The following cases and commentary, which focus on pressure ulcers and pain management, are excerpted from ACP's Medical Knowledge Self-Assessment Program (MKSAP 17).
Case 1: Pressure ulcer dressing
A 75-year-old woman is hospitalized for heart failure and is undergoing diuresis, which has led to intermittent urinary incontinence. Medical history is otherwise unremarkable. Her only medication is furosemide.
On physical examination, temperature is normal, blood pressure is 145/92 mm Hg, pulse rate is 78/min, respiration rate is 18/min. BMI is 29. She has bilateral crackles in the lung bases, an S3 gallop, and 2+ pitting edema of the lower extremities. There is erythema with superficial skin breakdown over the sacrum and coccyx at the top of the gluteal cleft. The area is moist.
There is no bone or muscle visible, and there is no eschar and scant exudate. There is no surrounding satellitosis or scale.
Which of the following is the most appropriate dressing to use?
A. Hydrocolloid dressing
B. Medical maggot packet
C. Vacuum-assisted closure device
D. Wet-to-dry gauze packing
Case 2: Diagnosing a lesion
A 79-year-old man is evaluated for pain in the buttocks region. He was diagnosed with non-Hodgkin large B-cell lymphoma 6 months ago. Although his lymphoma has responded well to therapy and he is without evidence of active disease, he required hospitalization three times for chemotherapy-associated complications during his treatment course. He has been bedbound at home during his lymphoma treatment. He describes the pain as severe when sitting and has difficulty finding a comfortable position lying down as well. He has the least pain when standing, but he is unable to stand for very long. He has had no fever. Medical history is otherwise remarkable for hypertension, hyperlipidemia, type 2 diabetes mellitus, and advanced chronic kidney disease being treated with in-center hemodialysis. Medications are felodipine, insulin, calcium carbonate, calcitriol, and erythropoietin.
On physical examination, the patient is afebrile, blood pressure is 104/58 mm Hg, and pulse rate is 64/min supine. BMI is 18. Weight is 58 kg (128 lb), decreased from 77 kg (170 lb) 5 months ago. He appears cachectic with temporal wasting. Examination of his back shows no vertebral tenderness to palpation. There is wasting of the gluteal muscles. Examination of the sacrum reveals a shallow ulcer that is 5 cm in diameter with a hard black eschar covering the base. There is no wound drainage and no surrounding erythema.
Which of the following is the most appropriate management of this patient's lesion?
A. Biopsy of the lesion
B. Intravenous antibiotics
C. Leave the wound open to air
D. Surgical debridement
Case 3: Prevention of pressure ulcers
A 91-year-old woman with advanced dementia is examined in her extended-care facility for a routine evaluation. She is nonverbal, incontinent of urine and stool, largely bedbound, and dependent on others for all activities of daily living. The patient's nurse notes that the patient has continued to lose weight despite being actively fed but raises no other concerns. Medical history is significant for hypertension, and her only medication is amlodipine.
On physical examination, blood pressure is 132/87 mm Hg; other vital signs are normal. The patient appears cachectic with temporal wasting. She is awake but is unresponsive to questions. Mucous membranes are moist. She does not appear to have any pain. There are mild early contractures of her ankles and hips. The remainder of the examination, including skin examination, is unremarkable.
Which of the following is the most appropriate intervention for preventing pressure ulcers in this patient?
A. Alternating-air mattress
B. Enteral nutrition
C. Foam mattress overlay
D. Frequent repositioning
Case 4: Analgesia with CAP
A 75-year-old woman is hospitalized, intubated, and mechanically ventilated for hypoxic respiratory failure due to community-acquired pneumonia. She is empirically started on ceftriaxone and azithromycin.
On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 110/65 mm Hg, pulse rate is 110/min, respiration rate is 14/min (ventilator is set at 14/min); BMI is 28. She appears anxious and uncomfortable with pleuritic chest pain, and she has become increasingly anxious with each painful breath. Pulmonary examination reveals diffuse crackles but no wheezing. The remainder of the physical examination is normal.
Chest radiograph shows multifocal infiltrates.
Which of the following is the most appropriate sedation and analgesia protocol for this patient?
A. Continuous benzodiazepine infusion
B. Interrupted benzodiazepine infusion
C. Interrupted opioid infusion
D. Neuromuscular blockade
Case 5: Comfort care
A 97-year-old woman is evaluated in the emergency department for acute abdominal pain radiating to her back. She is found to have a ruptured aortic aneurysm. Following discussion with the patient and her family, she declines any attempt at endovascular or surgical intervention and requests that care be focused on keeping her comfortable. Her estimated life expectancy is hours to days. Medical history is significant for hypertension, and her only medication prior to admission was felodipine.
On physical examination, temperature is normal, blood pressure is 90/48 mm Hg, pulse rate is 115/min, and respiration rate is 24/min. BMI is 22. She is awake, alert, and able to answer questions. She appears frail and is in obvious pain. Her abdomen is tender to palpation with guarding. No bowel sounds are detected.
