Prevention of Pressure Ulcers in the Surgical Patient

Go Big or Go Home: Obesity and Total Joint Arthroplasty

Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended.

Assessment of the risk factors for intraoperative pressure injuries in patients

AIM

This study was conducted to assess the risk factors for pressure injuries in patients during surgery.

METHODS

In this descriptive cross-sectional study, the risk of pressure injuries during surgery was evaluated in 250 patients in a university hospital. Data were collected through a Patient Descriptive Information Form (PDIF) and the 3S Intraoperative Pressure Injury Risk Assessment Scale (IPIRAS).

RESULTS

The mean age of the patients was 44.15 ± 17.00, and 52.4% were female. In addition, it was determined that the mean 3S IPIRAS score was higher in patients who were male, were aged ≥60 years, were obese, had a chronic disease, and had low serum albumin and hemoglobin levels (p < .05). During the surgery of the patients included in the study, support surfaces were used in 67.6%, positioning aids were used in 82.4%, and 55.6% had normal skin. Patients who underwent CVS procedures for more than 6 h, did not use support surfaces during surgery, had moist skin, or used vasopressors had higher and significantly different mean 3S IPIRAS scores (p < .05).

CONCLUSIONS

According to the results, all surgical patients were at risk for pressure injury in the intraoperative period. In addition, it was found that male gender was associated with risk factors and that being aged ≥60 years, obesity, chronic disease, low serum hemoglobin and albumin levels, CVS, operations lasting more than 6 h, moist skin, vasopressor drugs, and not using support surfaces during surgery increased the risk of pressure injuries significantly.

Pressure injuries in the operating room: who are at risk?

OBJECTIVE

Operating room (OR)-related pressure injuries (PIs) constitute the majority of all hospital-acquired PIs. The aim of this study is to reveal the prevalence and risk factors of OR-related PIs.

METHOD

This study used a cohort design. The data were collected at Acıbadem Maslak Hospital in Istanbul between November 2018 and May 2019. The study population consisted of all patients undergoing surgery between these dates (n=612). The haphazard sampling method was used following application of the inclusion criteria. A patient identification form, the 3S intraoperative pressure ulcer risk assesment scale and the Braden Scale were used to collect data.

RESULTS

Within the scope of the study, data were collected from 403 patients, of which 57.1% (n=230) were female and 42.9% (n=173) were male; mean age was 47.90±18.15 years. During surgery, PIs were detected in 8.4% of patients. In total, 42 PIs were detected in patients in the study; 92.8% were stage 1 and 7.2% were stage 2. It was determined that the PIs observed in 11.8% (n=4) of the patients were related to device/instrument use and 23.5% (n=8) were related to the positioning device. Risk factors found to be significant in the development of PIs were sex (male) (p=0.049), large amount of bleeding during surgery (p=0.001), dry (p=0.020) and lighter skin (p=0.012), duration of surgery (p=0.001), type of anaesthesia (p=0.015), and medical devices used (p=0.001).

CONCLUSION

Early identification of risk factors may reduce OR-related PIs. Guidelines and procedures that focus on preoperative, intraoperative and postoperative evaluation can be developed to reduce and prevent surgery-related PIs and to standardise care.

Humans have a basic physical and psychological need to move the body: Physical activity as a primary drive

Physical activity, while less necessary for survival in modern times, is still essential for thriving in life, and low levels of movement are related to numerous physical and mental health problems. However, we poorly understand why people move on a day-to-day basis and how to promote greater energy expenditure. Recently, there has been a turn to understand automatic processes with close examination of older theories of behavior. This has co-occurred with new developments in the study of non-exercise activity thermogenesis (NEAT). In this narrative review, it is hypothesized that psycho-physiological drive is important to understand movement in general and NEAT, specifically. Drive, in short, is a motivation state, characterized by arousal and felt tension, energizing the organism to acquire a basic need. Movement is a biological necessity, like food, water, and sleep, but varies across the lifespan and having the greatest impact before adolescence. Movement meets various criteria for a primary drive: (a) deprivation of it produces feelings of tension, such as an urge or craving, known as affectively-charged motivation states, and particularly the feelings of being antsy, restless, hyper or cooped up, (b) provision of the need quickly reduces tension - one can be satiated, and may even over-consume, (c) it can be provoked by qualities of the environment, (d) it is under homeostatic control, (e) there is an appetite (i.e., appetence) for movement but also aversion, and (f) it has a developmental time course. Evidence for drive has mainly come from children and populations with hyperkinetic disorders, such as those with anorexia nervosa, restless legs syndrome, and akathisia. It is also stimulated in conditions of deprivation, such as bed rest, quarantine, long flights, and physical restraint. It seems to be lacking in the hypokinetic disorders, such as depression and Parkinson's. Thus, drive is associated with displeasure and negative reinforcement, subsuming it within the theory of hedonic drive, but it may fit better within new paradigms, such as the WANT model (Wants and Aversions for Neuromuscular Tasks). Recently developed measurement tools, such as the CRAVE scale, may permit the earnest investigation of movement drive, satiation, and motivation states in humans.

