Effects of warming therapy on pressure ulcers--a randomized trial

Pressure injury risk factors in adult orthopaedic surgical patients: a cross-sectional study and random forest

OBJECTIVE

To identify the most important risk factors for predicting pressure injury (PI) occurrence in adult orthopaedic surgical patients based on investigation data, thereby identifying at-risk patients and facilitating formulation of an effective patient care strategy.

METHOD

Patients were assessed with an instrument designed by the authors specifically for this study in a cross-sectional investigation following the STROBE checklist. The random forest method was adopted to select the most important risk factors and predict occurrence of PIs.

RESULTS

A dataset of 27 risk factors from 1701 patients was obtained. A subset of the 15 most important risk factors was identified. The random forest method had a high prediction accuracy of 0.9733 compared with 0.9281 calculated with a logistic model.

CONCLUSION

Results indicated that the selected 15 risk factors, such as activity ability, friction/shear force, skin type and anaesthesia score, performed very well in predicting the occurrence of PIs in adult orthopaedic surgical patients.

The Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review

Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.

Comparison of interface pressures on three operating table support surfaces during surgery

AIM OF THE STUDY

To investigate the effect of support surface usage and positions on interface pressure during surgery.

MATERIALS AND METHODS

This randomized controlled experimental study was conducted between October 2018 and June 2019. The study included patients who had planned surgery in supine and prone positions. The sample size was 72 patients. Patients were assigned to three groups (gel support surface, viscoelastic support surface and standard operating table) according to the determined randomization table. During the surgery, the pressure in the patients' body was recorded. The statistics program IBM SPSS Statistics 25.0 packaged software was used in the analyses of data.

RESULTS

There was no statistically significant difference between the total body average interface pressure (mmHg) values between the supporting surfaces in the prone position. There was a statistically significant difference between the total body average interface pressure (mmHg) values between the support surfaces in the supine position, and the average interface pressure measured on the viscoelastic foam support surface was significantly lower than the gel support surface and the standard operating table.

CONCLUSION

In the study, the use of viscoelastic foam support surface was found to be more effective than the use of a standard operating table and gel support surface. Viscoelastic foam support surface is recommended for patients at risk for pressure injury in the operating room.

The Prevention of Positioning Injuries During Gynecologic Surgery. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/077, October 2020)

Purpose Positioning injuries are relatively common, forensically highly relevant complications of gynecologic surgery. The aim of this official AWMF S2k-guideline is to provide statements and recommendations on how to prevent positioning injuries using the currently available literature. The literature was evaluated by an interdisciplinary group of experts from professional medical societies. The consensus on recommendations and statements was achieved in a structured consensus process. Method The current guideline is based on the expired S1-guideline, which was updated by a systematic search of the literature and a review of relevant publications issued between February 2014 and March 2019. Statements were compiled and voted on by a panel of experts. Recommendations The guideline provides general and specific recommendations on the prevention, diagnosis and treatment of positioning injuries.

The effect of uncoated paper application on skin moisture, risk of pressure injury and incidence of pressure injury in neurologic intensive care unit patients: A randomized controlled trial

AIM

This study aimed to evaluate the effects of uncoated paper on skin moisture, pressure injury risk and pressure injury incidence in neurological intensive care unit patients.

METHODS

A randomized controlled design was used. The experimental group (n = 68) received usual care (repositioning every 2 h and use of an air mattress) and application of uncoated paper on the sacral area for 5 days, whereas the control group (n = 67) received only usual care. A repeated measures analysis of variance was used to determine changes in the skin moisture and risk of pressure injury between the groups. A chi-squared test was used to determine the change in the incidence of pressure injuries for sacral area. Data were collected from 20 October 2017 to 6 March 2018.

RESULTS

There were statistically significant differences in the skin moisture and risk of pressure injuries between the experimental and control groups. However, a significant difference was not observed in the incidence of pressure injuries between the groups.

CONCLUSION

The use of uncoated paper may be a valid nursing intervention for the prevention of pressure injuries in neurological intensive care unit patients.

Effect of Perioperative Active Body Surface Warming Systems on Analgesic and Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Inadvertent perioperative hypothermia is a common complication of surgery, and active body surface warming (ABSW) systems are used to prevent adverse clinical outcomes. Prior data on certain outcomes are equivocal (ie, blood loss) or limited (ie, pain and opioid consumption). The objective of this study was to provide an updated review on the effect of ABSW on clinical outcomes and temperature maintenance.

METHODS

We conducted a systematic review of randomized controlled trials evaluating ABSW systems compared to nonactive warming controls in noncardiac surgeries. Outcomes studied included postoperative pain scores and opioid consumption (primary outcomes) and other perioperative clinical variables such as temperature changes, blood loss, and wound infection (secondary outcomes). We searched Ovid MEDLINE daily, Ovid MEDLINE, EMBASE, CINHAL, Cochrane CENTRAL, and Web of Science from inception to June 2019. Quality of evidence (QoE) was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Subgroup analysis sought to determine the effect of preoperative + intraoperative warming versus intraoperative warming alone. Metaregression evaluated the effect of year of publication, use of neuromuscular blockers, anesthesia, and surgery type on outcomes.