Laboratory studies are significant for a hemoglobin level of 8.0 g/dL (80 g/L) and serum creatinine level of 5.9 mg/dL (521 µmol/L).
Her antihypertensive medication is held.
Which of the following is the most appropriate treatment of this patient's pain?
A. Fentanyl, transdermally
B. Hydromorphone, intravenously
C. Morphine, intravenously
D. Tramadol, orally
Answers and commentary
Correct answer: A. Hydrocolloid dressing.
The most appropriate dressing for this patient is a hydrocolloid or foam dressing to reduce wound size. In a recent clinical guideline addressing the treatment of pressure ulcers, in several studies hydrocolloid dressings were found to result in reduced wound size compared with usual care. Hydrocolloid dressings stick to the skin and help absorb exudates, leading to the formation of a protective gel around wounds; these dressings seem to outperform gauze dressings in the management of pressure ulcer wounds. This patient is an older woman with diuresis and experiencing urinary incontinence and moisture buildup on the sacrum. She has signs of a shallow sacral decubitus ulcer on physical examination. Besides ensuring that appropriate preventive measures are in place, including turning the patient frequently, keeping her dry, ensuring adequate nutritional intake, and encouraging her to get out of bed frequently, the patient may also benefit from protein or amino acid supplementation and electrical stimulation (generally high-voltage pulsed stimulation) as adjunctive therapy to accelerate wound healing.
Maggot therapy can be used in areas of tissue necrosis requiring debridement but should not be used for early stage decubiti. Vacuum-assisted closure devices are generally employed for much deeper wounds and would not be indicated in this setting. Wet-to-dry gauze works by packing in wet gauze, which then dries out and, on removal, performs mild debridement of wounds. This is generally used to help close deeper wounds with areas of necrotic tissue and is not indicated in this patient.
- In a recent clinical guideline on the treatment of pressure ulcers, hydrocolloid dressings are recommended in comparison to usual care to reduce wound size.
Correct answer: D. Surgical debridement.
This patient has a sacral decubitus pressure ulcer that is unstageable, and the most appropriate treatment is surgical debridement. Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough or eschar. The black eschar at the base of the wound prevents adequate evaluation of wound depth and further impairs wound healing. Therefore, this patient should undergo debridement of the eschar to expose healthy, viable tissue in order to assess the depth of the wound, allow for wound staging, and promote healing. Debridement can be accomplished either surgically or with specialized dressings, such as saline wet-to-dry dressings or autolytic dressings.
Lymphomatous invasion of the skin is highly unlikely in this patient without other evidence of active disease following recent treatment; therefore, biopsy is not indicated.
Antibiotics would be indicated in the case of an infected pressure ulcer; however, there is no evidence that this patient's wound is infected at this time. There is no visible drainage or pus, and there is no surrounding erythema to suggest cellulitis. Additionally, he has no systemic signs or symptoms of infection.
The goal environment for ideal wound healing is a moist wound bed that controls excess exudate. The wound bed should be neither too moist (macerated) nor too dry. Leaving a wound open to air to dry is rarely, if ever, appropriate management.
- Debridement of eschar is necessary in patients with unstageable pressure ulcers to assess the depth of the wound and promote wound healing.
Correct answer: C. Foam mattress overlay.
A foam mattress overlay is the most appropriate intervention in this patient at risk for a pressure ulcer. Pressure ulcers are a common occurrence in hospitals and long-term care settings, affecting up to 3 million patients and costing nearly $11 billion per year in the United States. It is far less costly to prevent pressure ulcers than to treat them; therefore, physicians need to be proactive in assessing risk for pressure ulcers and instituting evidence-based preventive measures. Risk factors include advanced age, cognitive impairment, reduced mobility, sensory impairment, and comorbid conditions that affect skin integrity (such as low body weight, incontinence, edema, poor microcirculation, and hypoalbuminemia). Intervention is warranted in this patient with multiple risk factors, including older age, advanced dementia, bedbound status, and urinary and fecal incontinence. A clinical practice guideline issued by the American College of Physicians (ACP) recommends the use of advanced static mattresses (a mattress made of foam or gel that does not move when a person lies on it) or an advanced static overlay (a material such as sheepskin or a pad filled with air, water, gel, or foam that is secured to the top of a bed mattress) to prevent pressure ulcers in at-risk individuals. These interventions have been found to lower the risk of pressure ulcers relative to standard hospital mattresses. Advanced static mattresses and overlays work by redistributing pressure and reducing shear that may lead to development of ulcers.
