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Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised
damage to the skin and/or underlying tissue that usually occur over a
bony prominence as a result of usually long-term pressure, or pressure in combination with
shear
Shear may refer to:
Textile production
*Animal shearing, the collection of wool from various species
**Sheep shearing
*The removal of nap during wool cloth production
Science and technology Engineering
*Shear strength (soil), the shear strength ...
or friction. The most common sites are the skin overlying the
sacrum
The sacrum (plural: ''sacra'' or ''sacrums''), in human anatomy, is a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae (S1S5) between ages 18 and 30.
The sacrum situates at the upper, back part ...
,
coccyx
The coccyx ( : coccyges or coccyxes), commonly referred to as the tailbone, is the final segment of the vertebral column in all apes, and analogous structures in certain other mammals such as horses. In tailless primates (e.g. humans and othe ...
,
heel
The heel is the prominence at the posterior end of the foot. It is based on the projection of one bone, the calcaneus or heel bone, behind the articulation of the bones of the lower Human leg, leg.
Structure
To distribute the compressive for ...
s, and
hip
In vertebrate anatomy, hip (or "coxa"Latin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) in medical terminology) refers to either an anatomical region or a joint.
The hip region is ...
s, though other sites can be affected, such as the
elbow
The elbow is the region between the arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa (also called the chelidon, or the elbow pit), and the lateral and the media ...
s,
knee
In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia (tibiofemoral joint), and one between the femur and patella (patellofemoral joint). It is the largest joint in the hu ...
s,
ankle
The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular join ...
s, back of
shoulder
The human shoulder is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder mak ...
s, or the back of the
cranium
The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone. However two parts are more prominent: the cranium and the mandible. In humans, the ...
.
Pressure ulcers occur due to pressure applied to
soft tissue
Soft tissue is all the tissue in the body that is not hardened by the processes of ossification or calcification such as bones and teeth. Soft tissue connects, surrounds or supports internal organs and bones, and includes muscle, tendons, ligam ...
resulting in completely or partially obstructed
blood flow
Hemodynamics or haemodynamics are the dynamics of blood flow. The circulatory system is controlled by homeostatic mechanisms of autoregulation, just as hydraulic circuits are controlled by control systems. The hemodynamic response continuously m ...
to the soft tissue. Shear is also a cause, as it can pull on blood vessels that feed the skin. Pressure ulcers most commonly develop in individuals who are not moving about, such as those who are on chronic bedrest or consistently use a wheelchair. It is widely believed that other factors can influence the tolerance of skin for pressure and shear, thereby increasing the risk of pressure ulcer development. These factors are
protein-calorie malnutrition,
microclimate
A microclimate (or micro-climate) is a local set of atmospheric conditions that differ from those in the surrounding areas, often with a slight difference but sometimes with a substantial one. The term may refer to areas as small as a few squ ...
(skin wetness caused by sweating or
incontinence
Incontinence or Incontinent may refer to:
*Fecal incontinence, the involuntary excretion of bowel contents
*Urinary incontinence, the involuntary excretion of urine
* Lack of moderation or self-control, especially related to sexual desire - see I ...
), diseases that reduce blood flow to the skin, such as
arteriosclerosis
Arteriosclerosis is the thickening, hardening, and loss of elasticity of the walls of Artery, arteries. This process gradually restricts the blood flow to one's organs and tissues and can lead to severe health risks brought on by atherosclerosis ...
, or diseases that reduce the sensation in the skin, such as
paralysis
Paralysis (also known as plegia) is a loss of motor function in one or more muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage. In the United States, roughly 1 in 50 ...
or
neuropathy
Peripheral neuropathy, often shortened to neuropathy, is a general term describing disease affecting the peripheral nerves, meaning nerves beyond the brain and spinal cord. Damage to peripheral nerves may impair sensation, movement, gland, or o ...
