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Case of the Month

The Phenomenon of Trombley-Brennan Terminal Tissue Injury in a Neonate

A Case Study

Jacob, Ani DNP, RNC-NIC, RN-BC; Grabher, Deborah MPA, RN-BC, NE-C

Editor(s): Newberry, Desi M. DNP, NNP-BC, Section Editor

Author Information
doi: 10.1097/ANC.0000000000000688
  • Free

Abstract

In the neonatal population, skin injuries are common. In a recent systematic review, the prevalence of neonatal skin injuries due to pressure, friction, shear, and stripping varied between 9.25% and 43.1%.1 Premature infants are at highest risk of pressure injury due to skin immaturity and the necessity of life-sustaining medical device use such as endotracheal tubes, nasal cannulas, and nasal or oral gastric tubes.1–7 Almost all reported skin injuries in the neonatal world are related to pressure or medical devices. It is unusual to have a skin injury not related to pressure or use of a medical device, and this case study is about a nonpressure, nonmedical device use–related skin injury in a neonate. In 2012, the term “terminal tissue injury” was first introduced in an article published by the American Journal of Hospice & Palliative Care.8 In that article, Trombley et al8 identified a phenomenon named as Trombley-Brennan terminal tissue injury (TB-TTI), in which they noted terminally ill patients developed a specific type of skin injury previously considered as pressure injury or deep tissue injury (DTI). TB-TTI was first identified in 2009 among adult palliative care patients.8,9 On the basis of our literature review, TB-TTI has not been identified or reported in the neonatal population. In adults, it was reported that tissue injuries or bruising appeared suddenly on bony and nonbony prominences of actively dying patients (Table 1).8,9 This case study presents a case of tissue injury in a neonate consistent with TB-TTI that occurred on the day preceding death.

TABLE 1. - Differential Diagnosis Between Kennedy Terminal Ulcer, Deep Tissue Injury and Trombley-Brennan Terminal Tissue Injurya
Type of Wound Kennedy Terminal Ulcer Deep Tissue Injury Trombley-Brennan Terminal Tissue Injury
Color
  • Red, black, or yellow

  • Purple or maroon

  • Pink, purple, or maroon

Presentation
  • Skin may not be intact

  • May begin as black speck, and size progresses rapidly

  • Discolored intact skin or blood-filled blister

  • Intact skin; bruise-like appearance

  • Sacrum may present as butterfly pattern

  • Bilateral injuries may mirror another

Causation
  • Unknown

  • Pressure and/or shear

  • Unknown

Location
  • Usually on sacrum

  • Over bony prominences

  • May or may not present over bony prominences

  • Noted on lower extremities and trunk

Shape
  • Pear shaped

  • Irregular shaped

  • Butterfly shaped, linear striations

Characteristics
  • Develops rapidly from blister/wound into full-thickness wound

  • Tissue may be painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue

  • Does not progress to skin breakdown

  • Remains intact

  • Wounds may extend in downward trajectory

  • Injury appears spontaneously

Time frame
  • May occur suddenly

  • Discoloration may darken and intensify over time

  • Occurs suddenly

Time from presentation to death
  • Days to weeks

  • Not related

  • Hours to days

aFrom Trombley, Brennan, et al.8 Used with permission.

PATIENT INFORMATION

A female infant was delivered at 32 4/7 weeks via emergent cesarean section for nonreassuring fetal heart tones. Prior to delivery, the mother was admitted to the hospital for severe preeclampsia and treated with strict bed rest, betamethasone, and magnesium sulfate. Her laboratory tests were significant for O-positive blood type, Rubella nonimmune, group βStreptococcus-positive, and human papilloma virus-positive; tests for rapid plasma reagin for syphilis and hepatitis B status were not completed. During delivery, it was revealed that there was a concealed placental abruption and many clots. After delivery, the infant had no tone and was cyanotic without a detectable heart rate. Apgar scores were 0/0/0/1/2 at 1/5/10/20/30 minutes of birth, respectively.

