Cath Lab Digest

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The sample size was too small and the number of variables (medication choices) too high to identify significant correlations regarding sedating medications, but several significantly positive correlations were noted with respect to vasopressive drugs. Use of vasopressin was strongly correlated with use of norepinephrine (r = .412, P = .026) and also correlated with use of epinephrine (r = .406, P = .029) and phenylephrine (r = .483, P = .008). Similarly, epinephrine was found to be positively correlated with use of dobutamine (r = .463, P = .011), and milrinone (r = .694, P = .000); the latter was also positively correlated with dopamine use (r = .413, P = .026).

Discussion

  This study expanded on previous work by other authors in exploring specific factors correlated with the phenomenon of skin failure.^1,3,6 It is clear skin does not fail on its own but is dependent on a number of other factors. All patients in this study (100%) were experiencing either a combination of two other organ system failures or another organ system failure plus sepsis at the time skin failure was observed. This study extends the literature on MODS by documenting specific circumstances under which the skin, as an organ system, fails. Of note: Several review articles include a discussion of skin failure, but actual research is lacking.

  The following factors were present in 90% or more of patients experiencing skin failure: renal failure, respiratory failure, failure of more than one organ system (not including skin failure), or an albumin level <3.5 g/dL. Wøien and Bjørk²³ previously noted that malnutrition states can be a cause of or an effect of ICU care. In this group of patients, compromised nutritional status as evidenced by a below-normal albumin level was an existing condition before skin failure in more than 90% of patients and may be a risk factor for skin failure.

  Age >50 years, generalized edema, ventilator use, or a mean arterial pressure <70 mm Hg were identified in 80% or more of patients in this sample. Because ventilator use was associated with use of one or more of the sedating or analgesic medications studied, this characteristic also was found in 80% or more of the patients studied.

  Additional factors associated with skin failure in 75% or more of patients included creatinine >1.5 mg/dL, weight >150 lb (68 kg), or a combination of both renal and respiratory failure (see Table 5). In his review of multiple organ failure, Deitch⁶ noted that identifying susceptible individuals is critical to preventing further organ system failure.

Limitations

  The results of this study were subject to several limitations, including a modest sample size, restriction to a single hospital’s ICU environment, and the absence of a control group (ICU patients who did not experience skin failure). In addition, demographic variables such as gender or ethnicity were not included, and variations in the anatomic location of skin failure were not investigated. Future studies should include a larger sample size and explore time lines for skin failure, other organ system failure, and additional information about the skin lesions.

Conclusion

  The skin is the body’s largest organ and it, like other organs, may experience complications, become dysfunctional, and ultimately fail. Patients in ICUs are susceptible to skin failure for a variety of reasons. Skin failure has been correlated with other organ system failures and individual patient factors. In this study, all patients had organ system failures at the time the skin failure was observed.