. The
healing
With physical trauma or disease suffered by an organism, healing involves the repairing of damaged tissue(s), organs and the biological system as a whole and resumption of (normal) functioning. Medicine includes the process by which the cells i ...
of pressure ulcers may be slowed by the age of the person, medical conditions (such as arteriosclerosis,
diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
or
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
), smoking or medications such as
anti-inflammatory
Anti-inflammatory is the property of a substance or treatment that reduces inflammation or swelling. Anti-inflammatory drugs, also called anti-inflammatories, make up about half of analgesics. These drugs remedy pain by reducing inflammation as o ...
drugs.
Although often prevented and treatable if detected early, pressure ulcers can be very difficult to prevent in critically ill people,
frail elders and individuals with impaired mobility such as wheelchair users (especially where spinal injury is involved).
Primary prevention
Preventive healthcare, or prophylaxis, consists of measures taken for the purposes of disease prevention.Hugh R. Leavell and E. Gurney Clark as "the science and art of preventing disease, prolonging life, and promoting physical and mental hea ...
is to redistribute pressure by regularly turning the person. The benefit of turning to avoid further sores is well documented since at least the 19th century. In addition to turning and re-positioning the person in the bed or wheelchair, eating a balanced diet with adequate protein and keeping the skin free from exposure to urine and stool is important.
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.
In 2013, there were 29,000 documented deaths from pressure ulcers globally, up from 14,000 deaths in 1990.
Presentation
Complications
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
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
,
amyloidosis
Amyloidosis is a group of diseases in which abnormal proteins, known as amyloid fibrils, build up in tissue. There are several non-specific and vague signs and symptoms associated with amyloidosis. These include fatigue, peripheral edema, weight ...
,
anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...
,
urethra
The urethra (from Greek οὐρήθρα – ''ourḗthrā'') is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body of both females and males. In human females and other primates, the urethra con ...
l
fistula
A fistula (plural: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") in anatomy is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow or ...
,
gangrene
Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...
and very rarely
malignant transformation
Malignant transformation is the process by which cells acquire the properties of cancer. This may occur as a primary process in normal tissue, or secondarily as ''malignant degeneration'' of a previously existing benign tumor.
Causes
There are ...
(
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
seroma
A seroma is a pocket of clear serous fluid (filtered blood plasma). They may sometimes develop in the body after surgery, particularly after breast surgery, abdominal surgery, and reconstructive surgery. They can be diagnosed by physical signs, ...
s,
hematoma
A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...
s,
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
s, or
wound dehiscence
Wound dehiscence is a surgical complication in which a wound ruptures along a surgical incision. Risk factors include age, collagen disorder such as Ehlers–Danlos syndrome, diabetes, obesity, poor knotting or grabbing of stitches, and trauma ...
. 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
Kidney failure, also known as end-stage kidney disease, is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney failure is classified as eit ...
and
amyloidosis
Amyloidosis is a group of diseases in which abnormal proteins, known as amyloid fibrils, build up in tissue. There are several non-specific and vague signs and symptoms associated with amyloidosis. These include fatigue, peripheral edema, weight ...
.
Pressure ulcers are also painful, with individuals of all ages and all stages of pressure ulcers reporting pain.
Cause
There are four mechanisms that contribute to pressure ulcer development:
# 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).
# 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.
# Shearing is a separation of the skin from underlying tissues. When a patient is partially sitting up in bed, their skin may stick to the sheet, making them 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.
# 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.
Risk factors
There are over 100 risk factors for pressure ulcers.
Factors that may place a patient at risk include
immobility,
diabetes mellitus
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
,
peripheral vascular disease
Peripheral artery disease (PAD) is an abnormal narrowing of arteries other than those that supply the heart or brain. When narrowing occurs in the heart, it is called coronary artery disease, and in the brain, it is called cerebrovascular diseas ...
,
malnutrition
Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues a ...
,
cerebral vascular accident
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
and
hypotension
Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the dias ...
.
