Respiratory/VentilationPressure ulcer incidence and risk factors in ventilated intensive care patients
Introduction
Pressure ulcers (PUs) pose a major health care challenge and are associated with an increased risk of infection and sepsis [1], disability, high level of dependence [2], longer hospital stay, and higher hospitalization costs [2], [3], [4]. Their reported incidence in critical care patients varies widely from 1% to 56%, which can be attributed to differences in clinical settings, study populations, methodology, and the definition of a PU [5], [6], [7], [8], [9], [10]. More than 100 risk factors for the development of PUs in a general hospital population have been identified in the literature [3]. Critical care patients usually have multiple risk factors for a PU, which tends to have a greater effect in this patient population [6], [8], [11]. The risk of a PU varies among intensive care unit (ICU) patients and is higher in some subgroups, especially those on mechanical ventilation (MV) [12]. Some characteristics of patients who require MV make them especially susceptible to the development of PUs, including mobility limitations; loss of sensory perception due to sedation and analgesia; maceration of skin due to incontinence, sweating, or leaking wounds; and frequent hemodynamic and oxygenation disorders. Nevertheless, the importance of the different risk factors implicated remains controversial [6], [12].
Pressure ulcer prevention can often be successful and is less costly than the treatment of established ulcers [13]. The first step is to correctly identify the patients at risk, but available PU risk assessment scales are not useful to discriminate the risk of PU in critical or other hospitalized patients [6], [14], [15]. New scales have been proposed for ICU patients, but these have not been validated [16], [17]. Few studies have been published on the incidence of PU in ventilated patients, a high-risk group [18], [19], and none have analyzed their specific risk factors. Information on PU incidence and risk factors in patients on MV may be especially useful for the early and appropriate implementation of preventive measures, with the consequent costs savings [13]. With this background, the objectives of this study were to determine the incidence of PUs (≥grade II) in subjects receiving MV for more than 24 hours and to prospectively identify the main risk factors for the development of PUs by these patients in the ICU.
Section snippets
Methods
This prospective cohort study was conducted in all 9 ICUs (94 beds) in the 5 hospitals in Granada province (Spain) from January to March and June to July 2001, for a total of 5 months. The study was approved by the ethical committees of participating hospitals who waived the need for written informed consent.
We included all patients on MV with either endotracheal intubation or noninvasive ventilation for more than 24 hours during their ICU stay. Exclusion criteria were pregnancy and age greater
Patient characteristics
Of the total of 1563 patients admitted to the ICU during the 5 months of the study, 299 patients (19%) required MV for 24 hours or more and were enrolled in the study. None of these patients were lost to follow-up. Table 1, Table 2 show the demographic and clinical characteristics of the patients. The mean (SD) age was 60 (17) years, 68% were male, and the mean (SD) APACHE III score was 71 (26) points. The median time on MV was 5 days (IQR, 2-13), and the mean (SD) time was 10 (15) days. The
Discussion
In this series of 299 patients requiring MV for more than 24 hours, the incidence density of PUs (≥grade II) was 13.4 cases per 1000 patient-days of ICU stay. Various independent predictors of PU development were identified, including higher age, worse first-day respiratory SOFA score, worse fourth-day cardiovascular SOFA score, and, interestingly, the winter season and duration of MV.
Acknowledgments
This study would have not been possible without the collaboration of the nursing staff in participating ICUs.
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See Appendix A.