Turning and Repositioning the Critically Ill Patient With Hemodynamic Instability

Abstract

In the critical care population, heart rate and rhythm, blood pressure, respiratory rate, and oxygen saturation are monitored continuously, providing immediate feedback regarding any changes in patient status. Hemodynamic instability is a term commonly used by clinicians to describe labile changes in cardiopulmonary status, although this term is poorly defined in the literature. The clinician's perception of hemodynamic instability may cause a delay or omission in turning, repositioning, and other interventions to advance patient mobility and may contribute to pressure ulcer formation. The intensive care unit's practice culture and individual clinician perceptions regarding hemodynamic instability may lead to staff not turning patients out of fear that they are "too unstable to turn." This article provides a discussion of the link between pressure ulcers and immobility, provides a review of current literature on progressive mobility and hemodynamic instability, and presents the results of a critical care consensus panel on safe and effective turning of critical care patients.

Vasopressors and Development of Pressure Ulcers in Adult Critical Care Patients

“…Persistent hypotension in combination with administration of a vasopressor may also be a warning sign that a patient is experiencing prolonged diminished perfusion to the skin, elevating the risk for pressure ulcers. Although repositioning strategies can be implemented in patients with unstable hemodynamic status, 36 the success of the intervention depends on stabilization of blood pressure after a position change. Caregivers should be aware that the potential damage to the skin due to hypotension may be nonmodifiable in some instances, even with the use of current evidence-based prevention strategies, because the underlying condition (hypotension refractory to vasopressors) cannot be successfully abated.…”

“…18 (13) 13 (3) 103 (39) 162 (61) (n = 119) 43 (36) 76 (64) 37 (14) 2 (1) 33 (12) 93 (35) 22 (8) 206 (78) 56 (21) 2 (4) 53 (20) 74 (10) 20 (12) 3 (6) 15 (10) 4 (10) 74 (23) 8 (5) (n = 19) 15 (4) 12 (2) 6 (15) 35 (85) (n = 31)…”

Five-Layered Soft Silicone Foam Dressing to Prevent Pressure Ulcers in the Intensive Care Unit

“…40,41 Thus, before deploying any dressings to help prevent pressure ulcers, testing is essential to determine if the dressing could reduce the deleterious effects of moisture, pressure, and shear on the body. [41][42][43] Brindle and colleagues [44][45][46] reported on a quality improvement project that used a 5-layer soft silicone foam dressing in which a reduction in sacral pressure ulcer formation in patients in a surgical ICU was noted. Several other nonrandomized trials using concurrent controls or historical controls also showed reductions in the occurrence of sacral pressure ulcers in critically ill patients.…”

Against All Odds: Preventing Pressure Ulcers in High-Risk Cardiac Surgery Patients

“…Risk factors for decubitus ulcers include mechanical ventilation, immobility, use of vasopressors, multiple comorbid conditions, spinal cord injury, severe illness, increased length of hospital stay, impaired nutrition, older age, low body mass index, diabetes, and renal insufficiency. 2,3 Medical device-related pressure ulcers are injuries associated with therapeutic or diagnostic devices. These pressure ulcers are most frequently found in ICUs, where continuous and invasive monitoring is essential.…”

“…A description of our techniques for turning high-risk ICU patients and consensus recommendations from a panel of critical care-certified clinicians has been published. 3 Efforts to protect other pressure points require equal attention during times of hemodynamic instability. Fluidized positioners are used to protect the occiput, repositioning the head at regular intervals.…”