Other factors are age of 70 years and older, current smoking history, dry skin, low body mass index, urinary and fecal incontinence, physical restraints, malignancy, and history of pressure ulcers.
Pathophysiology
Pressure ulcers may be caused by inadequate blood supply and resulting
reperfusion injury
Reperfusion injury, sometimes called ischemia-reperfusion injury (IRI) or reoxygenation injury, is the tissue damage caused when blood supply returns to tissue ('' re-'' + '' perfusion'') after a period of ischemia or lack of oxygen (anoxia or h ...
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.
According to
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer M ...
, pressure ulcers are one of the eight preventable iatrogenic illnesses. If a pressure ulcer is acquired in the hospital, the hospital will no longer receive reimbursement for the person's care. Hospitals spend about $5 billion annually for treatment of pressure ulcers.
Sites
![Pressure ulcer points](https://upload.wikimedia.org/wikipedia/commons/b/bc/Pressure_ulcer_points.svg)
Common pressure sore sites include the skin over the
ischial tuberosity
The ischial tuberosity (or tuberosity of the ischium, tuber ischiadicum), also known colloquially as the sit bones or sitz bones, or as a pair the sitting bones, is a large swelling posteriorly on the superior ramus of the ischium. It marks th ...
, the
sacrum
The sacrum (plural: ''sacra'' or ''sacrums''), in human anatomy, is a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae (S1S5) between ages 18 and 30.
The sacrum situates at the upper, back part ...
, the heels of the feet, over the heads of the
long bones of the foot, buttocks, over the shoulder, and over the
back
The human back, also called the dorsum, is the large posterior area of the human body, rising from the top of the buttocks to the back of the neck. It is the surface of the body opposite from the chest and the abdomen. The vertebral column runs ...
of the head.
Biofilm
Biofilm
A biofilm comprises any syntrophic consortium of microorganisms in which cells stick to each other and often also to a surface. These adherent cells become embedded within a slimy extracellular matrix that is composed of extracellular ...
is one of the most common reasons for delayed healing in pressure ulcers. Biofilm occurs rapidly in wounds and stalls healing by keeping the wound inflamed. Frequent debridement and antimicrobial dressings are needed to control the biofilm. Infection prevents healing of pressure ulcers. Signs of pressure ulcer infection include slow or delayed healing and pale
granulation tissue
Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size ...
. Signs and symptoms of
systemic infection
A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole.
Examples
* Mastocytosis, including mast cell activation syndrome and eosinophilic esophagitis
* Chronic fatigue syndrome
* Systemic vascul ...
include fever, pain, redness, swelling, warmth of the area, and purulent discharge. Additionally, infected wounds may have a
gangrenous
Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...
smell, be discolored, and may eventually produce more pus.
In order to eliminate this problem, it is imperative to apply
antiseptic
An antiseptic (from Greek ἀντί ''anti'', "against" and σηπτικός ''sēptikos'', "putrefactive") is an antimicrobial substance or compound that is applied to living tissue/skin to reduce the possibility of infection, sepsis, or putre ...
s at once.
Hydrogen peroxide
Hydrogen peroxide is a chemical compound with the formula . In its pure form, it is a very pale blue liquid that is slightly more viscous than water. It is used as an oxidizer, bleaching agent, and antiseptic, usually as a dilute solution (3% ...
(a near-universal
toxin
A toxin is a naturally occurring organic poison produced by metabolic activities of living cells or organisms. Toxins occur especially as a protein or conjugated protein. The term toxin was first used by organic chemist Ludwig Brieger (1849– ...
) is not recommended for this task as it increases inflammation and impedes healing. Dressings with
cadexomer iodine
Cadexomer iodine is an iodophor that is produced by the reaction of dextrin with epichlorhydrin coupled with ion-exchange groups and iodine. It is a water-soluble modified starch polymer containing 0.9% iodine, calculated on a weight-weight basis, ...