The infant's resuscitation included positive pressure ventilation, chest compressions, intubation, epinephrine, and normal saline. After 30 minutes of life, her heart rate was stable around 100 beats/min and she was transferred to the neonatal intensive care unit (NICU). In the NICU, she was initially placed on a high-frequency oscillating ventilator (HFOV), which was later changed to synchronized intermittent ventilation. Her initial vital signs were temperature of 36°C, heart rate of 120 beats per minute, oxygen saturation of 97%, blood pressure (BP) of 58/34, and mean arterial pressure (MAP) of 42. She had severe hypotonia, absent gag reflex with fixed and dilated pupils, and was unresponsive to stimuli. A chest radiograph showed respiratory distress syndrome. She continued to require mechanical ventilation throughout her stay in the NICU with moderate settings and minimal to no oxygen requirement. Her admitting diagnoses were 32 weeks' prematurity, severe respiratory distress, severe perinatal depression, and perinatal distress.

The infant received surfactant therapy and was placed on antibiotics. She received platelet transfusions for thrombocytopenia and packed red blood cell transfusions for anemia (hematocrit of 23.7%). She had mild electrolyte imbalances initially, which was resolved with the administration of total parentral nutrition (TPN). Nevertheless, she exhibited persistent hyponatremia, with serum sodium levels between 121 and 134 mg/dL, and was treated with normal saline intravenous infusions throughout her hospitalization in addition to TPN.

Her arterial blood gas (ABG) results were consistent with metabolic acidosis during the first 2 days, and she was placed on HFOV. She also received sodium bicarbonate intravenous infusions. With the history of prolonged hypoxia, an electroencephalographic (EEG) study and a magnetic resonance imaging test were obtained at the recommendation of pediatric neurology. The results confirmed the diagnosis of severe hypoxic-ischemic encephalopathy (HIE). Despite supportive treatment, her laboratory findings, especially serum sodium, continued to be abnormal and the clinical team was concerned about her prognosis based on these in addition to EEG results. The infant continued to receive ventilator support, a dopamine drip, hydrocortisone intravenous push injections, and TPN.

CLINICAL FINDINGS

On day of life 10, skin changes consistent with that of TB-TTI were identified on the lateral side of both knees. New 2-cm reddened oval areas were found at the same site (mirror image) adjacent and laterally. Skin remained intact and the discoloration had clear demarcations of borders. Throughout the NICU stay, the infant was cared for on a pressure relief device with regular position changes. Moreover, there was no pressure exerted on the discolored skin areas. Therefore, the possibility of a pressure-related injury was minimal. Suspecting the diagnosis of TB-TTI, the healthcare team obtained an ABG test. The result—pH, 6.96; pco2, 83; po2, 42; HCO3, 18 with 15.3 base excess—indicated the infant's deteriorating condition. The BP was 42/20 with an MAP of 27. The suspected TB-TTI skin findings along with the infant's clinical data supported the possibility of her impending death and provided the clinical team with evidence to share with the family of the timing that the end was near.

THERAPEUTIC INTERVENTION

After the diagnosis of HIE, an ethics consult was initiated to discuss a treatment plan for the infant with her parents. The ethics team, which includes physicians, nurses, social workers, clergies, and a patient and family relations team member, suggested withdrawal of support and proposed comfort care. Because of their religious convictions, the parents did not consider withdrawal of treatment an option and requested full interventional and supportive care for their infant; this decision was supported by the medical team. The infant's ongoing life-sustaining support included mechanical ventilation, vasopressors, TPN, and platelet transfusions as needed. The infant also received morphine sulfate with hydrocortisone for cerebral swelling until the end of her life (Figure 1).

FIGURE 1
FIGURE 1:
Timeline picture showing the events in chronological order. ABG indicates arterial blood gas; CBC, complete blood cell count; EEG, electroencephalographic; NUCU, neonatal intensive care unit; TPN, total parentral nutrition; and TB-TTI, Trombley-Brennan terminal tissue injury.

