Surgical assessment is essential in patients with pressure sores
I congratulate the BMJ in highlighting this very important problem.
The formation of pressure sores, either in the sacrum or the leg, is often
multi-factorial (1); and management plan goes far beyond good nursing care
and provision of alternating pressure mattresses. As such, it needs to be
managed in a multi-disciplinary team.
Physicians may be unaware of the importance of surgery in the
management of pressure sores. Referral to surgeons of different
specialties is often delayed. General surgeons can debride devitalised
tissues, and in selective cases, provide a temporary defunctioning
colostomy in incontinent patients with extensive sacral sores. Vascular
surgeons can improve the blood supply in order to encourage healing, and
plastic surgical advice should be sought on the use of vacuum-assisted
closure (VAC) device and various grafts or flaps (2, 3).
In the case of foot or heal decubitus ulcers, clinical examination of
peripheral arterial system and measurement of the ankle-brachial pressure
index (ABPI) is of paramount importance. We in the vascular unit work
closely with other hospital physicians (e.g. care of elderly or stroke
team) looking after patients with decubitus ulcers. Patients with a
decreased ABPI should have an initial arterial duplex assessment, and to
proceed to angioplasty or arterial reconstructive surgery if appropriate.
Osteomyelitis of the underlying bone must be ruled out, as orthopaedic
debridement may be necessary.
Full thickness or extensive sacral pressure sores will fail to heal
if the patency of the internal iliac arteries is compromised, and such
lesions are often amenable to angioplasty or stenting. Once the blood
supply is restored or improved, repeated surgical debridement (often in
the operating theatre) will be necessary before the placement of the VAC
device. Once the ulcer bed is healthy, it will support the muscle or
musculocutaneous flaps by the plastic surgeons.
1. Vale L, Noble DW. Overlays or mattresses to prevent pressure
sores? BMJ 2006; 332(7555): 1401-1402.
2. Smith N. The benefits of VAC therapy in the management of pressure
Br J Nurs. 2005; 13(22): 1359-1365.
3. Pers M, Snorrason K, Nielsen IM. Primary results following
surgical treatment of pressure sores. Scand J Plast Reconstr Surg. 1986;
Competing interests: No competing interests