Skin Failure Research Articles

Skin injury: Associations with variables related to perfusion and pressure.

Skin injuries are a major healthcare problem that are not well understood or prevented in the critically ill, suggesting that underappreciated variables are contributing. This pilot study tested the hypothesis that perfusion-related factors contribute to skin injuries diagnosed as hospital-acquired pressure injuries (HAPIs). A total of 533 adult patients were followed over 2574 critical care days (mean age 62.4, standard deviation (SD) 14.3 years, mean body mass index 30.4 (SD 7.4) kg/m2, 36.4% female). This was a secondary analysis of prospective, non-randomised clinical data from an intensive care unit at a large urban teaching hospital. Factors related to perfusion, specifically two or more infusions of vasopressors/inotropes, temporary mechanical circulatory support (MCS), extracorporeal membrane oxygenation, and durable MCS, were analysed to determine whether they were more strongly associated with HAPIs than immobility due to prolonged mechanical ventilation (>72 h) or operating room time (>6 h). Patients diagnosed with a HAPI had a statistically significant higher risk of being exposed to variables related to perfusion and immobility (P < 0.05 for each variable). Perfusion-related variables, except durable MCS, had a larger effect on skin breakdown (number needed to harm (NNH) 4-10) than immobility-associated variables (NNH 12-17). The finding that perfusion-related variables predicted HAPIs may warrant consideration of alternative diagnoses, such as skin failure due to impaired perfusion as a pathophysiological process that occurs concurrently with multisystem organ failure. Differentiation of skin injuries primarily from circulatory malfunction, rather than external pressure, may guide the development of more effective treatment and prevention protocols. This pilot study suggests that the contribution of perfusion to skin injuries should be explored further.

The unavoidable pressure injury/ulcer: a review of skin failure in critically ill patients.

Due to an ageing population and prolonged lifespan, pressure injury (PI) incidence is increasing. Patients with a PI typically endure longer hospital stays, which create a significant burden on healthcare resources and costs. With appropriate preventive interventions, most PIs can be avoided; however, skin failure may become inevitable in particular instances. These are classified as unavoidable PIs. Patients in a critical condition are exposed to a unique set of therapies, medications and bodily states. Oftentimes, these instances decrease tissue tolerance, which may promote PI formation. Patients who are critically ill, especially those with extended stays in the intensive care unit, are susceptible to skin failure due to: prolonged immobility; mechanical ventilation; acute respiratory distress syndrome; COVID-19; sepsis; multiorgan system dysfunction; vasopressor use; and treatment with extracorporeal membrane oxygenation. Poor perfusion leading to skin breakdown results from the compounding factors of circulatory collapse, build-up of metabolites, compromised lymphatic drainage, patient comorbidities, and ischaemia via capillary blockage in patients who are critically ill. In addition, similar physiology is present during end-of-life multisystem organ failure, which creates unavoidable skin deterioration. The aim of this review is to provide an overview of circumstances which decrease tissue tolerance and ultimately lead to PI development, despite adequate preventive measures in patients who are critically ill.

Construction of a Risk Prediction Model for the Occurrence of Acute Skin Failure in Critically Ill Patients: A Prospective Study.

The risk factors for acute skin failure (ASF), a serious complication of the skin, are not fully understood. This study was designed to explore the risk factors for ASF in critically ill patients and construct a clinical prediction model. Intensive care unit patients were prospectively observed and assigned into two groups: with and without ASF. A logistic regression model was constructed, and its predictive power and clinical utility were evaluated. Of the 204 eligible patients enrolled as participants, 58 (28.43%) developed ASF. Sepsis, vasoactive drugs, and age were shown to be risk factors for ASF, whereas peripheral perfusion index ratio and albumin level were shown to be protective factors. The area under the receiver operating characteristic curve was 0.83. The maximum Youden index of the model was 0.39 (specificity: 0.87, sensitivity: 0.77). The Hosmer-Lemeshow test (p = .20) and calibration curve showed good fitness and predictive utility with respect to the model. The developed model effectively predicts ASF risk, allowing for the early identification of high-risk patients. Identifying risk factors such as sepsis, vasoactive drugs, and age and considering protective factors such as peripheral perfusion index and albumin levels may help optimize care plans. Clinical staff should pay special attention to these factors and their impact on skin health in critically ill patients.

Scoping Review of Wounds in Hospitalized Adults with COVID-19 Over the First Three Years of the Pandemic.

