Exploring Pressures, Tissue Perfusion and Body Positioning: A Pilot Evaluation among critically Ill Patients (EXTREME Pressure Study)

The pilot procedures will be separated into two sets of procedures; one for the healthy participants and the other for the critically ill patients in the Intensive Care Unit (ICU). An indepth procedures guide is prodived for the data collectors with information regarding each step of the data collection process. Following healthy participant recruitment and consent, the participant will be positioned in three body positions: 30 degree semi-recumbent supine, 1/4 lateral turn and prone ( as per the ICU guidelines). The tilt degree of bed angles is checked with a tilt meter and pillow placement confirmed against the study guide. For each position the participant will be placed on a pressure mapping mat (X-sensor pressure mapping system) and data will be collected. The participant will remain in the position for 5-10 minutes and Interface Pressure (IP) and Peak Pressure Index (PPI) measures will be recorded (2 minute recording) after the mattress settling time is complete. Following repositioning (i.e. rolling participant to off load the peak IP), Doppler (Perimed laser doppler perfusion monitor: Periflux 4000, probe 404) data collection will be conducted to measure tissue reperfusion for the points of peak pressure. This includes a 2 minute baseline period, 5 minute loading period and 10 minute offloaded period, as per the study procedures guide. For the critically ill patients, consent will be given by the patient or substitute decision maker, each patient will be placed in two body positions: 30 degree supine semi-recumbent and 1/4 lateral turn. The Doppler will be attached to the point of peak pressure which was determined by data collection on the healthy adults (sacrum for the supine semi-recumbent position and greater trochanter for the 1/4 lateral turn position) to measure tissue reperfusion when the patient’s weight is offloaded. A total of 6 patients [one in each Body Mass Index (BMI) group in each SOFA category (SOFA <5; SOFA 5 and >)] will be placed on a pressure mapping mat to collect IP and PPI measures. Data collection is conducted once per participant/patient and patient data collection is co-ordinated with the bedside nurse so data collection is conducted during the routine pressure area care turn time. Due to the nature of the critically ill patients, data collection is dependent on the patients condition and is delayed or cancelled if patients are scheduled for procedures or if their condition deteriorates. Total data collection time is approximately 45 minutes. Data collection consists of a series of patient turns which are supervised by the bedside registered nurse, the ICU patient care officer and the data collection team (a doppler technician and a data collection nurse). The participant/patient's waist measurement will be taken during data collection and the braden score will be calculated on the day of data collection. All information will be documented on the data collection tool, there are check boxes on the data collection tool to ensure adherence to the protocol. Patient demographic information, admission details, patient history, patient assessment, SOFA score, APACHE II and III calculations, cardiotonic drug administration and inclusion/exclusion criteria checklist will be completed on the enrollment form for data collection. Procedures: 1. All healthy adults will be pressure mapped and Doppler data collected. Depending on the patient’s criteria, the patient may be pressure mapped. For pressure mapping, the participant/patient is positioned on top of a pressure mapping mat for 5-10 minutes to allow mattress sewttleing time and a 2 minute recording to measure the distribution of pressure for the areas of body in contact with the bed. The participant/patient will be positioned on their back in a supine semi-recumbent position (the bed head will be raised to 30 degrees, the knees will be raised to 10 degrees, a pillow will be under the participant/patients head and heel wedge will be in place) and on their side in a lateral quarter turn (pillows will be placed to support the head, back and between the knees and the bed will be tilted 10 degrees) for data collection. Healthy adult prone position is based on the ICU guidelines; the participant’s arms are to be placed along the body with the forearms pronated. NOT to be placed in the ‘swimmers’ position. The participant’s arms are NOT to be positioned greater than or equal to 90 degrees to the body. 2. After pressure mapping is complete, the study nurse will use double sided tape to secure the Doppler to the surface of the sacrum (like a band aid). The ICU team will take a 2 minute recording of the participant/patient's baseline tissue perfusion. The ICU team will position the participant/patient in supine semi-recumbent position - the bed head will be raised to 30 degrees, the knees will be raised to 10 degrees, a pillow will be under the participant/patients head and heel wedge will be in place. 3. The participant/patient will remain on their back in the supine semi-recumbent position for 5minutes. 4. After 5 minutes, the participant/patient will be rolled on to their side to offload the Doppler and tissue reperfusion measurements will be recorded for 10 minutes. Once the recordings are saved the Doppler will be gently removed from the participant/patients skin and cleaned/prepared for the next recording. 5. The Doppler will be taped to the surface of the participant/patient’s greater trochanter, the ICU team will take a 2 minute recording of the participant/patient's baseline tissue perfusion. 6. The ICU team will position the participant/patient in the lateral body position to load the Greater Trochanter with pressure- pillows will be placed to support the head, back and between the knees and the bed will be tilted 10 degrees. 7. The participant/patient will remain on their side in the lateral position for 5minutes. 8. After 5 minutes, the participant/patient will be rolled to offload the Doppler and tissue reperfusion measurements will be recorded for 10 minutes. 9. The healthy participants will also be pressure mapped and doppler data collected for the prone position (positioned as per the ICU protocol). 10. All recordings will be reviewed and saved, the patient will be positioned as per the registered nurses request for pressure area care.