The factors of pres­sure ulcer’s heal­­ing in critical­ly ill patients

Summary

Aim:

The aim of the study was to identify and analyse the factors influenc­­ing the course of heal­­ing pres­sure ulcers in critical­ly ill patients, then compare the variability of the heal­­ing in patients after stabilisation.

Patients and methods:

We chose a comparative multi-case study us­­ing qualitative and quantitative research methods as the research strategy. The study sample consisted of three critical­ly ill patients with pres­sure ulcers.

Results:

In our study, all patients went to a critical condition after a therapeutic intervention on the heart (cases A, C –  cardiac surgery; case B –  radiological intervention). The pres­sure ulcers occur­red dur­­ing control­led and supportive ventilation, continuous intravenous sedation and analgesia. Hypoxia, hemodynamic instability, vasopres­sors with vasoconstrictive ef­fects, obesity, malnutrition, im­mobility, inability to change position in control­led and supportive ventilation are factors which do not contribute to the pres­sure ulcers healing. In case A, heal­­ing occur­red after verticalization of the patient, by improv­­ing the self-care, vitamin C with zinc and add­­ing protein supplements (sipping). After 8 months pres­sure ulcer was definitely healed. In the case B (coma vigil), 80% of the area of pres­sure ulcers was healed after introduction to the percutaneous endoscopic gastrostomy (PEG) feeding. In case C, heal­­ing was complicated by quadriplegia and malnutrition which did not improve even by administer­­ing vitamins oral­ly, the patient was fed via nasogastric tube. Despite negative pres­sure wound ther­apy, heal­­ing did not occur.

Conclusion:

The impact of mobility and nutrition on pres­sure ulcers heal­­ing was significantly confirmed in our study. It has been shown that nasogastric feed­­ing is inadequate compared to PEG (nutritional­ly defined enteral nutrition).

Key words:

pressure ulcer – critically ill – factors of healing – mobility – nutrition

Introduction

Critical il­lness is a life-threaten­­ing condi­tion which, in the absence of medical intervention, can lead to death or serious harm. It arises as a consequence of one or more pathophysiological proces­ses that lead to respiratory, cardiovascular failure [1] with pos­sible neurological damage (poly­neuropathy and myopathy of critical­ly il­l) [2]. Critical­ly ill patients require highly specialized nurs­­ing care in a technological­ly sophisticated environment [3]. They represent the most medical­ly fragile and vulnerable population in the hospital, who are at high risk for develop­­ing pres­sure ulcers (PUs) (on a multifactorial basis). The prevalence of PUs among patients in the Intensive Care Unit (ICU)/ Department of Anesthesiology and Intensive Medicine (DAIM) is reported from 13 to 45.5% [4– 6]. The occur­rence of PUs is often unavoidable among patients in intensive and resus­cita­-tion care in spite of the succes­sful imple­mentation of the program­mes for the prevention of PUs. The risk to develop PUs begins on the 1^st day fol­low­­ing the admis­sion to ICU [7], after 15 days of hospitalisation almost all patients are at high risk of the development of PUs, especial­ly the elderly patients [8]. Most often PUs are located in the sacrum [9,10] and buttock [11]. They are as­sociated with mobility limitation, forced position and other constraints (chest drains, abdominal drains) in ventilated patients, which also complicate and make the heal­­ing process harder.

Aim

The aim of the study was to identify and analyse the factors influenc­­ing the course of heal­­ing PUs in critical­ly ill patients, then compare the variability of the heal­­ing in patients after stabilisation.

Patients and methods

We chose a comparative multi-case studyus­­ing qualitative and quantitative research methods as the research strategy (mixed methods comparatory multiple-case study). Objectivized scales for as­ses­smentof consciousness (Glasgow Coma Scale; GCS), evaluation of agitation and sedation(Richmond Agitation and Sedation Scale; RASS), nutrition (body mass index; BMI, mini nutrition as­ses­sment; MNA), self-care (activity of daily living; ADL) were used to verify the identification of critical­ly ill patients. The risk of PU development was as­ses­sed by Braden Scale [12]. We excluded the presence of PUs from neglect and/ or non-delivery of nurs­­ing care, so cal­led sororigenic wounds, based on the Root Cause Analysis (RCA) as described by Pokorná et al [11]. We as­ses­sed the factors influenc­­ing wound heal­­ing based on the best available evidence, includ­­ing international recom­mendations and management of care and treatment of PUs (age, nutrition, pharmacother­apy, physical activity). We monitored the level of PU based on the National Pres­sure Ulcer Advisory Panel (NPUAP) I to IV and local wound characteristics accord­­ing to the University Hospital in Martin (UHM) protocol (Record of PU treatment).

