Pressure sores. Epidemiology and current management concepts

Pressure sores remain common, with a prevalence of 5 to 9% and more than 70% occurring in patients over 70 years of age. They are often falsely ascribed to poor nursing care, but can more usefully be regarded as a potentially preventable complication of an acute immobility illness. Prevention involves identification of patients at risk, appropriate nursing care measures and the use of special equipment. Much of the special equipment is excessively complex and not validated by clinical trial work. The airwave system, polystyrene bead bed system and Vaperm mattress have been best studied and are effective. Management of the established sore involves treatment of the underlying medical condition(s), attention to hydration and nutrition, prevention of further tissue trauma and the use of special dressings and procedures which facilitate the inflammatory repair response. There is considerable doubt about the use of 'traditional' wound applications such as gauze or chlorinated lime and boric acid solution ('Eusol'). An extensive range of newer products is now available but these have not yet been subjected to controlled clinical trials. A useful starting point is to classify pressure sores into 4 clinical types depending on amount of tissue damage and depth of ulcer. The least severe sore (type 1) can be protected using polyurethane film dressings. Deeper ulcers (types 2 and 3) can be easily and quickly treated by hydrocolloid or alginate dressings which optimise the local wound environment, thus facilitating tissue repair. However, there may be no satisfactory dressing for sacral (near-anal) sores which are more difficult to treat than those at other body sites because of dressing detachment. Cavity ulcers (type 4) can be managed with silastic foam or hydrocolloid or alginate dressings. Debridement of necrotic material is best done manually by scalpel/scissors, although streptokinase/streptodornase (Varidase Topical) may also help if used correctly. Antiseptics have little part to play and ulcers are best cleaned with warm normal saline. Systemic antibiotics are indicated only when surrounding cellulitis is present, although metronidazole is useful for malodorous sores.