1. Preventing Pressure Ulcers in the Hemodynamically Unstable Patient
Lea Crestodina MSN RN GNP CWOCN CDE

2. Objectives
After participating in this educational experience, the participant should be better able to:
Describe the stages of pressure injury according to the National Pressure Ulcer Advisory Panel (NPUAP)
Identify specific risk factors for pressure injury development in the critically ill patient
List 3 measures that can be implemented to prevent pressure injury in the hemodynamically unstable patient

3. Anatomy and Physiology of the Skin
Largest organ in the body
(21 square feet)
Protects from the external environment
Maintains homeostasis of internal environment
Produces Vitamin D
Receives 1/3 of blood flow
Ranges in thickness from less than 1 mm to 5 mm
Dependent on all other systems for survival

4. It takes a Team!
Medical ICU

5. NPUAP Definition of Pressure Ulcers
 “Localized injury to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue.”
Major causes of pressure ulcers are pressure and tissue tolerance.
“Tissue tolerance determines the ability of the skin and underlying structures to withstand pressure successfully. Tissue tolerance is influenced by both extrinsic risk factors such as friction, shear, and moisture and intrinsic factors such as nutritional status, age, hypotension, comorbid conditions, and poor oxygen perfusion.”
Braden and Berkstrom 1986

6. Pressure Injury: A Significant Problem
Prevalence in ICU ( ) %
VanGilder, MacFarlane, Harrison, Lachenbruch and Meyer. (2010)
CMS Nonpayment
2008 CMS began the nonpayment for never events which include stages 3 and 4
Avoidable vs Unavoidable Pressure Ulcers
NPUAP White Paper
Estimated new cases per year: 2.5 million (NPUAP)
60,000 deaths per year directly related to pressure ulcers
More pressure ulcers develop every year than new cases of cancer

7. Stage 1 Pressure Injury
Category/Stage I: Non-blanchable erythema Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

8. Stage 2 Pressue Injury
Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also appear as an intact or open/ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not visible. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

9. Stage 3 Pressure Injury: Full-thickness skin loss
Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and /or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

10. Stage 4 Pressure Injury
Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

11. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.

12. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, moroon or purple discoloration
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filed blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness tissue injury (Unstagable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic or dermatological conditions.

13. Controversies in staging
Never Events: Oct. 2008: US Center for Medicare and Medicaid Services (CMS) stopped coverage for costs associated with hospital-acquired pressure ulcers (HAPUs) (Stages 3, 4 and unstageable)
Estimated cost per HAPU: $ $70,000
Estimated 3 million adults annually
Individual ulcers: 20, ,7000
Medicare estimates: each ulcer adds $43,18 cost to each hospital stay
Estimated annual cost: 9.1 billion billion
Avoidable vs Unavoidable (2014)

14. WOCN Position Statement Avoidable vs Unavoidable
Purpose: To refute the assumption that all pressure ulcers are avoidable.
Statement of Position: There are clinical circumstances in which a pressure
ulcer is unavoidable. Pressure ulcer formation is a complex process that may not
be halted, even with excellent multidisciplinary care (Thomas, 2003). The skin is
the largest organ in the body and its integrity is dependent upon the function of
all other organ systems for nutrition, circulation, and immune function (Langemo
& Brown, 2006). The burden of disease can overwhelm the skin, even with
appropriate preventive interventions (Witkowski & Parish, 2000). Yet, the
responsibility of the healthcare facility or agency to adopt best practices aimed at
pressure ulcer prevention should not be minimized. There are increasing reports
of success in reducing the prevalence and incidence of pressure ulcers by
implementing evidence-based clinical practice guidelines (Ayello & Lyder, 2008)

15. Risk Factors for Pressure Ulcer Development
Braden Scale Risk Factors
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
Multi-system failure
Advanced age
Disease process
Extended hospitalization
ICU status
Use of pressors

16. Sequence of Events/Pathologic Process
Normal response to Ischemia
Loss of blood flow and hypoxia
Vessel Dilatation
Pressure Relief
Reactive Hyperemia

17. Hemodynamic Instability
Result of dysfunction of primary body systems:
Respiratory
Ventilator/Settings
Cardiovascular
Balloon Pump
ECMO
Cardiogenic Shock
Neurological
Decreased sensorium due to sedation
Renal
CVVHD
Hemodialysis
Characteristics
Labile blood pressure and hypotension
Bradycardia or tachycardia
Hypoxemia
Hypoperfusion

18. What is the Evidence for Pressure Ulcer Prevention?
Can these patients safely be turned?
Are there any preventative products?
Which patients are most likely to break down?