Magnitude of position-related soft tissue injuries and associated factors among elective adult surgical patients at Tikur anbessa specialized hospital, Addis ababa, Ethiopia

Background

Position-related soft tissue injuries are the cause of additional suffering for surgical patients, and increase treatment costs. Though its prevalence is underreported, its consequences range from acute mild injuries to lifelong disabilities.

Objective

To assess magnitude and associated factors of position-related soft tissue injuries among elective adult surgical patients at Tikur Anbessa Specialized Hospital, Addis Ababa.

Method

An institutional-based cross-sectional study design was conducted among 292 elective adult surgical patients at Tikur Anbesa specialized hospital from January 1, 2021, to May 30, 2021. A systematic random sampling technique was used and data was collected by pre-tested questionnaire through data retrieval from chart and patients observation in the post anesthesia care unit. Both bi-variable and multi-variable logistic regression analysis were done to evaluate the association between dependent and independent variables. The level of statistical significance was decided at p-value less than 0.05.

Results

The magnitude of position-related soft tissue injuries in our study was 9.6%. The lower Body Mass Index AOR = 6.12; 95%CI: (1.02-16.3), surgical duration more than 4 h AOR = 5.04; 95%CI:(1.19-21.2) and lateral position AOR = 8.01; 95% CI: (1.2-30.5) were found to be independently associated with position related soft tissue injury.

Conclusion

Our study found that the magnitude of position-related soft tissue injury was high. Surgical teams must develop the local protocol or adopt protocol to prevent the position-related soft tissue injury and factors associated should be identified a head of surgery.

Factors Associated with Pressure Injury Among Critically Ill Patients in a Coronary Care Unit

OBJECTIVE

To ascertain the incidence of pressure injuries (PIs) in patients in the coronary care unit (CCU), identify PI characteristics, and determine associated risk factors.

METHODS

Researchers conducted a retrospective investigational study of patients' medical records. A total of 820 patients who were admitted to the CCU between January 2018 and December 2020 met the study criteria. Of these, 200 patients who developed PIs after admission to the CCU were included in this study. This study examined the clinical features of PIs, as well as five PI risk factors: patient characteristics; length of stay; intrinsic factors; care factors, including medical devices; and vasopressor agents.

RESULTS

The incidence of PIs among patients in the CCU was 24.4%. At initial detection, 79.5% of these injuries were already at stage 2 or higher. The results indicated a significant correlation between PI stage and hemoglobin level. Moreover, the authors also found relationships between the use of medical devices (eg, arterial catheters, oxygen tubes, and Levin tubes) and PI onset.

CONCLUSIONS

Critically ill patients in the CCU use various medical devices for an extended period with severe consequences. The risk factors affecting PI are multifactorial. Therefore, the implementation of PI prevention and early detection strategies for patients in the CCU are crucial.

Comparative frenectomy with conventional scalpel and dual-waved laser in labial frenulum

Aim

The purpose of the study is to compare the labial frenectomy between the laser surgery (erbium yttrium aluminum garnet and neodymium-doped yttrium aluminum garnet (Er:YAG and Nd:YAG)) and the scalpel method.

Methods

The trial was a randomized controlled test. Thirty four patients aged from 5 to 10 years requiring the frenectomy were included in this study. Patients were randomly divided into two groups: group A: Er:YAG and Nd:YAG laser group and group B: scalpel group. In addition, this comparison considered the following factors: surgical time and Visual Analog Scale (VAS) pain score, which includes intraoperative pain, postoperative pain and complications, such as speaking and chewing, for 1 day and 7 days following labial frenectomy. After 3 months, we recorded the healing outcome by photos.

Results

There was a statistically significant difference in mean surgical time between laser surgery (mean=224±59 s) and scalpel surgery (mean=740±168 s). According to VAS scores of the intraoperative period (3 hours after the operation and 1st postoperative day of pain), chewing and speaking were statistically higher in group B than those in group A; but in the 7th postoperative day of pain, there was no significant difference in speaking and chewing. After 1 month, all of the patient results were recorded, including the healing of wound and scar. Except for one patient in group B who had a scar, all patients achieved good results.