, silver, or honey have been shown to penetrate bacterial biofilms. Systemic
antibiotics
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention o ...
are not recommended in treating local infection in a pressure ulcer, as it can lead to bacterial resistance. They are only recommended if there is evidence of advancing
cellulitis
Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...
,
bony infection, or
bacteria in the blood.
Diagnosis
Classification
The definitions of the pressure ulcer stages are revised periodically by the
National Pressure Injury Advisory Panel (NPUAP) in the United States and the European Pressure Ulcer Advisory Panel (EPUAP) in Europe. 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.
Briefly, they are as follows:
* Stage I: 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 II: Partial thickness loss of
dermis
The dermis or corium is a layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided i ...
presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns,
perineal dermatitis, maceration or excoriation.
* Stage III: Full thickness tissue loss.
Subcutaneous fat
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and mac ...
may be visible but bone, tendon or muscle are not exposed.
Slough
Slough () is a town and unparished area in the unitary authority of the same name in Berkshire, England, bordering west London. It lies in the Thames Valley, west of central London and north-east of Reading, at the intersection of the M4 ...
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
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and macr ...
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 IV: Full thickness tissue loss with exposed
bone
A bone is a Stiffness, rigid Organ (biology), organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red blood cell, red and white blood cells, store minerals, provid ...
,
tendon
A tendon or sinew is a tough, high-tensile-strength band of dense fibrous connective tissue that connects muscle to bone. It is able to transmit the mechanical forces of muscle contraction to the skeletal system without sacrificing its ability ...
or
muscle
Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...
. Slough or
eschar
An eschar (; Greek: ''ἐσχάρᾱ'', ''eskhara''; Latin: ''eschara'') is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, ...
may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage 4 pressure ulcer varies by anatomical location. The
bridge of the nose, ear,
occiput
The occipital bone () is a cranial dermal bone and the main bone of the occiput (back and lower part of the skull). It is trapezoidal in shape and curved on itself like a shallow dish. The occipital bone overlies the occipital lobes of the cereb ...
and
malleolus
A malleolus is the bony prominence on each side of the human ankle.
Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promine ...
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
A fascia (; plural fasciae or fascias; adjective fascial; from Latin: "band") is a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches to, stabilizes, encloses, and separates muscles and other internal organs. ...
, tendon or
joint capsule
In anatomy, a joint capsule or articular capsule is an envelope surrounding a synovial joint.osteomyelitis
Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...
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
Cartilage is a resilient and smooth type of connective tissue. In tetrapods, it covers and protects the ends of long bones at the joints as articular cartilage, and is a structural component of many body parts including the rib cage, the neck an ...
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
An eschar (; Greek: ''ἐσχάρᾱ'', ''eskhara''; Latin: ''eschara'') is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, ...
(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.
* Suspected deep tissue injury: A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. A deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
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.
Ischemic fasciitis
Ischemic fasciitis
Ischemic fasciities (IF), also termed atypical decubital fibroplasia or decubital ischemic fasciitis, is a rare pseudosarcomatous (i.e. easily mistaken for a sarcoma) tumor. It was first described by E. A. Montgomery et al. in 1992. This tumor typ ...
(IF) is a benign tumor in the class of
fibroblastic and myofibroblastic tumors
Fibroblastic and myofibroblastic tumors (FMTs) develop from the mesenchymal stem cells which differentiate into fibroblasts (the most common cell type in connective tissue) and/or the myocytes/myoblasts that differentiate into muscle cells. FMTs ...
that, like pressure ulcers, may develop in elderly, bed-ridden individuals.
These tumors commonly form in the
subcutaneous tissue
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and macr ...
s (i.e. lower most tissue layer of the skin) that overlie bony protuberances such as those in or around the hip, shoulder,
greater trochanter
The greater trochanter of the femur is a large, irregular, quadrilateral eminence and a part of the skeletal system.
