Decubitus ulcers: pathophysiology and primary prevention

Abstract

Background: Pressure sores are a serious complication of multimorbidity and lack of mobility. Decubitus ulcers have become rarer among bed-ridden patients because of the conscientious use of pressure-reducing measures and increased mobilization. Nonetheless, not all decubitus ulcers can be considered preventable or potentially curable, because poor circulation makes some patients more susceptible to them, and because cognitive impairment can make prophylactic measures difficult to apply.

Methods: A systematic literature search was performed in 2004 and 2005 in the setting of a health technology assessment, and a selective literature search was performed in 2009 for papers on the prevention of decubitus ulcers.

Results: Elderly, multimorbid patients with the immobility syndrome are at high risk for the development of decubitus ulcers, as are paraplegic patients. The most beneficial way to prevent decubitus ulcers, and to treat them once they are present, is to avoid excessive pressure by encouraging movement. At the same time, the risk factors that promote the development of decubitus ulcers should be minimized as far as possible.

Conclusions: Malnutrition, poor circulation (hypoperfusion), and underlying diseases that impair mobility should be recognized if present and then treated, and accompanying manifestations, such as pain, should be treated symptomatically. Over the patient's further course, the feasibility, implementation, and efficacy of ulcer-preventing measures should be repeatedly re-assessed and documented, so that any necessary changes can be made. Risk factors for the development of decubitus ulcers should be assessed at the time of the physician's first contact with an immobile patient, or as soon as the patient's condition deteriorates; this is a prerequisite for timely prevention. Once the risks have been assessed, therapeutic measures should be undertaken on the basis of the patient's individual risk profile, with an emphasis on active encouragement of movement and passive relief of pressure through frequent changes of position.

Figure 1

A grading scale for decubitus ulcers of increasing severity: the designation of grades 1 through 4 is based on the depth of ulceration and the structures that are affected (reprinted with the kind permission of the National Pressure Ulcer Advisory Panel, NPUAP)

Figure 2

A grade 2 decubitus ulcer with erythema that does not blanch with finger pressure, induration, and incipient blistering (reprinted with the kind permission of Dr. M. Michaelis, Albertinen-Haus, Hamburg).

Figure 3

The pathophysiology of decubitus ulcers: pressure damage and aggravating factors. The generation of a pressure sore: local ischemic damage because of externally applied pressure and concomitant risk factors

Figure 4

Decision flowchart for individualized planning of decubitus ulcer prevention (modified from Armstrong et al. 2008). Evidence-based recommendation grades are given according to the scheme of the Oxford Centre of Evidence-Based Medicine: Level A, good evidence; Level B, adequate evidence; Level C, small amount of evidence.