A Prospective, Descriptive Study of Characteristics Associated with Skin Failure in Critically Ill Adults
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In a review of the components and sequelae of sepsis, Sharma and Eschun19 described sepsis as an auto-destructive process that allows extension of the patient’s response to an infection. Organ dysfunction or failure can result, and may be the first sign of sepsis. The authors point out that any organ system may be affected by sepsis, but the microcirculatory system is the key target. Sepsis affecting this system may negatively affect the ability to extract oxygen from the circulatory system, leading to tissue edema and hypoxia.
Systemic inflammatory response syndrome (SIRS) independently can lead to organ damage. Schulman and Hare’s20 review of SIRS noted “a greater incidence of sepsis in the ICU population than any other major disease”; sepsis is the main cause of ICU deaths, and more than $16 billion is spent annually in the US to manage this complication and its sequelae. The inflammatory response involved in sepsis often results in high mortality rates, even with appropriate treatment.
Acute respiratory failure (ARF) is another common complication in ICU patients. In a prospective, multicenter observational cohort study, Vincent et al21 reviewed characteristics of 458 patients admitted with ARF to participating ICUs. Characteristics associated with ARF included older patients, presence of neurologic failure, and a history of an infection during or before the ICU stay. Patients with and without ARF had mortality rates of 34% and 16%, respectively. Factors associated with death from ARF include multi-organ failure, hematologic malignancy, chronic renal failure, liver cirrhosis, circulatory shock, infection, and old age. The authors noted the presence of ARF in 56% of ICU patients. Extrapulmonary factors were found to be related to ARF and to mortality.
During a serious illness, ICU patients are also at risk for developing adrenal insufficiency (AI). In their study of 104 surgical ICU patients, Rivers et al22 found that up to 28% of seriously ill patients are found to have occult or unrecognized AI; the authors also found abnormally low levels of serum cortisol in 34 patients (32.7%). All patients in this sample met the criteria for SIRS and experienced sepsis or septic shock.
Finally, several authors have addressed malnutrition as both a cause and a consequence of ICU complications. In their prospective study, Wøien and Bjørk23 collected nutritional data from 21 critically ill patients during the first 3 days of the ICU stay and tested a feeding algorithm to enhance nutritional intake. The authors concluded that use of a method such as a nutritional support algorithm improved the delivery of nutrients in ICU patients.
Methods and Procedures
This prospective, descriptive, 18-month study consisted of a concurrent chart review of patients in adult critical care units (ICUs) who were diagnosed with acute skin failure by certified wound care nurses. The study took place in a large, tertiary care center in the southeastern US. After review and approval by a joint university and hospital Institutional Review Board, informed consent for participation was obtained from patients or family members with authority to grant consent.
All patients admitted to the adult intensive care units age 18 years or older with acute skin failure were eligible for study participation. Exclusion criteria included patients with co-existing dermatologic diagnoses such as burn wounds, exfoliative drug rashes, dermatitis, psoriasis, or Stevens-Johnson Syndrome.
After a certified wound and ostomy care nurse (CWOCN) identified eligible patients, a member of the WOCN team collected the data directly from the patient and the medical record. The data were abstracted to a collection form designed for this purpose.