19. Challenges in Care Clear lack of guidelines in this area
Turning vs not turning
Fear of exacerbating instability
“Do not turn” orders
There is not sufficient evidence to determine which patients should not be turned
Recovery to baseline A consensus group maintained that individuals can generally tolerate alterations in hemodynamic status that occur with repositioning if recovery to baseline occurs within 10 to 20 minutes
Tod Brindle a CWOCN at Virginia Commonwealth University Hospital in Richmond, Virginia has done a lot of research in this area.
His publication was the most through that I was able to find.
He convened a consensus panel of critical care nurses, physicians and WOC nurses to develop a guideline for turning the critically ill patient.
Clear lack of guidelines in this area
Brindle, 2013

20. It takes a team!
Surgical Trauma ICU

21. “Gravitational Equilibrium”
Patients left in stationary positions for long periods of time may have even more difficulty with position changes
Vollman, K. 2010
Gravitational equilibrium or “Horizontal orthostatic hypotension”
Critically ill patients already have:
1. Poor vascular tone
2. Dysfunctional autonomic feedback loops
3. Low cardiovascular reserve
They will not be able to or at least be less equipped to adapt to the gravitational changes that occur with shifts in body position
A patient becomes “hemodynamically calibrated” to a certain position, making it very difficult to move that patient.
Exacerbation of this response:
Age
Hypovolemia
Fever
Vasodilators or antihypertensives
History of lower extremity venous disease
Inappropriate turning

22. Consensus Panel
1. Identify clinical indicators that would classify a patient as “ too unstable to turn”
2. Define strategies to safely turn the ICU patient and prevent the development of Vollman’s “gravitational equilibrium”
3. Define strategies to manage the patient with sufficiently severe hemodynamic instability for turning
Brindle, 2013

23. Findings of the Panal
90% of the panel agreed that with individualized turning plans all patients could be safely turned
There will be some situations when the patient cannot be safely moved without potentially fatal consequences. (100%
Consensus could not be reached on setting specific parameters for turning.
Agreed that patients should not be turned if a life threatening arrhythmia develops, fluid is being given to maintain blood pressure, actively hemorrhaging, or hemodynamic changes that do not recover within 10 minutes of repositioning Brindle, 2013

24. Further Findings
80% consensus that unstable fractures of the pelvis with active hemorrhaging
Unstable spinal injuries

25. VCU Guidelines for Turning
Conditions precluding turning
Interventions for the Unstable Patient
Trial turn attempted at least every8 hours
Mini-turns
Weight shift at least every 30 minutes
Elevate heels
Reposition head, arms and legs at least every hour, consider passive ROM.
Consider continuous lateral rotation therapy to prevent development of “gravitational equilibrium” Begin slowly
Go slow with turns
Brindle, 2013

26. Skin Trivia
What is the epidermal turnover time in a young adult

27. Epidermal Turnover Time

28. What is the evidence? Pressors/Oxygenation and Pressure Ulcers
Nurse researchers conducted a retrospective chart review on the monthly sheets of point prevalence rates from Jan 2010-Oct. 2010
Bly, Schallom,
Sona, and Klinkenberg
2016
Study was done to examine 41 different variable and the relationship to pressure ulcers.
Pressure ulcers POA were excluded
The purpose of this study, done in St. Louis, was to examine the variables related to extrinsic and intrinsic pressure, oxygenation, perfusion and baseline comorbid conditions. The authors were looking at the complex risk factors involved in pressure ulcer development.