It is directed lateral and medially and slightly posterior. In the adult it is about 2–4 cm lower than the femoral head.Stan ...
of the
femur
The femur (; ), or thigh bone, is the proximal bone of the hindlimb in tetrapod vertebrates. The head of the femur articulates with the acetabulum in the pelvic bone forming the hip joint, while the distal part of the femur articulates with ...
,
iliac crest
The crest of the ilium (or iliac crest) is the superior border of the wing of ilium and the superiolateral margin of the greater pelvis.
Structure
The iliac crest stretches posteriorly from the anterior superior iliac spine (ASIS) to the posterior ...
,
lumbar
In tetrapod anatomy, lumbar is an adjective that means ''of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum.''
The lumbar region is sometimes referred to as the lower spine, or as an area of the back i ...
region, or
scapular region.
IF tumors differ from pressure ulcers in that they typically do not have extensive ulcerations of the skin and on
histopathological
Histopathology (compound of three Greek words: ''histos'' "tissue", πάθος ''pathos'' "suffering", and -λογία ''-logia'' "study of") refers to the microscopic examination of tissue in order to study the manifestations of disease. Spec ...
microscopic analysis lack evidence of
acute inflammation
Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...
as determined by the presence of various types of
white blood cells
White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from mult ...
.
These tumors are commonly treated by surgical removal.
Prevention
In the United Kingdom, the
Royal College of Nursing
The Royal College of Nursing (RCN) is a registered trade union in the United Kingdom for those in the profession of nursing. It was founded in 1916, receiving its royal charter in 1928. Queen Elizabeth II was the patron until her death in 2022. ...
has published guidelines in ''Pressure Ulcer Risk Assessment and Prevention'' that call for identifying people at risk and taking preventive action; the UK National Standards for Care Homes to do so as well.
[Pressure Relief and Wound Care](_blank)
Independent Living (UK) Recent 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.
Internationally, the NPIAP, EPUAP and Pan Pacific Pressure Injury Alliance, together with wound organizations from 15 countries around the world, published updated the international evidence-based clinical practice guideline in 2019.
The 2019 guideline was developed by an international team of over 180 clinical specialists and updates the 2009 EPUAP/NPUAP clinical guideline and the 2014 NPUAP/EPUAP/PPPIA clinical guideline. The guideline includes recommendations on strategies to treat pressure ulcers, including 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
Functional electrical stimulation (FES) is a technique that uses low-energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system. More specifically, FES can ...
).
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.
Also, the benefit of using systemic or topical antibiotics in the management of pressure ulcer is still unclear.
It is important to understand that before turning and repositioning occur, a risk assessment tool is used to determine if the patient will need it. Some of the most common risk assessment tools are the Braden Scale, Norton, or Waterlow tools. The type of risk assessment tool that is used, will depend on which hospital the patient is admitted to and the location. After the risk assessment tool is used, a plan will be developed for the patient individually to prevent Hospital- Acquired Pressure Injuries. This plan will consist of different turning and repositioning strategies. These risk assessment tools provide the nursing staff with a baseline for each patient regarding their individual risk for acquiring a pressure injury. Factors that contribute to these risk assessment tools are moisture, activity, and mobility. These factors are considered and scored using the scale being used, whether it be the Braden, Norton, or Waterlow scale. The numbers are then added up and based on that final number, a score will be given and appropriate measures will be taken to ensure that the patient is being properly repositioned. Unfortunately, this is not always completed in hospitals like it should be.
The most important care for a person at risk for pressure ulcers and those with bedsores is the redistribution of pressure so that no pressure is applied to the pressure ulcer.
In the 1940s
Ludwig Guttmann
Sir Ludwig Guttmann (3 July 1899 – 18 March 1980) was a German-British neurologist who established the Stoke Mandeville Games, the sporting event for people with disabilities (PWD) that evolved in England into the Paralympic Games. A Jewis ...
introduced a program of turning
paraplegics
Paraplegia, or paraparesis, is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek ()
"half-stricken". It is usually caused by spinal cord injury or a congenital condition that affects the neural ...
every two hours thus allowing bedsores to heal. Previously such individuals had a two-year
life-expectancy
Life expectancy is a statistical measure of the average time an organism is expected to live, based on the year of its birth, current age, and other demographic factors like sex. The most commonly used measure is life expectancy at birth ...
