Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 55

CLINICAL PRACTICE GUIDELINE

causes abscess formation), however, large and
persistent seromas may require repeated
percutaneous needle drainage (Levi, 2007).
A hematoma may develop with uncontrolled
bleeding filling potential dead spaces similar to
seromas. Hematomas that occur immediately
after surgery can either be due to bleeding vessels
missed during final closure of incisions in the
operating room, or as the result of clot or
cauterized eschar being displaced from previously
controlled bleeding points due to episodes of
extreme hypertension that may result from
recovery from anesthesia or with autonomic
dysfunction from painful stimuli. Internal bleeding
may also result from disruption of tissue layers
and vasculature due to shear injury. The clinical
signs of active bleeding with hematoma formation
include persistent bleeding into surgical drains or
from the suture or staple line, and a balottable
fluid collection. This collection of blood creates a
very good culture medium and thus is prone to
secondary infection. Hematomas should be
evacuated in the operating room with control of
any active bleeding sites (Levi, 2007).
As with any surgical procedure, suppurative
wound infection is a potentially serious
complication after flap reconstruction of pressure
ulcers. Infection of the superficial skin structures
(cellulitis) presents as peri-incisional erythema
and disruption of the incision and is apparent
from physical exam. The incision should be
opened in order to achieve effective drainage of
the infection, and to rule out any deeper infection.
Infections of deeper structures can be insidious
with late presentation of purulent drainage from
the incision. This can be due to accumulation of
purulent material with the potential dead space
underneath the flap, forming a contained abscess
that will eventually seek spontaneous drainage.
The incision must be opened further to ensure
adequate drainage and to enable dressing changes
to be done. This can frequently be performed at
the bedside; however, in rare cases extensive
infection may require washout in the operating
room (Levi, 2007).

Pressure
Redistribution and
Support Surfaces

The effects of pressure on the soft tissue are
determined by three factors: the magnitude of the
pressure, the duration of the pressure, and the
ability of the skin and its supporting structures to
endure the pressure without adverse effects.
Preventive measures targeting the intensity of the

pressure include selecting an appropriate support
surface and facilitating a body posture that
minimizes areas of high pressures on the
supporting surfaces with or without appropriate
postural support. The duration of pressure is
addressed by turning, weight-shifting
effectiveness and frequency, and the use of an
active support surface, such as an alternating
pressure support surface, that can actively
redistribute pressure on the body surfaces
(Sprigle and Sonenblum, 2011).

Bed Positioning
21. Use bed positioning devices and techniques
that are compatible with the bed type and
the individual's health status.


Avoid positioning individuals directly on
pressure ulcers regardless of the pressure
ulcer anatomical location (trochanter,
ischium, sacrum, and heel) unless such
position is necessary for performance of
ADLs, such as eating or hygiene.



Use pillows, cushions, and positioning aids
to reduce pressure on existing pressure
ulcers or vulnerable skin areas by elevating
them away from the support surface.



Avoid closed cutouts or donut-type cushions.



Prevent contact between bony prominences.



Elevate the head of the bed no higher than
30 degrees unless medically necessary.



Reposition individuals in bed at least every
2 hours.

(Scientific evidence-II, V; Grade of recommendation-B;
Strength of panel opinion-Strong)

The use of a positioning device is an effective
means of raising the ulcer off the support surface.
A bridging technique may be used to support
bony prominences with pillows proximal and
distal to the prominence. Adequate pressure relief
with no support contact at the sacrum of the
supine individual was accomplished using this
technique by Bogie et al. (1992). Proper
placement of cushions behind the back and
between the legs will assist in pressure relief of
bony prominences that may contact each other or
the surface of the bed (Land, 1995; Lowthian,
1993). Positioning devices should also maintain
postural alignment and prevent postural deviation.
Avoid ring cushions (donuts) as they are more
likely to cause pressure ulcers than to prevent
them (Crewe, 1987). Pressure-relieving cutouts
should be open to the edge of the cushion to
allow blood flow to the surrounding tissue and

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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