Conclusion

Based on the results of this study, it can be concluded that Nd:YAG laser is an efficient and more comfortable alternative to the scalpel for a frenectomy in upper lip frenulum.

The influence of anaemia on pressure ulcer healing in elderly patients

Anaemia is a common and multifactorial blood disorder in elderly individuals. This condition may be a significant barrier to pressure ulcers healing as it is associated with a decreased level of oxygen being supplied to body tissues. Some nutritional deficiencies such as iron, vitamin B12 and folate may also cause anaemia and have a negative impact on pressure ulcer healing. An increased iron demand in hard-to-heal pressure ulcers is a significant factor associated with the risk of anaemia of chronic disease in elderly patients. Anaemia screening and correction may need to be considered as well as iron supplementation if required in pressure ulcer prevention and management.

Risk Factors for Facial Pressure Ulcers in Patients Who Underwent Prolonged Prone Orthopedic Spine Surgery

MINI

This study evaluated incidence and risk factors associated with the development of facial pressure ulcers (FPU) in patients who underwent spine surgery in prone position. A total of 300 cases were studied. The incidence of FPU after prone spine surgery using head padded device >3 hours was 27.3%. Hypotension, higher temperature, prolonged operation time, and much crystalloid therapy were the independent risk factors.

Comparison of Interface Pressures and Subjective Comfort of Pressure-Relieving Overlays on the Operating Table for Healthy Volunteers

(1) Background: Pressure ulcers in the hospital setting occurring within 72 h after surgery are called perioperative pressure injuries. The aim of this study was to provide data for the prevention of perioperative pressure injuries following the use of pressure-relieving overlays by measuring the interface pressures and subjective comfort. (2) Methods: This study is based on a repeated measures design. The subjects included 30 healthy volunteers aged 18 to 57 years. Interface pressures of the sacrum and both heels were measured in the supine position, and the subjective comfort was evaluated with visual analog scale after applying polyurethane foam, gel pad, and egg crate foam for relief. (3) Results: The pressures in the sacrum and both heels were the lowest with polyurethane foam, and the subjective comfort was the highest. (4) Conclusions: Inexpensive polyurethane foam with satisfactory pressure relief is recommended as an overlay for surgical patients.

Adding a Visual Communication Tool to the Electronic Health Record to Prevent Pressure Injuries

Health care organizations no longer receive reimbursement for stage 3, stage 4, and unstageable hospital-acquired pressure injuries, which are never events that require interdisciplinary collaboration to treat and prevent. Perioperative patients are at risk for developing pressure injuries that may not manifest until five or more days after surgery. This quality improvement project aimed to inform inpatient nursing and health care professionals of the potential areas of skin breakdown after surgery using an annotated image (AI) depicting intraoperative patient positioning. To gauge OR nurses' use of the AI, we tracked image addition to the patient records weekly from May 2018 to May 2019 and found an overall average participation rate of 80% to 90%. Adding the AI of surgical positioning and pressure points raised awareness of the potential for skin breakdown and became a valuable communication tool for the inpatient nurses who were providing postoperative care to prevent pressure injuries.

Protecting prone positioned patients from facial pressure ulcers using prophylactic dressings: A timely biomechanical analysis in the context of the COVID-19 pandemic

Prone positioning is used for surgical access and recently in exponentially growing numbers of coronavirus disease 2019 patients who are ventilated prone. To reduce their facial pressure ulcer risk, prophylactic dressings can be used; however, the biomechanical efficacy of this intervention has not been studied yet. We, therefore, evaluated facial soft tissue exposures to sustained mechanical loads in a prone position, with versus without multi‐layered silicone foam dressings applied as tissue protectors at the forehead and chin. We used an anatomically realistic validated finite element model of an adult male head to determine the contribution of the dressings to the alleviation of the sustained tissue loads. The application of the dressings considerably relieved the tissue exposures to loading. Specifically, with respect to the forehead, the application of a dressing resulted in 52% and 71% reductions in soft tissue exposures to effective stresses and strain energy densities, respectively. Likewise, a chin dressing lowered the soft tissue exposures to stresses and strain energy densities by 78% and 92%, respectively. While the surgical context is clear and there is a solid, relevant need for biomechanical information regarding prophylaxis for the prone positions, the projected consequences of the coronavirus pandemic make the present work more relevant than ever before.

