Value of pressure injury assessment scales for patients in the intensive care unit: Systematic review and diagnostic test accuracy meta-analysis

ObjectivesTo review and examine the evidence of the value of pressure injury risk assessment scales in intensive care patients.Research methodologyWe searched MEDLINE, Embase, CINAHL, Web of Science, the Cochrane Library, China Biomedical Literature Service System, VIP Database and CNIK from inception to February 2019. Two reviewers independently assessed articles’ eligibility and risk of bias using the Quality Assessment of Diagnostic Accuracy Studies-II (QUADAS-2). We used a hierarchical summary receiver operating characteristics (HSROC) model to conduct the meta-analysis of diagnostic accuracy.ResultTwenty-four studies were included, involving 16 scales and 15,199 patients in intensive care settings. Results indicated that the top four risk assessment scales were the Cubbin & Jackson Index (SEN = 0.84, SPE = 0.84, AUC = 0.90), the EVRUCI scale (SEN = 0.84, SPE = 0.68, AUC = 0.82), the Braden scale (SEN = 0.78, SPE = 0.61, AUC = 0.78), the Waterlow scale (SEN = 0.63, SPE = 0.46, AUC = 0.56). The Norton scale and the other eleven scales were tested in less than two studies and need to be further researched.ConclusionThe Braden scale, most frequently used in hospitals, is not the best risk assessment tool for critically ill patients. The Cubbin & Jackson Index has good diagnostic test accuracy. However, low quality of evidence and important heterogeneity were observed.     

Predictors of pressure injury development in critically ill adults: A retrospective cohort study

ObjectiveThe purpose of this research was to identify predictors of pressure injury, using data from the electronic health records of critically ill adults.MethodologyA retrospective cohort study was conducted using logistic regression models to examine risk factors adjusted for age, gender, race/ethnicity and length of stay.SettingThe study cohort included 1587 adults in intensive care units within an urban academic medical centre.Main Outcome MeasuresThe presence or absence of a hospital-acquired pressure injury was determined during monthly skin integrity prevalence surveys. All pressure injuries were independently confirmed by two Certified Wound Care Nurses.ResultsEighty-one (5.1%) of the 1587 cohort patients developed pressure injuries. After adjusting for confounders, the clinical variables associated with pressure injury development included mean arterial pressure <60 mmHg and lowest Total Braden score up to two weeks prior to the date of HAPI development or date of prevalence survey for the comparison group.ConclusionsThis study provides a more comprehensive understanding about pressure injury risk in critically ill adults, identifying extrinsic and intrinsic factors associated with pressure injury development. Prospective multisite studies are needed to further examine these potential contributors to pressure injury development within the context of adherence to prevention interventions.     

Prevalence of pressure injuries among critically ill patients and factors associated with their occurrence in the intensive care unit: The PRESSURE study

BackgroundThe prevalence of pressure injuries (PIs) in critically ill patients has been extensively studied, but there is uncertainty regarding the risk factors. The main objective of this study was to describe the prevalence of PIs in critically ill patients. Secondary objectives were to describe PI, use of preventive measures for PI, and factors associated with occurrence of PI in the intensive care unit (ICU).Material and methodsThis was a 1-day point-prevalence study performed on a weekday in June 2017 in ICUs in France. On the same day, we noted the presence or absence of PI in all hospitalised patients of the participating ICUs, data on the ICUs, and the characteristics of patients and of PI.ResultsEighty-six participating ICUs allowed the inclusion of 1228 patients. The prevalence of PI on the study day was 18.7% (95% confidence interval: 16.6–21.0). PIs acquired in the ICU were observed in 12.5% (95% confidence interval: 10.6–14.3) of critically ill patients on the study day. The most frequent locations of PI were the sacrum (57.4%), heel (35.2%), and face (8.7%). Severe forms of PI accounted for 40.8% of all PIs. Antiulcer mattresses were used in 91.5% of the patients, and active and/or passive mobilisation was performed for all the patients. Multiple logistic regression analysis identified longer length of stay in the ICU, a higher Simplified Acute Physiology Score, higher body weight, motor neurological disorder, high-dose steroids, and absence of oral nutrition on the study day as factors independently associated with occurrence of PI in the ICU.ConclusionThis large point-prevalence study shows that PIs are found in about one of five critically ill patients despite extensive use of devices for preventing PI. Acquisition of PI in the ICU is strongly related to the patient's severity of illness on admission to the ICU and length of stay in the ICU.     