The study sample consisted of three critical­ly ill patients with PUs and the PU was acquired and formatted dur­­ing hospitalisation at DAIM. All patients, after stabilisation, were dispensarised in the Outpatient Wound Care Department (OWCD) of the UHM. Sampl­­ing was deliberate.

Results

Clinical case study A. 66-year-old patient (female) with advanced cardiac failure after a cardiac bypass surgery (coronary artery bypass graft-left internal mam­mary artery to ramus interventricularis anterior, vena saphena magna to ramus marginalis sinister; CABG-LIMA to RIA, VSM to RMI). Pre-surgery Braden scale 11 points (high risk of PU development), with no clinical and laboratory manifestations of malnutrition. Post-surgery complicated by PU acquired. PU was dia­gnosed on the 5^th day after admis­sion (NPUAP I) with a tendency to grow in size and non-healing. Significant factors slow­­ing the heal­­ing of PU were multimorbidity (hypoxia, ischemic heart dis­ease –  New York Heart As­sociation Functional Clas­sification III), st. p. myocardial infarction, recur­rent myocardial revascularization, WHO III arterial hypertension, diabetes mel­litus type II on insulin, chronic obstructive pulmonary dis­ease), metabolic syndrome, pharmacother­apy (vasopres­sors), BMI 32,9 (first degree obesity) and im­mobility as­sociated with supportive ventilation, deficiency of self-care in all daily activities. After 14 days the patient was transfer­red to the coronary unit of UHM. A PU of dimensions 22 × 15 cm (NPUAP IV) (Fig. 1), reach­­ing depth of 2– 3 cm when as­ses­s­­ed by the wound care nurse, the doctor made a necrectomy. Combination of sodium hypochlorite and chlorine flush­­ing (NaOCl/ HOCl) were recom­mended, charcoal with silver and iodopolyvidone activated local­ly accord­­ing to the needs. The state of nutrition was as­ses­sed in relation to the PU treatment (MNA 12.5 points –  poor nutritional state), mobility and self-care (ADL 30 points –  high dependence). Recom­mendation: anti-decubitus mattres­s, repositioning, timely mobilisation and verticalization, protein supplements, sip­­-p­­ing of enteral nutrition and vitamin C with zinc. Dur­­ing the month of treatment in UHM, the PU was reduced to 12 × 10 × 1– 2 cm, the wound bed was only slightly coated, and gel contain­­ing NaOCl/ HOCl was local­ly applied in combination with 10% povidone and a suf­ficient absorbent layer. Daily redres­s­­ing by a home care nurse, visits to the OWCD –  once a month. Local treatment accord­­ing to the wound healing –  hydrogel, calcium alginate dres­s­­ing with silver. After 10 days of treatment in home care, there was a reduction to NPUAP III, after a month reduction to 8 × 7 × 1– 2 cm. Further treatment with alginate cover, self-adhesive foam dres­s­­ing with soft silicone adhesive layer shaped for sacrum. After 5 months, PU 0.5 × 1 cm in size, only minimal secretion (Fig. 2) and after 8 months it is definitely healed.