29. Results Four variables were found to be significant
1. Any transport off the unit
2. Number of days to bed change (Low air loss)
3. Systolic blood pressure less than 90 mm Hg.
4. Use of more than one vasopressor

30. What is the Evidence? Use of Vasopressors and Development of Pressure Ulcers
Retrospective correlational design
306 bed medical-surgical and cardiothoracic ICU
Patients who received vasopressors during 2012
Norepinephrine and vasopressin were significantly associated with the development of pressure ulcers
Vasopressin was the only significant predictor in multivariate analysis
Vasopressin-Pitressin
Norepinephrine-dopamine
The authors found that with higher doses of vasopressin, the development of pressure ulcers was higher.
They found that at the time of the addition of the second pressor, patients may be most vulnerable to pu development
Since vasopressin is frequently given with a seond line vasopressor agent, this may be the point at which the patient becomes most suseptible to pressure ulcers
Cox and Roche, 2015

31. What is the Evidence? Use of Bundles to Prevent Pressure Ulcers
Many studies on bundles
Usually include an acronym, education, review of turning practices, algorithms, reeducation on Braden Scale
Jochem and Wiegand, 2014

32. What is the Evidence? Soft Silicone Dressings
Santamaria-ICU setting
n=219 Intervention Group
N=221 Control Group
5 pressure ulcers in intervention group vs 20 in control group
Kalowes- ICU setting
n=184 Prevention Group
n=183 Control Group
8 pressure ulcers in control group and 1 DTI in intervention group

33. Soft Silicone Dressings
Use of dressing for prevention has been looked at for some time now
The dressing reduces friction and shear
May change the microclimate of the skin and reduce pressure ulcer risk in this way
Now made specifically for the sacrum and the heel
Many brands

34. Patient Positioning Devices
Relatively new
Make it easier to do small, slow shifts, thus less likely to drop pressure or sats
A number of different brands

35. Pressure Ulcers vs Acute Skin Failure in the Adult Critical Care Patient
Two distinct, yet related clinical phenomena
Skin Failure Definition: “ an event in which the skin and underlying tissue die due to the hypoperfusion or failure of other organ systems”
Study done in New Jersey: retrospective case-control methodology in 2 Magnet-designated medical centers
Developed a model to look at those who developed ulcers and those who did not

36. Pressure Ulcer vs Acute Skin Failure
Inclusion criteria:
At least a 3 day ICU stay
Adults
Exclusion criteria:
End of life
Findings: Those with Peripheral Arterial Disease were found to be 4 times more likely to develop skin failure
Mechanical ventilation greater than 72 hours also associated with acute skin failure
Much more research needed on this subject
Delmore, Cox et al., 2015

37. It takes a team!
CVIVU

38. Take Home Message Your ICU Bring your ideas Be creative
Get a physician advocate
Start a unit based team

39. References
Bly, D., Schallom, M., Sona, C., & Klinkenberg, D. (2016, March). A model of pressure, oxygenation, and perfusion risk factors for pressure ulcers in the intensive care unit. American Journal of Critical Care, 25,
Brindle, C. T., Malhotra, R., O’Rourke, S., Currie, L., Chadwik, D., Falls, P., ... Crehan, S. (2013, May/June). Turning and repositioning the critically ill patient with hemodynamic instability: A literature review and consensus recommendations. Journal of Wound, Ostomy, Continence Nursing, 40,
Delmore, B., Cox, J., Rolnitzky, L., Chu, A., & Stolfi, A. (2015, November). Differentiating a pressure ulcer from acute skin failure in the adult critical care patient. Advances in Skin & Wound Care, 28,
Edsberg, L. E., Langemo, D., Baharestani, M. M., Posthauer, M. E., & Goldberg, M. (2014, July/August). Unavoidable pressure injury: state of the science and consensus outcomes. Journal of Wound, Ostomy, Continence Nursing , 41,

40. References
Jochem, K., & Wiegand, L. (2014, March). Using a bundle approach to reduce pressure ulcers in an ICU. American Journal of Safe Patient Handling & Movement, 4(1),
Manzano, F., Perez-Perez, A. M., Martinez-Ruiz, S., Garrido-Colmenero, C., Rolden, D., Jimenez-Quintana, M. D., ... Colmenero, M. (2014). Hospital-acquired presure ulcersand risk of hospital mortality in intensive care patients on mechanical ventilation. Journal of Evaluation in Clinical Practice, 20,
Tayyib, N., Coyer, F., & Lewis, P. A. (2015). A two-arm cluster randomized control trial to determine the effectiveness of a pressure ulcer prevention bundle for critically ill patients. Journal of Nursing Scholarship, 47,

41. Questions???

42. Thank you