Predictive risk scales for development of pressure ulcers in pediatric patients admitted to general ward and intensive care unit

BACKGROUNDMore than ten special scales are available to predict the risk of pressure ulcers in children. However, the performances of those scales have not yet been compared in China. AIMTo compare the Waterlow, Braden Q, and Glamorgan scales, and identify more suitable pressure ulcer evaluation scale for the pediatric intensive care unit (PICU).METHODSTrained nurses used the Waterlow, Braden Q, and Glamorgan scales to assess pediatric patients at Sun Yat-sen Memorial Hospital (China) within 24 h of admission from May 2017 to December 2020 in two stages. Skin examination was carried out to identify pressure ulcers every 3 d for 3 wk. RESULTSThe incidence of pressure ulcers was 3/28 (10.7%) in the PICU and 5/314 (1.6%) in the general pediatric ward. For children in the general ward, the Waterlow, Braden Q, and Glamorgan scales had comparable area under the operating characteristic curve (AUC) of 0.870, 0.924, and 0.923, respectively, and optimal cut-off values of 14, 14, and 29 points. For PICU, the Waterlow, Braden Q, and Glamorgan scales had slightly lower AUC of 0.833, 0.733, and 0.800, respectively, and optimal cut-off values of 13, 16, and 27 points. Braden Q demonstrated a satisfactory specificity, and during the second stage of the study for PICU patients, the AUC of the Braden Q scale was 0.810, with an optimal cut-off value of 18.35 points.CONCLUSIONThe Waterlow, Braden Q, and Glamorgan scales have comparable performance, while the Braden Q scale demonstrates a better specificity and can be successfully used by pediatric nurses to identify patients at high risk of pressure ulcers in PICU.     

Predictive ability of the EVARUCI scale and COMHON index for pressure injury risk in critically ill patients: A diagnostic accuracy study

Background

Hospital-acquired pressure injuries are a costly and largely preventable complication occurring in a variety of acute care settings. Patients admitted to the intensive care unit are at greater risk of developing pressure injuries.

Factors associated with anxiety in critically ill patients: A prospective observational cohort study

BackgroundAnxiety is an unpleasant emotion that most intensive care patients experience. This emotion is an important issue in intensive care settings because of its prevalence, adverse effects and severity. Little is known about the factors associated with state and trait anxiety during critical illness.ObjectivesTo describe the patterns of state anxiety reported by intensive care patients, and identify factors associated with state and trait anxiety.DesignProspective observational cohort study.SettingsOne mixed intensive care unit in Brisbane, Australia.ParticipantsAdults (n = 141, ≥18 years) admitted to the intensive care unit for ≥24 h; able to communicate verbally or non-verbally; understand English; and, open their eyes spontaneously or in response to voice.MethodsOutcomes were state anxiety as measured by the Faces Anxiety Scale and trait anxiety as measured by the State-Trait Anxiety Inventory. Pre-intensive care factors tested for possible associations with both state and trait anxiety were: age, gender, marital status, employment status, level of education, smoking status, personality trait of optimism and evidence of mental health care/treatment. Intra-intensive care factors tested were: reason for admission to the intensive care unit, delirium, pain, airway status, hours of mechanical ventilation, severity of illness, days of stay in intensive care, exposure to corticosteroids, opioids, benzodiazepines, anxiolytics, antidepressants, beta-blockers, anaesthetic agents and analgesics; length of sedation and analgesia and total doses of sedatives and analgesics.ResultsOf 141 participants, 98 (70%) were male with an average age of 54 (standard deviation: ±15) years and stayed in intensive care for about 4 (Interquartile Range: 3–7) days. The majority (n = 115; 82%) of participants experienced state anxiety at least once during their stay in intensive care, with 57% reporting moderate to severe levels. Factors related to state anxiety in intensive care were pain and trait anxiety. Factors associated with trait anxiety were trait optimism, state anxiety, evidence of mental health care/treatment and age.ConclusionsThis study provides a better understanding of contributing factors for anxiety in the critically ill. Trait anxiety and state anxiety were significantly associated with each other, namely, patients who were anxious by nature experienced higher levels of state anxiety, which persisted throughout their stay in the intensive care unit. Recognising the importance of state and trait anxiety assessments using validated tools and determining ways to manage anxiety in the critically ill are critical aspects of the intensive care nurses role.     

