I concur that without addressing or being able to address pressure , infection, and wound environment the goal changes from healing to maintaining.  All the modalities suggested are of value. For a Stage IV, if able to keep a good seal, the VAC is great, also using the irrigation component if an Inpatient really maximizes the VAC benefit..  Newer dressings that wick the moisture away from the wound bed , do not traumatize with removal, and facilitate clean environment will promote healing.  Like cars, all dressing have the basic tires and engines, the bells and whistles make the choice harder, don't be 'wowed' by the add-ons.  Patience also plays a factor , choose a course and then allow time and the body an opportunity to show a response. 

I'm afraid the question can't be answered apodeictically, because choosing a correct treatment is less about the classification of the wound itself than about its needs (and those of the patient) at this time and the aim of the treatment. A pressure ulcer category III or IV usually primarely needs surgery. Thus to prepare the wound for surgical closure should be the main task. Debridement and cleansing of the wound need other techniques than sustaining granulation or obtaining definitive wound closure. Would you mind to tell us more about the patient and his wound (age, general state, history of the pressure ulcer, localisation, size, stage, ...)?

Demetris, unfortunately, I have no any answer. Perhaps, the most rapid way is to look for some advices in Internet. Try, in any case.

Dear Xavier, I forgot to mention that we speak for the treatment after the surgery cleaning, actually we are a month after that cleaning. So, the question now is about choosing the proper kind of wound dressing. (Elder patient)

Dear Galina, I am searching in Internet and every company claims that its product is the best, so I am fully confused... Probably RG guys will enlighten me...

You are rather right, Demetris. I believe, our medic colleagues could help you.

Dear Demetris

The short answer is that ,IT DEPENDS:

Is the wound healable? Meaning can the cause of the pressure ulcer be corrected (bed surface corrected, nutritional status corrected, mobility correctable,sensation correctable - follow the Braden scale parameters and correct all of those) If it can be corrected the wound can heal. Then your priority is: Debridement, Infection control and Moisture balance.

If the Braden parameters cannot be corrected at all the wound will be non-healable despite all efforts to do so with dressings. Your priority is then to control infection to give the patient most advantage against the ulcer progressing and getting worse.

Most of the time it is something in between. Cause can be corrected but patient choice or system factors prevent correction. Then the priority is patient comfort (no smell, no pain, no exudate the bed full etc), infection control and protection of current status.

You have then addressed the cause and dressing choice will be according to those priorities. See the paper" Considerations in Wound Bed Preparation 2011)

Best wishes

Hiske

If the wound is surgically debrided and clear of infection, wouldn't a wound vac then be the next most appropriate modality to foster healing?

I concur that without addressing or being able to address pressure , infection, and wound environment the goal changes from healing to maintaining.  All the modalities suggested are of value. For a Stage IV, if able to keep a good seal, the VAC is great, also using the irrigation component if an Inpatient really maximizes the VAC benefit..  Newer dressings that wick the moisture away from the wound bed , do not traumatize with removal, and facilitate clean environment will promote healing.  Like cars, all dressing have the basic tires and engines, the bells and whistles make the choice harder, don't be 'wowed' by the add-ons.  Patience also plays a factor , choose a course and then allow time and the body an opportunity to show a response. 

Thank you dear Debbie, for your clear and helpful response.

The use of an occlusive dressing, such as Duoderm, is appropriate.  Assuming that the ulcer has been cleaned of debris and not irritated with betadine or Dakin's soultion, the deficit can be filled with the Duoderm granules.  The occlusive dressing acts as an autolytic debriding agent.

 A relatively new self-adaptive wound dressing may also be useful for the described pressure ulcer since Wolcott and Fischenich have shown it to be beneficial in aiding the healing of 122 pressure ulcers, 432 diabetic ulcers, 259 venous ulcers, 60 surgical wounds, and 241 chronic wounds, among others. Wolcott and Fischenich published some of their findings in the April 2014 issue of Todayswoundclinic (pg 1-3). Sometimes the dressings are changed once per week and sometimes twice per week.  The self-adaptive wound dressing is designed to adjust the moisture content in the micro areas of the wound bed dynamically, absorbs and sequesters any microorganisms, and causes little to no trauma during dressing changes. It also appears at least to support autolytic debridement. Sometimes a pressure dressing may be needed over the self-adaptive wound dressing. If interested, ten clinical case studies are available at the manufacturer’s website: http://www.enluxtrawoundcare.com/clinical.html  

Another strategy is to send photos to the tech representatives of several of the dressing manufacturers and ask them if their dressing would be suitable for the current stage of healing in your patient's ulcer. I'd also ask what benefits and when you should expect to see them.  

Dear Kathy, thank you for your detailed response. I think that the photo sending is a very good idea about specifying the exact case for each patient.

The best method to heal a bed sore (I presume) pressure ulcer in my experience is to dress it with old timer Edingburgh Solution.  The detail of this composition (hydrogen peroxide in a certain preparation) can be found in the Bailey's Textbook of Surgery.

Applied it wet (sterile dressing).   Cover the wet sterile dressing with dry 4x4 gauze.

Then change the dressing daily.  The wet dressing will dry up by the time you change ii. When you remove the gauze with sterile dressing kit, it will remove some of the necrotic material of the wound with it.  It it stuck too much, just put some of the wet Edingburgh solution on it to loosen it.  Then  Put a new wet Hydrogen peroxide solution(Edingburgh Solution)  gauze onto the ulcer for  the next day, and cover the wet gauze again with one or two layers of dry gauze.  The solution strength of Edinburgh Solution is usually not painful.  The advantage of this approach is that you do not need do any debridement.

Gradually you will see the whitish necrotic material disappeared.  And then the wound start looking red and pink with healthy granulation tissue now forming the ulcer bed.

