National Pressure Injury Advisory Panel (NPIAP) Think Tank Defines Non-Pressure Skin Failure in the Critically Ill

Skin failure in the critically ill was the topic for a multidisciplinary think tank hosted by the NPIAP in August of 2024. Skin failure has been the subject of many articles and has many definitions. This think tank offered a new definition for a skin failure not related to exposure to pressure. Non-pressure skin failure in the critically ill is defined as skin injury that occurs despite standard preventive interventions and for which no other etiology has been identified.

The critically ill patient was discussed by this think tank due to the high incidence in that population. It is important to recognize the importance of the caveats in the phrase: injury that occurs despite standard preventive interventions and exclusion of other causes. Non-pressure skin failure is considered unavoidable, because all the appropriate care was provided. This phrase is not an excuse for substandard care. So, the diagnosis is to be used after a root cause analysis is conducted affirming that proper care was done. Second, other conditions are not present that could explain the skin presentation. For example, purpuric skin changes. Determining the cause of changes in skin is not elementary, not every open wound is a pressure injury, not every open wound in the critically ill is non-pressure related skin failure. Other etiologies must be considered when the disease has a presentation in the skin.

A distinct etiology for non-pressure related skin failure in the critically ill has not been elucidated to set it apart from pressure injury. The concept of tissue tolerance is important. The current definition of pressure injury includes: “The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and the condition of the soft tissue. The think tank discussed hypoperfusion, which is a component of tissue tolerance, and considered how tissue tolerance can be reduced with hypoperfusion. There has been a lot of study of pressure, for example how much pressure? For how long? What role does shear play in tissue injury? How does the support surface redistribute the pressure?

In persons with normal perfusion, usual amounts of pressure are applied to soft tissue and the body can reperfuse when tissue is offloaded so the skin and soft tissue is not injured. A possible hypothesis which could be tested is that in hypoperfusion, which is common in many critically ill patients, blood is shunted from the skin, skeletal muscle, and blood either does not reach the skin or there is not enough time to fully reperfuse the tissue before pressure in applied again. For example, if the patient is lying on his back for 2 hours and turned to the side for 2 hours, generally 2 hours off the back would be enough time to restore blood and remove waste products from the skin of the sacrum. But when perfusion is poor, it may not enough time, and the skin fails to remain intact. So, the wound that develops, did not develop due to pressure, it developed due to lack of blood flow to remove waste products and restore tissue oxygen.

Dermatologists consider histopathology to be crucial to fully explain the disease within the skin. Therefore, the consensus statement was:

Histopathology for non-pressure related skin failure in the critically ill has not been described.
A biopsy would be especially helpful to the understanding of this problem. No biopsy of a lesion, that is labeled as non-pressure related skin failure in the critically ill, has been obtained. The group recognized the problem with obtaining a biopsy during critical illness.

The think tank drew this conclusion on pathophysiology. 
A distinct pathophysiology for non-pressure related skin failure in the critically ill is not clear. Based on limited evidence, hypoperfusion has been proposed to contribute to the pathophysiology of non-pressure related skin failure.  
A clear pathophysiology of non-pressure related skin failure in the critically ill is not present. The hypothesized material presented above is a reasonable start, but much more work is needed. 
Consensus was reached on a great need for a clear description of the condition. 
Research is needed to establish a reproducible description of the characteristic morphology and natural history of non-pressure related skin failure. 
Most conditions of the skin are taught and represented with photographs. Even with photographs we have seen confusion among clinicians in staging pressure injury. Because non-pressure related skin failure will be a new diagnosis, photographs will be more important. There were no photographs that the think tank could examine from the literature. So, it was difficult to discern non-pressure related skin failure from the Kennedy Terminal Lesion, the Trombley-Brennan Terminal Tissue Injury and deep tissue pressure injury of the sacrum.

This multidisciplinary task force members with expertise in their fields are listed below. Drs. Lev-Tov, Mervis, Schallom and Siparsky and Ms. Pontieri-Lewis and Vollman were recommended by their respective professional societies to participate in this project.

  Joyce Black, PhD, RN, FAAN, University of Nebraska, College of Nursing, Omaha, NE
  Jill Cox, RN, PhD, APN-c, CWOCN, Rutgers University, NJ
  Janet Cuddigan, RN, PhD, FAAN University Of Nebraska, College of Nursing, Omaha, NE
  Jessie Jenkins, MD, Omaha, NE
  Hadar Lev-Tov, MD, MAS, American Academy of Dermatology, Miami, FL
  Joshua Mervis, MD, FAAD, American Academy of Dermatology, Boston, MA
  T. Samuel Nwafor, MD, FACP, FAPWCA, Mountain Vista Medical Center, Mesa, AZ 
Vicky Pontieri-Lewis, RN, CWOCN, Wound Ostomy Continence Nurse Society, NJ
  Marilyn Schallom, RN, PhD, CCRN, American Association of Critical-Care Nurses, St Louis, MO 
  Carri Siedlik, APRN, The American Academy of Hospice and Palliative Medicine,  Omaha, NE
  Nicole Siparsky, MD, FACS, FCCM, Society of Critical Care Medicine, Chicago, IL
  Kathleen Vollman, MSN, RN, CCNS, World Federation of Critical Care Nurses, Detroit, MI
  Nicole Walkowiak, MSN, RN, CRRN, CWOCN, CNL, ICU Nurse Rush, Chicago, IL

Joyce Black and Janet Cuddigan with the National Pressure Injury Advisory Panel organized the work of the group. Mikel Gray, PhD, CUNP, CCNP-AP from the University of Virginia served as the moderator. The University of Nebraska Medical Center's College of Nursing funded the expenses for the group and the assistance of AMC in Chicago made it work seamlessly.