Vasopressors and Development of Pressure Ulcers in Adult Critical Care Patients

Abstract

Background Vasopressors are lifesaving agents used to raise mean arterial pressure in critically ill patients in shock states. The pharmacodynamics of these agents suggest vasopressors may play a role in development of pressure ulcers; however, this aspect has been understudied. Objective To examine associations between type, dose, and duration of vasopressors (norepinephrine, epinephrine, vasopressin, phenylephrine, dopamine) and development of pressure ulcers in medical-surgical and cardiothoracic intensive care unit patients and to examine predictors of the development of pressure ulcers in these patients. Methods A retrospective correlational design was used in a sample of 306 medical-surgical and cardiothoracic intensive care unit patients who received vasopressor agents during 2012. Results Norepinephrine and vasopressin were significantly associated with development of pressure ulcers; vasopressin was the only significant predictor in multivariate analysis. In addition, mean arterial pressure less than 60 mm Hg in patients receiving vasopressors, cardiac arrest, and mechanical ventilation longer than 72 hours were predictive of development of pressure ulcers. Patients with a cardiac diagnosis at the time of admission to the intensive care unit were less likely than patients without such a diagnosis to experience pressure ulcers while in the unit. Conclusion The addition of vasopressin administered concomitantly with a first-line agent (often norepinephrine) may represent the point at which the risk for pressure ulcers escalates and may be an early warning to heighten strategies to prevent pressure ulcers. Conversely, because vasopressors cannot be terminated to avert development of pressure ulcers, these findings may add to the body of knowledge on factors that potentially contribute to the development of unavoidable pressure ulcers.

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

“…[10][11][12][13] Some physiological (intrinsic) and nonphysiological (extrinsic) risk factors that may place adults at risk for pressure ulcer development are advanced age; comorbid conditions including diabetes mellitus, peripheral vascular disease, cerebral vascular accident, sepsis, cardiovascular disease, and hypotension; severity of illness (as indicated by Acute Physiology and Chronic Health Evaluation [APACHE] IV score) 14 ; and iatrogenic factors such as the use of vasopressors. 11,12,15 A hypothesis exists that these physiological risk factors place the patients at risk because of impairment of the microcirculation system. 16 Microcirculation is controlled in part by central sympathetic vasoconstrictor impulses from the brain and secretions from localized endothelial cells.…”

“…Because neural and endothelial control of blood flow is impaired during an illness state, the patient may be more susceptible to ischemic organ damage (eg, pressure ulcers). [15][16][17] Additional risk factors that have been correlated with pressure ulcer development are smoking history, dry skin, low body mass index, impaired mobility, altered mental status (ie, confusion), urinary and fecal incontinence, and malnutrition. 15,17,18 Although research has indicated that many of these factors are significantly related to the development of HAPUs in ICU patients, the findings were not consistent in all of the studies in which these relationships were tested.…”

“…[15][16][17] Additional risk factors that have been correlated with pressure ulcer development are smoking history, dry skin, low body mass index, impaired mobility, altered mental status (ie, confusion), urinary and fecal incontinence, and malnutrition. 15,17,18 Although research has indicated that many of these factors are significantly related to the development of HAPUs in ICU patients, the findings were not consistent in all of the studies in which these relationships were tested. 19,20 This inconsistency may in part be associated with the lack of valid risk assessment tools 21,22 specifically for critically ill patients, noted most recently by Richardson and Barrow.…”

“…30 The correlation between a low score on the Braden Scale (high risk) and HAPU development among critically ill patients is well established. [7][8][9][14][15][16][20][21][22][23][24][25][26][27][28][29][30] These patients are often exposed to pressure from being immobile and unconscious, thus unable to change positions independently. [4][5][6][7][8][9][31][32][33][34] Shear forces are present on the sacrum from head-of-bed elevation with mechanical ventilation.…”

“…[4][5][6][7][8][9][31][32][33][34] Shear forces are present on the sacrum from head-of-bed elevation with mechanical ventilation. 15,[27][28][29]35 Preventive care is frequently organized into a comprehensive plan, including the "SKIN" (surfaces, keep the patients turning, incontinence management, nutrition) bundle. 34 These bundles reduce pressure ulcer rates but have not eliminated HAPUs.…”