Pressure ulcer risk assessment in the ICU. Is it time for a more objective measure?

BACKGROUND: The Braden scale, one of the most widely used risk assessment tools is often criticized when used in the Intensive Care Unit. Most patients in the Intensive Care Unit are at risk of pressure ulcer development meaning that the Braden score will usually indicate high risk for these patients. This study set out to determine the correlation between Sub-Epidermal Moisture measurements and Braden scores among Intensive Care Unit patients. METHODS: This study employed an observational research design. Braden score was assessed on all study days (1-5), in addition to visual skin assessment and Sub-Epidermal Moisture measurements at the sacrum and heels. Sub-Epidermal Moisture measurements were categorised as low (<0.5), borderline abnormal (≥0.5), and high (≥0.8). Correlation was assessed between Sub-Epidermal Moisture levels and Braden scores. RESULTS: A total of 53 participants were recruited. The median (interquartile range) baseline Braden score was 9 (9-10) and 81 % (n = 43) of participants were at very high/high risk of pressure ulcer development. Braden scores remained relatively constant over time with little fluctuation in scores. 19 % (n = 10) of patients had normal (<0.5) Sub-Epidermal Moisture delta measurements on enrolment, and all developed abnormal measurements by day 2. There were no significant correlations between Braden scores and Sub-Epidermal Moisture measurements. CONCLUSION: Although this was not its original intention, a missing link with the Braden scale is that it does not provide information on how patients are responding to the adverse effects of pressure and shear forces. Furthermore, in patients who are critically unwell, most patients are classified as being "at risk" of pressure ulcer development. Therefore, an objective measure of how patients are responding to pressure and shear forces at different anatomical areas is needed. IMPLICATIONS TO CLINICAL PRACTICE: Sub-Epidermal Moisture measurements can offer more information, not only on identifying those who are at risk, but also how those patients are tolerating this risk at different anatomical sites.

"A-PePSI LIGhT" Assessment Score to Predict Pressure Sore Impaired Healing Late Recurrence, Immobility, Greater Surface, Inhibited Thrombocytes.

BACKGROUND: Complication rates of up to 46 percent are reported following pressure sore surgery. Pressure sore patients often exhibit ineffective postoperative wound healing despite tension-free flap coverage, necessitating surgical revision and prolonged hospitalization. Rather than pressure sore recurrence, such impaired healing reflects a failed progress through the physiologic stages of the normal wound-healing cascade. The principal objective of the study reported here was to elucidate potentially modifiable inherent variables that predict predisposition to impaired healing and to provide a tool for identifying cases at risk for complicated early postoperative recovery following pressure sore reconstruction. METHODS: A retrospective chart review of late-stage (stage 3 or higher) sacral and ischial pressure sore patients who underwent flap reconstruction from 2014 to 2019 was performed. A multivariable logistic regression model was used to identify key patient and operative factors predictive of impaired healing. Furthermore, the Assessment Score to Predict Pressure Sore Impaired Healing (A-PePSI) was established based on the identified risk factors. RESULTS: In a cohort of 121 patients, 36 percent exhibited impaired healing. Of these, 34 patients suffered from dehiscences, necessitating surgical revision. Statistically significant risk factors comprising late recurrence (OR, 3.8), immobility (OR, 12.4), greater surface (>5 cm diameter; OR, 7.3), and inhibited thrombocytes (aspirin monotherapy; OR, 5.7) were combined to formulate a prognostic scoring system (A-PePSI LIGhT). CONCLUSIONS: The A-PePSI LIGhT score serves as a prognostic instrument for assessing individual risk for impaired healing in pressure sore patients. Preoperative risk stratification supports rational decision-making regarding operative candidacy, allows evidence-based patient counseling, and supports the implementation of individualized treatment protocols. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Moisture associated skin damage (MASD) in intensive care patients: A Norwegian point-prevalence study.