RESULTS

Fifty-four articles (3976 patients) were included. Pooled results demonstrated that ABSW maintained normothermia compared to controls, during surgery (30 minutes postinduction [mean difference {MD}: 0.3°C, 95% confidence interval {CI}, 0.2-0.4, moderate QoE]), end of surgery (MD: 1.1°C, 95% CI, 0.9-1.3, high QoE), and up to 4 hours postoperatively (MD: 0.3°C, 95% CI, 0.2-0.5, high QoE). ABSW was not associated with difference in pain scores (<24 hours postoperatively, moderate to low QoE) or perioperative opioid consumption (very low QoE). ABSW increased patient satisfaction (MD: 2.2 points, 95% CI, 0.9-3.6, moderate QoE), reduced blood transfusions (odds ratio [OR] = 0.6, 95% CI, 0.4-1.0, moderate QoE), shivering (OR = 0.2, 95% CI, 0.1-0.4, high QoE), and wound infections (OR = 0.3, 95% CI, 0.2-0.7, high QoE). No significant differences were found for fluid administration (low QoE), blood loss (very low QoE), major adverse cardiovascular events (very low QoE), or mortality (very low QoE). Subgroup analysis and metaregression suggested increased temperature benefit with pre + intraoperative warming, use of neuromuscular blockers, and recent publication year. ABSW seemed to confer less temperature benefit in cesarean deliveries and neurosurgical/spinal cases compared to abdominal surgeries.

CONCLUSIONS

ABSW is effective in maintaining physiological normothermia, decreasing wound infections, shivering, blood transfusions, and increasing patient satisfaction but does not appear to affect postoperative pain and opioid use.

Estratégias de enfermagem para prevenção de lesão por pressão em pacientes cirúrgicos

Objetivo: Identificar na literatura as estratégias utilizadas pela equipe de enfermagem para prevenção de lesão por pressão em pacientes cirúrgicos. Métodos: Revisão integrativa, utilizando a estratégia PICo, tendo como questão norteadora: “quais as estratégias utilizadas pela equipe de enfermagem para prevenção de lesão por pressão em pacientes cirúrgicos?” As buscas foram realizadas nas bases de dados Web of Science, MEDLINE via PubMed, CINAHL, Cochrane, Scopus e no índice bibliográfico LILACS via BVS, sendo analisados 12 estudos. Resultados: O Brasil se destacou com quatro publicações e os estudos de coorte, com nível de evidência IV, prevaleceram em seis artigos. As intervenções tecnológicas para prevenção de lesão por pressão no centro cirúrgico foram colchões para distribuição de pressão, dispositivo para redução de pressão no calcâneo, instrumentos validados específicos para a classificação do risco de lesão por pressão em pacientes cirúrgicos, além de superfícies de apoio contendo polímero viscoelástico e outros utensílios para alívio da pressão decorrente do peso e de dispositivos médicos. Com relação às intervenções educativas, destacaram-se os protocolos, os treinamentos e a simulação realística. Conclusão: Observou-se que essas estratégias reduziram a incidência de lesão por pressão, além de diminuírem os custos e garantirem a satisfação dos pacientes.

Nursing strategies for pressure injury prevention in surgical patients

Objective: To identify in the literature the strategies used by nursing teams to prevent pressure injury in surgical patients. Methods: Integrative review, using the PICo strategy, with the guiding question: “What are the strategies used by the nursing team to prevent pressure injury in surgical patients?” The searches were performed in the Web of Science, MEDLINE via PubMed, CINAHL, Cochrane, Scopus and LILACS bibliographic index via VHL, from where 12 studies were analyzed. Results: Brazil stood out with four publications and cohort studies, with level of evidence IV, prevailed in six articles. Technological interventions for the prevention of Pressure Injury in the operating room were pressure distribution mattresses, a device to reduce pressure on the calcaneus, specific validated instruments for the classification of the risk of Pressure Injury in surgical patients, in addition to support surfaces containing polymer viscoelastic and other tools to relieve pressure from weight and medical devices. Regarding educational interventions, protocols, training and realistic simulation stood out. Conclusion: It was observed that these strategies reduced the incidence of pressure injury, in addition to reducing costs and ensuring patient satisfaction.

Critical biomechanical and clinical insights concerning tissue protection when positioning patients in the operating room: A scoping review

An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning-related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.

Perioperative Pressure Injuries: A Systematic Literature Review

OBJECTIVE

To conduct a systematic review to investigate risk factors, incidence, and preventive strategies for perioperative pressure injuries (PIs).

METHODS

The authors reviewed four databases for literature published from January 2001 to December 2017. Selected articles included primary quantitative studies with prospective, descriptive, and longitudinal design or randomized controlled trials that evaluated risk factors, incidence, and preventive strategies for perioperative PIs. The studies included were evaluated for methodological quality using the Edwards Method Score. The authors used a standardized extraction form to extract inclusion and exclusion criteria, participant demographics, methodology, PI risk instrument and classification systems, type of surgery and anesthesia, PI risk factors, incidence, preventive strategies, and outcomes evaluation.

