 2013, there were 29,000 documented deaths from pressure ulcers globally, up from 14,000 deaths in 1990.^[6]

The United States has tracked rates of pressure injury since the early 2000s. Whittington and Briones reported nationwide rates of pressure injuries in hospitals of 6% to 8%.^[7] By the early 2010s, one study showed the rate of pressure injury had dropped to about 4.5% across the Medicare population following the introduction of the International Guideline for pressure injury prevention.^[8] Padula and colleagues have witnessed a +29% uptick in pressure injury rates in recent years associated with the rollout of penalizing Medicare policies.^[9]

Pressure ulcers can trigger other ailments, cause considerable suffering, and can be expensive to treat. Some complications include autonomic dysreflexia, bladder distension, bone infection, pyarthrosis, sepsis, amyloidosis, anemia, urethral fistula, gangrene and very rarely malignant transformation (Marjolin's ulcer – secondary carcinomas in chronic wounds). Sores may recur if those with pressure ulcers do not follow recommended treatment or may instead develop seromas, hematomas, infections, or wound dehiscence. Paralyzed individuals are the most likely to have pressure sores recur. In some cases, complications from pressure sores can be life-threatening. The most common causes of fatality stem from kidney failure and amyloidosis. Pressure ulcers are also painful, with individuals of all ages and all stages of pressure ulcers reporting pain.^{[citation needed]}

There are four mechanisms that contribute to pressure ulcer development:^[10]

1. External (interface) pressure applied over an area of the body, especially over the bony prominences can result in obstruction of the blood capillaries, which deprives tissues of oxygen and nutrients, causing ischemia (deficiency of blood in a particular area), hypoxia (inadequate amount of oxygen available to the cells), edema, inflammation, and, finally, necrosis and ulcer formation. Ulcers due to external pressure occur over the sacrum and coccyx, followed by the trochanter and the calcaneus (heel).
2. Friction is damaging to the superficial blood vessels directly under the skin. It occurs when two surfaces rub against each other. The skin over the elbows can be injured due to friction. The back can also be injured when patients are pulled or slid over bed sheets while being moved up in bed or transferred onto a stretcher.
3. Shearing is a separation of the skin from underlying tissues. When a patient is partially sitting up in bed, skin may stick to the sheet, making the skin susceptible to shearing in case underlying tissues move downward with the body toward the foot of the bed. This may also be possible on a patient who slides down while sitting in a chair.
4. Moisture is also a common pressure ulcer culprit. Sweat, urine, feces, or excessive wound drainage can further exacerbate the damage done by pressure, friction, and shear. It can contribute to maceration of surrounding skin thus potentially expanding the deleterious effects of pressure ulcers.

There are over 100 risk factors for pressure ulcers.

Pressure ulcers may be caused by inadequate blood supply and resulting reperfusion injury when blood re-enters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas. Within 2 hours, this shortage of blood supply, called ischemia, may lead to tissue damage and cell death. The sore will initially start as a red, painful area. The other process of pressure ulcer development is seen when pressure is high enough to damage the cell membrane of muscle cells. The muscle cells die as a result and skin fed through blood vessels coming through the muscle die. This is the deep tissue injury form of pressure ulcers and begins as purple intact skin.^[14]

According to

Common pressure sore sites include the skin over the

The definitions of the pressure ulcer stages are revised periodically by the National Pressure Injury Advisory Panel (NPIAP)^[20] in the United States and the European Pressure Ulcer Advisory Panel (EPUAP) in Europe.^[21] Different classification systems are used around the world, depending upon the health system, the health discipline and the purpose for the classifying (e.g. health care versus, prevalence studies versus funding.^[22] Briefly, they are as follows:^[23][24]

• Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area differs in characteristics such as thickness and temperature as compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).
• Stage 2: Partial thickness loss of
  perineal dermatitis
  , maceration or excoriation.
• Stage 3: Full thickness tissue loss.
  Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue
  and stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.
• Stage 4: Full thickness tissue loss with exposed
  occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/tendon is visible or directly palpable. In 2012, the National Pressure Injury Advisory Panel stated that pressure ulcers with exposed cartilage
  are also classified as a stage 4.
• Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels is normally protective and should not be removed.
• Deep Tissue Pressure Injury (formerly suspected deep tissue injury): Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change^{[25][26][27][28][29][30][31]} often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.^[32]

The term medical device related pressure ulcer refers to a cause rather than a classification. Pressure ulcers from a medical device are classified according to the same classification system being used for pressure ulcers arising from other causes, but the cause is usually noted. Pressure injury from medical devices on mucous membranes should not be staged.

There are various approaches that are used widely for preventing pressure ulcers.[38] Suggested approaches include modifications to bedding and mattresses, different support systems for taking pressure off of affected areas, airing of surfaces of the body, skin care, nutrition, and organizational modifications (for example, changing the care routines in hospitals or homes where people require extended bedrest).^[38][39] Overall, unbiased clinical studies to determine the effectiveness of these types of interventions and to determine the most effective intervention are needed in order to best prevent pressure ulcers.^{[38][40][41][42][43]}

Numerous evidence-based and expert consensus-based clinical guidelines have been to developed to help guide medical professionals internationally^[22] and in specific countries including the UK.^[44][45][46] The Standardized Pressure Injury Prevention Protocol (SPIPP) Checklist is a derivative of the International Guideline that was designed to facilitate consistent implementation of pressure injury prevention.^[47] In 2022, United States Congress passed legislation updating the Military Construction and Veterans Affairs and Related Agencies Appropriations Act, 2015 (H.R. 4355) to establish the SPIPP Checklist as law that United States Department of Veterans Affairs (VA) facilities should adhere to in order to keep patients safe from harm.