To synthesize the literature on skin failure and pressure injuries among hospitalized patients with COVID-19. An electronic literature search using relevant keywords and controlled vocabulary was conducted in March 2023 on MEDLINE/PubMed, Embase, and CINAHL. Manual citation searches of included articles and grey literature, including the Wound, Ostomy, and Continence Nurses Society website were performed. Articles published in English between 2020 and April 2023 were considered. Articles were included if they reported on COVID-19 positive hospitalized adults with wounds that were not present upon admission. A total of 31 articles met these criteria. Covidence was used to extract the data and was reviewed by multiple team members. Of the 31 studies, 27 reported new onset skin lesions during hospitalization. Wounds were classified as pressure injuries, skin failure, livedo racemosea and/or, retiform purpura, and associated with microvascular thrombosisthrombotic vasculopathy. Most pressure injuries were associated with prone position and affected patients often had multiple comorbidities including hypertension, diabetes mellitus, end-stage renal disease, heart disease, and COPD. Four articles highlighted an increased risk of new onset wounds, and three emphasized the importance of distinguishing deep tissue pressure injuries from ischemic-related lesions in patients with COVID-19. The evidence suggests an increased risk of ischemic lesions and pressure injuries (PI) in patients with COVID-19 infection. This phenomenon may have inflated the numbers of PI during the pandemic and adversely affected nursing quality measures in acute care environments.

The development and nutritional quality of Lyophyllum decastes affected by monochromatic or mixed light provided by light-emitting diode.

Edible fungi has certain photo-sensitivity during the mushroom emergence stage, but there has been few relevant studies on the responses of Lyophyllum decastes to different light quality. L. decastes were planted in growth chambers with different light qualities that were, respectively, white light (CK), monochromatic red light (R), monochromatic blue light (B), mixed red and blue light (RB), and the mixture of far-red and blue light (FrB). The photo-sensitivity of L. decastes was investigated by analyzing the growth characteristics, nutritional quality, extracellular enzymes as well as the light photoreceptor genes in mushroom exposed to different light treatments. The results showed that R led to mycelium degeneration, fungal skin inactivation and failure of primordial formation in L. decastes. The stipe length, stipe diameter, pileus diameter and the weight of fruiting bodies exposed to RB significantly increased by 8.0, 28.7, 18.3, and 58.2% respectively, compared to the control (p < 0.05). B significantly decreased the stipe length and the weight of fruiting body, with a decrease of 8.5 and 20.2% respectively, compared to the control (p < 0.05). Increased color indicators and deepened simulated color were detected in L. decastes pileus treated with B and FrB in relative to the control. Meanwhile, the expression levels of blue photoreceptor genes such as WC-1, WC-2 and Cry-DASH were significantly up-regulated in mushroom exposed to B and FrB (p < 0.05). Additionally, the contents of crude protein and crude polysaccharide in pileus treated with RB were, respectively, increased by 26.5 and 9.4% compared to the control, while those in stipes increased by 5.3 and 58.8%, respectively. Meanwhile, the activities of extracellular enzyme such as cellulase, hemicellulase, laccase, manganese peroxidase, lignin peroxidase and amylase were significant up-regulated in mushroom subjected to RB (p < 0.05), which may promote the degradation of the culture materials. On the whole, the largest volume and weight as well as the highest contents of nutrients were all detected in L. decastes treated with RB. The study provided a theoretical basis for the regulation of light environment in the industrial production of high quality L. decastes.

Uncommon toxic epidermal necrolysis -like presentation of cutaneous lupus erythematosus: A series of 6 cases.

TEN like Lupus erythematosus is an uncommon life-threatening variant of Lupus erythematosus. It is usually associated with flares of systemic lupus erythematosus and also because of widespread skin erosions, it can cause acute skin failure. It is often confused with drug induced TEN, however the management of both the diseases is different and hence correct diagnosis becomes crucial. In this study we aimed to assess the clinical characteristics and outcome of TEN like LE in the Indian population. All patients satisfying ACR/EULAR 2019 criteria for SLE and clinically diagnosed with TEN like LE were retrospectively reviewed. A total of 6 patients were identified. All patients were female. Except 1 patient who presented de-novo, the others had pre-existing symptoms of connective tissue disease. Half of the patients had palmoplantar involvement. Mucosal involvement was only mild. Majority had systemic involvement in the form of nephritis followed by arthralgia, autoimmune hepatitis and autoimmune hemolytic anemia.

A survey of skin failure perceptions amongst pressure injury management staff in China: A cross-sectional study.

