Repositioning a Sedated ICU Patient Whose Blood Pressure Falls With Every Turn
A 62-year-old man is on day four of mechanical ventilation in a medical ICU with septic shock from a perforated sigmoid diverticulum. He is sedated to RASS -4 and receives noradrenaline at 0.12 micrograms/kg/min. His Braden score is 12: moisture 2, activity 1, mobility 1, nutrition 2, friction/shear 3, sensory perception 3. The sacrum shows a 3 x 2 cm superficial break in the skin with a red-pink wound bed and intact blistering at one edge; the skin was intact on admission. Each two-hourly turn produces a fall in mean arterial pressure from about 72 to 58 mmHg and a SpO2 fall from 96% to 88%, recovering in four to five minutes once supine. The family has asked the nurse-in-charge to "stop turning him because it is killing him". The unit has one nursing assistant for eight patients and no low-air-loss mattress is free. The intensivist is in theatre.
1. Using the Braden subscales and the haemodynamic data, set the repositioning plan for the next eight hours. Justify each component rather than simply stating a turning frequency.
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Read the subscales, not just the total. A total of 12 is high risk, but the drivers here are activity 1 and mobility 1 (immobility), moisture 2 (a sedated septic patient with frequent stools), and friction/shear 3 (microclimate plus head-up positioning for ventilation). Nutrition 2 and sensory 3 are secondary and cannot be fixed in eight hours. The plan has to attack the modifiable drivers - moisture, shear, and duration of unrelieved pressure - instead of defending a two-hourly clock.
Pre-turn safety screen, repeated before every turn: MAP at least 65 mmHg sustained for 15 minutes; noradrenaline rate unchanged for the previous 15 minutes; SpO2 at least 92% on unchanged FiO2; no new arrhythmia; a documented RASS. If any element fails, do not do a full turn - do micro-repositioning instead.
Turn technique: 30-degree lateral tilt with a wedge, not 90 degrees; head of bed kept at or below 30 degrees; slide sheet or two-person turn to reduce shear; sacrum offloaded with a pillow. If MAP falls below 65 mmHg or SpO2 below 90%, return supine at once, record the time of intolerance, re-optimise (fluid bolus, analgesia, brief increase in vasopressor if prescribed) and retry. A recorded, promptly abandoned turn is good practice; an unrecorded six-hour omission is not.
Between turns: 15-degree tilt and limb, heel and occiput offloading every 30-60 minutes; this interrupts pressure without the haemodynamic cost of a full lateral turn.
Moisture and shear: structured incontinence care with a barrier product, change of absorbent pad at each episode, and avoidance of drag on the sacrum.
Escalation: request a low-air-loss or alternating-pressure surface as soon as one is free, refer to the dietitian, and hand over the intolerance pattern at every shift change.
2. How would you respond to the family's request, and what would you document?
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The request comes from fear, not from ignorance, so the first move is to acknowledge the observation: they have watched the blood pressure and saturation fall and have concluded that turning is harmful. Agreeing to stop turning would be wrong; ignoring their fear would guarantee that they interfere or that the patient's care becomes a daily conflict.
Explain in three parts. First, what they saw is real: the numbers do fall, and the team is monitoring for exactly that. Second, why turning still matters - the skin over the sacrum is already damaged, and unrelieved pressure over hours causes damage that reaches muscle and bone, which cannot be reversed, unlike a four-minute dip in blood pressure. Third, what has changed because of their concern: a pre-turn check, a smaller 30-degree tilt rather than a full turn, cushioning, and an immediate return to the back if the numbers fall.
Be explicit about limits: sedation and ventilation are medical decisions, and the family cannot direct them; but their observations are useful and should be reported. Offer to ask the intensivist to speak to them at the next review.
Documentation: the family's concern in their own words; the explanation given; the agreed modified plan; the name of the person who was told and the time. Document the objective data for every turn - MAP and SpO2 before, during and after, and the reason if a turn was deferred. "Not turned, unstable" is not a defensible entry; "Turn deferred 02:00 - MAP 56 on noradrenaline 0.14, pre-turn screen failed, 15-degree tilt and heels offloaded, intensivist informed 02:10" is.
3. Which prevention elements are missing in this unit, and which indicators would you use to audit the problem?
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Missing elements, in order of immediate yield:
- Surface: a patient with a Braden of 12, sepsis and immobility should already be on a pressure-redistributing surface; waiting for a mattress to be "free" is a system failure, not a nursing one.
- Moisture management: no structured incontinence or barrier-care plan is described, yet moisture scored 2 and is one of the few rapidly reversible subscales.
- Nutrition: nutrition scored 2, and no dietetic referral or albumin is mentioned; catabolism in septic shock drives tissue breakdown.
- Skill mix: one assistant for eight patients makes two-hourly turning physically impossible, so the documented schedule is fiction - a classic source of falsified records.
- Heels and occiput: not mentioned anywhere, and heel pressure injuries are the second commonest site in ventilated patients.
Audit indicators:
- Pressure injury incidence per 1,000 patient-days, stratified by stage and unit-acquired status.
- Percentage of high-risk patients (Braden 18 or below, or Braden 12 or below for a focused audit) with a documented repositioning plan and, for each shift, at least one documented turn or a documented reason for deferral.
- Time from identification of high risk to placement on an appropriate surface.
- Completion rate of the pre-turn safety screen, sampled from the observation chart.
A run chart over eight weeks is more useful than a single snapshot; a rising incidence with high documented compliance suggests the documentation, not the care, is being audited.