ORIGINAL ARTICLE
The relationship between dermal pressure ulcers, oxygenation and perfusion in mechanically ventilated patients

https://doi.org/10.1016/j.iccn.2004.07.005Get rights and content

Summary

Background:

More than 1.5 million hospitalized patients develop dermal pressure ulcers (DPUs) annually, which increases cost and prolongs length of stay. Mechanically ventilated patients may be at a high risk for DPU development, but research has not focused on the prevalence of dermal pressure ulcers in this population or the factors associated with dermal pressure ulcer development.

Objectives:

To determine the prevalence of dermal pressure ulcers in subjects receiving mechanical ventilation and to describe the relationship between systemic oxygenation, tissue perfusion, and the prevalence of dermal pressure ulcers.

Methods:

Subjects from an Intensive Care Unit in a Midwestern hospital in the United States were recruited into this descriptive, correlational study following intubation. Variables included: demographics, general subject status (weight, serum albumin), ventilatory status, oxygenation status (arterial blood gas analysis including concentration of hydrogen ions, partial pressure of carbon dioxide, partial pressure of oxygen, and amount of oxygen carried by hemoglobin), perfusion status (mean arterial pressure, heart rate, urine output), and skin condition. The Braden Scale was used to measure the risk of skin breakdown, with any skin breakdown being classified in stages ranging from I to IV (I having minimal breakdown, IV having maximal breakdown). Braden Scores range from 6 to 23, with a score of 6 indicating high risk and a score of 23 indicating low risk. Data were collected every other day after admission to the Medical Intensive Care Unit until extubation, transfer, or death.

Results:

Subjects (n = 40) were primarily Caucasian (77.5%), having a mean age of 56.4 years (±14.6 years). Half of the sample was male (50%). Twenty percent of the sample developed DPUs. A Pearson's correlation identified the significant associations between the Braden Score and MAP, PaCO2, largest weight fluctuation in a 3-day period, and change in weight from admission to discharge. Surprisingly, the lowest Braden Score was not significantly associated with the development of DPUs.

Conclusions:

Mechanically ventilated patients are vulnerable to developing dermal pressure ulcers as evidence by 20% of the subject population developing a dermal pressure ulcer. The most significant factors related to a low Braden Score in this group are fluid shifts and fluid weight gain. This may be an important predictor of dermal pressure ulcers not currently assessed clinically.

Introduction

More than one and a half million hospitalized patients develop dermal pressure ulcers (DPUs) annually, increasing hospitalization cost by $15,229 and prolonging patients’ stay by 8.2 days (Doan-Johnson, 1998, Fife et al., 2001). Dermal pressure ulcers not only cause pain; they also produce an inflammatory response with hyperemia (excess amount of blood in an organ), fever, and leukocytosis while increasing risk for systemic infection and mortality (Huether, 2000, Allman, 1998). Dermal pressure ulcers can develop during the first week of hospitalization in an intensive care unit (Fife et al., 2001). Mechanical ventilation, a general intervention for critically ill patients, can lead to decreased venous return to the heart, left ventricular end-diastolic volume, cardiac output, and hypotension with decreased tissue perfusion. Ventilated patients also experience impaired mobility, increased risk for infection, and poor nutritional status.

Investigators have primarily focused on preventing and identifying patients’ risk factors. Age, immobility, incontinence, catabolic disease, pressure on bony prominence, shearing forces, friction, and moisture increase the risk for pressure ulcers (Bourdel-Marchasson et al., 2000). Bourdel-Marchasson et al. (2000) found that hypoalbuminemia, which reflects the body's protein loss, is a major risk factor, especially in older subjects when serum albumin decreases very early during acute illness; this places a greater risk of DPU development with an increase in age. Assessment of risk factors that promote the development of dermal pressure ulcers has been found to be underutilized and performed inaccurately by clinicians in the health field, with several studies finding that a majority of patients are not assessed for dermal pressure ulcer risk factors (Thomas, 2001, Perneger et al., 1998, Stotts et al., 1998).