MAIN RESULTS

Of the 115 publications identified, 11 met the inclusion criteria. The risk assessment and PI classification instruments used differed in every study. Incidence of PI varied throughout the studies and was reduced by warming therapy and by a skin care intervention program.

CONCLUSIONS

Further studies are necessary to develop a standard risk assessment instrument and preventive strategies and to clarify some contradictions evident in the literature.

Therapeutic hypothermia and pressure ulcer risk in critically ill intensive care patients: A retrospective study

OBJECTIVE

To examine the role of therapeutic hypothermia in pressure ulcer development in critically ill patients.

RESEARCH METHODOLOGY

Retrospective study in a mixed intensive care unit over 2010-2013. The incidences of pressure ulcers among patients treated with therapeutic hypothermia (n = 148) and the non-hypothermia patient population (n = 6197) were compared.

RESULTS

Patients treated with hypothermia developed more pressure ulcers (25.0%) than the non-hypothermia group 6.3% (p < 0.001). More patients in the hypothermia group were rated as the high pressure ulcer risk group, as defined by the modified Jackson/Cubbin (mJ/C) risk score ≤29 than the rest of the patients. Among the therapeutic hypothermia patients more pressure ulcers tended to emerge in the lower risk group (mJ/C score ≥30) (p = 0.056). Intensive care mortality was higher in the hypothermia (24.3%) than the non-hypothermia group (9.3%, p < 0.0001).

CONCLUSION

Patients treated with therapeutic hypothermia should be considered at high risk for pressure ulcer development and should be managed accordingly. The hypothermia may not as such increase the risk for pressure ulcers, but combined with the severity of the underlying illness, may be more likely. The pressure ulcer risk in this patient group cannot be reliably assessed by the Jackson/Cubbin risk scale.

Factors that influence effective perioperative temperature management by anesthesiologists: a qualitative study using the Theoretical Domains Framework

PURPOSE

Inadvertent perioperative hypothermia (IPH) is associated with a range of adverse outcomes. Safe and effective warming techniques exist to prevent IPH; however, IPH remains common. This study aimed to identify factors that anesthesiologists perceive may influence temperature management during the perioperative period.

METHODS

After Research Ethics Board approval, semi-structured interviews were conducted with staff anesthesiologists at a Canadian academic hospital. An interview guide based on the Theoretical Domains Framework (TDF) was used to capture 14 theoretical domains that may influence temperature management. The interview transcripts were coded using direct content analysis to generate specific beliefs and to identify relevant TDF domains perceived to influence temperature management behaviour.

RESULTS

Data saturation was achieved after 15 interviews. The following nine theoretical domains were identified as relevant to designing an intervention for practices in perioperative temperature management: knowledge, beliefs about capabilities, beliefs about consequences, reinforcement, memory/attention/decision-making, environmental context and resources, social/professional role/identity, social influences, and behavioural regulation. Potential target areas to improve temperature management practices include interventions that address information needs about individual temperature management behaviour as well as patient outcome (feedback), increasing awareness of possible temperature management strategies and guidelines, and a range of equipment and surgical team dynamics that influence temperature management.

CONCLUSION

This study identified several potential target areas for future interventions from nine of the TDF behavioural domains that anesthesiologists perceive to drive their temperature management practices. Future interventions that aim to close the evidence-practice gap in perioperative temperature management may include these targets.

Comparison of resistive heating and forced-air warming to prevent inadvertent perioperative hypothermia

BACKGROUND

Forced-air warming is a commonly used warming modality, which has been shown to reduce the incidence of inadvertent perioperative hypothermia (<36°C). The reusable resistive heating mattresses offer a potentially cheaper alternative, however, and one of the research recommendations from the National Institute for Health and Care Excellence was to evaluate such devices formally. We conducted a randomized single-blinded study comparing perioperative hypothermia in patients receiving resistive heating or forced-air warming.

METHODS

A total of 160 patients undergoing non-emergency surgery were recruited and randomly allocated to receive either forced-air warming (n=78) or resistive heating (n=82) in the perioperative period. Patient core temperatures were monitored after induction of anaesthesia until the end of surgery and in the recovery room. Our primary outcome measures included the final intraoperative temperature and incidence of hypothermia at the end of surgery.

RESULTS

There was a significantly higher rate of hypothermia at the end of surgery in the resistive heating group compared with the forced-air warming group (P=0.017). Final intraoperative temperatures were also significantly lower in the resistive heating group (35.9 compared with 36.1°C, P=0.029). Hypothermia at the end of surgery in both warming groups was common (36% forced air warming, 54% resistive heating).

CONCLUSION

Our results suggest that forced-air warming is more effective than resistive heating in preventing postoperative hypothermia.

CLINICAL TRIAL REGISTRATION

NCT01056991.