BACKGROUND: Critically ill patients are at risk of developing moisture associated skin damage and pressure ulcers. These conditions may co-exist and be difficult to distinguish, but a simultaneous investigation may provide a true prevalence. OBJECTIVES: To investigate the prevalence of moisture associated skin damage and associated factors among Norwegian intensive care patients. METHODS: A multi-centre one-day point-prevalence study. RESULTS: Totally, 112 patients participated in the study. Overall, 15 patients (13%, 15/112) had some type of moisture associated skin damage of which six cases (5%, 6/112) were related to faeces and/or urine (incontinence associated dermatitis). Skin breakdown occurred primarily in the pelvic area. Overall, 87% (97/112) had an indwelling urinary catheter. Stools were reported in 42% (47/112) of the patients on the study day, mostly liquid or semi-liquid. Overall, 11% (12/112) had a faecal management system. Only a few care plans for moisture associated skin damage prevention and care existed. CONCLUSION: Patients in this study were vulnerable to skin breakdown in the pelvic area. Nevertheless, a low prevalence of skin breakdown existed. This may relate to intensive care nurses' qualifications, the 1:1 nurse-patient staffing, the high prevalence of urinary catheters and few patients having stools.

Pressure Injury.

BACKGROUND: Pressure injury is seen across all healthcare settings and affects people of any age and health condition. It imposes a significant burden, with annual costs of up to $17.8 billion in the United States alone. Despite considerable resources it exhausts, the disease remains very prevalent, and the incidence is on the rise. This is in part due to aging population, growing number of nursing home residents, poorly understood biology, and dismal track record of clinical research in this field. METHODS: In our Review Article, we discuss the disease pathophysiology, clinical manifestation, evidence based recommendations for risk assessment, prevention and timely management, existing challenges, and directions to improve research on the field. This article encompasses dedicated sections on the full spectrum of the pressure related pathologies including "conventional pressure ulcers", "medical device related pressure injuries", "pressure injuries in mucosal membranes", "pressure injuries in pediatric population", "pressure injury at end of life", and the "role of pressure in pathogenesis of diabetic foot ulcers".

Sequential Organ Failure Assessment (SOFA) to Predict Pressure Ulcer Risk in Intensive Care Patients: A Retrospective Cohort Study.

Pressure ulcer (PU) risk assessment practices in adult intensive care unit (ICU) patients remain varied. PURPOSE: The authors assessed the performance of the Sequential Organ Failure Assessment (SOFA) scale and its subcategories in predicting the development of PUs. METHODS: A retrospective cohort study was conducted of all adult patients admitted to the mixed medical-surgical ICU of a Finnish tertiary referral hospital between January 2010 and December 2012. Data (diagnoses, demographics, clinical information, treatments, and instrument scores) were retrieved from the ICU database. Wilcoxon and chi-squared tests were used to examine patient subgroup (medical or surgical ICU and intensive care or high-dependency care patients), length of ICU stay (LOS), modified Jackson/Cubbin (mJ/C) scores and SOFA subcategory variables, and first-day SOFA scores. PU association was determined by logistical regression. RESULTS: Among the 4899 patients in the study population, the overall PU incidence of acquired PUs was 8.1%. Medical patients had significantly more PUs (145/1281; 11.3%) than surgical patients (212/3468; 6.1%) (P <.0001). In all subgroups, significantly more patients with PUs had higher SOFA scores (mean 8.24) than patients without PUs (mean 6.74) (P =.001). The difference persisted when patients with LOS ≥3 days in the ICU were considered. Among the SOFA subcategories, the Glasgow Coma score, renal and respiratory disorders, and hypotension were significantly (P <.0001) linked to PU development. First-day total SOFA score and its cardiovascular and respiratory subcategory scores were the most important predictors of PUs. CONCLUSION: The total SOFA score provides an additional tool to assess PU risk in ICUs and should be used together with the Braden or the mJ/C Scale.

Feasibility of sub-dermal soft tissue deformation assessment using B-mode ultrasound for pressure ulcer prevention.

Pressure Ulcer (PU) prevention remains a main public health issue. The physio-pathology of this injury is not fully understood, and a satisfactory therapy is currently not available. Recently, several works suggested that mechanical strains are responsible of deformation-induced damage involved in the initiation of Deep Tissue Injury (DTI). A better assessment of the internal behavior could allow to enhance the modeling of the transmission of loads into the different structures composing the buttock. A few studies focused on the experimental in vivo buttock deformation quantification using Magnetic Resonance Imaging (MRI), but its use has important drawbacks. In clinical practice, ultrasound imaging is an accessible, low cost, and real-time technic to study the soft tissue. The objective of the present work was to show the feasibility of using B-mode ultrasound imaging for the quantification of localised soft-tissue strains of buttock tissues during sitting. An original protocol was designed, and the intra-operator reliability of the method was assessed. Digital Image Correlation was used to compute the displacement field of the soft tissue of the buttock during a full realistic loading while sitting. Reference data of the strains in the frontal and sagittal planes under the ischium were reported for a population of 7 healthy subjects. The average of shear strains over the region of interest in the fat layer reached levels up to 117% higher than the damage thresholds previously quantified for the muscular tissue in rats. In addition, the observation of the muscles displacements seems to confirm previous results which already reported the absence of muscular tissue under the ischium in the seated position, questioning the assumption commonly made in Finite Element modeling that deep tissue injury initiates in the muscle underlying the bone.