, normally succumbing to blood and skin infections. Guttmann had learned the technique from the work of Boston physician Donald Munro.
There is lack of evidence on prevention of pressure ulcer whether the patient is put in 30 degrees position or at the standard 90 degrees position.
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.
Support surfaces
A 2015
Cochrane systematic review
A systematic review is a Literature review, scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from publ ...
found that people who lay on high specification or high density foam mattresses were 60% less likely to develop new pressure ulcers compared to regular foam mattresses. Sheepskin overlays on top of mattresses were also found to prevent new pressure ulcer formation. There is unclear research on the effectiveness of alternating pressure mattresses. Pressure-redistributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. There are several important terms used to describe how these support surfaces work. These terms were standardized through the Support Surface Standards Initiative of the NPUAP. 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. 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. For individuals with paralysis, pressure shifting on a regular basis and using a
wheelchair cushion Wheelchair cushions are cushions specifically designed to provide comfort and protection against injury for wheelchair users. They also aid in properly positioning the user in the correct posture.
Wheelchair users are at great risk for pressure sor ...
featuring pressure relief components can help prevent pressure wounds.
A 2022
Cochrane systematic review
A systematic review is a Literature review, scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from publ ...
aimed to find out how effective pressure redistributing static chairs (as opposed to wheelchairs) are for preventing pressure ulcers. 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. The authors did not find any
randomised controlled trials
A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical t ...
that were eligible for inclusion. More research is needed to establish how effective pressure redistributing static chairs are for preventing pressure ulcers.
Controlling the heat and moisture levels of the skin surface, known as skin microclimate management, also plays a significant role in the prevention and control of pressure ulcers.
Nutrition
In addition, adequate intake of protein and calories is important.
Vitamin C
Vitamin C (also known as ascorbic acid and ascorbate) is a water-soluble vitamin found in citrus and other fruits and vegetables, also sold as a dietary supplement and as a topical 'serum' ingredient to treat melasma (dark pigment spots) an ...
has been shown to reduce the risk of pressure ulcers. People with higher intakes of vitamin C have a lower frequency of bed sores in those who are bedridden than those with lower intakes. Maintaining proper nutrition in newborns is also important in preventing pressure ulcers. If unable to maintain proper nutrition through protein and calorie intake, it is advised to use supplements to support the proper nutrition levels. 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.
Organisational changes
There is some suggestion that organisational changes may reduce incidence of pressure ulcers.
Cochrane systematic review
A systematic review is a Literature review, scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from publ ...
s on organisation of health services, risk assessment tools, wound care teams, and education have concluded that evidence is uncertain as to the benefit of these organisational changes. This is largely due to the lack of high-quality research in these areas.
Other prevention therapies
A
Cochrane systematic review
A systematic review is a Literature review, scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from publ ...
found use of creams containing fatty acids may be more effective in reducing incidence of pressure ulcers compared to creams without fatty acids.
Silicone dressings may also reduce pressure ulcer incidence.
There is no evidence that massage reduces pressure ulcer incidence.
Treatment
Internationally, the NPIAP, EPUAP and Pan Pacific Pressure Injury Alliance, together with wound organizations from 15 countries around the world published updated their international evidence-based clinical practice guideline in 2019.
The 2019 guideline was developed by an international team of over 180 clinical specialists and updates the 2009 EPUAP/NPUAP clinical guideline and the 2014 NPUAP/EPUAP/PPPIA clinical guideline.
The guideline includes recommendations on strategies to treat pressure ulcers, including 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
Functional electrical stimulation (FES) is a technique that uses low-energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system. More specifically, FES can ...