Nurses play a major role in protecting patients from developing dermal pressure ulcers. While nurses are well educated on the risk factors associated with DPU development, they are often not as well educated about DPU management. Nurses who have the knowledge to address the problems associated with dermal pressure ulcers can provide quality wound care, but studies show that many nurses have little to no formal education about dermal pressure ulcers and wound healing, and there is no formal evidence based protocol for skin care in use (Hadcock, 2000). Ferrell et al. (1993) found that dry gauze is the most commonly used dressing for the treatment of DPUs, whereas significant data suggests that for chronic wounds, therapy that dehydrates the wound can be detrimental to the wound's ability to heal (Fowler and Goupil, 1984, Gorse and Messner, 1987, Kurzuk-Howard et al., 1985). The best wound management is based on the clinical circumstances. Bourdel-Marchasson et al. (2000) found that the use of oral nutritional supplements prevented skin breakdown in a group of critically ill patients aged 65 and older.

Only one other recent study has investigated the prevalence of dermal pressure ulcers in an intensive care setting. Fife et al. (2001) performed a study in the neurologic intensive care unit in order to explore the risk factors for pressure ulcers in an intensive care setting, the Braden Scale as a predictor of pressure ulcer risk in critically ill patients, and whether pressure ulcers were likely to occur early in a hospital stay. Twenty-three of the 186 subjects (12.4%) recruited for this study developed a Stage II or higher dermal pressure ulcer, with the average length of stay of 6.4 days. The subjects had Braden Scores ranging from 8 to 23, with subjects who developed DPUs having a score of 15 or less. Fife et al. found the Braden Scale to be a primary predictor of skin breakdown, with patients at risk having a Braden Score of less than 16 and patients who need aggressive preventative care of 13 or less. However, only 11% of the subjects in this study were receiving mechanical ventilation.

Decreased oxygenation and decreased tissue perfusion leads to tissue necrosis, allowing for the development of dermal pressure ulcers. Patients in a critical care setting on mechanical ventilation may be especially at risk, due to lack of mobility, increase pressure on bony prominences, and decreased oxygen delivery. There are no studies that investigate the development of skin breakdown in mechanically ventilated patients and the relationship between DPU development and oxygenation and tissue perfusion. Thus, the purpose of this study is two-fold: (1) to determine the prevalence of dermal pressure ulcers in subjects receiving mechanical ventilation; and (2) to describe the relationship between systemic oxygenation, tissue perfusion, and the occurrence of dermal pressure ulcers.

Section snippets

Design

In this descriptive, correlational study, subjects who met inclusion criteria were enrolled in the study upon admission into a Medical Intensive Care Unit (MICU) in the Midwestern United States. The prevalence of DPU and the relationship between DPUs and oxygenation and perfusion variables were determined by a review of the current medical records.

Setting and subjects

This study was conducted in a medical intensive care unit of a hospital in the Midwestern United States. This unit has 25 beds with an annual daily

Sample

The sample (n = 40) primarily consisted of Caucasian (77.5%) individuals. Exactly half of the subjects were male (50%), and the mean age of the sample was 56.37 ± 14.6 years. Almost one half of the subjects (42.5%) were admitted with a respiratory diagnosis, while a third (27.5%) were admitted with a diagnosis of cancer (Table 1). There were no statistically significant differences in Braden score and selected perfusion and oxygenation variables between those subjects who developed a DPU and

Discussion

The purpose of this study was to determine the prevalence of dermal pressure ulcers in mechanically ventilated patients in a critical care setting and to determine the relationship between perfusion, systemic oxygenation, and the development of dermal pressure ulcers. The primary findings of this study indicate that mechanically ventilated patients are vulnerable to skin breakdown. No relationship between this study's perfusion variables and oxygenation variables and DPU development was

Conclusion

The purpose of this study was to determine the prevalence of dermal pressure ulcers in mechanically ventilated patients and to describe the relationship between systemic oxygenation and tissue perfusion in patients receiving mechanical ventilation. In this study, 20% of the subjects receiving mechanical ventilation in the medical intensive care unit developed dermal pressure ulcers. No relationship was identified between the perfusion and oxygenation variables evaluated in this study and

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