How to manage a patient with suspected end-stage skin failure versus deep tissue injury (DTI) over the sacrum who is nil per os (NPO)?

Management of Suspected End-Stage Skin Failure vs. Deep Tissue Injury Over Sacrum in NPO Patient

In an NPO patient with suspected end-stage skin failure versus DTI over the sacrum, immediately institute enteral nutrition via nasogastric tube while implementing aggressive pressure relief and wound care protocols, as nutritional support is critical for tissue viability and healing regardless of the underlying diagnosis. 1

Distinguishing Between End-Stage Skin Failure and DTI

Clinical Assessment

• End-stage skin failure presents as skin death due to hypoperfusion concurrent with severe dysfunction or failure of other organ systems, occurring despite appropriate preventive care 2
• DTI shows purple or maroon discoloration of intact skin with defined borders, often with surrounding erythema, and typically has a history of pressure exposure ("time down") 3, 4
• DTI most commonly appears over the sacrum/coccyx and heels, with rapid deterioration despite appropriate interventions being the hallmark 4
• In the retrospective study of 128 DTIs, 66.4% completely resolved or progressed toward resolution, while only 9.3% deteriorated to full-thickness tissue loss 5

Key Differentiating Features

• History matters: Document any periods of immobility, hypotension, or prolonged pressure exposure 3
• Skin appearance: Purple-maroon discoloration with defined borders suggests DTI rather than end-stage skin failure 5, 3
• Systemic context: End-stage skin failure occurs with heavy disease burden and multi-organ dysfunction, often in hospice or end-of-life patients 2

Immediate Management for NPO Status

Nutritional Intervention (Critical Priority)

• Insert nasogastric tube immediately and institute nasogastric feeding if the patient cannot maintain adequate nutrition orally 1
• Provide continuous enteral nutrition throughout the acute phase 1
• Deliver 20-25 kcal/kg daily during the early catabolic phase, increasing to 25-30 kcal/kg daily during the anabolic recovery phase 1

Rationale: The NPO status is a critical barrier to healing regardless of whether this is DTI or end-stage skin failure. Nutritional support directly impacts tissue viability, immune function, and wound healing capacity.

Wound Care Protocol

Pressure Relief (Highest Priority)

• Place patient on a pressure-relieving mattress immediately 1
• Implement strict repositioning protocols to eliminate pressure over the sacrum
• Use antishear handling techniques when moving or positioning the patient 1

Local Wound Management

• For intact purple-maroon skin (suspected DTI):

  • Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the area 1
  • Apply nonadherent dressings if skin breakdown occurs (Mepitel or Telfa) 1
  • Use secondary foam or burn dressing to collect exudate 1

• Cleansing regimen:

  • Irrigate gently using warmed sterile water, saline, or chlorhexidine (1:5000) 1
  • Apply topical antimicrobial agents only to sloughy areas, guided by local microbiological advice 1
  • Consider silver-containing products/dressings for infection prevention 1

Infection Surveillance

• Take swabs for bacterial and candidal culture from the wound on alternate days 1
• Employ strict barrier nursing to reduce nosocomial infections 1
• Administer systemic antibiotics only if clinical signs of infection are present 1

Monitoring and Reassessment

Clinical Follow-Up

• Average follow-up in DTI cases is approximately 6 days, though some require up to 14 weeks 5
• Monitor for three possible trajectories:
  • Complete resolution or progression toward healing (most common at 66.4%) 5
  • Unchanged appearance (24.2% remain as purple-maroon discoloration) 5
  • Deterioration to full-thickness tissue loss (9.3%) 5

Surgical Consultation Considerations

• If the wound shows clinical deterioration, extension of tissue damage, local sepsis, or delayed healing despite conservative management, consider surgical consultation 1
• For stage IV pressure injuries with suspected underlying pelvic osteomyelitis, multidisciplinary evaluation including infectious disease and surgery is warranted 1

Critical Pitfalls to Avoid

• Do not withhold nutritional support in NPO patients—this is a modifiable risk factor that directly impacts outcomes 1
• Avoid premature surgical debridement of purple-maroon intact skin, as most DTIs resolve with conservative management 5
• Do not assume all sacral wounds in critically ill patients are preventable pressure injuries—end-stage skin failure can occur despite optimal care in patients with multi-organ dysfunction 2
• Avoid using adhesive dressings that could cause further epidermal detachment through shearing forces 1

Goals of Care Consideration

If this patient has multi-organ failure and is approaching end-of-life, the diagnosis may be end-stage skin failure rather than DTI 2. In such cases, shift focus from curative to palliative wound care while maintaining comfort and dignity. However, nutritional support and pressure relief remain appropriate comfort measures even in palliative contexts 2.