Clinical case study B. 64-year-old patient (male) with severe anoxic brain injury after C reactive protein (for malignant rhythm disorder in acute ST-Elevation Myocardial Infarction, after percutaneous coronary intervention on RIA with stent implantation, repeatedly defibril­lated, intubated, admitted to DAIM for control­led ventilation. Braden scale 4 points (very high risk of PU). Persist­­ing unconsciousness with decerebrate rigidity, quadriplegic, in coma vigil. Due to the inability to maintain airway pas­sage, tracheostomy can­nula inserted, transfer­red to the ICU of the Pulmonary Clinic. Fed via nasogastric tube (NGT). Wound care nurse contacted due to the occur­rence of numerous PUs, mostly with necrosis: the sacral area for extensive necrosis 12 × 15 cm NPUAP non-quantifiable stage (Fig. 3), in the left trochanter 7 × 5 cm (NPUAP II), right heel necrosis 5 × 3.5 cm, outer ankle 1 × 2 cm (NPUAP II), left tibia necrosis 2 × 5 cm and 1 × 3 cm (NPUAP II), on the left hell dry fur­rowed skin at risk for PU, outer ankle necrosis 1.5 × 1.5 cm and the outside of shin necrosis 1 × 2 cm and 1 × 3 cm.

Necrectomy and debridement of all PUs performed, flush­­ing with NaOCl/ HOCl solution, 10% povidone iodine surface treatment and deep high-absorbency fibre with reinforced fiberglass and silver dres­sing, sacrum and tibia with semi-permeable foam­­ing bandage. Recom­mended anti-decubitus mattres­s, twice daily rehabilitation with a physiotherapist, enteral feed­­ing NGT. Dur­­ing the 1^st month of treatment heal­­ing process of PU wasinitiated, mainly in the sacral area, dimen­sions 10 × 10 × 1 cm (NPUAP II-III) and 9 ×7 × 1– 2 cm (NPUAP IV) (Fig. 4) occur­red in the left tro­chanter –  significant deterioration.

Patient released to home care, visited by a home care nurse daily. Clinical and laboratory manifestations of malnutrition (Tab. 1), thus percutaneous endoscopic gastrostomy (PEG), Flocare CH18 fy was inserted, enteral nutritional support provided (complete liquid nutrition with fibre and docosahexaenoic acid/ eicosapentaenoic acid, combined with isocaloric nutritional support for patients with diabetes or with glucose-tolerance disorders, with soluble fibre).

Enteral nutrition administered by a continuous feed­­ing pump for 16 h a day. Five weeks after PEG placement, a significant improvement in heal­­ing PU was identified. Accord­­ing to the UHM documentation, 80% of the PUs area was healed. Flush­­ing with NaOCl/ HOCl solution recom­mended, surface PU to be treated with 10% povidone iodine and deep high-absorbency fibre with reinforced fiberglass and silver dres­sing, sacrum and tibia with semi-permeable foam­­ing bandage. After 7 months of treatment, in the sacral area the defect of 8 × 4 cm (NPUAP II) (Fig. 5), the right trochanter healed, left 2.5 × 2.5 cm (Fig. 6), wound bed granulates. The wounds on the right heel and the right forearm healed ful­ly. On the left tibia newly formed decubitus 2 × 2 cm and 2 × 1.5 cm, visible tendons (NPUAP IV). Flush­­ing with polyhexanide, hydrocol­loid and 10% povidone iodine local­ly applied. Factors decelerat­­ing the heal­­ing proces­s –  multimorbidity (arterial hypertension WHO III, ischemia, diabetes mel­litus type 2 on insulin), pharmacother­apy (vasopres­sors), malnutrition (clinical and laboratory) and im­mobility in con­nection with control­led ventilation and subsequently in a persistent vegetative state, coma vigil.