The Effect of Selected Risk Factors on Perioperative Pressure Injury Development

Patients undergoing operative and other invasive procedures are at high risk for developing pressure injuries. This study aimed to determine the incidence of perioperative pressure injuries in patients who underwent procedures lasting two hours or more in Turkey and the risk factors that affect the development of pressure injuries. Data were collected during the perioperative period. The incidence of perioperative pressure injuries was 40.4%. The results of univariate logistic regression analysis showed that intraoperative vasopressor use, skin turgor, and diastolic blood pressure less than or equal to 60 mm Hg were significantly related to the development of pressure injuries. There was no significant difference between patients who developed pressure injuries and patients who did not when comparing their preoperative Braden Scale scores. Perioperative nurses should assess each patient for pressure injury risk and perform interventions to prevent pressure injuries during each stage of the patient's perioperative course.

Preventing iatrogenic facial pressure ulcers during spinal surgery: Prospective trial using a novel method and review of literature

To assess the outcome of a novel method of preventing facial pressure ulcers in spinal surgery and a review of literature. A prospective trial using a novel method of facial protection using paraffin tulle gras dressing to cover bony prominences during spinal surgical procedures was performed. Patients were reviewed at 24 hours and 6 weeks. A telephone survey was also conducted post discharge. Over an 8-month period, 12 patients (7F:5M, age 9-72 years) underwent spine surgery for tumour stabilisation (n = 7), deformity correction (n = 4), and degenerative presentation (n = 1) with mean operative time of 472 minutes (range 150-785 minutes) in prone position. All patients were managed by the same team using an agreed protocol. No pressure ulcers were noted in our study. One patient sustained minimal erythema, which resolved after 24 hours. All patients were satisfied with the care received. Facial pressure ulcers though much reduced are still common in spinal surgery. The common factors are the long duration of surgery, shear, friction, moisture, and intrinsic factors. Our strategy of an appropriate facial support and constant vigilance helped eliminate the incidence of iatrogenic facial ulcers in spinal surgery.

Risk for surgical positioning injuries: scale validation in a rehabilitation hospital

OBJECTIVE

to validate the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning in the stratification of risk for injury development in perioperative patients at a rehabilitation hospital.

METHOD

analytical, longitudinal and quantitative study. An instrument and the scale were used in the three perioperative phases in 106 patients. The data were analyzed using descriptive and inferential statistics.

RESULTS

most patients showed high risk for perioperative injuries, both in the scale score with estimated time and in the real-time score, with a mean of 19.97 (±3.02) and 19.96 (±3.12), respectively. Most participants did not show skin lesions (87.8%) or pain (92.5%). Inferential analysis enabled us to assert that the scale scores are associated with the appearance of injuries resulting from positioning, therefore, it can adequately predict that low-risk patients are unlikely to have injuries and those at high risk are more likely to develop injuries.

CONCLUSION

the scale validation is shown by the association of scores with the appearance of injuries, therefore, it is a valid and useful tool, and it can guide the clinical practice of perioperative nurses in rehabilitation hospitals in order to reduce risk for injuries due to surgical positioning.

Postoperative pressure injuries in adults having surgery under general anaesthesia: systematic review of perioperative risk factors

BACKGROUND

Pressure injuries (PIs) after surgery affect thousands of people worldwide. Their management is expensive, a cost that can be reduced with proper preventive measures. Patients having surgery under general anaesthesia are at risk of developing PI, yet no specific tool has been developed to assess the risk in these patients. This review aimed to summarize the published data on perioperative risk factors associated with the development of PI in adults having surgery under general anaesthesia.

METHODS

All studies reporting on risk factors associated with the development of PI were included. Data were extracted from all articles and meta-analysis was performed when three or more studies reported on a specific variable.

RESULTS

The analysis identified five factors significantly associated with the development of PIs: cardiovascular disease, respiratory disease, diabetes mellitus, low haemoglobin level and longer duration of surgery. Factors not associated included serum albumin concentration, use of vasopressors during surgery, use of corticosteroids, sex and age.

CONCLUSION

Cardiovascular disease, respiratory disease, diabetes mellitus, anaemia and duration of surgery should be taken into consideration when trying to identify surgical patients at high risk of developing PIs. These factors could be used to predict PIs after surgery.

Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes

Nowadays, obesity and related comorbidities like type 2 diabetes, hypertension, dyslipidaemia and obstructive sleep apnoea syndrome are considered one of the medical challenges of the 21st century. Even with the rise of bariatric and metabolic surgery, obesity and metabolic syndrome are reaching endemic proportions. Even in 2020, obesity is still a growing problem. There is increasing evidence that next to bariatric surgery, exercise interventions in the perioperative period could give extra beneficial effects. In this regard, effects on anthropometrics, cardiovascular risk factors and physical fitness. The aim of this review is to summarise effects of preoperative and postoperative exercise, tools for screening and directions for future research and implementations.