This study sought to evaluate the perceptions of pressure injury (PI) management staff regarding skin failure (SF). Additionally, an analysis of influencing factors based on the collected data was conducted to establish a foundation for targeted SF training. A descriptive, cross-sectional survey was undertaken in October-November 2023, utilising a convenience sampling method involving selected management staff of PI from 16 provinces in China. A total of 501 nursing participants were included, exhibiting an overall perception level that was moderately low. Although the majority were aware of the possibility of SF (n = 417, 83.23%), only 60% reported an understanding of the fundamentals of SF, with the lowest level of comprehension observed in differentiating between SF and PI (n = 212, 42.31%). Overall attitudes were generally positive. Regarding behaviour, active learning was more prevalent (n = 340, 67.86%), but training is less (n = 287, 57.29%). Family education (n = 401, 80.04%) and nursing record monitoring (n = 426, 85.03%) demonstrated better behaviour. Further analysis revealed that training (t = 13.937, p < 0.001) and professional title (F = 4.681, p = 0.010) had a significant effect on participants' perceptions. These findings underscore that there remains a substantial lack of perception about SF amongst participants. Overall, participants exhibited a positive attitude towards SF, highlighting the need for future improvements in SF training.

Research progresses on acute skin failure in children

Acute skin failure (ASF) is an inevitable damage to the skin and subcutaneous tissue caused by hemodynamic instability and/or low perfusion. At present, there are some understandings and reports about adult ASF at home and abroad, but there are few reports about children's ASF. This article reviewed the definition, pathophysiological changes, risk factors, clinical manifestations, and management of children's ASF, and put forward suggestions in order to provide ideas for clinical diagnosis and treatment of children's ASF, and promote the further study of children's ASF.

Fast Screening of Fentanyl Illicit Drug By the Electrochemical Enhancement of Raman Intensity

Fentanyl is a potent opioid drug used as an analgesic and anesthetic because it is approximately 100 times more potent than morphine and 50 times more potent than heroin as an analgesic. However, the overdose of fentanyl requires small dose and can cause stupor, changes in pupil size, clammy skin, cyanosis, coma, and respiratory failure leading to death. During the last years the illicit fentanyl and its analogues have been responsible for most drug overdose deaths in different countries and for that reason, the development of identification and detection methods is mandatory.Spectroelectrochemical methods are currently proposed for the screening of this drug [1]. For instance, the combination of electrochemistry (EC) and surface-enhanced Raman scattering (SERS) has received growing attention due to the enhancement of Raman intensity associated with EC-SERS effect. However, the generation of reproducible SERS substrates is a traditional limitation of this effect. In that way, activation of metallic screen-printed electrodes (SPEs) by electrochemical routes allows to obtain reproducible nanostructures with excellent SERS properties [2], opening new gates for analytical applications.In this work, the development of a fentanyl detection method based on EC-SERS effect is achieved. Spectroelectrochemical screening of this drug with metallic SPEs consists of two consecutive steps performed in a single experiment: (1) electrochemical generation of metallic NPs with SERS effect and (2) Raman detection of fentanyl present in solution.Metallic SPEs provide interesting results being not only useful in the characterization of fentanyl, but also for analytical purposes. The proposed EC-SERS method with gold SPEs allows the detection of 0.33 ug/ml fentanyl and offers a rapid, efficient, and accurate approach for the detection of this drug.

Skin failure: A historical perspective

When you understand the past, you can help set a course for future care.

Differential diagnosis of stage 2, 3 and 4 pressure injuries of the pelvis and lower extremity: a case series.

Constant, unrelieved pressure of local tissue, particularly over bony prominences, may provoke damage that progresses to necrosis and pressure injury (PI). Differentiating PIs from conditions of similar appearance is imperative to minimising complications and implementing prompt treatment. This case series describes several conditions that may be mistaken for a PI. Outlined are the key differences in patient history, presentation and clinical cues that assist in correctly identifying the true pathology behind these conditions. Conditions reviewed included: pyoderma gangrenosum; necrotising fasciitis; genital herpes; Marjolin ulcer, Rosai-Dorfman disease; vascular disease; coagulopathies; calciphylaxis; trauma and surgical wounds; pilonidal cysts; graft-versus-host disease; hidradenitis suppurativa; Stevens-Johnson syndrome; epidermolysis bullosa; radiation wounds; spider bites; and end-of-life skin failure pressure ulcers (also known as Kennedy ulcers). Although commonly recognised and diagnosed, stage 2, 3 and 4 PIs occasionally prove to be difficult to pinpoint, with undefined characteristics and similarities in presentation to several other conditions. Therefore, it is clinically vital to be aware of their appearance, risk factors and aetiology in order to make an appropriate patient assessment and avoid misdiagnosis.

