Bedsores are localized injuries to the skin and underlying tissue that usually occur over a bony prominence as a result of pressure. These can also occur as a result of a combination of pressure and shear and/or friction in the areas with partial. Similarly, complete blood flow obstruction may cause bedsores.
There are various other names for this condition-
- Pressure ulcers
- Pressure injuries
- Decubitus ulcer
All these names are used interchangeably but recently it has been agreed upon that pressure injuries is the best describing term.
Pressure injuries affect the following sites
Above areas are more common but less commonly, pressure sores also affect
- Back of the occiput
Pathophysiology of Bedsores
The pressure causing ischemia and necrosis is the final step of developing pressure injuries.
Thus, the pressure injuries result from sustained prolonged pressure enough to impair blood flow to soft tissue.
This happens when this external pressure exceeds the arterial capillary pressure and venous capillary closing pressure. So there is a decrease in blood flow and return.
Though tissues can withstand capable withstanding enormous pressures for a small duration, prolonged pressure leads to ischemia and necrosis, which are often revealed as ulceration.
The starting even is the compression of the tissues against an external object such as a mattress, bed rail etc.
Shear forces and friction aggravate the effects of pressure.
Maceration due to sweat or incontinence may aggravate the matter further.
The muscle is the most susceptible tissue to pressure. Skin can withstand ischemia up to 12 hours though.
So when ulceration is visible at the skin level, significant underlying muscle damage would have occurred.
Reperfusion of the tissue [when the pressure is removed such as by turning to the other side] is further thought to worsen the injury though the exact mechanism is not understood. This ischemia-reperfusion is thought to be responsible for the enlargement of ulcers and/or responsible for becoming chronic.
Staging of Pressure Ulcers
- Stage I
- Difficult to detect stage
- Intact skin with non-blanchable redness of a localized area
- Usually over a bony prominence
- Blanching is difficult in dark skins, look for differences in skin color from the surroundings.
- The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
- Stage II
- The damage extends to the dermis
- A shallow open ulcer with a red-pink wound bed, without slough
- May present as blister too
- Stage III
- Full-thickness tissue loss, subcutaneous fat visible
- bone, tendon or muscle are not exposed.
- Slough may be present but does not obscure the depth of tissue loss
- Undermining and tunneling of the ulcer present
- Undermining results from the overhang of margins of ulcers
- Tunneling implies the formation of form passageways between the skin and various subcutaneous structures
- Depth varies by anatomical location
- Shallow in areas without subcutaneous tissue such as the nose, ear, occiput, and malleolus
- Deep in other areas with subcutaneous tissue
- Stage IV
- Full-thickness tissue loss with exposed bone, tendon or muscle.
- Slough or eschar may be present
- Undermining and tunneling present
- Depth varies with location as in stage III.
- Full-thickness tissue loss in which the base is covered by slough or eschar
- Can be staged only after slough/eschar removal
Causes of BedSores
Pressure on the part
When a patient is immobile for long periods, there could be a prolonged constant force of external devices like brace or wheelchair or of the bone at the bony prominences.
Shear can contribute to one of the major causes of skin breakdown when sitting [ when one glides over without actually lifting the skin from the surface.
It is also common during transfers, reaching, weight shifts or repositioning.
Moisture on the skin causes the skin to lose the dry outer layer and reduces the tolerance of the skin for pressure and shear.
People who are immobile are at the highest risk of developing bedsores.
Risk Factors for Bedsores
- Impaired mobility [often the most common factor]. For example, following patients are not able to turn or move unless assisted.
- Neural weakness
- Heavily sedated
- Unconscious or anesthetized
- Restrained persons
- Decubitus following a traumatic brain injury traumatic injury.
- Muscle atrophy/Cachexia
- Contractures or spasticity
- Failure/inability to feel pain
- Neural causes
- Under regional anesthesia/block
- Poor skin quality
- Presence of a discharging
- Poor nutritional status
Work up for Bedsores
- Low hemoglobin
- Raised WBC count
- Raised ESR
- Protein levels in blood
- Decreased if nutrition is poor
- Urine microscopic examination
- Urine Culture
- Blood culture if sepsis is suspected
- To look for osteomyelitis when suspected
- Tissue Biopsy
- To know deep infection
- To rule out underlying malignancy
- To look for presence of biofilm
Treatment of Bedsores
For stage 1 and 2 bedsores, nonoperative treatment is enough. However, for 3 and 4 stages surgery in one for or the other may be required.
Overall, the key factors for treatment are
- Medical care
- Control of offending factor-like fistula
- Reducing the pressure
- Frequent turning
- Soft supportive surfaces
- Wound care
- Control of infection
- Negative pressure wound therapy
Some of the experimental treatments are
- Hyperbaric oxygen therapy
- Growth factors
Different Treatment Options of Bedsores
For other treatments of pressure injuries to succeed, optimization of the patient comes first. Optimization includes managing the conditions that contribute to the formation. The issue is determined in every case and there could be more than one issue that needs to be tackled.
For example, where feasible drugs or surgical procedures should be used to control spasticity. Improvement of nutritional status can be addressed by proper diet, Vitamin and micronutrient deficiencies should be addressed.
Similarly, factors like incontinence should be addressed by proper care or surgical procedure if the situation allows.
The fistula can be surgically removed.
Removal of Pressure
Removal of pressure is very important and often therapeutic alone in stage I bedsores. [Stage II bedsores are quite amenable to dressings and pressure removal]
After it has been determined what is causing pressure, both general and specific measures should be initiated.
These measures are also preventive in nature, thus preventing the further development of bedsores.
These measures include
- Turning and repositioning the patient every two hours, sooner if the situation allows. remains the cornerstone of prevention and treatment through pressure relief.
- Lying on an angled bed to alleviate pressure on a particular part
- Specialized support surfaces for bedding and wheelchairs
- Can be dynamic or static [dynamic use of external energy like electricity to alternate pressure points]
- Can be pressure reducing or relieving
- Latter reduce the pressure below capillary pressure [which is one of the factors for development of bedsores]
- Various products are commercially available and use different materials
- Foam, Air, gel water
- Hard to say as of now if one is superior to others
Wound care is a multipronged approach and all of wound care is beyond the scope of this article. So we would just lightly touch the outline
Wound care, depending on the wound type can consist of more than one of the following
- Wound cleaning
- Regular simple dressings
- Gel dressings
- Collagen fillings
- Vaccum assisted closure or VAC
- Specialized dressings
- Wound debridement
- Flap surgeries for wound coverage
For those with Stage III or IV ulcers require once the necrotic tissue has been removed, a moisture retentive dressing or gel is used to facilitate healing. Advanced cases require flap surgery.
Prevention of Pressure Injuries
Following people are high risk groups for bedsores and preventing measures should be taken in them
- Elderly and immobile
- Chronically ill [for example stroke]
- Altered mental status
- Those with loss of sensation in a part
- Persons with decreased sensation or paralysis
Following are the preventive measures that are to be initiated
- Drug therapy for control of medical issues
- Skincare for improved skin quality
- Regular repositioning
- Cushion under prominences
- Educating about signs of Pressure injuries
- Regan MA, Teasell RW, Wolfe DL, Keast D, Mortenson WB, Aubut JA. A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury. Arch Phys Med Rehabil. 2009 Feb. 90(2):213-31. [Link]
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- Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD. Treatment of pressure ulcers: a clinical practice guideline from the American college of physicians. Ann Intern Med. 2015 Mar 3. 162(5):370-9.
- McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2015 Sep 3. CD001735.