Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians

Pressure ulcers affect 3 million adults in the United States across health care settings. They have a major impact on health status, quality of life, and health care costs. Treatment of pressure ulcers is critical to promote healing and minimize the risk for complications. Treatment interventions include management of conditions that give rise to pressure ulcers (support surfaces and nutritional support), protection and promotion of wound healing (wound dressings; topical applications; and various adjunctive therapies that are used in addition to standard pressure ulcer care, such as vacuum-assisted closure, ultrasound therapy, electrical stimulation, and hyperbaric oxygen therapy), and surgical repair of the wound (1) (Table 1). Treatment of pressure ulcers often requires a multidisciplinary approach involving nurses, physicians, and other members of a care team. Table 1. Selected Pressure Ulcer Treatment Interventions The purpose of this American College of Physicians (ACP) guideline is to present the available evidence on the comparative effectiveness of treatments for pressure ulcers. The target audience for this guideline includes all clinicians, including physicians, nurses, dietitians, and physical therapists. The target patient population comprises adults with pressure ulcers. For recommendations on the risk assessment and prevention of pressure ulcers, please refer to the accompanying ACP guideline (2). Methods This guideline is based on a systematic evidence review (3), an updated evidence review (Supplement), and an evidence report sponsored by the Agency for Healthcare Research and Quality (AHRQ) (1) that addressed the following key questions: Supplement. Pressure Ulcer Treatment Strategies: Update to a Comparative Effectiveness Review 1. In adults with pressure ulcers, what is the comparative effectiveness of treatment strategies for improved health outcomes, including but not limited to complete wound healing, healing time, reduced wound surface area, pain, and prevention of serious complications of infection? Does the comparative effectiveness of treatment strategies differ on the basis of features (anatomical site or severity) of the pressure ulcers, patient characteristics, and health care settings? 2. What are the harms of treatments for pressure ulcers? Do the harms differ on the basis of features (anatomical site or severity) of the pressure ulcers, patient characteristics, and health care settings? We searched MEDLINE, EMBASE, CINAHL, EBM Reviews, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and the Health Technology Assessment database through February 2014 for studies in English. The primary outcomes of interest for this guideline include complete wound healing and wound size (surface area, volume, and depth) reduction. Additional outcomes include pain, prevention of sepsis, prevention of osteomyelitis, recurrence rate, and harms of treatment (including but not limited to pain, dermatologic complications, bleeding, and infection). Although most studies reported statistical significance of various outcomes, the guideline panel assessed clinically significant changes when evaluating the evidence. Further details about the methods and inclusion and exclusion criteria applied in the evidence review are available in the full AHRQ report (1) and the Supplement. This guideline rates the quality of evidence and strength of recommendations by using ACP's guideline grading system (Table 2). Details of the ACP guideline development process can be found in ACP's methods paper (4). Table 2. The American College of Physicians' Guideline Grading System Benefits and Comparative Effectiveness of Pressure Ulcer Treatment Strategies Most studies reported on only 1 outcome each (such as reduction of pressure ulcer size, improved wound healing, or rate of wound healing). Complete wound healing was reported in few studies; intermediate outcomes, such as reduction of wound size and rate of wound healing, were used to assess efficacy of the interventions. Some improvements were seen only in patients with large ulcers (>7 cm). Table 1 provides descriptions of the various treatment strategies, and Table 3 summarizes the evidence. Moderate-quality evidence showed that air-fluidized beds reduced pressure ulcer size compared with other surfaces (610), but pressure ulcer outcomes did not differ in comparisons of other support surfaces (low- to moderate-quality evidence) (1114, 2125). Moderate-quality evidence showed that protein-containing supplements improved wound healing (2740), although vitamin C supplementation did not (low-quality evidence) (26). Low-quality evidence showed that hydrocolloid dressings reduced ulcer size compared with gauze dressings (4251) and that platelet-derived growth factor (PDGF) improved wound healing (6973). Findings were mixed or did not differ for hydrocolloid compared with foam dressings (moderate-quality