Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

The predictive value of perioperative inflammatory parameters measurements in patients with shin injury

Namen dela Z raziskavo smo želeli ugotoviti ali lahko natančno izdelan protokol določanja biokemičnih in imunskovnetnih laboratorijskih pokazateljev v perioperativnem obdobju izboljša pooperativni nadzor poškodovanca po operaciji zloma goleni, olajša izbiro ustreznega antibiotičnega zdravljenja in pomaga pri odločanju o nujnosti revizijskega kirurškega posega. Zanimalo nas je, kateri pokazatelj v perioperativnem obdobju najbolje napoveduje nastanek popoškodbenega osteitisa po visokoenergetskem zlomu goleni. Izhodišča Popoškodbeni osteitis (PO) je resen zaplet, ki se pojavi v 0,4 % – 7 % travmatoloških in ortopedskih operativnih posegov. Visokoenergetska poškodba goleni je ena izmed najpogostejših poškodb dolgih cevastih kosti v cestnem prometu, padcu z višine ali delovnih poškodbah. Poškodba prizadene mehkotkivno ovojnico goleni in povzroči zapletene zlome. Nastane obsežna oteklina, izliv krvi in mrtvina mehkih tkiv goleni, kar omogoči vdor in razrast prisotnih ali s poškodbo vnešenih bakterij, ki povzročijo okužbo. Sekundarne poškodbe med kirurškim posegom s hematomi, oteklino tkiv in uporabo vsadkov za učvrstitev kosti dodatno prispevajo k razvoju okužbe kosti. Nastanek okužbe kosti pri poškodovancu je posledica primarnega vnosa povzročitelja ob poškodbi pri odprtem zlomu in sekundarnega vnosa pri zaprtem zlomu po odprti naravnavi in notranji učvrstitvi zloma (ang. open reduction and internal fixation-ORIF). Zgodnja prepoznava okužbe kosti je pomembna, da se izognemo hudim kasnejšim zapletom. Diagnosticiranje potekajoče okužbe kosti je težavno, saj nimamo visoko specifičnega in očutljivega laboratorijskega testa. Serumski označevalci vnetja C-reaktivni protein (CRP), prokalcitonin (PCT) in koncentracija belih krvničk lahko podprejo klinični sum, vendar ne razlikujejo z visoko specifičnostjo in občutljivostjo med sočasnim vnetnim odzivom na okužbo in sistemskim odzivom gostitelja na poškodbo ter operativni poseg. Metode in preiskovanci V prospektivno opazovalno raziskavalno študijo smo vključili 86 poškodovancev sprejetih na Klinični oddelek za travmatologijo Univerzitetnega kliničnega centra v Ljubljani od januarja 2012 do decembra 2014 z visokoenergetsko poškodbo goleni po opravljeni odprti repoziciji in notranji učvrstitvi zloma goleni. Vrednosti imunskovnetnih in biokemičnih laboratorijskih pokazateljev smo izmerili ob sprejemu (SPR), prvi pooperativni dan (POD1) in četrti pooperativni dan (POD4). Rezultati Od vključenih 86 poškodovancev je bilo 20 poškodovancih s PO, 11 poškodovancev po odprtem zlomu (55%) in 9 poškodovancev po zaprtem zlomu goleni (45%). Najpogostejše mesto zloma je bila diafiza golenice in nato spodnji del golenice, ki je bil tudi najbolj dovzeten predel za nastanek PO. Politravmatizirani poškodovanci in poškodovanci s pridruženimi zlomi so z večjo verjetnostjo razvili PO po zlomu goleni. Na našem vzorcu smo ugotovili povezanost vrednosti CRP ob SPR, POD1 in albuminov na POD4 z nastankom PO. Pri klinični presoji razvoja PO moramo upoštevati še druge pomembne dejavnike tveganja: obseg poškodbe mehkih tkiv, pridružene multiple zlome, prejetje večih odmerkov transfuzij krvi, konverzijo zunanjega fiksaterja v dokončno osteosintezo. Zaključki Zdravljenje popoškodbenega osteitisa po zlomu goleni lahko izboljšamo s perioperativnim določanjem laboratorijskega označevalca vnetja CRP v kombinaciji z določanjem pooperativne vrednosti serumskih albuminov in ob upoštevanju dejavnikov