Pressure on skin overlying bony prominences (e.g., spine including sacrum, scapulae, elbows, greater trochanters, heels, and ankles) can result in decubitus ulcers (69-75).
Decubiti occur in patients in nursing homes and hospitals or at home (73,76). Prevalence of ulcers in these patients was about 11% in one series (73). One prospective postmortem study showed a similar frequency (72). The frequency of decubitus ulcers varies from 0.1% in the community to 30% in spinal cord rehabilitation patients (73).
Any individual who is confined to bed can develop a decubitus ulcer. Poor nutrition, vascular insufficiency (e.g., diabetes mellitus), accumulation of urine and feces due to incontinence, and friction arising from the actions of caregivers (e.g., repositioning patient on the bed) are contributing factors (69,71-75,77). Rubbing of the skin likely removes an already devitalized epidermis (78). The area of pressure first shows erythema (stage 1), then proceeds to a blister or superficial ulcer (stage 2), full thickness cutaneous necrosis with extension into the subcutaneum and fascia (stage 3), and eventual involvement of underlying muscle and supporting structures (bone, tendon, joint capsule; stage 4 [69,71,73-75]).
Deep decubitus ulcers run the risk of sepsis secondary to cellulitis and osteomyelitis (71-74,76,79-81). Microscopic assessment can determine whether soft tissue and bony inflammation are present; however, clinical signs of sepsis and microbiological studies—i.e., a positive blood culture—support the role of the decubitus ulcers in the cause of death (70,72,74,75,78,80,81). Bacterial contaminants of the wound site are common (69,75). Bacteremia is aerobic (e.g., Staphylococcus aureus) or anaerobic (e.g., bacteroides ). Polymicrobial bacteremia does not necessarily indicate contamination. Other infectious foci must be excluded (80).
Decubitus ulcers in hospitalized patients have been associated with an increased mortality risk (73,75,76,79,82). Decubiti, irrespective of the stage, are markers of debilitation and indicate that multiple factors related to terminal illness led to the death of the patient (79,82). The development of advanced-stage ulcers raises concern about the
individual's care (Fig. 25; refs. 71, 72, 74, 76, 80, 83, and 84). Animal studies have shown that muscle necrosis develops after sustained pressure lasting 1 to 2 h (74,75). Frequent repositioning in a busy hospital setting is a challenge. There may be no intervention strategy that completely reduces the incidence of decubitus ulcers (77).
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