Management of Patients With Kennedy Terminal Ulcer: Challenges and Best Practices

Whether receiving acute, long-term, or home care, patients at the end of life may experience skin failure due to hemodynamic changes and insufficient perfusion of skin tissue. Skin failure begins as superficial ulcers that can quickly become full-thickness lesions, which are referred to as Kennedy terminal ulcers. Skin lesions commonly occur in the final 6 weeks of life and can occur even in the presence of a comprehensive care plan. The pathogenesis of Kennedy terminal ulcers is often misunderstood and these ulcers are commonly misdiagnosed as pressure injuries. This confusion may lead to aggressive care with subpar clinical outcomes that cause further psychological and emotional distress to patients and family members. Patients at the end of life must be provided care focused on their comfort rather than wound healing. To provide the highest quality of care to patients, four end-of-life strategies should be used, including: taking account of the preferences of patients and families, protecting the skin, describing the wound, and preserving a high quality of care. The terms, pathophysiological and clinical manifestations, and nursing treatments related to skin failure at the end of life described in the literature are introduced in this paper. Furthermore, monitoring indicators of nursing quality are provided.

An Overview of Clinical Manifestations of Dermatological Disorders in Intensive Care Units: What Should Intensivists Be Aware of?

Acute skin failure is rarely the primary diagnosis that necessitates admission to an intensive care unit. Dermatological manifestations in critically ill patients, on the other hand, are relatively common and can be used to make a key diagnosis of an adverse drug reaction or an underlying systemic illness, or they may be caused by factors related to a prolonged stay or invasive procedures. In intensive care units, their classification is based on the aetiopathogenesis of the cutaneous lesion and, in the meantime, distinguishes critical patients. When evaluating dermatological manifestations, several factors must be considered: onset, morphology, distribution, and associated symptoms and signs. This review depicts dermatological signs in critical patients in order to lay out better recognition.

Results of the 2022 Wound Survey on Skin Failure/End-of-Life Terminology and Pressure Injuries

To summarize the major findings of a survey first conducted in 2019 and repeated in 2022 and review new concepts (angiosomes and pressure injuries) and challenges due to the COVID-19 pandemic. This survey captures participants' ranking of agreement or disagreement with 10 statements on Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, skin failure, and unavoidable/avoidable pressure injuries. The survey was hosted online by SurveyMonkey from February 2022 until June 2022. All interested persons were able to participate in this voluntary, anonymous survey. Overall, 145 respondents participated. The same nine statements achieved at least 80% agreement (somewhat agree or strongly agree) as in the previous survey. The one statement that did not reach consensus also failed to reach consensus in the 2019 survey: "The concept of skin failure does not include pressure injuries." It is the authors' hope that this will stimulate more research into terminology and etiology of skin changes in persons at end of life and encourage more research regarding terminology and criteria to define which skin lesions are unavoidable or avoidable.

Examining Violaceous Skin Discoloration during the COVID-19 Pandemic: Conducting Research in Resource Scarcity.

To describe the observed patterns and presentations of violaceous discoloration that appeared to be related to the COVID-19 disease process. This retrospective observational cohort study included adults who were COVID-19 positive with purpuric/violaceous lesions in pressure-adjacent areas of the gluteus without preexisting pressure injury. Patients were admitted to an ICU at a single quaternary academic medical center between April 1 and May 15, 2020. Data were compiled by review of the electronic health record. The wounds were described by location, tissue type (violaceous, granulation, slough, eschar), wound margin (irregular, diffuse, nonlocalized), and periwound condition (intact). A total of 26 patients were included in the study. Purpuric/violaceous wounds were found predominantly on White (92.3%) men (88.0%) aged 60 to 89 years (76.9%) with a body mass index 30 kg/m2 or higher (46.1%). The majority of wounds were located on the sacrococcygeal (42.3%) and fleshy gluteal regions (46.1%). Wounds were heterogeneous in appearance (poorly defined violaceous skin discoloration of acute onset), and the patient population had clinical characteristics similar to acute skin failure (eg, concomitant organ failures and hemodynamic instability). Additional larger population-based studies with biopsies may assist in finding patterns related to these dermatologic changes.

Microscopic and metabolic investigations disclose the factors that lead to skin cracking in chili-type pepper fruit varieties.