Members of the neonatal care team (social workers, NICU chaplain, case management and developmental care team, nurses, and medical providers) supported the family throughout the mother's hospital stay. Despite support provided by the social work team to facilitate visits, after the mother's discharge, the parents were unable to visit. Parents received daily phone calls from the healthcare team providing updates on the infant's condition.

After the identification of the TB-TTI findings, the interdisciplinary team called the family to inform them of the change in their infant's condition. The signs consistent with TB-TTI, in addition to severe acidosis and hypotension, encouraged the medical team to have parents come to “say their goodbyes.” The social work team arranged for transportation so that her parents were present at the time of her death. The ethics team met the family and escorted them to a private space for physical and emotional comfort. The mother held her daughter until the time of her death. The NICU attending physician and the ethics committee physician were present at the bedside to provide support.

The hospital has an interdisciplinary team that responds to system stressors, real or anticipated, that are affecting an individual, family, or a group of healthcare employees and the team is called “Team Lavender.” This team includes a chaplain, a social worker, a patient and family-centered care member, a nursing administrator as well as the frontline staff, and a certified Reiki practitioner. The team responds to “Team Lavender” calls, and the members also arrived to the unit to provide support to the additional family members and caregivers. The interventions included debriefing with the care providers, active listening, Reiki, breathing exercises, and quietness/silence. The family was provided with emotional and spiritual support, using active listening and silence, the opportunity to express their feelings without interruptions. They were also provided with resources to observe religious practices according to their beliefs.

DISCUSSION

The death of an infant is an extremely emotional and stressful event for parents. Most family members want to be present with their loved ones during their last moments yet often are unable to do so due to the unpredictability of the time of death. The authors of the original TB-TTI study concluded that the presence of TB-TTI in an adult is a completely unavoidable occurrence related to organ failure and an indicator of impending death that has facilitated the ability to unite family members with their loved ones in the final moments of life (Brennan et al, unpublished data).10 Our literature review did not reveal a reported occurrence in the pediatric population, and to our knowledge, this is the first reported TB-TTI phenomenon in the neonatal population. A retrospective study on 19 critically ill pediatric patients with skin injuries concluded that these skin injuries are a subset of pressure injuries and “may actually represent acute skin failure as a consequences of multiorgan dysfunction syndrome (MODS).” MODS is defined as a state where homeostasis depends on interventions.4 Those authors described skin failure as an event where death of skin and underlying tissues occur due to hypoperfusion. They concluded that identification of this phenomenon is important for timely disease identification and management. The skin injuries identified were full thickness on the day they were identified compared with pressure ulcers with gradual progression from simple to complex skin injuires.4 However, the description of skin failure (full-thickness skin injuries) varied from that of TB-TTI skin injuries (Table 1).

The healthcare team's ability to recognize the specific characteristics that differentiate TB-TTI phenomenon from that of Kennedy terminal ulcer (KTU), or DTI (Table 1), is important as the implications of the diagnosis is very different from those of other tissue injuries. This awareness could potentially shift the focus of care from treatment or management to preparing the parents/family and the caregivers to anticipatory end-of-life care and death. Similar to previously reported findings in adults, the infant in this case had affected skin areas that did not blanch, were deep reddish-purple, and increased in number and size within a short period of time.8 In KTU, the skin injury progresses rapidly into a full-thickness wound.11 In contrast, DTI progress in a slow and steady fashion.12 Also present in our case were injuries in nonbony and low pressure areas that typically occur on lower legs, shins, and thighs. In addition, our case had bilateral (mirror) linear injuries consistent with a pattern of linear striations in their presentation on the lower limbs (Figure 2). A final finding in our case that is consistent with features of TB-TTI was that superior skin and wound care did not prevent development or progression of the skin injury.8,9,12–15

FIGURE 2
FIGURE 2:
A photograph of Trombley-Brennan terminal tissue injury in an adult patient.

Identification of TB-TTI in the neonatal population could ensure timely care and support to families of dying infants at this most critical time. The healthcare team would potentially have more time to determine the plan of care that is most beneficial to the patient and family. Early identification of an imminent death of a neonate can also mobilize support teams for the healthcare professionals who go through a grieving process along with the family. In this case, the early identification of TB-TTI helped the clinicians to mobilize the hospital's “Team Lavender” to offer support to the family and the care providers.