tveganja. Perioperativna dinamika CRP, še posebaj značilen porast prvi operativni dan glede na raven ob sprejemu in nizka vrednost albminov četrti pooperativni dan, morata biti resen opozorilni znak za lečečega kirurga, da oceni dejavnike tveganja in opravi revizijo. Nadaljne raziskave na večjem vzorcu bi lahko določile pomen razširjene periopetativne diagnostike za preventivo zgodnje okužbe po zlomu goleni.Aim The objectives of the study were to investigate whether the biochemical and immunoinflammatory patient profile could facilitate postoperative monitoring, guide the antibiotic treatment and timing of revision surgery. Background Posttraumatic osteomyelitis (PO), occuring in 0.4 to 7% operations performed in orthopaedic and trauma surgery, is a major and serious complication. One of the most common injuries sustained after road traffic accidents is a tibial fracture. The force necessary to produce fracture also means considerable soft-tissue injury, with oedema, necrosis, hematoma and foreign bodies that potentiate bacterial virulence. Secundary injuries during surgical procedures with hematoma, tissue oedema and utilisation of implants for ostheosynthesis also contribute to the development of bone infection. Bone infection morbidity is principally the consequence of sustained primary contamination at presentation in open fracture and secondary contamination in closed fracture patients that underwent open reduction and internal fixation (ORIF). Early diagnosis of acute posttraumatic osteomyelitis (PO) is of vital importance for avoiding devastating complications. Diagnosing PO is difficult due to the lack of a highly specific and sensitive test, such as in myocardial infarct, stroke and intracranial bleeding. Serum inflammatory markers, C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC) can support clinical findings but they are not able to differentiate between inflammatory response to infection and the host response to non-infection insult with high specificity and sensitivity. Methods and patients This prospective nonrandomised cohort study included 86 patients after high-energy injury to the shin requiring primary surgical treatment ORIF addmited to Klinični oddelek za travmatologijo Univerzitetnega kliničnega centra v Ljubljani from January 2012 to December 2014. Values of the biochemical and immunoinflammatory profile were measured on admission (ADD), first-postoperative day (POD1) and fourth-postoperative day (POD4). Results 20 patients developed PO of total of 86 patients included in the present study, 11 after open fracture (55%) and 9 after closed fracture (45%). The most frequent site of fracture was tibial shaft fracture followed by distal tibial Pilon fracture. In the PO group, distal tibia was predilection site of infection. Multiple sites fractured and polytraumatized patients were more likely to develop PO. We discovered on our sample that the development of PO is associated with increased CRP on ADD, POD1 and decreased albumins on POD4. The assessment of other important risk factors such as: the extent of soft tissue damage, multiple fractures, transfusion rate, need for conversion primary external fixation to intramedullary (IM) nailing or locking plate fixation can empower our clinical judgment of PO. Conclusions We can improve prediction of posttraumatic osteomyelitis by using the perioperative inflammatory biomarker CRP in combination with postoperative albumins levels and other associated independent risk factors. Further studies are needed to prove that these differences can be useful in diagnosing the risk of infection