The hydrophobic cuticle encasing the fruit skin surface plays critical roles during fruit development and post-harvest. Skin failure often results in the fruit surface cracking and forming a wound-periderm tissue made of suberin and lignin. The factors that make the fruit skin susceptible to cracking have yet to be fully understood. Herein, we investigated two varieties of chili peppers (Capsicum annuum L.), Numex Garnet, whose fruit has intact skin, and Vezena Slatka, whose fruit has cracked skin. Microscopical observations, gas chromatography-mass spectrometry, biochemical and gene expression assays revealed that Vezena Slatka fruit form a thicker cuticle with greater levels of cutin monomers and hydroxycinnamic acids, and highly express key cutin-related genes. The skin of these fruit also had a lower epidermal cell density due to cells with very large perimeters, and highly express genes involved in epidermal cell differentiation. We demonstrate that skin cracking in the Vezena Slatka fruit is accompanied by a spatial accumulation of lignin-like polyphenolic compounds, without the formation of a typical wound-periderm tissues made of suberized cells. Lastly, we establish that skin cracking in chili-type pepper significantly affects fruit quality during post-harvest storage in a temperature-dependent manner. In conclusion, our data highlight cuticle thickness and epidermal cell density as two critical factors determining fruit skin susceptibility to cracking in chili-type pepper fruit.

An investigation on the mechanical behaviour of sandwich composite structures with circular honeycomb bamboo core

Sandwich panels made with a bamboo core of different dimensions, packing geometries and facing materials are subjected to three-point bending tests and assessed through statistical and failure analysis. In addition to promoting a circular economy, this architecture holds great promise for replacing secondary structural components in sustainable construction and transportation facilities. The statistical analysis responses are associated with the equivalent density of the panels, flexural strength and modulus of the panels, skin stress and core shear strength and modulus. Individual bamboo rings are also characterised using physic mechanical and interfacial bonding tests. Treated aluminium face sheets provide the best mechanical performance compared to glass fibre-reinforced composite (GFRP) ones by increasing the overall properties of the sandwich panels. The specific face sheet material and void percentage affect the equivalent density, with lower values (~ 0.48 g/cm3) when using GFRP skins, larger bamboo rings and cubic packing. Sandwich panels with 30 mm bamboo rings and hexagonal packing provide higher flexural properties, i.e. ~ 43 MPa strength and ~ 7.6 GPa modulus, and skin stress (~ 288 MPa), while those with 20 mm bamboo rings have higher shear stiffness (~ 132 MPa) and resistance (~ 3.33 MPa). Sandwich panels made with aluminium skins show evident skin-polymer debonding, while those with GFRP have premature skin failure and lower structural performance. The proposed sandwich panels present remarkable and competitive mechanical performance concerning commercial analogous structures, generally used in the aeronautical and automotive industries.

Acute Skin Failure Associated with Severe COVID-19.

Acute Skin Failure Associated with Severe COVID-19.

Cutaneous Anomalies of the Critically Ill Patient.

Critically ill patients are at high risk for organ failure, including that of the integumentary system. Nurses working in intensive care are adept at performing comprehensive assessments that include the skin. Although pressure injury is a well-known complication associated with critical illness, patients may also have debilitating and life-threatening dermatoses. Conditions such as skin failure and medical adhesive-related skin damage are commonly seen in the critically ill. Infectious processes, such as Fournier gangrene, invasive candidiasis, mucormycosis, and herpetic lesions, can result in severe or superimposed critical illness and elude detection. Similarly, cutaneous manifestations of COVID-19 may develop prior to commonly recognized symptoms of infection. Nurses and providers caring for critically ill patients should be aware of common, but less widely known, skin conditions to facilitate early detection and treatment.

Cutaneous Manifestations of COVID-19 in Critical Care.

SARS-CoV-2 infection can cause virus-mediated endothelial dysfunction, which in turn may lead to coagulopathy and ischemic microangiopathy. In the critical care population, cutaneous skin manifestations related to vascular compromise due to COVID-19 include livedo and purpura. These lesions can be difficult to differentiate from other dermatologic conditions seen in this population, including skin failure and deep-tissue pressure injuries. In addition, similarities in underlying pathophysiological mechanisms of these skin conditions can cause diagnostic overlap. Skin failure is known to occur in critical care patients owing to disease severity and shunting of blood to vital organs. COVID-19-related ischemic lesions can mimic the clinical course of deep-tissue pressure injury. The viral endothelial dysfunction present in patients with COVID-19 decreases tissue tolerance, which can result in an increased risk of hospital-acquired pressure injury. Extrinsic factors can also complicate diagnosis of cutaneous lesions in patients with COVID-19.