[Development and Evaluation of Electronic Health Record Data-Driven Predictive Models for Pressure Ulcers]

PURPOSE

The purpose of this study was to develop predictive models for pressure ulcer incidence using electronic health record (EHR) data and to compare their predictive validity performance indicators with that of the Braden Scale used in the study hospital.

METHODS

A retrospective case-control study was conducted in a tertiary teaching hospital in Korea. Data of 202 pressure ulcer patients and 14,705 non-pressure ulcer patients admitted between January 2015 and May 2016 were extracted from the EHRs. Three predictive models for pressure ulcer incidence were developed using logistic regression, Cox proportional hazards regression, and decision tree modeling. The predictive validity performance indicators of the three models were compared with those of the Braden Scale.

RESULTS

The logistic regression model was most efficient with a high area under the receiver operating characteristics curve (AUC) estimate of 0.97, followed by the decision tree model (AUC 0.95), Cox proportional hazards regression model (AUC 0.95), and the Braden Scale (AUC 0.82). Decreased mobility was the most significant factor in the logistic regression and Cox proportional hazards models, and the endotracheal tube was the most important factor in the decision tree model.

CONCLUSION

Predictive validity performance indicators of the Braden Scale were lower than those of the logistic regression, Cox proportional hazards regression, and decision tree models. The models developed in this study can be used to develop a clinical decision support system that automatically assesses risk for pressure ulcers to aid nurses.

Risk assessment for perioperative pressure injuries

Objectives:

to evaluate and classify patients according to the Risk Assessment Scale for Perioperative Pressure Injuries; verify the association between sociodemographic and clinical variables and the risk score; and identify the occurrence of pressure injuries due to surgical positioning.

Method:

observational, longitudinal, prospective and quantitative study carried out in a teaching hospital with 278 patients submitted to elective surgeries. A sociodemographic and clinical characterization questionnaire and the Risk Assessment Scale for Perioperative Pressure Injuries were used. Descriptive, bivariate and logistic regression analyses were applied.

Results:

the majority of patients (56.5%) presented a high risk for perioperative pressure injury. Female sex, elderly group, and altered body mass index values were statistically significant (p < 0.05) for a higher risk of pressure injuries. In 77% of the patients, there were perioperative pressure injuries.

Conclusion:

most of the participants presented a high risk for development of perioperative decubitus ulcers. The female sex, elderly group, and altered body mass index were significant factors for increased risk. The Risk Assessment Scale for Perioperative Pressure Injuries allows the early identification of risk of injury, subsidizing the adoption of preventive strategies to ensure the quality of perioperative care.

A prediction tool for hospital-acquired pressure ulcers among surgical patients: Surgical pressure ulcer risk score

Surgical patients are prone to developing hospital-acquired pressure ulcers (HAPU). Therefore, a better prediction tool is needed to predict risk using preoperative data. This study aimed to determine, from previously published HAPU risk factors, which factors are significant among our surgical population and to develop a prediction tool that identifies pressure ulcer risk before the operation. A literature review was first performed to elicit all the published HAPU risk factors before conducting a retrospective case-control study using medical records. The known HAPU risks were compared between patients with HAPU and without HAPU who underwent operations during the same period (July 2015-December 2016). A total of 80 HAPU cases and 189 controls were analysed. Multivariate logistic regression analyses identified eight significant risk factors: age ≥ 75 years, female gender, American Society of Anaesthesiologists ≥ 3, body mass index < 23, preoperative Braden score ≤ 14, anaemia, respiratory disease, and hypertension. The model had bootstrap-corrected c-statistic 0.78 indicating good discrimination. A cut-off score of ≥6 is strongly predictive, with a positive predictive value of 73.2% (confidence interval [CI]: 59.7%-84.2%) and a negative predictive value of 80.7% (CI: 74.3%-86.1%). SPURS contributes to the preoperative identification of pressure ulcer risk that could help nurses implement preventive measures earlier.

Pressure Injury Development in Patients Treated by Critical Care Air Transport Teams: A Case-Control Study

BACKGROUND

The US Air Force transports critically ill patients from all over the world, with transport times commonly ranging from 6 to 11 hours. Few outcome measures have been tracked for these patients. Traditional methods to prevent pressure injuries in civilian hospitals are often not feasible in the military transport environment.