Effects of positive end-expiratory pressure on cerebral hemodynamics in acute brain injury patients.

Peer reviewed: TrueAcknowledgements: The authors would like to thank the Italian Ministero della Salute for the support.Background: Cerebral autoregulation is the mechanism that allows to maintain the stability of cerebral blood flow despite changes in cerebral perfusion pressure. Maneuvers which increase intrathoracic pressure, such as the application of positive end-expiratory pressure (PEEP), have been always challenged in brain injured patients for the risk of increasing intracranial pressure (ICP) and altering autoregulation. The primary aim of this study is to assess the effect of PEEP increase (from 5 to 15 cmH2O) on cerebral autoregulation. Secondary aims include the effect of PEEP increase on ICP and cerebral oxygenation. Material and Methods: Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP monitoring and undergoing multimodal neuromonitoring including ICP, cerebral perfusion pressure (CPP) and cerebral oxygenation parameters obtained with near-infrared spectroscopy (NIRS), and an index which expresses cerebral autoregulation (PRx). Additionally, values of arterial blood gases were analyzed at PEEP of 5 and 15 cmH2O. Results are expressed as median (interquartile range). Results: Twenty-five patients were included in this study. The median age was 65 years (46-73). PEEP increase from 5 to 15 cmH2O did not lead to worsened autoregulation (PRx, from 0.17 (-0.003-0.28) to 0.18 (0.01-0.24), p = 0.83). Although ICP and CPP changed significantly (ICP: 11.11 (6.73-15.63) to 13.43 (6.8-16.87) mm Hg, p = 0.003, and CPP: 72.94 (59.19-84) to 66.22 (58.91-78.41) mm Hg, p = 0.004), these parameters did not reach clinically relevant levels. No significant changes in relevant cerebral oxygenation parameters were observed. Conclusion: Slow and gradual increases of PEEP did not alter cerebral autoregulation, ICP, CPP and cerebral oxygenation to levels triggering clinical interventions in acute brain injury patients

Effects of short-term hyperoxemia on cerebral autoregulation and tissue oxygenation in acute brain injured patients.

Peer reviewed: TrueAcknowledgements: The authors would like to thank the Italian Ministero della Salute for the support.Introduction: Potential detrimental effects of hyperoxemia on outcomes have been reported in critically ill patients. Little evidence exists on the effects of hyperoxygenation and hyperoxemia on cerebral physiology. The primary aim of this study is to assess the effect of hyperoxygenation and hyperoxemia on cerebral autoregulation in acute brain injured patients. We further evaluated potential links between hyperoxemia, cerebral oxygenation and intracranial pressure (ICP). Methods: This is a single center, observational, prospective study. Acute brain injured patients [traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH)] undergoing multimodal brain monitoring through a software platform (ICM+) were included. Multimodal monitoring consisted of invasive ICP, arterial blood pressure (ABP) and near infrared spectrometry (NIRS). Derived parameters of ICP and ABP monitoring included the pressure reactivity index (PRx) to assess cerebral autoregulation. ICP, PRx, and NIRS-derived parameters (cerebral regional saturation of oxygen, changes in concentration of regional oxy- and deoxy-hemoglobin), were evaluated at baseline and after 10 min of hyperoxygenation with a fraction of inspired oxygen (FiO2) of 100% using repeated measures t-test or paired Wilcoxon signed-rank test. Continuous variables are reported as median (interquartile range). Results: Twenty-five patients were included. The median age was 64.7 years (45.9-73.2), and 60% were male. Thirteen patients (52%) were admitted for TBI, 7 (28%) for SAH, and 5 (20%) patients for ICH. The median value of systemic oxygenation (partial pressure of oxygen-PaO2) significantly increased after FiO2 test, from 97 (90-101) mm Hg to 197 (189-202) mm Hg, p < 0.0001. After FiO2 test, no changes were observed in PRx values (from 0.21 (0.10-0.43) to 0.22 (0.15-0.36), p = 0.68), nor in ICP values (from 13.42 (9.12-17.34) mm Hg to 13.34 (8.85-17.56) mm Hg, p = 0.90). All NIRS-derived parameters reacted positively to hyperoxygenation as expected. Changes in systemic oxygenation and the arterial component of cerebral oxygenation were significantly correlated (respectively ΔPaO2 and ΔO2Hbi; r = 0.49 (95% CI = 0.17-0.80). Conclusion: Short-term hyperoxygenation does not seem to critically affect cerebral autoregulation

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study (Intensive Care Medicine, (2021), 47, 2, (160-169), 10.1007/s00134-020-06234-9)

The original version of this article unfortunately contained a mistake. The members of the ESICM Trials Group Collaborators were not shown in the article but only in the ESM. The full list of collaborators is shown below. The original article has been corrected