Management of Pressure Ulcers and Pressure-Related Injury

Pressure ulcers, or pressure-related injuries, result from localized injury to the skin and underlying tissues due to unrelieved pressure, usually over a bony prominence, resulting in ischemia, cell death, and tissue necrosis. Pressure injuries are increasing in incidence due to an aging population with increasing rates of obesity, diabetes, and cardiovascular disease. A rapidly expanding geriatric population with impaired mobility, diminished sensation, and poor nutrition—factors exacerbated by the end-stage effects of dementia, obesity, osteoarthritis, and diabetes as well as cardiovascular and cerebrovascular disease—have a greater propensity toward, and a higher prevalence of, pressure injury. Our aim in this paper is to determine through a review of the literature whether any new literature exists, indicating greater effectiveness in pressure ulcer prevention or treatment as compared to standard of care. We examined which studies of available support surfaces, new and currently utilized wound dressings or any other treatment modalities have provided evidence of any greater effectiveness than standard of care in the prevention of pressure injury and in promotion of pressure ulcer healing. Our objective is to provide healthcare providers with an assessment of the relative efficacy of the various interventions available to facilitate their decision-making in the healing of their patient’s pressure ulcers. Goals for pressure injury prevention or treatment, especially in the geriatric population, address repositioning for pressure redistribution and accurate diagnosis of wound etiology, including comorbidities in aging, cognition, care of aging skin, and patient or family goals in care (healing versus palliation). We performed a literature search of the Cochrane Database of Systematic Reviews, Ovid Medline, and PubMed for published studies, reviews, and meta-analyses using the keywords pressure ulcer, pressure injury, wound care, bedsore, decubitus ulcers, and support surfaces. We also examined the reference lists of included studies to identify additional trials, position statements, guidelines, and reviews. We limited our review to English language publications between January 2008 and November 2018. We identified 36 studies for review. Despite this relatively large number of studies, there remains a disturbing lack of good-quality evidence regarding the effectiveness of support surfaces or repositioning for pressure ulcer prevention or treatment, for any class of dressing or topical therapy for promotion of wound healing, or for nutritional supplementation to facilitate wound healing. These studies yielded little evidence to warrant an update to the current standard of care for pressure ulcer prevention or management. The prevention and management of pressure ulcers requires a varied approach including assessment of risk, institution of preventive measures, and interventions to promote wound healing. Several tools for pressure injury risk assessment have been developed; a comparative description of these scales is provided. Understanding comorbidities (e.g., cardiovascular disease, diabetes, and neurodegenerative disorders) as well as complicating issues common to the elderly population that can impact pressure injury treatment (e.g., malnutrition, polypharmacy, incontinence, frailty, and disability) helps tailor wound care to this population.