ICU危重病患者血清酶活性与病情的关系

目的探讨ICU危重病患者 5种血清酶活性的变化及其与病情及预后的关系。方法检测 1 32例危重病患者血清ALT、AST、LDH、AKP、GGT的酶活性 ,其中合并多功能器官障碍综合征 (MODS)患者 60例 ,死亡 2 0例 ,并以 1 0 0例健康体检者作为正常对照组。结果危重病组ALT、AST、LDH、AKP、GGT明显高于正常对照组 (P <0 .0 1 ) ;MODS组与非MODS组 5种酶相比较 ,有显著性差异 ;死亡组又明显高于存活组 (P <0 .0 1 )。结论血清酶活性既可反映ICU危重病患者的病情及预后 ,又是早期判断MODS的重要指标。     

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

Aims and objectives: The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). Background: Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. Design: A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. Methods: A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patient‘s skin condition and stage of pressure ulcer. Results: Out of the 253 patients, 72 (28·4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41·7%), stage II (45·8%), stage III (10·4%) and stage IV (2·1%). In ICU B, the incidence was 31·6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut‐off score of 4. The area under the receiver‐operating characteristic curve was 0·888 (confidence interval: 0·84–0·93). Conclusion: The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.     

Heterogeneity hampers the identification of general pressure injury risk factors in intensive care populations: A predictive modelling analysis

ObjectiveTo determine risk factors for pressure injury in distinct intensive care subpopulations according to admission type (Medical; Surgical elective; Surgery emergency; Trauma/Burns).Methodology/designPredictive modelling using generalised linear mixed models with backward elimination on prospectively gathered data of 13 044 adult intensive care patients.Settings1110 intensive care units, 89 countries worldwide.Main outcome measuresPressure injury risk factors.ResultsA generalised linear mixed model including admission type outperformed a model without admission type (p = 0.004). Admission type Trauma/Burns was not withheld in the model and excluded from further analyses. For the other three admission types (Medical, Surgical elective, and Surgical emergency), backward elimination resulted in distinct prediction models with 23, 17, and 16 predictors, respectively, and five common predictors only. The Area Under the Receiver Operating Curve was 0.79 for Medical admissions; and 0.88 for both the Surgical elective and Surgical emergency models.ConclusionsRisk factors for pressure injury differ according to whether intensive care patients have been admitted for medical reasons, or elective or emergency surgery. Prediction models for pressure injury should target distinct subpopulations with differing pressure injury risk profiles. Type of intensive care admission is a simple and easily retrievable parameter to distinguish between such subgroups.     

Hypophosphatemia in critically ill patients

Purpose

The aim of this study was to assess the association of phosphate concentration with key clinical outcomes in a heterogeneous cohort of critically ill patients.

Materials and Methods

This was a retrospective observational study at a general intensive care unit (ICU) of an Australian university teaching hospital enrolling 2730 adult critically ill patients.

