1. JOURNAL CLUB
Supervised By: Dr. Sarmad Hiwa Arif
Prepared By: Meeran Earfan

2. Annals of Surgery
Vol. 257, Number 4, April 2013
Review Article
Current Thoughts for the
Prevention & Treatment of
Pressure Ulcers
Using the Evidence to Determine Fact or Fiction
Steven M. Levine, MD, Sammy Sinno, MD, Jamie P. Levine, MD, and
Pierre B. Saadeh, MD

3. Introduction
Pressure ulcers are a significant cause of morbidity.
2-28% of nursing home residents experience pressure
ulcers.
These wounds result from sustained pressure against
the skin & cause a local inflammatory reaction,
potentially leading to bacterial contamination or
systemic disease.
The severity varies according to the amount & quality
of tissue involved.

4. Ulcer Grading Classification
Classification Description
Grade I Erythema with intact skin
Grade II Skin erosion, blistering, partial loss of epidermis, and/or dermis
Grade III Loss of all skin layers & damage to subcutaneous tissue possibly
down to fascia
Grade IV Damage to muscle, bone, or supportive structures (tendons or
joints)

5. Risk Factors & Associations
One study showed that, incontinence, smoking,
hypoalbominemia, alcoholism, & diabetes were all
associated with pressure ulcer formation.
Pressure & friction have both been shown
experimentally to increase susceptibility to decubitus
ulcer formation.

6. Methods
Electronic searches were performed using the
following databases: CENTRAL, Ovid MEDLINE (1950
to August 2011), Ovid EMBASE (1980 to August 2011),
Ovid CINAHL (1982 to August 2011), & Google Scholar.
Many key words were then searched in each of the
databases.
The search revealed several identified modalities for
treatment &/or prevention of pressure ulcers. They
then assessed each modality for the level of evidence
that exists in the most current literature.

7. Levels of Evidence
Level of Evidence Description
Level I Randomized controlled clinical trials, randomized
systematic reviews
Level II Cohort studies, outcomes research
Level III Systematic review of case-control studies
Level IV Case series, case-control studies & reviews
Level V Expert opinions, experimental studies, animal- based
research

8. Results:
Modalities for
Prevention & Treatment
of Pressure Sores

9. Wound Cleansers (Level II)
By removing dead tissue & foreign bodies from the
wound, wound cleansers prepare the wound bed for
dressing application.
Double-blinded randomized controlled trials have
demonstrated the efficacy of Saline Spray containing
aloe, Silver Chloride, & Decyl Glucoside in improving
ulcer healing when compared with Saline alone.

10. Repositioning (Level V)
Although repositioning is commonly used to prevent
pressure ulcer formation, to date, there are no
randomized controlled trials that support this
intervention.
Yet the evidence is insufficient to suggest optimal
protocols for the frequency of positioning or optimal
position for patients with pressure sores.
Nevertheless, repositioning is considered a practice
with good face value, as added pressure to an area of
vascular compromise will undoubtedly lead to a
decrease in capillary blood flow.

11. Negative Pressure Therapy (Level I)
Negative pressure devices are reducing wound edema,
decreasing the wound bioburden, & increasing local
blood supply. However, the literature is inconclusive as
to whether this therapy has an advantage for healing of
pressure ulcers.
2 randomized controlled studies examined this for
pressure ulcers. One showed a reduction in ulcer
volume using vaccum- assisted wound closure,
whereas another showed equivocal results when
compared with traditional dressings.

12. Debridement (Level III, IV)
Debridement options for pressure ulcers can include
biologic, autolytic, chemical, mechanical and enzymatic
debridement.
Biologic: larvae or maggots.
Autolytic: naturally occurring enzymes that dissolve
sloughed tissue.
Chemical: sodium hypochlorite (Dakin’s).
Mechanical: wet to dry dressing, wound cleansing, &
whirlpool debridement.
Enzymatic: collagenase, papain, or urea.
A recent Cochrane review demonstrated that there are no
randomized controlled trials to support any one methods
of debridement over another.