 Skin gradually will grow along the edge and then the ulcer becomes smaller and smaller.  

As this healing is healing by second intention,  finally you see the whole wound healed.  (Provided that is not a radiation ulcer).  Be patient, depends how big is the wound, it may takes 2 months for it to heal.  The rate of healing is calculable  e.g. a 10 cm wound with a 1 mm/day will take about 100 days.

The good news is that you see the wound looks smaller each day after all the necrotic tissue were removed when you take away the necrotic tissue with the dry gauze.

The nurse loves me and you because as they see chronic pressure sore ulcer which had been there for 10 or more years become healed.

This works beautifully.  I learnt this while I was in medical school and got the experience perfected when I was doing my orthopedics.    And few years later when I was  at Waimano Home Honolulu where there are wards of  retarded mental children/adult with really bad bed sores some of them over 10 years.

I have cured all of them when I left my rotation.  The nurses were so amazed and grateful to me rotating through, to tackle a problem which they have never been able to heal for last 20 years.

The scientific basis can briefly explained.

1) Bacteria cannot develop resistance to antiseptic like hydrogen peroxide

particularly notorious germ like pseudomonas which will soon out smart most of the antibiotic cream in the market

2) It is very low cost

3) It is general not painful because of the chronic ulcer, destroying most nerve.

4) The cause of the chronicity is that the bacteria keep eating away the new skin trying to form and creep over the granulation, and then the nurse removes all new formed skin cell when they change the dressing.

Oh one final point,  when the wound is getting clean and healthy (red) without much necrotic tissue.  You do not need to change the gauze every day.  You keep the dressing on (so the skin now can grow back migrating to cover the wound).  Then you only change the dressing, when you see ozzing or blood soaking through the dry gauze.  Then you change it when you see the oozing soak through.  (because then the dressing has the risk of germ going through the barrier.   At the end for example the last few mm of healing, you can even leave the dressing on for 1 week or more, so that the creeping dermis will now finish the whole covering!   For the last few weeks, you may put an Sofratulle dressing on and let it healed for two weeks, so the final layer of epidermis can be formed.

From this valuable knowledge and experience,  I have confidence to heal very chronic skin ulcer (except radiation induced).

Good luck and God bless you !

If there were one best dressing, there would only be one on the market. There are many factors that go into decisions about treatment for a Stage III or IV pressure ulcer. First, the wound needs to be clean. We usually have these patients surgically debrided. Wounds with foul odor or pus may be packed with 1/4% Dakins solution moistened roller gauze and changed every 8 hours. We never use peroxide or Betadine solution for wounds like this, as there is plenty of evidence that they (as well as Dakins) inhibit the growth and migration of fibroblasts. If we use Dakins, we use it only to control odor and pus, and once the wound is clean, we switch to normal saline only (unless using a NPWT system, as below).  Wet-to-dry dressings should never be used, as they rip out granulation tissue along with the necrotic tissue. Packing should be wet-to-moist and changed often enough to 1) prevent it drying and 2) to maintain activity of the bleach component of Dakins (which evaporates out in about 8 hours).

Secondly, underlying osteomyelitis must be diagnosed and treated. For stage IV pressure ulcers with exposed bone, 90% will have osteomyelitis. We usually get a bone biopsy for culture at the same time as our surgical debridement, and consult with infectious disease service on appropriate antibiotiic management.

Once this therapy is well underway, and infection markers (CRP, sed rate, and WBC) are on a downward trend, we often use a negative pressure wound therapy system (such as the KCI VAC), usually using silver sponge if the wound is known to be infected (not just colonized). We will sometimes combine this with a wound matrix dressing such as MatriStem or EpiFix. We used to use Oasis, but prefer the MatriStem. This would be for conservative management, where the patient is not a candidate for or refuses soft tissue rotation flap surgery. Stage III and IV pressure ulcers over the ischiums often do not heal sufficiently with conservative (non-surgical) management to allow a reasonable sitting time after recovery; a well designed flap done by a skilled plastic surgeon can often result in a surface that allows even 8-10 hours of sitting daily on an appropriate wheelchair pressure reducing cushion (often custom made) combined with a strict regimen of wheelchair weight shifts every 15-30 minutes.  We require a minimum of 6 weeks total bedrest with no sitting or ROM to the involved limbs post-operatively for flap patients, and then a 3 week progressive sitting program (in the ideal patient).

Of course proper nutrition is critical at every stage of this process. We generally will not do a flap on a patient who does not have a pre-albumin of at least 23, and we prefer it to be higher. We may place a feeding tube to supplement patient's own oral intake to achieve this (generally aiming for 120 gm. of dietary protein daily as long as their renal function is good).  We sometimes, cautiously, use a 6-8 week course of oral oxandralone for underweight patients who cannot get their pre-albumin up in spite of a lowering CPR and excellent dietary intake.  We also check and correct low serum zinc levels as needed.

Dear David, your post was one of the most promising I have read, thank you and keep saving lifes of human beings...

Dear Kathleen, thank you for the detailed analysis of the whole patient treatment (nutrition, osteomyelitis and other critical issues).

Unfortunately for us, our patient passed away.

God blessed her soul.

My condolence, dear Demetris. God blessed her soul, indeed...

Thank you my dear Galina.

This is so sad. What was the cause of death? Sepsis? Protein depletion? Was this a SCI patient?

My condolences to both the family and to you.

Dear Kathy, thank you very much, I wish you to live in health.

Great resource for your question

 http://www.aafp.org/news/health-of-the-public/20150304acpbedsoreguides.html

I would add 2 other ways :

- negative pressure therapy

- tenderwet dressing

I guess that you are also paying attention to offloading,nutrition and pain

Best wishes of success