Results

We studied 10?504 phosphate measurements with a mean value of 1.17 mmol/L (measurements every 28.8 hours on average). Hyperphosphatemia (inorganic phosphate [iP] concentration > 1.4 mmol/L) occurred in 45% and hypophosphatemia (iP ≤ 0.6 mmol/L) in 20%. Among patients without any episodes of hyperphosphatemia, patients with at least 1 episode of hypophosphatemia had a higher ICU mortality than those without hypophosphatemia (P = .004). In addition, ICU nonsurvivors had lower minimum phosphate concentrations than did survivors (P = .009). Similar results were seen for hospital mortality. However, on multivariable logistic regression analysis, hypophosphatemia was not independently associated with ICU mortality (adjusted odds ratio, 0.86 [95% confidence interval, 0.66-1.10]; P = .24) and hospital mortality (odds ratio, 0.89 [0.73-1.07]; P = .21). Even when different cutoff points were used for hypophosphatemia (iP ≤ 0.5, 0.4, 0.3, or 0.2 mmol/L), hypophosphatemia was not an independent risk factor for ICU and hospital morality. In addition, timing of onset and duration of hypophosphatemia were not independent risk factor for ICU and hospital mortality.

Conclusions

Hypophosphatemia behaves like a general marker of illness severity and not as an independent predictor of ICU or in-hospital mortality in critically ill patients.     

Intra-abdominal hypertension in the critically ill: Interrater reliability of bladder pressure measurement

Purpose

Intra-abdominal hypertension is frequently underdiagnosed and defined by intra-abdominal pressure (IAP) 12 mm Hg or higher. Increasing IAP may compromise organ viability and culminate in abdominal compartment syndrome. Bladder pressure measurement is a surrogate for IAP, but measurement properties are unknown in the intensive care unit. Our primary objective was to assess the agreement of bladder pressure measurements in critically ill patients.

Methods

We conducted an observational study examining the correlation of measurement variability of bladder pressure. Four raters (2 nurses and 2 physicians) measured IAP. Patient's age, Acute Physiology and Chronic Health Evaluation II, body mass index, mechanical ventilation parameters, and demographics were collected.

Results

Fifty-one patients had bladder pressures measured in quadruplicate, producing 204 measurements. Among 51 patients, the mean age was 61.9 years, Acute Physiology and Chronic Health Evaluation II was 23.8, and body mass index was 27.8 kg/m². The average bladder pressure was 12.4 (SD, ± 6.2) mm Hg. The interrater agreement by intraclass correlation coefficient was 0.745 (95% confidence interval [CI], 0.637-0.825), 0.804 (95% CI, 0.684-0.882), and 0.626 (95% CI, 0.428-0.767) among all raters, physicians, and nurses, respectively.

Conclusions

Agreement on bladder pressure was high among 4 clinicians and were not significantly different between physicians and nurses. Given that medical/surgical treatments are considered on bladder pressure values, understanding their reliability is essential to monitor critically ill patients.     

Etiology of troponin elevation in critically ill patients

Purpose

The aim of this study was to assess the etiology of cardiac troponin elevation among patients admitted to the intensive care unit (ICU) and to examine whether etiology affects mortality and length of stay.

Methods

All patients admitted over 2 months underwent screening with troponin measurements and were included if 1 or more measurements were elevated. Two adjudicators retrospectively reviewed patient charts to determine the likely cause of troponin elevation.

Results

Of 103 patient admissions, 52 (50.5%) had 1 or more elevated troponin measurements, and 49 (94.2%) had medical charts available for review. Troponin elevation was adjudicated as myocardial infarction (MI) in 53.1% of patients, sepsis in 18.4%, renal failure in 12.2%, and other causes in 16.3%. Overall ICU mortality was 16.0%; 2.0% for patients with no troponin elevation, 23.1% in patients with MI, and 39.1% in patients with troponin elevation not due to MI. Having an elevated troponin level not due to MI was significantly associated with increased hospital mortality compared with having no troponin elevation.

Conclusions

The most common cause of troponin elevation among critically ill patients was MI. Patients with elevated troponin had worse outcomes compared with patients without troponin elevation, and troponin elevation not due to MI was predictive of increased hospital mortality.     