OBJECTIVES

The incidence rate and risk factors are described of en route-related pressure injuries for patients overseen by the Critical Care Air Transport Team.

METHODS

This retrospective, case-control, medical records review investigated risk factors for pressure injury in patients who developed a pressure injury after their transport flight compared with those with no documented pressure injuries.

RESULTS

The pressure injury rate was 4.9%. Between 2008 and 2012, 141 patients in whom pressure injuries developed and who had received care by the team were matched with 141 patients cared for by the team but did not have pressure injury. According to regression analysis, body mass index and 2 or more Critical Care Air Transport Team transports per patient were associated with pressure injury development.

CONCLUSION

Although the pressure injury rate of 4.9% in this cohort of patients is consistent with that reported by civilian critical care units, the rate must be interpreted with caution, because civilian study data frequently represent the entire intensive care unit length of stay. Targeted interventions for patients with increased body mass index and 2 or more critical care air transports per patient may help decrease the development of pressure injury in these patients.

Review of the Current Management of Pressure Ulcers

Significance: The incidence of pressure ulcers is increasing due to our aging population and the increase in the elderly living with disability. Learning how to manage pressure ulcers appropriately is increasingly important for all professionals in wound care. Recent Advances: Many new dressings and treatment modalities have been developed over the recent years and the goal of this review is to highlight their benefits and drawbacks to help providers choose their tools appropriately. Critical Issues: Despite an increased number of therapies available on the market, none has demonstrated any clear benefit over the others and pressure ulcer treatment remains frustrating and time-consuming. Future Directions: Additional research is needed to develop products more effective in prevention and treatment of pressure ulcers.

Operating department practitioners care of the patient with diabetes in the perioperative period

Diabetes mellitus (DM) is a of group metabolic diseases which are defined by hyperglycaemia affecting multiple organs. The condition is found in people of all ages and ethnicities. Diabetes mellitus affects 180 million people worldwide and increasing numbers of patients are presenting with diabetic complications and the need for surgical intervention. This article describes the pathophysiology of DM and the management of the condition, particularly type I and type 2, in the perioperative phase of the surgical patient journey.

Prevalence and Predictors of Pressure Injuries From Spine Surgery in the Prone Position: Do Body Morphological Changes During Deformity Correction Increase the Risks?

MINI: Pressure injuries are prevalent in patients undergoing spine surgery while prone. Multiple risk factors exist and should be addressed. We found that patients undergoing spinal deformity correction surgery are at unique risk (odds ratio 3.31, P = 0.010) due to body morphological changes occurring secondary to intraoperative changes in spinal alignment.

STUDY DESIGN

Review of data and prospective study.

OBJECTIVE

To investigate the prevalence and predictive factors of pressure injuries in spine surgery performed in the prone position, and to determine whether morphological changes and truncal shifts occurring during deformity correction predispose to this complication.

SUMMARY OF BACKGROUND DATA

Spine surgery performed in the prone position presents the risk of developing pressure injuries. This risk is potentially increased in deformity correction, because it tends to involve more extensive procedures, with associated longer operating times.

METHODS

Cases of pressure injuries after spine surgery in the prone position were reviewed to ascertain prevalence and determine risk factors. Data including patient factors (age, sex, height, weight, body mass index, American Society of Anesthesiologists grade, comorbidities, Braden scale, neurological status, spinal pathology) and surgical factors (approach, procedure type, number of screws, operated levels, operative time) were collected. Independent risk factors were identified via multivariate analysis. A subsequent prospective analysis of all patients undergoing spinal deformity correction was conducted by performing intraoperative measurements of body morphological changes and shifts in truncal positions. Statistical correlation was performed to determine whether positional shifts cause pressure injuries.

RESULTS

The prevalence of pressure injuries was 23.0%. Previous skin problems (P = 0.034), myelopathy (P = 0.013), operative time >300 minutes (P = 0.005), and more than four operated levels (P = 0.006) were independent predictors of pressure injuries. Being a spinal deformity patient was also an independent risk factor for developing pressure injuries (odds ratio 3.31, P = 0.010). Significant changes in body measurements during deformity correction were predictive of pressure injuries.

CONCLUSION

Pressure injuries are prevalent in patients undergoing spine surgery while prone. Future studies should investigate strategies to prevent this complication based on the multiple risk factors identified in the present study. Patients undergoing spinal deformity correction surgery are particularly at risk due to intraoperative body morphological changes. Improved padding methods should be trialed in future studies.

LEVEL OF EVIDENCE

3.

