Editing Pressure injuries (section)

== Management ==

=== General: ===

** Pain control
*** Topical anaesthetics have limited evidence - probably don't use
*** Topical opioids have shown some small benefit in trials
*** Mostly will require systemic analgaesia
*** Reconsider wound management techniques if pain is bad
** Treat infection only in clinically infected wounds. Evaluate for osteomyelitis.
** Assess and improve nutrition
** Reposition every two hours. Use support surfaces to offload pressure from the area. Consider air-fluidised beds for patients that are difficult to position due to multiple pressure areas.
** Prevent contamination
*** Little evidence for IDC/rectal tube
*** Consider colostomy if site is prone to faecal contamination
** Daily monitoring with wound care nurse.

=== Wound care: ===

** General principles:
*** Debride necrotic tissue
*** Appropriate dressings or wound packing to promote healing
*** Wound coverage
** Specific regimens:
*** Stage 1: cover for protection
*** Stage 2: generally need little debridement. Require a dressing to maintain a moist wound environment.
*** Stage 3 and 4: require debridement of necrotic tissue and possibly treatment of infection. Following wound bed preparation, coverage may involve skin grafting or other tissue transfer procedures.
**** If the wound is small and relatively clean, can try to manage on the ward with debriding dressings such as Prontosan

=== Surgical ===

** Debridement
*** Debride all necrotic tissue, preferably in OT in most cases
*** Obtain tissue culture
*** Bone biopsy, if involved, for confirmation of OM
*** Meticulous haemostasis is necessary, because these wounds have a propensity to bleed
*** Use outside-to-inside approach, starting from skin
*** Usually apply a VAC - quite good evidence for it in this setting
** Diversion
*** Consider for patients with longstanding and deep sacral and ischial pressure injuries
*** Can end up being permanent
*** In selected patients, can improve healing times
** Reconstruction
*** Need a stable wound bed, free of infection, with optimised medical factors before considering
*** Padding of pressure points with full thickness, well-vascularised skin
*** Fasciocutaneous flaps are often used for closure