Background Although most intensive care patients are at risk for pressure ulcers, not all experience such ulcers. Objective To examine a model of variables related to extrinsic and intrinsic pressure on skin and underlying tissues, oxygenation, perfusion, and baseline comorbid conditions to identify risk factors associated with pressure ulcers in critically ill adults. Method A retrospective chart review was conducted on patients identified by weekly rounds from January 2010 through October 2010 to determine the prevalence of pressure ulcers. Variables were analyzed via bivariate analysis and logistic regression for unit-acquired pressure ulcers. Results Data on 345 patients with 436 intensive care admissions were reviewed. Variables were significant in each model category at P < .05. In the regression analysis of first admission only (n = 306), the model was significant ( P < .001) and yielded correct classification of 86.3% of patients. For all intensive care admissions (n = 391), the model was significant ( P < .001) and yielded correct classification of 83.9% of patients. In both models, 4 of the same variables were significant: any transport off the unit, number of days to bed change, systolic blood pressure less than 90 mm Hg, and use of more than 1 vasopressor. History of pulmonary disease and presence of a feeding tube were also significant in regression analyses. Conclusions Several variables within the model of pressure, oxygenation, and perfusion were significantly associated with development of pressure ulcers.

Background Device-related pressure ulcers from noninvasive ventilation masks alter skin integrity and cause patients discomfort. Objective To examine the incidence, location, and stage of pressure ulcers and patients’ comfort with a nasal-oral mask compared with a full-face mask. Methods A before-after study of a convenience sample of patients with noninvasive ventilation orders in 5 intensive care units was conducted. Two groups of 100 patients each received either the nasal-oral mask or the full-face mask. Skin was assessed before the mask was applied and every 12 hours after that or upon mask removal. Comfort levels were assessed every 12 hours on a Likert scale of 1 to 5 (1, most comfortable). Results A pressure ulcer developed in 20% of patients in the nasal-oral mask group and 2% of patients in the full-face mask group ( P < .001). Comfort scores were significantly lower (more comfortable) with the full-face mask (mean [SD], 1.9 [1.1]) than with the nasal-oral mask (mean [SD], 2.7 [1.2], P < .001). Neither mean hours worn nor percentage adherence differed significantly: 28.9 (SD, 27.2) hours and 92% for full-face mask and 25 (SD, 20.7) and 92% for nasal-oral mask. No patients who had a pressure ulcer develop with the nasal-oral mask had a pressure ulcer develop with the full-face mask. Conclusion The full-face mask resulted in significantly fewer pressure ulcers and was more comfortable for patients. The full-face mask is a reasonable alternative to traditional nasal-oral masks for patients receiving noninvasive ventilation.

Background Guidelines recommending head of bed (HOB) elevation greater than 30º to prevent ventilator-associated pneumonia conflict with guidelines to prevent pressure ulcers, which recommend HOB elevation less than 30º. Objectives To examine the feasibility of 45º HOB elevation and describe and compare the occurrence of reflux, aspiration, and pressure ulcer development at 30º and 45º HOB elevation. Methods A randomized 2-day crossover trial was conducted. HOB angle was measured every 30 seconds. Oral and tracheal secretions were analyzed for pepsin presence. Skin was assessed for pressure ulcers. Wilcoxon signed rank tests and Kendall τ correlations were conducted. Results Fifteen patients were enrolled; 11 completed both days. Patients were maintained at 30º (mean, 30º) for 96% of minutes and at 45º (mean, 39º) for 77% of minutes. No patients showed signs of pressure ulcers. A total of 188 oral secretions were obtained, 82 (44%) were pepsin-positive; 174 tracheal secretions were obtained, 108 (62%) were pepsin-positive. The median percentage of pepsin-positive oral secretions was not significantly higher ( P = .11) at 30º elevation (54%) than at 45º elevation (20%). The median percentage of pepsin-positive tracheal secretions was not significantly higher ( P = .37) at 30º elevation (71%) than 45º elevation (67%). Deeper sedation correlated with increased reflux ( P = .03). Conclusions HOB elevation greater than 30º is feasible and preferred to 30º for reducing oral secretion volume, reflux, and aspiration without pressure ulcer development in gastric-fed patients receiving mechanical ventilation. More deeply sedated patients may benefit from higher HOB elevations.

Background Because reflux of gastric juice into the oropharynx must precede its aspiration into the lungs, it is reasonable to hypothesize that the detection of pepsin (the major gastric enzyme in gastric juice) in oral secretions may provide a relatively noninvasive method of predicting risk for aspiration. Objective To describe the incidence of pepsin in oral and tracheal secretions collected concurrently from a sample of 50 gastric-fed patients undergoing mechanical ventilation. Methods An exploratory descriptive design with a convenience sample from 4 medical and surgical intensive care units. An oral secretion and a tracheal secretion were collected concurrently from each patient (yielding a sample of 50 oral and 50 tracheal secretions). The tracheal secretions were obtained via the inline suction system with an attached sputum trap; oral secretions were obtained via a Yankauer suction tip with an attached sputum trap. All specimens were assayed for pepsin by the Western blot method. Results Oral secretions from 10 patients (20%) and tracheal secretions from 2 patients (4%) were pepsin-positive. Both patients with pepsin-positive tracheal secretions also had pepsin-positive oral secretions. Pepsin was not found in the tracheal secretions from the remaining 8 patients with pepsin-positive oral secretions. Conclusions Although reflux of gastric juice into the oropharynx must precede its aspiration into the lungs, individual reflux events do not necessarily lead to aspiration. Thus, it is reasonable that we found pepsin 5 times more often in oral secretions than in tracheal secretions.

• Background Recent research indicates that oral measurement of body temperature is a reliable option in orally intubated patients. In situations such as protective isolation, where dedicated electronic thermometers are not available, are single-use chemical dot thermometers an acceptable alternative? • Objective To determine the accuracy of single-use chemical dot thermometers in orally intubated adult patients. • Methods Subjects included a convenience sample of 85 adult patients admitted to 1 of 2 intensive care units (surgical trauma and neuroscience). For each patient, oral temperatures were measured concurrently (within 5 minutes) with a chemical dot thermometer and an electronic thermometer. The sequence of temperature measurements was alternated with each subsequent patient. Both thermometers were placed in the same posterior sublingual pocket opposite the side of the endotracheal tube. • Results Measurements obtained with electronic and single-use chemical dot thermometers correlated strongly (r = 0.937). With the chemical dot thermometer, body temperature was overestimated in 11.8% of the measurements and underestimated in 10.8% of the measurements by 0.4°C or more. The difference between oral temperatures measured with the 2 different thermometers was not related to the patient’s age, sex, or sublingual pocket location or to the order of thermometer use. • Conclusion The chemical dot thermometer is useful and reliable for measuring body temperature of orally intubated patients. When measurements of body temperature have important consequences for decisions about treatment, clinicians should use an electronic thermometer to confirm measurements made with a chemical dot thermometer.