Pressure ulcer

Pressure ulcer
Other names	Decubitus (plural: decubitūs), or decubitous ulcers, pressure injuries, pressure sores, bedsores
Stage IV decubitus displaying the tuberosity of the ischium protruding through the tissue, and possible onset of osteomyelitis.
Specialty	Plastic surgery
Complications	infection

Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction. The most common sites are the skin overlying the sacrum, coccyx, heels, and hips, though other sites can be affected, such as the elbows, knees, ankles, back of shoulders, or the back of the cranium.

Pressure ulcers occur due to pressure applied to soft tissue resulting in completely or partially obstructed blood flow to the soft tissue. Shear is also a cause, as it can pull on blood vessels that feed the skin. Pressure ulcers most commonly develop in individuals who are not moving about, such as those who are on chronic bedrest or consistently use a wheelchair. It is widely believed that other factors can influence the tolerance of skin for pressure and shear, thereby increasing the risk of pressure ulcer development. These factors are protein-calorie malnutrition, microclimate (skin wetness caused by sweating or incontinence), diseases that reduce blood flow to the skin, such as arteriosclerosis, or diseases that reduce the sensation in the skin, such as paralysis or neuropathy. The healing of pressure ulcers may be slowed by the age of the person, medical conditions (such as arteriosclerosis, diabetes or infection), smoking or medications such as anti-inflammatory drugs.

Although often prevented and treatable if detected early, pressure ulcers can be very difficult to prevent in critically ill people, frail elders, and individuals with impaired mobility such as wheelchair users (especially where spinal injury is involved). Primary prevention is to redistribute pressure by regularly turning the person. The benefit of turning to avoid further sores is well documented since at least the 19th century.^[1] In addition to turning and re-positioning the person in the bed or wheelchair, eating a balanced diet with adequate protein^[2] and keeping the skin free from exposure to urine and stool is important.^[3]

The rate of pressure ulcers in hospital settings is high; the prevalence in European hospitals ranges from 8.3% to 23%, and the prevalence was 26% in Canadian healthcare settings from 1990 to 2003.^[4] In 2013, there were 29,000 documented deaths from pressure ulcers globally, up from 14,000 deaths in 1990.^[5]

The United States has tracked rates of pressure injury since the early 2000s. Whittington and Briones reported nationwide rates of pressure injuries in hospitals of 6% to 8%.^[6] By the early 2010s, Lyder and colleagues had research the rate of pressure injury to drop to about 4.5% across the Medicare population, following the introduction of the International Guideline for pressure injury prevention.^[7] Padula and colleagues have witnessed a +29% uptick in pressure injury rates in recent years associated with the rollout of penalizing Medicare policies.^[8]