Regional uptake an variations in orthopaedic enhanced recovery pathways in knee and hip total arthroplasty

The use of enhanced recovery (ER) pathways for hip and knee arthroplasty has increased over the last decade, and the adoption within orthopaedics is becoming more common. We have demonstrated a regional variation and institutional inconsistency of uptake and delivery of ER pathways in our region. Units that have a unified pathway were more likely to have consistency in treatment and early analgesia for patients. We would advocate that units use an agreed enhanced recovery pathway to optimise patient recovery from hip and knee arthroplasties.

Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults

BACKGROUND

Inadvertent perioperative hypothermia is a phenomenon that can occur as a result of the suppression of the central mechanisms of temperature regulation due to anaesthesia, and of prolonged exposure of large surfaces of skin to cold temperatures in operating rooms. Inadvertent perioperative hypothermia has been associated with clinical complications such as surgical site infection and wound-healing delay, increased bleeding or cardiovascular events. One of the most frequently used techniques to prevent inadvertent perioperative hypothermia is active body surface warming systems (ABSW), which generate heat mechanically (heating of air, water or gels) that is transferred to the patient via skin contact.

OBJECTIVES

To assess the effectiveness of pre- or intraoperative active body surface warming systems (ABSW), or both, to prevent perioperative complications from unintended hypothermia during surgery in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 9, 2015); MEDLINE (PubMed) (1964 to October 2015), EMBASE (Ovid) (1980 to October 2015), and CINAHL (Ovid) (1982 to October 2015).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared an ABSW system aimed at maintaining normothermia perioperatively against a control or against any other ABSW system. Eligible studies also had to include relevant clinical outcomes other than measuring temperature alone.

DATA COLLECTION AND ANALYSIS

Several authors, by pairs, screened references and determined eligibility, extracted data, and assessed risks of bias. We resolved disagreements by discussion and consensus, with the collaboration of a third author.

MAIN RESULTS

We included 67 trials with 5438 participants that comprised 79 comparisons. Forty-five RCTs compared ABSW versus control, whereas 18 compared two different types of ABSW, and 10 compared two different techniques to administer the same type of ABSW. Forced-air warming (FAW) was by far the most studied intervention.Trials varied widely regarding whether the interventions were applied alone or in combination with other active (based on a different mechanism of heat transfer) and/or passive methods of maintaining normothermia. The type of participants and surgical interventions, as well as anaesthesia management, co-interventions and the timing of outcome measurement, also varied widely. The risk of bias of included studies was largely unclear due to limitations in the reports. Most studies were open-label, due to the nature of the intervention and the fact that temperature was usually the principal outcome. Nevertheless, given that outcome measurement could have been conducted in a blinded manner, we rated the risk of detection and performance bias as high.The comparison of ABSW versus control showed a reduction in the rate of surgical site infection (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.20 to 0.66; 3 RCTs, 589 participants, low-quality evidence). Only one study at low risk of bias observed a beneficial effect with forced-air warming on major cardiovascular complications (RR 0.22, 95% CI 0.05 to 1.00; 1 RCT with 12 events, 300 participants, low-quality evidence) in people at high cardiovascular risk. We found no beneficial effect for mortality. ABSW also reduced blood loss during surgery but the magnitude of this effect seems to be irrelevant (MD -46.17 mL, 95% CI -82.74 to -9.59; I² = 78%; 20 studies, 1372 participants). The same conclusion applies to total fluids infused during surgery (MD -144.49 mL, 95% CI -221.57 to -67.40; I² = 73%; 24 studies, 1491 participants). These effects did not translate into a significant reduction in the number of participants being transfused or the average amount of blood transfused. ABSW was associated with a reduction in shivering (RR 0.39, 95% CI 0.28 to 0.54; 29 studies, 1922 participants) and in thermal comfort (standardized mean difference (SMD) 0.76, 95% CI 0.29 to 1.24; I² = 77%, 4 trials, 364 participants).For the comparison between different types of ABSW system or modes of administration of a particular type of ABSW, we found no evidence for the superiority of any system in terms of clinical outcomes, except for extending systemic warming to the preoperative period in participants undergoing major abdominal surgery (one study at low risk of bias).There were limited data on adverse effects (the most relevant being thermal burns). While some trials included a narrative report mentioning that no adverse effects were observed, the majority made no reference to it. Nothing so far suggests that ABSW involves a significant risk to patients.

AUTHORS' CONCLUSIONS

Forced-air warming seems to have a beneficial effect in terms of a lower rate of surgical site infection and complications, at least in those undergoing abdominal surgery, compared to not applying any active warming system. It also has a beneficial effect on major cardiovascular complications in people with substantial cardiovascular disease, although the evidence is limited to one study. It also improves patient's comfort, although we found high heterogeneity among trials. While the effect on blood loss is statistically significant, this difference does not translate to a significant reduction in transfusions. Again, we noted high heterogeneity among trials for this outcome. The clinical relevance of blood loss reduction is therefore questionable. The evidence for other types of ABSW is scant, although there is some evidence of a beneficial effect in the same direction on chills/shivering with electric or resistive-based heating systems. Some evidence suggests that extending systemic warming to the preoperative period could be more beneficial than limiting it only to during surgery. Nothing suggests that ABSW systems pose a significant risk to patients.The difficulty in observing a clinically-relevant beneficial effect with ABSW in outcomes other than temperature may be explained by the fact that many studies applied concomitant procedures that are routinely in place as co-interventions to prevent hypothermia, whether passive or active warming systems based in other physiological mechanisms (e.g. irrigation fluid or gas warming), as well as a stricter control of temperature in the context of the study compared with usual practice. These may have had a beneficial effect on the participants in the control group, leading to an underestimation of the net benefit of ABSW.

