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