evidence) (5259), radiant heat (moderate-quality evidence) (6063), topical collagen (low-quality evidence) (42, 6668), and oxandrolone (41). Low-quality evidence showed that dextranomer paste was inferior to other wound dressings for reducing ulcer area (64, 65). Moderate-quality evidence showed that electrical stimulation accelerated wound healing as an adjunctive therapy (7483), and low-quality evidence showed no difference or mixed findings for the other adjunctive therapies assessed, including electromagnetic therapy (8487), therapeutic ultrasound (8890), negative-pressure wound therapy (9193), light therapy (9496), and laser therapy (100103). Table 3. Evidence for Pressure Ulcer Treatment Strategies Effectiveness of Pressure Ulcer Treatment Strategies Based on Pressure Ulcer Features, Patient Characteristics, and Health Care Settings Low-quality evidence from 3 fair-quality retrospective studies showed that patients with sacral pressure ulcers had a lower recurrence rate after surgery than those with ischial pressure ulcers (104106). Low-quality evidence from 1 fair-quality study showed that patients with spinal cord injury had a higher rate of recurrent pressure ulcers after surgical flap closure than other patients with pressure ulcers (104). Low-quality evidence from 1 good-quality and 3 fair-quality studies showed that electrical stimulation was similarly effective in patients with spinal cord injuries compared with other patients (74, 78, 80, 81). Low-quality evidence from 1 good-quality and 8 fair-quality studies showed that electrical stimulation produced similar results in a hospital and a rehabilitation center (7483). Harms of Pressure Ulcer Treatment Strategies Reporting of harms was sparse, and comparison among trials was difficult because of heterogeneity of treatments or populations. Support Surfaces Evidence was insufficient to conclude about harms for various support surfaces because few studies reported adverse events and those that reported them mostly found no statistically significant difference compared with controls. Nutrition Evidence was insufficient to conclude about harms for nutritional supplementation because adverse event reporting was poor for these studies. Medications More patients had elevated liver enzyme levels (32.4% vs. 2.9%; P<0.001) with oxandrolone than with placebo, but there was no difference in withdrawals due to adverse events (19% vs. 18%) (41). Local Wound Applications Skin irritation, inflammation, and tissue damage and maceration were the most commonly reported harms for various dressings and topical therapies (moderate-quality evidence). Evidence was insufficient to determine whether specific dressings or topical therapies resulted in less harm than others. Evidence was also insufficient to conclude about harms for biological agents because few harms were reported and the studies lacked precision. Surgery The most commonly reported harm from surgery was dehiscence. Reoperation due to recurrence or flap (tissue placed over the open wound) failure ranged from 12% to 24% among patients treated with surgery (low-quality evidence) (105, 107). Low-quality evidence from 1 intervention series showed a 21% complication rate for all skin flap surgeries and showed that tensor fascia lata flaps were associated with higher complication rates (49%), whereas rotation flaps were associated with the lowest complication rates (12%) compared with other surgical flap procedures (108). Adjunctive Therapies The most common adverse effect reported with electrical stimulation was skin irritation (low-quality evidence) (75, 79, 81). No substantial adverse effects were reported for light therapy (94, 95, 97, 98) or laser therapy (100103) (low-quality evidence). Harms of Pressure Ulcer Treatments Based on Pressure Ulcer Features, Patient Characteristics, and Health Care Settings Dehiscence was more common if bone was removed during the surgery (low-quality evidence) (105), and patients with ischial ulcers had higher complication rates than those with sacral or trochanteric ulcers (low-quality evidence) (107, 109). Low-quality evidence showed that frail elderly patients had more adverse events associated with electrical stimulation than younger patients (75, 79, 81). Summary Treatment of pressure ulcers involves multiple methods intended to alleviate the conditions contributing to ulcer development (support surfaces, repositioning, and nutritional support), protection of the wound from contamination and creation of a clean wound environment, promotion of tissue healing (local wound applications, debridement, and wound cleansing), adjunctive therapies, and consideration for surgical repair. Evidence showed that many interventions were similar to controls for alleviation of pressure ulcers. Air-fluidized beds were superior to other support surfaces (primarily standard hospital beds) for reducing pressure ulcer size. Alternating-air beds and lowair-loss mattres