The Prevention of Positioning Injuries during Gynecologic Operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077, February 2015)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Positioning injuries after lengthy gynecological procedures are rare, but the associated complications can be potentially serious for patients. Moreover, such injuries often lead to claims of malpractice and negligence requiring detailed medical investigation. To date, there are no binding evidence-based recommendations for the prevention of such injuries. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. The recommendations cover.

Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians

DESCRIPTION

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers.

METHODS

This guideline is based on published literature on this topic that was identified by using MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists. Searches were limited to English-language publications. The outcomes evaluated for this guideline include pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk, and harms. This guideline grades the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients at risk for pressure ulcers.

RECOMMENDATION 1

ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence).

RECOMMENDATION 2

ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence).

RECOMMENDATION 3

ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence).

Infection control hazards associated with the use of forced-air warming in operating theatres

A review is presented of the published experimental and clinical research into the infection control hazards of using forced air-warming (FAW) in operating theatres to prevent inadvertent hypothermia. This evidence has been reviewed with emphasis on the use of ultra-clean ventilation, any interaction it has with different types of patient warming (and FAW in particular), and any related increased risk of surgical site infection (SSI). We conclude that FAW does contaminate ultra-clean air ventilation; however, there appears to be no definite link to an increased risk of SSI based on current research. Nevertheless, whereas this remains unproven, we recommend that surgeons should at least consider alternative patient-warming systems in areas where contamination of the operative field may be critical. Although this is not a systematic review of acceptable randomized controlled clinical trials, which do not exist, it does identify that there is a need for definitive research in this field.

Retrospective review of predisposing factors for intraoperative pressure ulcer development

STUDY OBJECTIVE

To evaluate the comorbidities and surgical factors involved in the genesis of intraoperative pressure ulcers.

DESIGN

Retrospective chart review.

SETTING

Anesthesiology department of a university medical center.

MEASUREMENTS

The charts of 222 patients with varying illness, who underwent an operation of at least two hours' duration, were analyzed retrospectively. Data on surgery type, case length, comorbidities, intraoperative surgical position, and area of ulceration were recorded.

MAIN RESULTS

Risk factors for intraoperative pressure ulcer development include surgical times of 4 hours or longer; comorbidities affecting tissue perfusion (namely, diabetes, hypertension, and nonspecific cardiac issues); supine placement during surgery; and abdominal, noncardiac thoracic, and orthopedic operations. Regions of the body most at risk for ulceration include the coccygeal/sacral region, the buttocks, genitalia, and heels.

CONCLUSIONS

Pressure ulcers are a costly, debilitating, and avoidable complication of surgery.

Preprocedure warming maintains normothermia throughout the perioperative period: a quality improvement project

Research supports the practice of preprocedure warming as a method to prevent the development of unplanned perioperative hypothermia. ASPAN defines hypothermia as a core temperature lower than 36°C. The purpose of this quality improvement project was to explore the idea that preprocedure warming maintains perioperative normothermia. Information was obtained through retrospective chart reviews (n = 148). Temperatures were compared for patients who received standard preprocedure care versus patients who were warmed with a warming gown for one hour preprocedure. Before the institution of warming, about 50% of the patients received in the PACU were hypothermic. After the warming was instituted, only 12% of patients were received in a hypothermic state in the PACU. Concepts discussed in this paper include preprocedure warming, postprocedure hypothermia, and complications associated with hypothermia.

Open treatment of pelvic and acetabular fractures

The open operative management of pelvic and acetabular fractures in the obese is technically demanding, with a significantly higher rate of complications compared with patients who are nonobese. The decision to perform surgery should involve a thorough understanding of risks, and patients should be counseled. Careful attention should be paid to patient factors; coexisting systemic conditions and patient positioning to reduce complications. Wound complications are most commonly seen, and techniques to reduce risk should be incorporated. When complications occur, aggressive management can result in successful salvage. Future areas of study should include methods to reduce risk of surgical site infections and improving our understanding of the physiologic alterations that occur with obesity. This article summarizes the current literature on open treatment of pelvic and acetabular fractures in the obese patient, reviews the physiologic adaptations of obesity as they relate to pelvic surgery, highlights risk factors for complications, and provides recommendations to reduce the incidence of complications.

A systematic review of the effectiveness of cutaneous warming systems to prevent hypothermia

AIMS

To retrieve and critique recent randomised trials of cutaneous warming systems used to prevent hypothermia in surgical patients during the intraoperative period and to identify gaps in current evidence and make recommendations for future trials.