Clinical case study C. 63-year-old man hospitalized for 1 month at DAIM after car-diac surgery for severe mitral regurgita-tion (mitral valve repair). After surgerydue to respiratory failure reintubated and con­nected to adaptive lung ventilation (ALV). Subsequently, septic shock with renal failure, healthcare as­sociated infection (methicil­lin-resistant Staphylococcus au­reus), bronchopneumonia (pseudomonas aeruginosa), mediastinitis, on the 7^th daysacral area PU dia­gnosed (NPUAP I). Afterstabilization and extubation of the pa­tient, quadriplegia, a neurology evaluated as a brainstem lesion, polyneuropathy of critical­ly ill patients persisted. Present additional comorbidities (dyslipo­protei­n­­-emia, heparase steatosis, chronic smok­­ing bronchitis, benign primary arterial hypertension WHO III). A patient transfer­red to a local hospital with sacral PU (NPUAP IV, 15 × 15 × 2 cm, reaches the rectum, wound bed coated, min. secretion) (Fig. 7), the tracheostomy can­nula inserted. Clinical and laboratory manifestations of malnutrition (Tab. 1), MNA 3.5 points (poor nutritional state), the patient is completely dependent on the help of others (ADL 0 points). OWCD performed necrectomy, enzymatic debridement, flush­­ing with NaOCl/ HOCl solution, hydrogel sterility compres­sion local­ly applied, antiseptic non-adhesive dres­sings from tul­le fabric impregnated with 0.5% chlorhexidine acetate, non-sticky viscose dres­s­­ing with honey. Repositioning, relieving, anti-decubitus mattres­s, vitamin C with zinc, protein supplements recom­mended. After 3 months, the PU was reduced (7 × 7 × 1 cm), the patient transfer­red to the social services house, treated outpatient for 2 months (flush­­ing with polyhexanide, local alginate with silver), the condition did not improve, adopted on NPWT. Dur­­ing the stay in the social services house, new ankle bilateral ulcers (NPUAP II), treated with anatomical­ly formed hydrocel­lular bandage, also appeared. A month after NPWT ther­apy the wound increased and deepened again (7 × 9 × 2 cm), wound bed coated, the progres­sion of decubitus, the macerated sur­round­­ing skin. The patient was treated by nurses in the social services house and OWCD was no longer visited.

Comparison of cases

In our study, all patients went to a critical condition after a therapeutic intervention on the heart (cases A, C –  cardiac surgery; case B –  radiological intervention). The PUs occur­red dur­­ing control­led and sup­portive ventilation, continuous intravenous sedation and analgesia at DAIM despite the implementation of standard preventative procedures us­­ing anti-decubitus aids. NPUAP IV was dia­gnosed within 14 days after admis­sion to DAIM. Hypoxia, he­modynamic instability, vasopres­sors withvasoconstrictive ef­fects, im­mobility, in­abili­ty to change position in control­led and supportive ventilation are factors which do not contribute to the PUs healing. Furthermore, in case A obesity, which complicated handl­­ing of the patient, the provision of semi-Fowler position on the bed, in cases B and C malnutrition (clinical and laboratory). The most important factors af­fect­­ing PUs heal­­ing were nutrition and mobility. In case A, heal­­ing occur­red after verticalization of the patient, by improv­­ing the self-care (gradual­ly ADL 80 points –  moderately self-suf­ficient), vitamin C with zinc and add­­ing protein supplements to the diet (sipp­­ing nutritional supplements) until PU was healed. In case B, PEG was inserted, enteral nutrition despite the persistent vigil coma was administered. In case C, heal­­ing was complicated by quadriplegia and malnutrition which did not improve even by administer­­ing vitamins oral­ly, the patient was fed with a slur­ry diet that was inadequate. Despite modern therapeutic approaches (NPWT), heal­­ing did not occur. In cases A (daughter and son) and B (wife), the patients had a great deal of support from the family, they were taken to home care. In case C, the patient was transfer­red to the social services home.

