Thank you everyone. And I hope this lecture is going to help you put it all together because we're going to talk about how to even define some of the terms that we've been using today. To start off, I have no disclosures. So we're going to take just a few moments to define skin failure. We're going to talk about some of the determinants of skin failure, and then we're going to talk about the different types. Now, we beat this like a dead horse, but I'm going to just kind of show this to you guys, putting everything all together. Skin is the biggest organ, obviously, in our body and it serves many different roles. Very important to think about these because as the skin starts failing, you're going to start losing all of these things and the ability to regulate. Now, a little bit of historical perspective. Skin failure was first defined in 1991 as a loss of normal temperature control with inability to maintain the core temperature, failure to prevent percutaneous loss of fluids, electrolytes, and proteins, with a resulting imbalance of the mechanical barrier to penetration of foreign materials. This was altered a little bit in 2006 when it was redefined, and this might be a little bit more reminiscent when we think about sepsis, septic shock, as an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organs. This is the first time that we actually talked about the perfusion affecting skin. This, perhaps, is what we're most familiar with, defined in 2017 as the state in which tissue tolerance is so compromised that cells can no longer survive in zones of physiological impairment, including hypoxia, local mechanical stress, impaired delivery of nutrients, and the buildup of toxic metabolic byproducts. Now, I know we've seen this slide before, but I'm going to take a moment and I'm going to delve into this a little bit. But Dr. Levine actually helped define some of the risk factors that can lead to some of the pathophysiological changes in certain situations, which ultimately disrupts the barrier, which leads to skin failure. So what are the risk factors? Acute and chronic conditions, age-related changes that we talked about, skin changes throughout the course of our lives, structural impairments. We talked about pharmacological impairments or factors that can affect skin. The dying process itself, as well as other dermatological conditions. Now, when you have some of these risk factors, and there's a pathophysiological process that goes on, whether it's hypoperfusion, hypoxia, inflammation, vascular permeability or edema, can lead to disruptions of the barrier, which ultimately result in skin failure. What I want to highlight here, and what I want to make sure is incredibly clear, is that the physiology, the risk, the pathophysiology is occurring even before sometimes we see the manifestations on the skin. And that's so super important for us to remember in the ICU setting, because by the time I see the manifestations, the disease process is already underway. Now, to define skin failure, we can define it as acute or chronic. Acute skin failure, big broad categories, there are thermal injuries, and I know several of my colleagues here are burn surgeons, so I'll let them talk more about that, as well as necrotizing fasciitis. Big topics, we know the treatments for those. Then we're going to talk a little bit, and I'm going to spend most of the time here talking about the dermatological manifestations. When we talk about chronic skin failure, it's the skin integrity failing to heal or regenerate normally. Now, I'll tell you that there's a third category that some, and I think we've alluded to this in some different portions here, is the end stage skin failure, and that's when the skin and the underlying tissue die due to hyperperfusion related to end of life, and that's when we're talking about palliative care. I'm not going to talk too much about that. I'm going to focus mostly on the dermatological manifestations. So first off, where are we seeing this? How are we seeing this in our ICUs? So about less than 5% of patients in our ICUs actually have primary dermatological disorders, and we'll define those in a moment. But up to 40% of our critically ill patients have some sort of dermatological manifestation, and that's really, really important. That's why we're having this lecture series and this panel here today, because it's much more prevalent than we think. Remember that they can also be markers of extracutaneous pathophysiology, and it's important that they can actually help us diagnose the underlying disease. So I've diagnosed, for example, a patient with renal failure seeing petechiae on their lower extremities, right? So you've got to be very mindful of these things and think about the bigger, broader spectrum. So here's what I think about when I think about dermatological manifestations. I think about this in four different categories. The first is the life-threatening skin conditions. These are the primary lesions that we talked about. These are disease processes that are associated with very high mortalities. They cause a deterioration of the cutaneous function, which leads to the failure of the skin. And we talked about the different layers of skin, but when that epithelium, specifically the stratum corneum, is interrupted, it can lead to loss of fluid, of protein, of immune function, which ultimately leads to infection, issues with