BACKGROUND

Hypothermia affects up to 70% of anaesthetised surgical patients and is associated with several significant negative health outcomes.

DESIGN

Systematic review using integrative methods.

METHODS

We searched CINAHL, EMBASE, Cochrane Register of Controlled Trials and Medline databases (January 2000-April 2007) for recent reports on randomised controlled trials of cutaneous warming systems used with elective patients during the intraoperative period. Inclusion criteria. We included randomised control trials examining the effects of cutaneous warming systems used intraoperatively on patients aged 18 years or older undergoing non-emergency surgery. Studies published in English, Spanish or Portuguese with a comparison group that consisted of either usual care or active cutaneous warming systems without prewarming were reviewed.

RESULTS

Of 193 papers initially identified, 14 studies met the inclusion criteria. There was moderate evidence to indicate that carbon-fibre blankets and forced-air warming systems are equally effective and that circulating-water garments are most effective for maintaining normothermia during the intraoperative period. Few trials reported costs.

CONCLUSIONS

Carbon-fibre blankets and forced-air warming systems are effective and circulating-water garments may be preferable. Future research should measure the direct and indirect costs associated with competing systems.

RELEVANCE TO CLINICAL PRACTICE

Nurses can use this review to inform their selection of warming interventions in perioperative nursing practice. They can also assess other factors such as nursing workload, staff training and equipment maintenance, which should be incorporated into future research.

Anesthetic care for patients with skin breakdown

Wound patients commonly have multiple comorbidities, which should be optimized before anesthesia. These factors contribute not only to skin breakdown but also other causes of mortality and morbidity. Skin becomes more vulnerable to damage from pressure, friction, shear, and moisture when the skin is dry, less elastic, and less perfused. Careful assessment and implementation of an anesthetic plan using regional or general techniques can improve outcomes. The anesthesiologist plays a vital role in maintaining homeostasis during the surgically stressful perioperative period of the wound patient. Aggressive wound management in the early stages is likely to prevent wound progression to deeper levels. Policies are being implemented to decrease the risk of pressure ulcers by prevention.

Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.

Systemic Warming as an Adjunct to Resuscitation in Peritonitis: A Pilot, Randomized Controlled Trial

BACKGROUND

Bacterial peritonitis is accompanied by a high risk of sepsis and endotoxin production resulting in physiological derangements and a high mortality rate. Localized and systemic warming improves tissue perfusion, oxygen tension, and outcomes after surgery. The purpose of this study was to examine the effectiveness of systemic warming as an adjunct to standard antibiotic and fluid resuscitation in patients with peritonitis.

METHODS

In this pilot randomized controlled trial, patients presenting with an acute abdomen were randomized into control and warmed groups using sequential envelopes. Local Ethics Committee approval was obtained. Systemic warming was delivered using the Inditherm warming mattress set at 40 degrees C. Standard oxygen, fluid resuscitation, and antibiotics were delivered simultaneously. Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded on admission and 24 h later or just prior to surgery, whichever was earlier.

RESULTS

Thirty-three patients were recruited. The APACHE II scores on admission were comparable (median 9.0 [range 2-23] and 9.0 [0-20], respectively, for the control and warmed groups (p = 0.70; Mann-Whitney U test)). No patient showed any adverse effects of warming. There were statistically significant improvements in APACHE II scores (p = 0.028; Wilcoxon signed ranks test) and the magnitude of its change (p = 0.048; Mann-Whitney U test) in the warmed group compared with the control group.

CONCLUSIONS

Systemic warming may reduce physiological derangements and improve the prognosis in patients with intra-abdominal crisis. The technique may be used safely as an adjunct to standard resuscitation in peritonitis.

Effects of Local and Systemic Warming on Postoperative Infections

BACKGROUND

There is increasing recognition that attention to optimal perfusion and oxygenation, normothermia, and normoglycemia is associated with low postoperative infection rates. The results of several studies on temperature maintenance will be presented.

METHODS

In a test of the value of systemic warming, patients undergoing major orthopedic, general, or urologic surgery were randomized to standard care with or without systemic warming using a disposable forced warm-air blanket. The addition of perioperative warming using a conductive carbon polymer mattress and overblanket to intraoperative warming was studied in patients undergoing major elective abdominal surgery. In a study of local warming, patients undergoing elective clean-wound surgery were randomized to local warming or non-warming. To determine the contribution of heat to eradication of methicillin-resistant Staphylococcus aureus, patients with stage III-IV pressure sores were randomized to receive or not receive local warming along with standard care.

RESULTS

The intraoperative improvement of cutaneous blood flow and oxygen tension in the systemically warmed group improved tissue viability and reduced the incidence of pressure sores. A statistically significant reduction in morbidity and mortality was found in the patients having the conductive mattress as well as an overblanket. Similar findings are being reported from studies of systemic warming as an adjunct to resuscitation of patients presenting with abdominal pain and elderly patients admitted after a fall or with a suspected fractured femoral neck. Local warming with non-contact radiant heat was as good as systemic warming in preventing surgical site infections.