Dynamic support surfaces, such as low–air-loss beds or alternating-air mattresses or overlays, have no demonstrated benefit in preventing pressure ulcers, and the ACP guideline recommends against their use in pressure ulcer prevention. Additionally, these dynamic systems are very costly and their use for this purpose represents a low value care intervention. The role of dynamic support surfaces is also unclear in treating patients with established pressure ulcers, as they have not definitively been shown to improve outcomes relative to advanced static support surfaces and frequent repositioning.
Although malnutrition is clearly a risk factor for pressure ulcers, there are minimal data supporting the effectiveness of enteral feeding as an intervention to prevent pressure ulcers. In some studies, the risk of ulcer development appeared higher in patients placed on enteral feedings than in those not receiving enteral nutrition. Additionally, enteral feeding is not without complications and may negatively influence quality of life. Although there is evidence that protein and amino acid supplementation are of benefit in patients with established pressure ulcers, the role of nutritional supplementation, and specifically enteral nutrition, for prevention of pressure ulcers has not been determined.
Frequent repositioning is often performed as a component of multimodal interventions to prevent pressure ulcers. Such multimodal interventions have been shown to be beneficial; however, there is a paucity of studies of repositioning alone and no good evidence to support repositioning alone as a pressure ulcer prevention tool. Nonetheless, repositioning should always be a part of a multimodal approach to pressure ulcer prevention.
- Advanced static mattresses or overlays reduce the risk of pressure ulcers in at-risk patients.
Correct answer: C. Interrupted opioid infusion.
The most appropriate management of this patient's pain and related anxiety is to use an opioid such as fentanyl as an interrupted infusion. Untreated pain increases the risk of posttraumatic stress disorder in patients in the ICU. Although pain assessment is difficult in critically ill patients, it should be monitored with a validated pain scale and not just with vital signs alone; physiologic indicators such as hypertension and tachycardia correlate poorly with valid measures of pain. The 2013 Society of Critical Care Medicine clinical practice guidelines for pain, agitation, and delirium recommend preemptive analgesia and/or nonpharmacologic interventions to alleviate pain. Opioids are considered the drug class of choice for treatment of non–neuropathic pain in critically ill patients, including mechanically ventilated adult patients in the ICU. Therefore, for this patient, an opioid analgesic such as fentanyl should be given as an interrupted infusion. Daily interruption of analgesia and sedation and spontaneous breathing trials should be used as a standard of care for appropriate patients in ICUs. Their use will shorten the need for mechanical ventilation by an average of 1.5 days, dramatically decrease the number of patients who require mechanical ventilation for more than 3 weeks, decrease ICU length of stay, and lower 1-year mortality.
Benzodiazepines, such as lorazepam, given either intermittently or continuously, should generally be avoided or used sparingly because benzodiazepines are a risk factor for delirium in patients in the ICU.
Neuromuscular blocking agents are sometimes used in patients with acute respiratory distress syndrome or in other critical care scenarios where control of carbon dioxide or patients' movements to allow mechanical ventilation are needed. This patient does not have an indication for neuromuscular blockade. Additionally, if needed, neuromuscular blockade should never be used as a single agent. It should only be used when adequate pain control and sedation of the patient are assured prior to its administration.
- Opioids are the drug class of choice for treatment of non–neuropathic pain in critically ill patients, including mechanically ventilated adult patients in the ICU, and should be given in an interrupted fashion when needed.
Correct answer: B. Hydromorphone, intravenously.
This patient with acute severe pain should be treated with hydromorphone. The opioid analgesic hydromorphone is a very effective pain medication. It is preferred over morphine in the setting of kidney failure because it is metabolized primarily by the liver and is less likely to lead to the accumulation of potentially toxic metabolites. When a parenteral route of medication administration is indicated, such as when titrating medication for acute pain, either intravenous or subcutaneous routes are acceptable. The intravenous route results in a faster onset of action, although the medication wears off faster; the subcutaneous route has only a slightly slower onset of action, but the effect may last longer. Absorption and effect are very reliable with both routes of administration. Although the intravenous route tends to be more commonly used, subcutaneous administration is a reasonable alternative in hospitalized patients who may not be good candidates for intravenous medications or may not wish intravenous access, as may occur in patients receiving comfort care measures.
Fentanyl transdermal patches should only be used in patients who already have some degree of opioid tolerance, and this patient is opioid naïve. Additionally, the onset of action for a fentanyl patch is 12 to 18 hours, far too long for a patient with acute severe pain.
Morphine is contraindicated in the setting of significant kidney failure (estimated glomerular filtration rate <30 mL/min/1.73 m2), even at the end of life, due to the accumulation of toxic metabolites that may cause neurotoxicity with symptoms of delirium, myoclonus, and seizure.
This patient has no bowel sounds on examination, and it is unclear whether she would absorb oral medication, such as tramadol. Additionally, oral medications have a longer onset of action than either intravenous or subcutaneous routes. In the setting of acute severe pain, a parenteral route with more reliable absorption and shorter onset of action is more appropriate.
- Morphine should be avoided in the setting of kidney failure.