Question 29.2
A 63 year old woman is admitted from the ward to intensive care for respiratory support following an emergency laparotomy for an acute abdomen eight days previously. The findings upon examination include:
A clinical photograph of a pressure sore
a) What complication has developed?
b) What are the risk factors for this complication?
c) What is the management of this complication?
d) What are the major preventative strategies for this complication in intensive care patients?
College Answer
a) What complication has developed?
Pressure area ulcer
b) What are the risk factors for this complication?
Duration of surgery, faecal incontinence and/or diarrhoea, low albumin concentrations, disturbed
sensory perception, obesity, moisture of the skin, impaired circulation, use of inotropic drugs, diabetes mellitus, too unstable to turn, decreased mobility, and high APACHE II score. Waterlow’s score, or other valid scores
c) What is the management of this complication?
Remove all pressure from area, appropriate wound management, plastic surgical review, and
adequate nutrition. Wound nurse team.
d) What are the major preventative strategies for this complication in intensive care patients? Maintaining clean and dry skin, visualise skin integrity twice a day, regular pressure relief, pressure relief mattresses
Discussion
This question closely resembles a part of Question 2 from the first paper of 2003. To simplify revision, the answer is reproduced here.
Risk factors for pressure ulcers in ICU
A good article from 2000 has an exhaustingly long table (Table 1).
Highlights from this article include the following:
- Prolonged immobility
- Use of neuromuscular junction blockers
- Age over 60
- Severe illness (APACHE II score over 13)
- Hemodynamic instability preventing pressure area care
- Diabetes
- Incontinence
- Low albumin
- Poor nutrition
- Oedema
- Peripheral vascular disease
- Steroid use
Prevention of pressure ulcers in ICU
- Risk assessment and monitoring
- Mobility (may be unreasonable in this context)
- Minimise sedation and restraints to allow for self-repositioning (may not be relevan in this context)
- Management of incontinence
- 2 hourly repositioning
- Air mattress or specialised foam (evidence is not strong)
- Adequate skin care
Management of pressure ulcers in the ICU
- Engagement of a multidisciplinary wound care team
- Debridement
- Antibacterial (silver sulfadiazine) dressings
- Frequent dressing changes
- Exudate-absorbing dressings
- Promote wound healing:
- Adequate nutritional supplementation, particularly of protein (2g/kg/day)
- Control of diabetes
- Avoidance of corticosteroids
- Optimisation of tissue perfusion
- Avoidance of oedema
References
Keller, Paul B., et al. "Pressure ulcers in intensive care patients: a review of risks and prevention." Intensive care medicine 28.10 (2002): 1379-1388.
Cullum, N., et al. "Beds, mattresses and cushions for pressure sore prevention and treatment." The Cochrane Library (2000).
REULER, JAMES B., and THOMAS G. COONEY. "The pressure sore: pathophysiology and principles of management." Annals of Internal Medicine94.5 (1981): 661-666.
Health Quality Ontario. "Pressure Ulcer Prevention: An Evidence-Based Analysis." Ontario health technology assessment series 9.2 (2009): 1.
Stratton, Rebecca J., et al. "Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis." Ageing research reviews 4.3 (2005): 422-450.
Henzel, M. Kristi, et al. "Pressure ulcer management and research priorities for patients with spinal cord injury: consensus opinion from SCI QUERI Expert Panel on Pressure Ulcer Research Implementation." J Rehabil Res Dev 48.3 (2011): xi-xxxii.
Theaker, C., et al. "Risk factors for pressure sores in the critically ill."Anaesthesia 55.3 (2000): 221-224