CONCLUSIONS

Attention to keeping patients warm, together with maintenance of optimal perfusion and oxygenation and euglycemia, represents a simple effective guideline. Several methods of warming are available for use during transport and resuscitation and to achieve perioperative normothermia.

A Systematic Review of Intraoperative Warming to Prevent Postoperative Complications

This systematic review examines whether preventing hypothermia during surgery prevents postoperative complications and thereby improves outcomes for patients. Twenty-six randomized controlled trials were identified, and data extraction and assessment of study quality were carried out by two researchers independently. The results of studies with similar patients, surgical procedures, and outcomes were pooled. Outcomes measured included postoperative pain levels, thermal comfort, and treatment costs. Postoperative complications identified were shivering, cardiac events, need for blood transfusion, wound infections, and pressure ulcers. The majority of studies favored treatment.

The incidence of pressure ulcers in surgical patients: a sample hospital in Turkey

AIM

This research was conducted for the purpose of determining the incidence of surgery-related pressure ulcer formation.

BACKGROUND

Patients undergoing surgery are prone to develop pressure ulcers during surgery. Pressure ulcer incidence in surgery population is reported between 3.5% and 29.5%. Some of these factors that occur during surgery are being under pressure for a long time, remaining wet, and metabolic and circulatory changes related to the surgery and anaesthesia.

DESIGN

The research was conducted as a prospective-analytic-descriptive study with 84 patients who agreed to participate in the study and who were 20 years old or older, having elective surgery, having a surgical procedure lasting two or more hours under general anaesthesia, and who had no risk for pressure ulcer development before surgery according to the Braden Pressure Ulcer Risk Assessment Scale. Research data were obtained using a Data Collection Form that has places for pre-, intra- and postoperative factors that may be related to surgery-related pressure ulcer development; a Body Mass Index Data Form and the Braden Pressure Ulcer Risk Assessment Scale. The Braden Pressure Ulcer Risk Assessment Scale was used to determine that patients had no risk for pressure ulcer development pre- and postoperatively and it was used for the purpose of establishing the patients risk status and areas at risk. Patients were monitored for pressure ulcers until the sixth postoperative day and risk status and areas at risk were determined. Data obtained in the research were analysed using percentage, chi-squared, McNemar and Cohen's Kappa tests for reliability between dependent groups.

RESULTS

At the conclusion of the research, the findings obtained showed that 54.8% of the patients (n = 46) were observed to have Stage 1 pressure ulcers. A total of 41.3% of the patients had pressure ulcers in more than one region and 56.5% of these were of the erythema type. During the six-day postoperative monitoring, 97.9% of the pressure ulcers were observed in the first three days.

CONCLUSION

The study made clear that surgery-related pressure ulcers are an important problem.

RELEVANCE TO CLINICAL PRACTICE

(i) Determining the incidence of pressure ulcers during surgery in Turkey; (ii) For nurses to be able to prevent surgery-related pressure ulcers, it is necessary for them to direct their care by knowing factors that have a role in the development of pressure ulcers during surgery therefore this study will be to call Turkish nurse's attention to pressure ulcers during surgery.

Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura

A tomada de decisão do enfermeiro na sua prática diária necessita ser fundamentada em conhecimento científico. A prática baseada em evidências é uma abordagem que preconiza a utilização de resultados de pesquisas na prática clínica, sendo a revisão integrativa um de seus recursos. A presente investigação é uma revisão integrativa que teve como objetivo avaliar as evidências disponíveis sobre as intervenções eficazes de enfermagem para a prevenção de lesões de pele no paciente cirúrgico, no período transoperatório, ou em decorrência desse. Para a seleção dos artigos utilizou-se duas bases de dados, Cinalh e Medline, e a amostra desta revisão constituiu-se de 14 artigos. Após análise dos artigos incluídos na revisão os resultados dos estudos apontaram que os dispositivos considerados mais eficazes na prevenção de lesões de pele foram em ordem descrecente o colchão de ar micropulsante, cobertura de colchão de polímero de visco elástico seco e almofadas de gel, sucessivamente.

Effects of perioperative hypothermia and warming in surgical practice

Perioperative hypothermia is common and adversely affects clinical outcomes due to its effect on a range of homeostatic functions. Many of these adverse consequences are preventable by the use of warming techniques. A literature search was conducted to identify relevant published articles on perioperative hypothermia and warming. The databases searched include MEDLINE (1966 to February 2005), EMBASE (1974 to February 2005), CINAHL, the Cochrane library and the health technology assessment database. Reference lists of key articles were also searched. The primary beneficial effects of warming are mediated through increased blood flow and oxygen tension at tissue level. Reduction in wound infection, blood loss and perioperative pain with warming is promising. However, more evidence from good-quality prospective randomised controlled trials is needed to evaluate the role of warming in improving overall morbidity, mortality and hospital stay as well as to clarify its role as an adjunct to resuscitation and during the pre-hospital transport phase of critically ill patients. Awareness of the risks of perioperative hypothermia is the key to prevention. Achieving normothermia throughout the patient's journey is a worthwhile goal in surgical patients.

