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Wound Care J Wound Ostomy Continence Nurs Wound Care J Wound Ostomy Continence Nurs. 2016;43(5):455-463. Published by Lippincott Williams & Wilkins The VCU Pressure Ulcer Summit Th e Search for a Clearer Understanding and More Precise Clinical Defi nition of the Unavoidable Pressure Injury Oscar M. Alvarez ¿ C. Tod Brindle ¿ Diane Langemo ¿ Karen Lou Kennedy-Evans ¿ Diane L. Krasner ¿ Mary R. Brennan ¿ Jeffrey M. Levine ABSTRACT This article reports the fi ndings of the Unavoidable Pressure Ulcer Committee (of the VCU Pressure Ulcer Summit) that was tasked with addressing key issues associated with pressure injuries that are unavoidable or unpreventable. Our goals were (1) to clarify nomenclature and descriptions surrounding “terminal ulceration,” (2) to describe the medical complications and comorbid conditions that can lead to skin failure and/or terminal ulceration, (3) to describe the variable possible causes of unavoidable pressure injuries, and (4) to present clinical cases to exemplify pressure injuries considered to be unavoidable. KEY WORDS: Charcot’s decubitus ominosus , Deep-tissue injury , Kennedy terminal ulcer , Pressure ulcers , Skin Changes at Life’s End (SCALE) , Skin failure , Trombley-Brennan terminal tissue injury , Unavoidable pressure injuries . INTRODUCTION enough pressure was removed from the external body, the skin cannot always survive; and (4) skin failure is not the same as Th e primary purpose of the VCU Pressure Ulcer Summit (held a pressure injury. It was also agreed that that there are clinical in March 2014) was to extend the process of ensuring quality scenarios and comorbid conditions that may make pressure healthcare delivery in pressure ulcer minimization spanning injury development unavoidable. Th ese include hemodynam- all healthcare settings, using the power of the Magnet model ic instability worsened with physical movement, inability to to unify and deliver a framework for change. 1 Th is article dis- maintain nutrition and hydration status, and the presence cusses fi ndings of a committee asked to review, better defi ne, of an advanced directive prohibiting artifi cial nutrition and and clinically describe conditions where pressure injury devel- hydration. opment is unavoidable. Th e NPUAP panelists reviewed existing defi nitions of Th e National Pressure Ulcer Advisory Panel (NPUAP) host- avoidable and unavoidable pressure injuries originally present- ed 2 consensus conferences, one was held in 2010 and a second ed in the Centers for Medicare & Medicaid Services Guidance in 2013, in an attempt to establish consensus around factors to Surveyors for Long Term Care Facilities. 4 Because the defi - related to unavoidable pressure injuries. 2 , 3 Unanimous consen- nition was specifi c to long-term care, the NPUAP advocat- sus was established for the following statements: (1) most (but ed expanding it to include all care settings. According to the not all) pressure injuries are avoidable; (2) pressure redistribu- NPUAP, an unavoidable pressure injury is one that develops tion surfaces cannot replace turning and repositioning; (3) if even though the provider has evaluated the patient’s clinical condition and pressure injury risk factors; defi ned and im- Oscar M. Alvarez, PhD, CCT, FAPWCA, Center for Curative and Palliative Wound Care, Calvary Hospital, Bronx, New York; and Department of Medicine, plemented interventions that are consistent with the patient’s New York Medical College, Valhalla. needs and goals, and formulated with recognized standards of C. Tod Brindle, MSN, RN, CWOCN, VCU Medical Center Wound Care Team, practice; monitored and evaluated the impact of interventions; Richmond, Virginia. and revised these approaches as appropriate. 3 Diane Langemo, PhD, RN, FAAN, University of North Dakota College of To the best of our knowledge, there are no defi nitive clinical Nursing, Grand Forks. studies that enable determination of which pressure injuries Karen Lou Kennedy-Evans, RN, FNP, APRN-BC, Kennedy, LLC, Tucson, are unavoidable. In addition, there are currently no validated Arizona. and reliable decision algorithms to determine unavoidability.4 Diane L. Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN, Harrisburg Th erefore, clinicians and other interested parties must rely area Community College–York Campus, York, Pennsylvania. on expert opinion. Etiologic factors associated with pressure Mary R. Brennan, MBA, RN, CWON, FACCWS, North Shore University injuries are pressure and shear, but they are hypothesized to Hospital, Manhasset, New York. interact with multiple contributing factors that add to the Jeffrey M. Levine, MD, AGSF, CWSP, Mount Sinai Beth Israel Hospital, Icahn complexity of pressure injury prevention and management. School of Medicine at Mount Sinai, New York. In the unavoidable pressure injury, pressure and/or shear are The authors declare no confl icts of interest. not the only causative factors; rather, other pathology exists Correspondence: Oscar M. Alvarez, PhD, CCT, FAPWCA, University Wound that specifi cally impairs the integrity of the skin. 3 It is the care Centers, 3175 East Tremont Ave, Bronx, NY 10461 ([email protected] ). opinion of this expert panel that, in most instances, preven- DOI: 10.1097/WON.0000000000000255 tive interventions can correct or improve factors involved in Copyright © 2016 by the Wound, Ostomy and Continence Nurses Society™ JWOCN ¿ September/October 2016 455 Copyright © 2016 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. 456 JWOCN ¿ September/October 2016 www.jwocnonline.com pressure-related skin uleration. However, circumstances do a clinician can expect to observe nonskin organ system failure exist where causative factors cannot be corrected or improved, and skin failure concurrently. rendering prevention unrealistic. Varon and Marik 18 further observed that the renal and re- Another challenge is attempting to defi ne whether unavoid- spiratory systems failed most frequently (89.7% each), fol- able pressure injurie are a separate entity or similar to previ- lowed by cardiac (34.5%), and hepatic systems (27.6%). Sep- ously described unavoidable ulcer development that occurs at sis was present in 62.1% of patients. Multiorgan failure was life’s end such as the Kennedy terminal ulcer (KTU), 7 Charcot’s also observed; 15 of 29 patients (51.7%) experienced failure of decubitus ominosus,8 Skin failure, 9 Trombley-Brennan termi- 3 organs or failure of 2 organs plus sepsis. Seventeen percent nal tissue injury (TB-TTI), 10 or Skin Changes at Life’s End experienced 2 organs failing in conjunction with skin failure. (SCALE). 11 Th is article provides an updated review of unavoid- Vasopressors were being administered to 69% of subjects, and able pressure injuries that have been identifi ed with end-of-life 37.9% were receiving 2 vasopressors. Th e researchers conclud- situations, along with pressure injuries occurring in the context ed that the skin does not fail on its own but is dependent on of permanent or temporary medical complications where pres- various others factors. In patients with renal failure, respirato- sure cannot be relieved and the skin (as an organ) fails. ry failure, or failure of more than 1 organ system other than skin, skin failure can be expected and therefore pressure inju- ries often develop that are probably unavoidable. PRESSURE ULCERS ASSOCIATED WITH TERMINAL Curry and associates 19 conducted a prospective, descriptive TISSUE INJURY OR SKIN FAILURE study of the characteristics associated with skin failure in crit- Skin failure was defi ned by Langemo and Brown as “an event ically ill adults. Th ey reported that the common sequence of in which the skin and underlying tissue die due to hypoper- failure of organs was usually respiratory, followed in order by fusion that occurs concurrently with severe dysfunction or hepatic, intestinal, and then renal. Deitch 20 reviewed 8 stud- failure of other organ systems.” 9 (p208) Patients who are criti- ies and concluded that the respiratory system commonly fails. cally ill with multiorgan failure (MOF) or mutliorgan dys- Initial respiratory failure may be partly attributable to compli- function syndrome (MODS) are at high risk for hypoper- cating factors of immobility imposed by intubation and ven- fusion resulting from microvascular dysfunction, increased tilator dependence. demand for oxygen, and vasoconstriction.3 , 9 Th is is only Lee and colleagues 21 retrospectively reviewed records of intensifi ed when MOF occurs concurrently with sepsis. In 3324 patients with a sacral pressure injury in order to identify addition, compromised skin integrity and skin failure are predictive risk factors related to diff erent stages of pressure in- associated with mortality. 12 juries. Th ey found that that 72% of patients with sacral pres- Individuals with MOF have decreased sympathetic vasomo- sure injuries were older than 65 years and more than 65% had tor tone and endothelial dysfunction, causing vasodilation and dysfunction of at least 1 organ or other major illness. A study hypotension. 13 , 14 While tissue blood fl ow may be increased, of 94,758 US residents who were discharged from hospital oxygen delivery to, and uptake by, the cells is diminished, 15 with a pressure injury also found a signifi cant association be- leading to hypoperfused tissue and compromised skin integ- tween ulcer formation and organ failure or serious infection. 22 rity. In a prospective study of 142 ICU patients, high APACHE-II Multiorgan dysfunction syndrome is defi ned as the pres- scale
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