Eye care for the critically ill

Purpose: To evaluate the effectiveness and efficiency of an algorithm in the prevention of ocular surface disease in sedated and unconscious patients in the intensive care unit (ICU).¶Methods: The eyes of all sedated and unconscious patients admitted to an ICU between September and December 1998 were managed according to an eye care algorithm. The applications of the preventive measures were assessed by a single observer twice weekly. The lid position, the presence and degree of keratopathy, sedation score, and the treatment received were documented at every assessment.¶Results: Thirty-four patients were recruited for management according to the eye care algorithm over a period ranging from 1 to 28 days. Four patients were excluded because of failure by staff to adhere to the protocol. In 18 patients no active treatment was required. Out of six patients who had conjunctival exposure and were given ocular lubricants, four maintained clear corneas. No corneal or conjunctival staining was noted in two of the four patients whose lids required closure with Micropore tape for corneal exposure. Use of lid taping and lubricants prevented corneal abrasion in two patients who were prone ventilated. The prevalence of ocular surface abnormalities was 8.7 % where the algorithm was properly followed (23 patients).¶Conclusion: The proposed eye care algorithm appears to be effective in preventing ocular surface abnormalities in the sedated and unconscious patients in the ICU, and efficient in that it may reduce the workload required for critically ill patients.     

Risk factors for delirium after surgery for craniocerebral injury in the neurosurgical intensive care unit

BACKGROUNDPostoperative delirium is common in patients who undergo neurosurgery for craniocerebral injury. However, there is no specific medical test to predict postoperative delirium to date.AIMTo explore risk factors for postoperative delirium in patients with craniocerebral injury in the neurosurgery intensive care unit (ICU). METHODSA retrospective analysis was performed in 120 patients with craniocerebral injury admitted to Hainan People’s Hospital/Hainan Hospital Affiliated to Hainan Medical University, The First Affiliated Hospital of Hainan Medical University, and The Second Affiliated Hospital of Hainan Medical University between January 2018 and January 2020. The patients were categorized into groups based on whether delirium occurred. Of them, 25 patients with delirium were included in the delirium group, and 95 patients without delirium were included in the observation group. Logistic regression analysis was used to explore the association between sex, age, educational level, Glasgow coma scale (GCS), complications (with or without concussion, cerebral contusion, hypoxemia and ventricular compression) and site of injury and delirium. RESULTSThe GCS score above 8 and concomitant disease of cerebral concussion, cerebral contusion, hypoxemia and ventricular compression, and damage to the frontal lobe were associated with delirium in patients admitted to neurosurgical intensive care unit (ICU) (all P < 0.05). However, age, sex, administration more than three medicines, and educational level were not significantly associated with the onset of delirium in patients with craniocerebral injury in the neurosurgical ICU (P < 0.05). Multivariate logistic regression analysis showed that GCS score above 8, cerebral concussion, cerebral contusion, hypoxemia, ventricle compression, and frontal lobe disorders were independent risk factors for delirium in patients with craniocerebral injury in the neurosurgical ICU (P < 0.05).CONCLUSIONGCS score, concussive concussion, cerebral contusion, hypoxemia, ventricle compression, and damage to frontal lobe are risk factors of postoperative delirium.     

手术患者压力性损伤风险评估工具的多中心测评研究

目的：检验手术患者压力性损伤风险评估工具在多中心临床应用的信效度及预测能力,并与Waterlow量表进行临床应用效果的对比。方法：采用配额抽样方法,选取2020年7月至12月天津市4所三级甲等医院530例全麻手术患者作为研究对象,对手术患者压力性损伤风险评估工具进行信效度检测,并与Waterlow量表进行压力性损伤风险预测能力的比较。结果：手术患者压力性损伤风险评估工具在手术前、手术后2个阶段的Cronbach’s α系数分别为0.809、0.804;平均量表水平的内容效度指数为0.905;旋转变换累积方差贡献率显示,12个条目均在8%左右,有较强的稳定性,特征值>1的条目累积方差贡献率为75.5%;其术前、术后ROC曲线下面积分别为0.722、0.732;Waterlow量表ROC曲线下面积为0.574。结论：手术患者压力性损伤风险评估工具有较好的信效度和预测能力,可有效判断手术患者压力性损伤风险程度,具有手术患者普适性特点,为手术室压力性损伤同质化预防管理奠定了基础。     

