Pressure sore

ICD-11

EH90.Z

Synonyms

Pressure ulcer, decubitus.

Epidemiology

Prevalence: 10% of hospitalized patients, 5% of patients requiring nursing care at home.

Definition

Pressure-induced defect of skin and subcutis.

Aetiology & Pathogenesis

Ischeamia caused by prolonged pressure over bony prominences in patients who are unable to move. Two hours of ischaemia are sufficient to induce a pressure sore. Diabetes mellitus, post cerebral infarct reduced mobility, polyneuropathies, severe obesity and cachexia are risk factors.

Signs & Symptoms

Initial livid or bruise-like colour changes over the pressure points, reduced capillary refill. This stage is reversible. Later ulcers develop, involving skin, subcutis, muscles and often extending to the bones. Fetid odour.

Localisation

Typical sites: sacrum, trochanters, scapulae, heels, vertebral column, elbows, hands, back of head.

Classification

Stage I: Livid erythema (macule or patch), some capillary refill.

Stage II: Ulcer to dermis

Stage III: Ulcer with full thickness skin loss to subcutaneous fat

Stage IV: Ulcer with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone.

Laboratory & other workups

Imaging studies, possibly nutritional evaluation, exclusion of diabetes and polyneuropathy.

Dermatopathology

Biopsies of the ulcer margin and base should be taken after 8 to 12 weeks of ulcers without tendency to heal, primarily to rule out tumors. Biopsy should be taken especially before invasive measures.

Course

If pressure is not relieved, relentlessly progressive. Risk of cellulitis and sepsis.

Complications

Progression, superinfection with mixed bacterial flora, often with anaerobes, cellulitis, sepsis, osteomyelitis.

Diagnosis

Clinical findings, assessment of depth with probe. Debridement. Imaging studies. Assessment of risk factors.

Differential diagnosis

Neuropathic pressure ulcer, ulcerated tumours, chronic infections with fistula formation, artefacts and injuries.

Prevention & Therapy

Prevention is most important.

In stage I the tissue damage is reversible. Immediate institution of pressure-relieving measurements. Protection of damaged skin. In stage II superficial tissue damage has occurred. Debridement of necrotic tissue and standard moist wound therapy. Appropriate antibiotic coverage.

In stages III and IV the actual extent of the tissue damage is often underestimated. Extensive debridement, resection of the overhanging wound edges, vacuum-assisted wound therapy, standard moist wound therapy. Pressure sores in stage III and IV often require reconstructive surgery.

Special

Consider the potential impact of impaired nutritional status.

5.2.4 Pressure sore