13. Enteral & Parenteral Feeding (Level II, III)
It is reasonable to conclude that nutritional optimization
has a beneficial effect on pressure sore healing.
A multicenter trial examining the effects of 2 daily oral
supplemental drinks showed this intervention to
significantly lower the incidence of pressure ulcers &
identified low serum albumin levels & lower limb fracture
as an independent risk factors.
A paired cohort study examined serum markers for
metabolism in patients with spinal cord injury with
pressure sores & noted that the surgical correction of sores
resolved the serologic abnormalities such as in Hb & ptn.

14. Vitamins & Minerals (Level I)
One double-blind randomized controlled trial of 88
patients with pressure sores showed a reduction in
pressure sore area on application with 500mg of Vit.C
twice daily for 4 weeks.
A multicenter study showed that application of 500mg
of Vit.C twice daily for 12 weeks improved healing
velocity.
A double-blind randomized controlled trialstudied the
administration 200mg of Zinc sulfate 3 times daily for
24 weeks, this intervention failed to show any
statistically significant effects in ulcer healing.

15. Specialized Mattresses (level I)
A recent Cochrane review identified 52 randomized
control trials & concluded that patients at high risk for
developing pressure ulcers should have specialized
mattresses as opposed to regular hospital mattresses.

16. Ultrasound Therapy (Level I)
Ultrasound therapy has been proposed to have a
therapeutic effect on wound healing.
The literature suggests, however, that ultrasound
therapy does not improve pressure sore healing.
No significant differences in healing were seen in 2
randomized controlled trials that compared
ultrasound therapy with sham ultrasound therapy.
Another study failed to show statistically significant
differences in healing between ultrasound/ultraviolet
treatment & standard of care.

17. Honey (Level II)
The mechanism of action of honey in wound healing
include antimicrobial activity, immunologic
modulation, & physiologic mediation.
One trial randomly assigned patient with pressure
ulcers to receive either honey or saline-soaked
dressings. This study found that the overall time to
healing in days was less in the honey-treated group.

18. Cellular Therapy(Level IV)
Apligraf is an FDA-approved, living, bilayered cell
therapy that has been shown to be efficacious in a case
study of patients with heel pressure ulcers.
In this study, 10 patients were treated with Apligraf &
pressure offloading. The patients in this study had
ulcers for an average of 161.3 days before using Apligraf
& subsequently achieved a mean time to complete
ulcer healing of 44 days with therapy.

19. Musculocutaneous & Fasciocutaneous Flap
Closure (Level III, IV, V)
A study of 30 patients showed excellent reconstructive
outcomes with tangentially split myocutaneous
gluteus perforator flaps for pressure sores
management without flap loss & few complications.
A recent review of the literature of all types of flaps
performed for ischial pressure sores found an overall
complication rate 0-80% & a recurrence rate from 0-
33.3%. Unfortunately, given the uniqueness of each
case including cause, age, & risk factors, it has been
impossible to determine a hierarchy for flap selection.

20. Miscellaneous Modalities (Level IV, V)
Sitting protocols postoperatively are of unclear
efficacy, as demonstrated in a study of hospice
patients.
Ostectomy was shown in one small study to be an
effective strategy to reduce the recurrence of pressure
sores.

21. Authors Protocol
Transfer to a specialized air mattress.
Optimization of nutrition, Vit. C 500mg twice daily.
Turning protocol every 2 hours (Despite no high level of
evidence to support its use).
Stage 1: Observation.
Stage 2: Wound cleansers in the form of saline spray that
contains aloe, silver chloride, or decyl glucoside.
Stage 3 & 4 almost always undergo sharp excisional
debridement, either at the bedside or in OT.
They prefer using fasciocutaneous flaps in ambulatory
patients to minimize potential morbidity.

22. Conclusions
Evidence-Based Summery of the Effectiveness of Various Modalities for the
Prevention & Treatment of Pressure Ulcers
Treatment Modality Level of Evidence Demonstrated Effectiveness?
Wound Cleanser II Yes
Repositioning V Best practice guidelines
Negative Pressure Therapy I No
Surgical Debridement III, IV Unclear which form of debridement is
best
Enteral & Parenteral Feeding II, III Yes
Vitamins & Minerals I Yes--- Ascorbic acid
No--- Zinc
Special Mattresses I Yes
Ultrasound Therapy I No
Honey II Yes
Flap closure III, IV, V Equivalence: depends on particular case