Support surfaces in the prevention of pressure ulcers in surgical patients: An integrative review

AIM

To assess the scientific evidence about the types of support surfaces used in intraoperative surgical practice in the prevention of pressure ulcers due to surgical positioning.

METHOD

This is an integrative literature review. The electronic databases Cochrane, PubMed, Web of Science, Scopus, Lilacs, and CINAHL were used. The descriptors surgical patients, support surfaces, perioperative care, patient positioning, and pressure ulcer were used in the search strategy. Articles that addressed the use of support surfaces intraoperatively, published between 1990 and 2016, were selected. The PRISMA guidelines were used to structure the review.

RESULTS

Of 18 evaluated studies, most were in English, followed by Portuguese and Spanish; most were performed by nurses. The most commonly cited support surfaces were viscoelastic polymer, micropulse mattresses, gel based mattresses, and foam devices.

CONCLUSION

There are gaps in knowledge regarding the most efficient support surfaces and the specifications of the products used to prevent pressure ulcers due to surgical positioning.

An Exploratory Descriptive Study of Registered Nurse Innovation: Implications for Levels of Adoption

PURPOSE

The aims of this study were to describe registered nurses' levels of personal innovativeness and registered nurses' perceived organizational innovativeness and determine the relationship between these 2 variables.

BACKGROUND

There is limited research to describe the levels of innovation of nurses within a hospital. The levels of innovation can determine the likelihood of adoption of evidence-based practices at the bedside. As change agents, clinical nurse specialists can determine successful implementation strategies tailored to nurse levels of innovation.

DESCRIPTION

This was a descriptive study at a midwest, urban, teaching, 408-bed Magnet hospital.

OUTCOMES

Surveys were completed by 217 nurses. The participants reported high personal innovativeness ((Equation is included in full-text article.)= 32.1; SD, 6.4), and the institution was perceived as innovative, with 90.3% of scores categorized as positive innovativeness. The statistically significant correlation was in the medical-surgical unit (r = -0.52, P < .01). There is no correlation between personal innovativeness and organizational innovativeness except for medical-surgical nurses (P = .03). They are likely to perceive the organization more innovative than themselves.

CONCLUSIONS

Determining adopter characteristics can be valuable to the clinical nurse specialist by adapting strategic interventions to advance nursing practice. Exploring levels of adoption can be an innovative strategy to transform nursing at the bedside and throughout the organization.

Pressure Ulcers: Factors Contributing to Their Development in the OR

The prevention of health care-associated pressure ulcers (HAPUs) is an important quality measure because HAPUs are considered a never event. The literature suggests that the prevalence rate of pressure ulcers is 8.5% or higher among patients who undergo surgical procedures that last longer than three hours. We performed a retrospective chart review to determine what factors contribute to the development of pressure ulcers in patients who undergo surgical procedures. The sample population included patients who acquired a pressure ulcer that was not present at admission and developed during their postoperative hospital stay. The project revealed consistent risk factors that may contribute to the development of pressure ulcers in patients who have undergone surgical procedures. These findings can drive the implementation of preventive measures to reduce the occurrence of HAPUs associated with surgical procedures.

Risk factors associated with heel pressure ulcers in hospitalized patients

PURPOSE

To develop and validate a method of predicting whether patients will develop a heel pressure ulcer during their hospital stay.

DESIGN

This retrospective case-control study used 2 separate data sets, one for an initial analysis followed by a second data set for validation analysis.

SUBJECTS AND SETTING

From 2009 to 2011, medical records of discharged patients with a DRG code for heel pressure ulcers in our urban, tertiary medical center were retrospectively reviewed. Using age as the matching criterion, we then reviewed cases of patients without heel pressure ulcers. The initial analysis comprised 37 patients with hospital-acquired heel pressure ulcers and 300 without. The validation analysis included 12 patients with heel pressure ulcers and 68 without.

METHOD

In order to develop this method of identifying patients with heel pressure ulcers, logistic regression modeling was used to select a set of patient characteristics and hospital conditions that, independently and in combination, predicted heel pressure ulcers. Logistic modeling produced adjusted and unadjusted odds ratios for each of the significant predictor variables. The validation analysis was employed to test the predictive accuracy of the final model.

RESULTS

Initial analysis revealed 4 significant and independent predictors for heel pressure ulcer formation during hospitalization: diabetes mellitus, vascular disease, immobility, and an admission Braden Scale score of 18 or less. These findings were also supported in the validation analysis.

CONCLUSION

Beyond a risk assessment scale, staff should consider other factors that can predispose a patient to heel pressure ulcer development during their hospital stay, such as comorbid conditions (diabetes mellitus and vascular disease) and immobility.