thermoregulation, osmoregulation, and then even hypercatabolic states. Examples of these are listed above. Now what about other diseases? So we talked about the primary, but dermatological manifestations we talked about can also be signs of other disease processes, such as systemic illnesses. Now with these, it's important to remember that the diseases that we see or the skin manifestations that we see can proceed, occur concurrently, or actually follow an acute exacerbation of a systemic illness. And most often in the ICU, we see these related to peripheral vascular damage due to an underlying systemic illness or manifestations of the immune response, for example, vasculitis. Moving on to secondary, to management of critical illness, this is what we're going to see the most in our ICUs. So these can be due to immobilization, malnutrition, impaired tissue perfusion, immune dysfunction, body temperature fluctuations, and difficulty maintaining the cutaneous barriers. This is kind of what the rest of my panelists have been talking about. I'm going to kind of put my perspective in for a moment as an emergency medicine physician with our boarding issue and our boarding crisis across the nation right now. I will tell you that some of the patients in the emergency department are there for 24, 72 hours sitting in gurneys. So it's one of the things that I do whenever I come in is if patients have been there for a very long time, and I see my nursing colleague definitely probably is going to agree with this, is one of the things I do is that if they've been there for a long time, they cannot sit in my gurney because I'll tell you they're not moving, they're not mobilizing, we're not doing any of that stuff in the emergency department, and that becomes a huge issue. So by the time they get to our ICUs, we're already creating issues. So what about infections? Lesions secondary to infectious agents are probably the most common thing that we see in the emergency department, or apologies, in the ICU setting, and this could be due to inflammatory dermatitis that occur in skin folds that we talked about or breakdown in skin and skin infections with either fungal infections or staph infections. Drug reactions I won't talk too much about. I know we talked about that earlier. What about the, and we don't often think about this, but injuries secondary to the devices we use. We use invasive and non-invasive devices all of the time, and all of these can actually cause issues whether it's coinciding infection, dermatitis, or inflammatory reactions, and even just the adhesives that we use and the antiseptics that we use. Very important to think about these. Pressure-related injuries, and I will tell you, until recently, whenever I thought skin failure, I thought pressure ulcer. So it's very important to remember that while this is a very important component, it's one of the many things on this list. When it comes to pressure ulcers, we know some of the risk factors, right? Prolonged immobilization, deep sedation, malnutrition, which we've talked about, and there are definitely, I'm assuming in all of your ICUs, ways to mitigate some of these risks. But as we stated, patient goes to the OR multiple times with interruption of their nutrition, some of these are not going to be preventable in all cases. And then vasopressor-induced. So whether a patient is in a shock physiology state, DIC, high-dose vasopressors, these cause issues which we've all seen as well. And again, there's probably in each of your ICUs some ways to mitigate these, especially with peripheral vasopressor uses. For example, in my home institution, just recently in the last year or two, they put limits on what we can use peripherally. And finally, we'll talk about those with previous dermatological manifestations. These are the ones with chronic diseases. Very important to remember that sometimes patients come into our ICUs already with pre-existing skin conditions. And why is that important? Well sometimes these conditions come with treatments that we need to continue in the ICU, or they might be exacerbated by their acute conditions. So very important to be mindful of that and not forget that, because again, it can make their skin condition significantly worse. So in conclusion, this is a term that we started using about 30 years ago, and it's been redefined multiple times. But it's still not as common in our vernacular, even in the ICU, as all of the other organ failures that we talk about on a daily basis. Very important to be mindful of those risk factors, of the pathophysiology that can cause the destruction in the barrier, and very, very important, perhaps what I took away most from being able to even put together this lecture, is that the pathophysiology is occurring even before we're seeing the skin manifestations. Skin failure can be acute or it can be chronic. And remember, skin failure is not the same as pressure ulcer. There's different types of skin failure. And the acute injury can be a primary disease unto itself or a manifestation of an extracutaneous process. Chronic skin failures should not be ignored. Sometimes treatments need to be continued, and they can be exacerbated by treatments in the ICU or by the patient's own underlying condition. This is my email address. I'm happy to answer any questions. Thank you very much.

skin failure

acute skin failure

chronic skin failure

skin manifestations

ICU setting