Discus­sion

Heal­­ing of a chronic wound, even in the best conditions, is a complex process that requires timely com­munication of cel­lular and extracel­lular components in order to restore the optimal function of the damaged tis­sue and also the quality of life of the individual. The quality of tis­sue regeneration and, in particular, the intensity of the inflam­matory response may be af­fected by a number of factors and ef­fects that should be analysed prior to establish­­ing the treatment and nurs­­ing plan (continuously as wel­l). Most authors divide these factors into system and local ones. Other divisions include internal (state of nutrition, vitamins and trace elements, tis­sue hypoxia, inadequate inflam­matory response, im­mune system disorders, age of the patient, etc.) and external (infection, pharmacother­apy, devitalised tis­sue, physicochemical ef­fects, etc.) Snyder et al. divided the above-mentioned factors into four categories based on the results of clinical studies: comorbidities, patient-centred factors, pharmaceuticals, micro-environment [13]. Impaired mobility to im­mobility exposes the individual to sustained pres­sure, friction [14] and so-cal­led shear force that applies when the patient occupies Fowler‘s position when the torso „slides“ down the pad, the process of PUs heal­­ing in the sacral and sedentary areas stagnates or worsens. Insuf­ficient food intake, poor nutrition (malnutrition) in combination with multiple co-morbidities were identified as key factors of heal­­ing PUs [15]. Randomized control­led trials have clearly highlighted the link between high-protein enteric nutrition, arginine, and vitamin C with zinc and heal­­ing of PUs [16– 20]. The general recom­mendations for heal­­ing PUs include nutritional supplements rang­­ing from 25 to 35 kcal/ kg per day [17]. All stages of heal­­ing the PUs require a suf­ficient intake of protein [21]. Trans Tasman Dietetic Group recom­mends 1.25– 1.5 g protein/ kg body weight for patients with mild to high risk of delayed PUs healing [22]. Ag­­ing is often as­sociated with unbalanced protein metabolism [23] and increased intake above 1.5 g/ kg per day can disrupt the nitrogen balance and cause dehydration. Therefore, it is important to monitor the hydration status and increase the intake of fluids with increased protein intake. Increased vitamin C intake with zinc is required for the wound heal­­ing proces­s, col­lagen production. Zinc is a co-factor for col­lagen production, an antioxidant, and it is important for protein synthesis, DNA and RNA and proliferation of inflam­matory cel­ls and epithelial cel­ls. Zinc deficiency can result in increased wound exudate. Zinc should be added, if clinical signs of zinc deficiency are present but should not exceed 40 mg per day. A high dose of zinc (> 40 mg/ day) is not recom­mended because it can adversely af­fect the copper status and may result in anaemia. If it is not pos­sible to provide oral intake, we should provide enteral nutrition (NGT, nasojejunal tube, PEG, percutaneous endoscopic jejunostomy). Accord­­ing to Cochrane’s review, we should be cautious when interpret­­ing the ef­fects of nutrition on PUs healing. In most studies, heal­­ing of PUs was monitored by a Pres­sure Ulcer Scale for Heal­­ing (PUSH) score, which is not a clear objective evidence, it lacks laboratory indicators on nutrition [24]. There are other factors of heal­­ing PUs, which should be included in management of the treatment of PUs (removal of pres­sure, exces­sive moisture caused by sweat, urine and stool, treatment of infection, treatment of the primary dis­ease, pain ther­apy) [25,26].

Conclusion

Critical­ly ill patients in intensive care units are the most disadvantaged for maintain­­ing intact skin, be­­ing at high risk, mainly due to limited mobility and physical activity. The impact of mobility and nutrition on PUs heal­­ing was significantly confirmed in our study. It has been shown that nasogastric feed­­ing is inadequate compared to the PEG (nutritional­ly defined enteral nutrition). There are other factors of heal­­ing PUs, which should be included in management of the nurs­­ing care and treatment of PUs, for example tis­sue hypoxia, inadequate inflam­matory response, im­mune system disorders, age of the patient, infection, pharmacother­apy, devitalised tis­sue, comorbidities, micro-environment etc.

Limitation of study

The study limits are sample size and only two factors influenc­­ing wound heal­­ing were root analyzed. Nutritional as­ses­sments are partial, some important laboratory parameters are absent (lymphocyte, transfer­rin, serum zinc). In critical­ly ill and im­mobile patients, the estimation of body weight by anthropometric measures is not accurate. This supports the need for equipment to be made widely available to accurately weigh patients.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.

The study was supported by the grant KEGA No. 070UK-4/2017 “The quality of nursing care for selected groups of patients”.

The study was conducted with the approval of the Ethics Commission of University Hospital in Martin. For collecting data, anonymous forms were used.

Mgr. Edita Hlinková, PhD.

Department of Nursing

Jessenius Faculty of Medicine

Malá Hora 5

036 01 Martin

Slovakia

e-mail: hlinkova@jfmed.uniba.sk

Accepted for review: 24. 6. 2018

Accepted for print: 10. 8. 2018