Soft silicone foam dressing is more effective than polyurethane film dressing for preventing intraoperatively acquired pressure ulcers in spinal surgery patients: the Border Operating room Spinal Surgery (BOSS) trial in Japan

Preventing intraoperatively acquired pressure ulcers (IAPUs) in patients undergoing spinal surgery in the prone position using a Relton-Hall frame is challenging. We investigated the efficacy of soft silicone foam dressings in preventing IAPUs. A prospective dual-center sham study was conducted among patients undergoing elective spinal surgery in a general hospital and a university hospital in Japan. The incidence of IAPUs that developed when soft silicone foam dressings and polyurethane film dressings were used was compared on two sides in the same patient. IAPUs developed on the chest in 11 of 100 patients (11%). Polyurethane film dressings were associated with a significantly higher rate of IAPUs than soft silicone foam dressings (11 versus 3, P = 0·027). A multivariate logistic regression analysis revealed that a diastolic blood pressure of <50 mmHg (P = 0·025, OR 3·74, 95% confidence interval [CI] 1·18-13·08) and the length of surgery (by 1 hour: P = 0·038, OR 1·61, 95% CI 1·03-2·64) were independently associated with the development of IAPUs. The use of soft silicone foam dressings reduced the risk of IAPUs (P = 0·019, OR 0·23, 95% CI 0·05-0·79) and was more effective than film dressings for preventing IAPUs in spinal surgery patients.

Pressure ulcers or moisture lesions: the theatre perspective

Pressure ulcers continue to be a cause for concern in the healthcare industry (IHI 2015). Unfortunately older patients are at a greater risk of developing pressure ulcers (Kottner et al 2013); moisture lesions and the presence of other comorbidities could have long term effects on the patient's health and recovery.

Association between the use of gel pads under patients' knees and the incidence of peroneal neuropathy following liver transplantation

INTRODUCTION

There have been intermittent reports of peroneal neuropathy (PN) occurring after liver transplantation. Although PN may not be viewed as a serious complication by liver transplant (LT) recipients who require the transplant for survival, PN can significantly reduce quality of life. The incidence of PN appears to have increased after the use of gel pads was introduced. These gel pads, which are placed under patients' knees during surgery, are used to reduce lower back strain and prevent contact between the peroneal nerve at the fibular head and the hard surface of the operating table. The aim of the present study was to investigate the association, if any, between the use of gel pads and the incidence of PN.

METHODS

The medical records of 261 adult LT recipients were retrospectively reviewed. The recipients were divided into gel pad (n = 167) and non-gel pad (n = 94) groups. The incidence and possible risk factors of PN were compared between the two groups.

RESULTS

The overall incidence of PN was 8.0% (21/261). The occurrence of PN was significantly higher in the gel pad group than in the non-gel pad group (10.8% vs. 3.2%; p < 0.05). Other possible risk factors were comparable between the two patient groups.

CONCLUSION

As the use of gel pads may increase the incidence of PN, we recommend against the use of gel pads under the knees of LT recipients.

Iyengar Yoga Therapy Intervention for Ischial Pressure Ulcers in a Patient with Amyotrophic Lateral Sclerosis: A Case Study

BACKGROUND

Although some research suggests that the formation of pressure ulcers is rare in patients with amyotrophic lateral sclerosis (ALS), several patients have nonetheless developed this problem. To date, however, no case reports in the literature have described patients with ALS who develop ischial pressure ulcers. Outside of the ALS literature, evidence suggests that ischial pressure ulcers frequently develop in wheelchair users and also in patients treated in various health care settings.

CASE DESCRIPTION

A patient diagnosed with ALS reported the development of ischial pressure ulcers after consistent immobility for 1 year (32 months after her ALS diagnosis). This patient, who was sitting on the wounds, was treated with ointment and morphine; the latter was ineffective in controlling the pain. Moving the patient from sitting to supine, lateral, or semilateral positions, either on the bed or wheelchair, to separate the ulcers from the surface of the chair or bed was deemed impossible because of exaggeration of other symptoms, including shortness of breath and pain in other parts of the body. A new method of postural alignment was developed to alleviate the pain associated with the pressure ulcer. This method, Iyengar yoga therapy, which uses props to reposition a patient, alleviated pain and healing of two pressure ulcers of the patient after 3 weeks of starting this intervention.

CONCLUSION

Although the ischial pressure ulcers were successfully treated in a patient with ALS, further study is necessary to investigate the effectiveness of this postural alignment intervention in ALS and other patient populations for the management of ischial pressure ulcers.