Dermatologic Problems in the Intensive Care Unit: Part IV

In this final section of our review, we discuss a variety of skin disorders often acquired during hospitalization in the intensive care unit. Environmental, nutritional, immunologic, and pharmacologic factors, among others, place patients at risk for drug eruptions, including leukocytoclastic vasculitis and anticoagulant-induced necrosis; moniliasis; acquired zinc deficiency; recurrent herpes simplex labialis; seborrheic dermatitis; contact dermatitis; and pressure sores.

A literature assessment of the use of miscellaneous topical agents, growth factors, and skin equivalents for the treatment of pressure ulcers

BACKGROUND

Agents reviewed for this manuscript were both rare and popular topical treatments for pressure ulcers.

OBJECTIVE

To review topical treatments for pressure ulcers and evaluate them based on available literature of controlled, blinded, and randomized trials.

METHODS

A MEDLARS database (1966-1993) search and a thorough review of reference article lists of key articles produced over 100 manuscripts. Studies were considered for review if they were conducted on humans with chronic stage II to IV pressure ulcers, in a properly controlled and randomized fashion.

RESULTS

The use of zinc acetate and aluminum hydroxide ointment, phenytoin, recombinant platelet-derived growth factor-BB (rPDGF-BB), and basic fibroblast growth factor (bFGF) have been evaluated in a controlled and blinded fashion. Many of the newer agents, cytokine growth factor (eg, rPDGF-BB and bFGF) and skin equivalents, are currently being scrutinized in clinical trials.

CONCLUSION

A paucity of data exist that adequately address the efficacy of any topical agent for the treatment of pressure ulcers.

Continent urinary diversion and diverting colostomy in the therapy of non-healing pressure sores in paraplegic patients

Immobilization and subsequent sacral decubitus or pressure sore formation is a danger faced by the paraplegic. We report on 4 patients treated with non-healing pressure sores. Three male patients had decubiti eroding into the posterior urethra and bladder neck area. One female patient had bladder neck and urethral loss secondary to Foley catheter erosion and a sacral pressure sore. All 4 had non-healing decubiti secondary to urinary contamination and, in addition, gross fecal contamination in the male patients. All patients failed previous muscular flaps and urinary diversion per suprapubic tube. In the male patients, suprapubic continent urinary diversion included bladder neck mobilization, closure of the distal urethra by oversewing and patching with bovine dura, and augmentation of the bladder with a Miami pouch. Fecal diversion was provided with a sigmoid colostomy. In the female patient, continent diversion was performed by forming a Miami pouch. Total diversion allowed healing of the pressure sores and provided a simpler method of personal hygiene. Details of the diversion and case studies will be presented.

Effects of malnutrition on development of experimental pressure sores

Using food-deprived rabbits we investigated the effects of nutritional deficiency on the development of pressure sores. The body weight of these animals was decreased significantly from normal. Organ weights of liver, heart, spleen, kidney, and testis were significantly decreased from normal as well. Protein deficiency in these animals was indicated by serum tests, as well as by histologic features of liver and testis and ultrastructural findings on fibroblasts. We produced lesions in malnourished as well as normal rabbits by exposing their skin to a balloon-produced compressive force of 120 +/- 10 mmHg for 4 hours. Biopsies were taken 1, 2, and 3 days after the pressure application. Histologic findings at each time were as follows: At day one, the degree of ischemic skin destruction in the malnourished animals was more severe than that in the normal ones, and thrombi were occasionally seen in the malnourished cases. At day two, proliferation of fibroblasts and macrophage infiltration were evidenced in the normal animals, whereas signs of collagen fiber degeneration as well as microthrombi were seen in the malnourished ones. At three days, epidermal cells covered the lesions in the case of normal animals; however, massive necrosis of the epidermis was still recognized in the malnourished rabbits. Thus, the healing process of pressure sores was strongly suppressed in the malnourished animals. This suppression was attributed to the reduction in fibroblast proliferation, capillary formation, macrophage infiltration, and also to the low level of epidermal cell proliferation.

Nutritional parameters at hospital admission as predictors of pressure ulcer development in elective surgery

Nutritional parameters obtained at hospital admission were studied to determine whether they would predict which surgical patients would develop pressure ulcers during a period of up to three weeks of hospitalization. Nutrition parameters were serum albumin, total protein, lymphocyte count, mid-arm muscle circumference, triceps skin fold, and weight change. Lymphocyte count was significant (p = 0.007, adjusted r2 = 0.019) in predicting the development of a pressure ulcer during hospitalization. Because lymphocyte count accounted for less than 2% of the variance, it is not a clinically significant predictor. When nonnutritional pressure ulcer risk factors were controlled for in the regression, no nutritional factors were predictive of ulcer development.