Before turning and repositioning a person, a risk assessment tool is suggested to determine what is the best approach for preventing pressure ulcers in that person. Some of the most common risk assessment tools are the

Efforts in the United States and South Korea have sought to automate risk assessment and classification by training machine learning models on electronic health records.[49]^[50][51]

An important aspect of care for most people at risk for pressure ulcers and those with bedsores is the redistribution of pressure so that no pressure is applied to the pressure ulcer.

Nursing homes and hospitals usually set programs in place to avoid the development of pressure ulcers in those who are bedridden, such as using a routine time frame for turning and repositioning to reduce pressure. The frequency of turning and repositioning depends on the person's level of risk.^[citation needed]

Various interventions have been developed to redistribute pressure including the use of different bed mattresses, support surfaces, and the use of static chairs.

The use of different types of mattresses including high density foam, surfaces with reactive fibers or gels in them, and surfaces that incorporate reactive water are sometimes suggested to redistribute pressure. The evidence supporting these interventions and whether they prevent new ulcers, increase the comfort level, or have other positive or more negative adverse effects is weak.^[55][56] Many support surfaces redistribute pressure by immersing and/or enveloping the body into the surface. Some support surfaces, including antidecubitus mattresses and cushions, contain multiple air chambers that are alternately pumped.^[57][58] Methods to standardize the products and evaluate the efficacy of these products have only been developed in recent years through the work of the S3I within NPUAP.^[59]

There is some evidence that the use of foam mattresses is not as effective as support approaches that include alternating pressure air surfaces or reactive surfaces.^[60][61] It is not clear if interventions that include a reactive air surface are more effective than reactive surfaces that include water or gel or other substrates.^[62][63] In addition, the effectiveness of sheepskin overlays on top of mattresses is not clear.^[38]

Static chairs (as opposed to wheelchairs) have also been suggested for pressure redistribution.^[64] Static chairs can include: standard hospital chairs; chairs with no cushions or manual/dynamic function; and chairs with integrated pressure redistributing surfaces and recline, rise or tilt functions. More research is needed to establish how effective pressure redistributing static chairs are for preventing pressure ulcers.^[64]

For individuals with limited mobility, pressure shifting on a regular basis and using a wheelchair cushion featuring pressure relief components can help prevent pressure wounds.^[65]

The benefits of nutritional interventions with various compositions for pressure ulcer prevention are uncertain.^[66] The International Guideline on Pressure Injury Prevention and Treatment lists evidence-based recommendations for prevention of pressure injury and their treatment.^{[citation needed]}

There is some suggestion that organisational changes may reduce incidence of pressure ulcers, with healthcare professionals central to the prevention of pressure ulcers in both hospital^[67] and community settings.^[68] It is not clear from studies on the effectiveness of these approaches as to the best organisational change that would benefit those at risk of pressure ulcers including organisation of health services,^[39] risk assessment tools,^[69] wound care teams,^[70] and education.^[71][72] This is largely due to the lack of high-quality research in these areas.

Caring for wounds and ulcers that have been started and the use of creams are also considerations in preventing worsening to ulcers and new primary ulcers. It is unclear if creams containing fatty acids are effective in reducing incidence of pressure ulcers compared to creams without fatty acids.^[73] It is also unclear if silicone dressings reduce pressure ulcer incidence.^[73] There is no evidence that massage reduces pressure ulcer incidence.^[74] Controlling the heat and moisture levels of the skin surface, known as skin microclimate management, may also play a role in the prevention and control of pressure ulcers.^[75] Skin care is also important because damaged skin does not tolerate pressure. However, skin that is damaged by exposure to urine or stool is not considered a pressure ulcer. These skin wounds should be classified as Incontinence Associated Dermatitis.^{[citation needed]}

Recommendations to treat pressure ulcers include the use of bed rest, pressure redistributing support surfaces, nutritional support, repositioning, wound care (e.g. debridement, wound dressings) and biophysical agents (e.g. electrical stimulation).^[46] Reliable scientific evidence to support the use of many of these interventions, though, is lacking. More research is needed to assess how to best support the treatment of pressure ulcers, for example by repositioning.^{[40][76][42][43]}

Necrotic tissue should be removed in most pressure ulcers. The heel is an exception in many cases when the limb has an inadequate blood supply. Necrotic tissue is an ideal area for bacterial growth, which has the ability to greatly compromise wound healing. There are five ways to remove necrotic tissue.

1. Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes and
   white blood cells
   . It is a slow process, but mostly painless, and is most effective in individuals with a properly functioning immune system.
2. Biological debridement, or
   FDA approved maggots as a live medical device.^[77]
3. Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue.
4. Mechanical debridement, is the use of debriding dressings, whirlpool or ultrasound for slough in a stable wound.
5. Surgical debridement, or sharp debridement, is the fastest method, as it allows a surgeon to quickly remove dead tissue.

It is not clear if one topical agent or dressing is better than another for treating pressure ulcers.[78] There is some evidence to suggest that protease-modulating dressings, foam dressings or collagenase ointment may be better at healing than gauze.^[78] The wound dressing should be selected based on the wound and condition of the surrounding skin. There are some studies that indicate that antimicrobial products that stimulate the epithelization may improve the wound healing.^[79] However, there is no international consensus on the selection of the dressings for pressure ulcers.^[80] Evidence supporting the use of alginate dressings,^[81] foam dressings,^[82] and hydrogel dressings,^[83] and the benefits of these dressings over other treatments is unclear.

Some guidelines for

Prognosis

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Epidemiology

Each year, more than 2.5 million people in the United States develop pressure ulcers.

• Perfusion – systemic biomechanics of blood delivery