Pressure ulcer risk factors in patients undergoing surgery

AIM

This paper reports a study to identify risk factors associated with pressure ulcer development among a mixed group of adult patients undergoing surgery.

BACKGROUND

Few studies have been carried out with patients undergoing surgery to assess the risk of pressure ulcer development, and so there is a little knowledge of the risk factors for this group. However, studies among non-surgical patients have shown that nutritional predictors such as low serum albumin level and low body mass index (BMI) are of great importance. An additional predictive factor may be low blood pressure. It is important to study these predictors further among patients undergoing surgery, using techniques such as multiple regression techniques, designed to identify the most important predictors for pressure ulcer development.

METHODS

A prospective comparative study was carried out in 1996-1998 with 286 adult patients undergoing surgical treatment. The data were collected from patient records by Registered Nurses preoperatively, for seven days postoperatively and thereafter once a week for up to 12 weeks. Perioperative data were also collected. The Risk Assessment Pressure Sore Scale was used, and data were collected on general physical condition, activity, mobility, moisture, food intake, fluid intake, sensory perception, friction and shear, body temperature and serum albumin.

RESULTS

Forty-one (14.3%) patients developed pressure ulcers during the observation period. The most common type was non-blanchable erythema. Those who developed pressure ulcers were significantly older, weighed less, and had a lower BMI and serum albumin. More women than men developed pressure ulcers. Risk factors identified in multiple stepwise regression analyses were female gender, American Society of Anaesthesiologists (ASA) status or New York Heart Association (NYHA) status and food-intake.

CONCLUSION

Special attention, with regard to risk of pressure ulcer development, should be paid to patients undergoing surgery who have low ASA or NYHA scores, low food intake and/or are women.

Predicting and preventing pressure ulcers in surgical patients

Pressure ulcers, regardless of their origin, represent negative outcomes for patients, including pain, additional treatments and surgery longer hospital stays, disfigurement or scarring, increased morbidity, and increased costs. The or is a high-risk environment for the development of pressure ulcers. Preoperative identification of patients at risk for pressure ulcer development is imperative if cost-effective, evidence-based preventive measures are to be implemented. This article presents a review of the literature pertaining to pressure ulcer development in surgical patients. Recommendations for future research and implications for practice are provided.

Review of Evidenced-Based Practice for the Prevention of Pressure Sores in Burn Patients

Pressure ulcers represent a complex clinical problem, with a reported incidence of 2.7% to 29.5% in hospitalized patients and an etiology that is multifactorial. The prevention of pressure sores in the burn patient population is clearly an area of practice in need of guidelines for care. A multidisciplinary group of advanced burn care professionals have compiled, critiqued, and summarized herein the current evidence of practice in nursing, nutrition, and rehabilitation as it pertains to the prevention of pressure sores after burn injuries. A broad overview of risk factors and assessment scales is described, and current intervention practices and recommendations for care are provided based, whenever possible, on research findings. In addition, research questions are generated in an attempt to move the specialty of burns toward the formal investigation of pressure sores with the ultimate goal being the development of evidence-based practice guidelines.

Eradication of methicillin-resistant Staphylococcus aureus from pressure sores using warming therapy

BACKGROUND

Nosocomial infection is a major cause of surgical morbidity and mortality. Methicillin-resistant Staphylococcus aureus (MRSA) has become a prominent organism in colonization and infection in surgical patients. Pressure sores are a major reservoir of MRSA.

MATERIALS AND METHODS

In this study, 33 patients with full-thickness pressure sores were randomized to receive standard care or radiant heat therapy using a Warm Up device (Augustine Medical, Eden Prairie, MN). Weekly microbial sampling was used for assessment of bacterial presence. None of the patients received antibiotics prior to or during the eight weeks of study.

RESULTS

More than 50 species of bacteria were present in the pressure sores with a median of four organisms per sample. Methicillin-resistant S. aureus was found in 14 of the patients' pressure sores. In the warming group (n = 8), MRSA was eradicated in six patients within 2 weeks of warming, whereas in the control group none had eradication (Fisher's exact test, p = 0.01). Eradication was defined as three consecutive weekly swabs without bacterial growth.

CONCLUSION

The warming of pressure sores is being assessed as an adjunct to healing, but there is some promise that colonization by MRSA may be eradicated, thereby reducing a potential reservoir of organisms. The risk to surgical patients when patients are harboring MRSA may be minimized by warming therapy.

Wound healing: a multidisciplinary approach for dermatologists

This article has provided a review of common and some less common approaches to wound healing. Chronic wound healing is one of the more challenging areas of medicine, with a nice balance of the science and art of medicine. An evidence-based, patient-centered approach can be used to effectively improve the care of many difficult to heal ulcers in often frustrated patients. The multidisciplinary wound clinic concept can work to improve the outcomes of patients with leg ulcers.