Foam dressings for treating pressure injuries in patients of any age in any care setting: An abridged Cochrane systematic review.

BACKGROUND: Pressure injuries are localised areas of injury to the skin and/or underlying tissues. OBJECTIVES: To assess foam dressings compared to other dressings in healing pressure injuries. DESIGN: Systematic review and meta-analysis DATA SOURCES: The review team searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Ovid Embase; EBSCO CINAHL Plus and the NHS Economic Evaluation Database. Authors also searched clinical trials registries and scanned reference lists for reviews, meta-analyses and health technology reports. No restrictions were applied to language, publication date or study setting. STUDY ELIGIBILITY CRITERIA: Published or unpublished randomised controlled trials and cluster- randomised controlled trials that examined the clinical or cost effectiveness of foam dressings for healing pressure injuries. PARTICIPANTS: Patients of any age with a pressure injury of Stage II or above in any care setting. INTERVENTIONS: Use of any foam wound dressing for treating Stage II pressure injuries or above. STUDY APPRAISAL AND SYNTHESIS METHODS: Full-text were assessed for eligibility using a priori criteria by two authors. Risk of bias was assessed using the Grading of Recommendations, Assessment, Development and Evaluation criteria, and Consolidated Health Economic Evaluation Reporting Standards. Risk ratio and mean difference with 95% confidence intervals were used to measure the effect. The review team used Review Manager 5 to enter narrative and qualitative data of included studies. RESULTS: Authors found nine studies published between 1994 and 2016 involving 483 participants with pressure injuries at Stage II or above. Included studies compared foam dressings with other types of dressings. However, it was unclear if the foam dressing affected healing (RR 1.00, 95% CI 0.78-1.28), time to complete healing (MD 5.67 days 95% CI-4.03-15.37), adverse events (RR 0.33, 95% CI 0.01-7.65), or reduction in pressure injury size (MD 0.30 cm2 per day, 95% CI -0.15 to 0.75), as the certainty of the evidence was very low. LIMITATIONS: Using the Grading of Recommendations, Assessment, Development and Evaluation criteria, the certainty and completeness of evidence was low to very low, making it difficult to draw comparisons between foam and other dressings. CONCLUSIONS AND IMPLICATIONS: It is uncertain whether foam dressings are more clinically effective, more acceptable to users, or more cost effective compared to alternative dressings in treating pressure injuries.

The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment.

AIM: The purpose of this study was to examine the relationship of subepidermal moisture and early stage pressure injury by visual skin assessment in elderly Korean. METHODS: Twenty-nine elderly participated at a particular nursing home. Data were collected for 12 weeks by one wound care nurse. Visual skin assessment and subepidermal moisture value were measured at both buttocks, both ischia, both trochanters, sacrum, and coccyx of each subject once a week. RESULTS: Subepidermal moisture value of stage 1 pressure injury was significantly higher than that of no injury and blanching erythema. After adjustment with covariates, odds ratios of blanching erythema to normal skin and stage 1 pressure injury to blanching erythema/normal skin were statistically significant (p < 0.05). Odds ratio of blanching erythema to normal skin was 1.003 (p = .047) by 1-week prior subepidermal moisture value, and that of concurrent subepidermal moisture value was 1.004 (p = .011). Odds ratio of stage 1 pressure injury to normal skin/blanching erythema was 1.003 (p = .005) by 1-week prior subepidermal moisture value, and that for concurrent subepidermal moisture value was 1.007 (p = .030). Subepidermal moisture was associated with concurrent and future (1 week later) skin damage at both trochanters. CONCLUSION: Subepidermal moisture would be used to predict early skin damage in clinical nursing field for the effective pressure injury prevention.