Nationally, many leading healthcare institutions have designated interdisciplinary support teams available 24/7/365 days, providing palliative and end-of-life support to patients and families. The team often includes ethics and palliative care experts, chaplains, social workers, administrators, and frontline staff.15,16 The group's mission includes support and counsel to the patient, family, caregiver, and healthcare team in any adverse or stress events. They may also provide services proactively for any impending stress events. The Massachusetts state–funded pediatric palliative care network, Cleveland Clinic's “Code Lavender,” and our institution's “Team Lavender” are examples of such support groups.17

CONCLUSION

To our knowledge, this is the first report consistent with TB-TTI identified in a neonate. Awareness of TB-TTI in terminally ill infants may assist the NICU healthcare team to recognize and plan for the impending death of an infant. Early recognition of this phenomenon could encourage timely communication with the parents to provide comfort and support for the family as well as mobilizing the available support resources.

References

1. August DL, New K, Ray RA, Kandasamy Y. Frequency, location and risk factors of neonatal skin injuries from mechanical forces of pressure, friction, shear and stripping: a systematic literature review. J Neonatal Nurs. 2018;24(4):173–180.
2. August DL, Edmonds L, Brown DK, Murphy M, Kandasamy Y. Pressure injuries to the skin in a neonatal unit: fact or fiction. J Neonatal Nurs. 2014;20(3):129–137.
3. Brandon D, Hill CM, Heimall L, et al. Neonatal Skin Care: Evidence-Based Clinical Practice Guideline. 2018 Available at https://www.awhonn.org/store/ViewProduct.aspx?id=11678739.
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5. Fujii K, Sugama J, Okuwa M, Sanada H, Mizokami Y. Incidence and risk factors of pressure ulcers in seven neonatal intensive care units in Japan: a multisite prospective cohort study. Int Wound J. 2010;7(5):323–328.
6. Ottinger D, Hicks J, Wilson S, Sperber K, Power K. The pressure is on! neonatal skin and nasal continuous positive airway pressure. Adv Neonatal Care. 2016;16(6):420–423.
7. Scheans P. Neonatal pressure ulcer prevention. Neonatal Netw. 2015;34(2):126–132.
8. Trombley K, Brennan MR, Thomas L, Kline M. Prelude to death or practice failure? Trombley-Brennan terminal tissue injuries. Am J Hosp Palliat Med. 2012;29(7):541–545.
9. Brennan MR, Trombley K. Kennedy terminal ulcers—a palliative care unit's experience over a 12-month period of time. World Council Enterostomal Ther J. 2010;30(3):20–22.
10. Brennan MR, Thomas L, Kline M. Prelude to death or practice failure? Trombley-Brennan terminal tissue injuries in adult palliative care patients. Unpublished paper, 2012.
11. Yastrub DJ. Pressure or pathology: distinguishing pressure ulcers from the Kennedy terminal ulcer. J Wound Ostomy Continence Nurs. 2010;37(3):249–250.
12. Ayello EA, Levine JM, Langemo D, Kennedy-Evans KL, Brennan MR, Sibbald RG. Reexamining the literature on terminal ulcers, SCALE, skin failure, and unavoidable pressure injuries. Adv Skin Wound Care. 2019;32(3):109–121.
13. Rivera J, Stankiewicz M. A review of clinical incidents—skin failure in the dying patient. J Stomal Ther Aust. 2018;38(1):12–14.
14. Nowicki JL, Mullany D, Spooner A, et al. Are pressure injuries related to skin failure in critically ill patients?. Aust Crit Care. 2018;31(5):257–263.
15. Levine JM. Skin failure: an emerging concept. J Am Med Dir Assoc. 2016;17(7):666–669.
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17. Stone RS. Code Lavender: a tool for staff support. Nursing. 2018;48(4):15–17.
Keywords:

neonate; pressure injury; skin failure; TB-TTI; terminal tissue injury

© 2019 by the National Association of Neonatal Nurses.