A 63-year-old female is admitted from a regional hospital to ICU for respiratory support
following an emergency laparotomy for an acute abdomen ten days previously. The findings
on examination include the following lesion as depicted in the image below:

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?

[Click here to toggle visibility of the answers]

College Answer

a)
Pressure area ulcer

b)
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, or other reason for decreased mobility,
High APACHE II score. Waterlow’s score, Braden’s score or other valid scores

c)
Remove all pressure from area
Appropriate wound management
Plastic surgical review
Adequate nutrition
Wound nurse team.
Bowel management system.

d)
Maintaining clean and dry skin
Visualise skin integrity twice a day
Regular pressure relief and pressure relief mattresses

Discussion

Yep, that's a pressure area.

This question is essentially a repat of Question 29.2 from the first paper of 2009,  Question 7 from the first paper of 2007 and Question 2d  from the first paper of 2003.

Risk factors

Modifiable risk factors

  • Prolonged immobility
  • Use of neuromuscular junction blockers
  • Use of steroids
  • Hemodynamic instability preventing pressure area care
  • Incontinence with soiling
  • Low albumin
  • Poor nutrition
  • Oedema
  • Hypotension

Non-modifiable risk factors and comorbidities

  • Low BMI (no padding!)
  • Altered mental state
  • Peripheral vascular disease
  • Diabetes
  • Age over 60
  • Severe illness (APACHE II score over 13)

Associated disease states:

  • malignancy
  • stroke
  • pneumonia
  • sepsis
  • heart failure

Management

  • 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

Prevention

  • Use of a "skin integrity care bundle", for example the InSpPiRE protocol (Coyer et al, 2015)
  • Risk assessment and monitoring
  • Mobility
  • Minimise sedation and restraints to allow for self-repositioning
  • Management of incontinence (rectal pouches, IDC)
  • 2 hourly repositioning
  • Air mattress or specialised foam (evidence is not strong)
  • Adequate skin care (clean and dry)
  • Adequate nutrition
  • Control of modifiable risk factors (eg. hypotension, oedema, low albumin, steroids)

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

Krupp, Anna E., and Jill Monfre. "Pressure Ulcers in the ICU Patient: an Update on Prevention and Treatment." Current infectious disease reports 17.3 (2015): 1-6.

Coyer, Fiona, et al. "Reducing Pressure Injuries in Critically Ill Patients by Using a Patient Skin Integrity Care Bundle (Inspire)." American Journal of Critical Care 24.3 (2015): 199-209.