Bedside colonoscopy for critically ill patients with acute lower gastrointestinal bleeding

Objective: To determine the clinical impact of bedside colonoscopy for critically ill patients with acute lower gastrointestinal (GI) bleeding. Design and setting: A 3-year retrospective analysis (chart review). Medical intensive care unit (ICU) of a 1,312-bed tertiary-care center in Taiwan. Patients and participants: Fifty-five people undergoing bedside colonoscopy for lower GI bleeding that developed while in the ICU. Interventions: Bedside colonoscopy. Measurements and results: Colonoscopy was successful in diagnosing the source of bleeding in 37 patients. Among them, colitis (15 patients, including ischemic, pseudomembranous, or radiation-induced) and acute hemorrhagic rectal ulcer (nine patients) were the most frequent confirmed causes. In seven patients, fresh blood was noticed above the colonoscopically accessible area and considered to originate from the small bowel. No adverse event was associated with colonoscopy. Spontaneous cessation of bleeding was noted in 29 (29/55, 53%) patients, whereas 16 (16/55, 29%) achieved endoscopic hemostasis. Ten (10/55, 18%) patients failed primary hemostasis or localization. Overall in-hospital mortality was 53% (29/55); however, hemorrhage-related death occurred in only two patients. Conclusions: ICU patients with acute lower GI bleeding have distinctive causes. Bedside colonoscopy is effective for diagnosis in two-thirds of patients, but only a minority of them needs endoscopic hemostasis.     

Assessment of a modified 4T scoring system for heparin-induced thrombocytopenia in critically ill patients

Purpose

The purpose of the study is to determine if a modified 4T (m4T) scoring system, which omits clinical evaluation of other thrombocytopenic etiologies, is different from the 4T scoring system's probability to predict a positive heparin-induced thrombocytopenia (HIT) laboratory test in the intensive care unit.

Materials and methods

This is a single-centered retrospective analysis of critically ill adults who had an enzyme-linked immunosorbent assay antiplatelet factor 4 antibody (ELISA anti-PF4 Ab) ordered. Patients were identified as HIT positive (optical density, ≥ 0.40) or HIT negative (optical density, < 0.40) based on the ELISA anti-PF4 Ab. Both 4T and m4T scores were calculated, and the diagnostic accuracy was compared using paired receiver operating characteristic curves.

Results

A total of 1487 adult intensive care unit patients with an ELISA anti-PF4 Ab ordered between January 2007 and December 2009 were eligible for study enrollment. Application of exclusion criteria and random selection yielded a total of 232 patients included for analysis (58 HIT-positive and 174 HIT-negative patients). The area under the curve for the 4T and m4T scores were 0.683 (95% confidence interval, 0.604-0.762) and 0.680 (95% confidence interval, 0.600-0.759), respectively (P = .065).

Conclusion

This study does not show a difference in the probability of the m4T and 4T scoring systems to predict a positive ELISA anti-PF4 Ab test in the critically ill patient population. Further prospective studies are needed to validate the m4T scoring system.     

手术患者术中压力性损伤评估框架的构建研究

目的：构建手术患者术中压力性损伤风险评估框架,为制定术中压力性损伤风险评估工具提供科学依据。方法：通过文献查询、现状调查和德尔菲函询法,对来自7个地区与压力性损伤研究相关的22名专家进行两轮函询。结果：手术患者术中压力性损伤风险评估内容,结构上包括术前风险评估阶段、术后风险评估阶段;内容包括患者固有因素7项、手术因素6项（术前为预计性评估、术后为实际性评价）;本研究专家的可靠性及权威性较高,两轮专家函询有效回收率分别为100%、95.4%,专家的权威系数分别为0.801、0.832,专家的肯德尔和谐系数分别为0.335、0.458。结论：本研究初步构建了清点单式术中压力性损伤风险评估工具的框架,为临床术中压力性损伤风险评估工具的制订奠定了基础。