).
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.
A 2020
Cochrane systematic review
A systematic review is a Literature review, scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from publ ...
of
randomized controlled trial
A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical te ...
s concluded that more research is needed to determine whether or not electrical stimulation is an effective treatment for pressure ulcers. In addition, the benefit of using systemic or topical antibiotics in the management of pressure ulcer is still unclear.
Debridement
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.
# Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes and
white blood cells
White blood cells, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. All white blood cells are produced and derived from mult ...
. It is a slow process, but mostly painless, and is most effective in individuals with a properly functioning immune system.
# Biological debridement, or
maggot debridement therapy
Maggot therapy (also known as larval therapy) is a type of biotherapy involving the introduction of live, disinfected maggots (fly larvae) into non-healing skin and soft-tissue wounds of a human or other animal for the purpose of cleaning out th ...
, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria. Although this fell out of favor for many years, in January 2004, the
FDA
The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...
approved maggots as a live medical device.
# Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue.
# Mechanical debridement, is the use of debriding dressings, whirlpool or ultrasound for slough in a stable wound.
# Surgical debridement, or sharp debridement, is the fastest method, as it allows a surgeon to quickly remove dead tissue.
Dressings
A 2017 Cochrane review found that it was unclear whether one topical agent or dressing was better than another for treating pressure ulcers. Protease-modulating dressings, foam dressings or collagenase ointment may be better at healing than gauze. 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. However, there is no international consensus on the selection of the dressings for pressure ulcers. Cochrane reviews summarise evidence on alginate dressings, foam dressings, and hydrogel dressings. Due to a lack of robust evidence, the benefits of these dressings over other treatments is unclear.
Some guidelines for
dressing are:
Other treatments
Other treatments include anabolic steroids, negative pressure wound therapy, phototherapy, support surfaces, reconstructive surgery, ultrasound, topical phenytoin and pressure relieving devices. There is little or no evidence to support or refute the benefits of most of these treatments compared to each other and placebo. When selecting treatments, consideration should be given to patients' quality of life as well as the interventions' ease of use, reliability, and cost.
Epidemiology
Pressure ulcers resulted in 29,000 deaths worldwide in 2013 up from 14,000 deaths in 1990.
[
Each year, more than 2.5 million people in the United States develop pressure ulcers. In acute care settings in the United States, the incidence of bedsores is 0.4% to 38%; within long-term care it is 2.2% to 23.9%, and in home care, it is 0% to 17%. Similarly, there is wide variation in ]prevalence
In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
: 10% to 18% in acute care, 2.3% to 28% in long-term care, and 0% to 29% in home care. There is a much higher rate of bedsores in intensive care
Intensive care medicine, also called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. It includes pro ...
units because of immunocompromised
Immunodeficiency, also known as immunocompromisation, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that a ...
individuals, with 8% to 40% of those in the ICU developing bedsores. However, pressure ulcer prevalence is highly dependent on the methodology used to collect the data. Using the European Pressure Ulcer Advisory Panel (EPUAP) methodology there are similar figures for pressure ulcers in acutely sick people in the hospital. There are differences across countries, but using this methodology, pressure ulcer prevalence in Europe was consistently high, from 8.3% (Italy) to 22.9% (Sweden). A recent study in Jordan also showed a figure in this range. Some research shows differences in pressure-ulcer detection among white and black residents in nursing homes.
See also
* Perfusion
Perfusion is the passage of fluid through the circulatory system or lymphatic system to an organ or a tissue, usually referring to the delivery of blood to a capillary bed in tissue. Perfusion is measured as the rate at which blood is deliver ...
—systemic biomechanics of blood delivery
References
Nathaniel Avilla, John Soto, Toni Tweedy, The Cochrane Database of Systematic Review
diariodelyaqui
Further reading
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External links
*
{{Authority control
Necrosis
Skin conditions resulting from physical factors