Pressure Ulcer Development in the Operating Room:

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.

A Study on Pressure Ulcer: Influencing Factors and Diagnostic Techniques

Pressure ulcer (PU) is one of the most common occurrences in bedridden subjects. Despite the standard of care, there is a huge challenge in monitoring immobile subjects in all the bodily pressure points. This increases the chance of onset of PU which in turn increases the expenditure for treating and managing the PU. Hence, we made a study on the biological and physiological factors that are responsible for the formation of PU and also on various techniques used for diagnosis. Thus, we have summarised the efficacy of various advanced diagnostic procedures with their limitations. Though there are advanced imaging techniques, risk assessment tools based on the visual inspection are widely followed in hospitals. Based on our observation, we here have identified three major areas; one being the development of mathematical modeling, the second is towards the development of non-invasive devices and finally to automate cot facility. We have also provided possible suggestions as to solutions that could be useful to researchers and for society. Thus, this review covers the present difficulty faced by bedridden subjects and respective care-takers along with the knowledge gap and a few suggestions as to future scope.

A Comparative Study of 2-Hour Interface Pressure in Different Angles of Laterally Inclined, Supine, and Fowler's Position

Insufficient research exists for position change intervals to eradicate pressure ulcers. We tried to provide evidence for the position change interval by comparing peak pressure, risk area ratio, and the time to reach 30 mmHg and 60 mmHg, and presented this in detail, according to the angle in the three positions. The study conducted RCTs on a total of 64 healthy adults. For two hours, interface pressure measurements were compared with 30° and 90° tilting at the inclined, 0° and 45° head-of-bed (HOB) elevation at the supine, and 30° and 45° HOB elevation at the Fowler’s position. The peak pressure on 30° tilting remained less than 60 mmHg for 2 h, unlike 90° tilting. To reach 60 mmHg took 78.18 min at 30° tilting, within 30 min at the 30° supine, 30° and 45° at the Fowler’s position, and 39.55 min at 0° supine. The pressure difference according to the angles was only significant at 30° and 90° tilting, with no difference in the other groups. To prevent pressure ulcers, position changes are required every 2 h in the 30° tilting position, every 1.5 to 2 h at 0° supine, and at least every 1.5 h for all the other positions.

Prevention of Pressure Injuries in the Operating Room: A Quality Improvement Project

Prevention of hospital-acquired pressure injuries (HAPIs) remains a crucial clinical challenge especially for those patients undergoing surgery. The purpose of this project was to examine whether a 5-layer silicone foam dressing applied to the sacrum of patients undergoing vascular surgery decreased the occurrence of sacral pressure injuries and to explore participant characteristics associated with the development of operating room (OR)-related pressure injuries. A pre-/postintervention design, quality improvement project in a convenience sample of 81 patients undergoing vascular surgery, in a 700-bed level I trauma acute care setting, in the Northeastern United States. Eighty-one patients undergoing vascular surgery participated in this project. Thirty-seven were in the preintervention group who were identified from the housewide pressure injury prevalence data from May and December 2010 and received standard pressure injury prevention while hospitalized. Forty-four patients in the intervention group were identified from a hospital-based outpatient vascular surgery office and preoperatively received the 5-layer silicone foam dressing in addition to standard care. Data were collected on the third and seventh postoperative days via the electronic medical record and paper medical records. Collected data included age, gender, comorbidities (diabetes, hypertension, peripheral vascular disease and, smoking status), presence of a 5-layer silicone sacral foam dressing, and pressure injury occurrence. Analysis included descriptive statistics, Fisher exact test to compare groups, and logistic regression to identify associated risk factors. More than 50% (n = 19) in the preintervention group developed a hospital-acquired pressure injury while only 1 subject (n = 2%) in the intervention group developed a hospital-acquired pressure injury (P = .000). Findings indicate that, after controlling for age, gender, and other comorbidities, application of a 5-layer silicone sacral foam dressing significantly reduced the likelihood of development of a new pressure injury (OR= 0.04, 95% confidence interval, 0.00-40; P = .006). This pre-/postquality improvement project, using a 5-layer silicone sacral foam dressing in addition to standard operating room pressure injury preventive interventions, for elective vascular surgical cases, resulted in a significant decrease in sacral operating room-related pressure injuries. These findings suggest the effectiveness of a 5-layer silicone foam dressing when added to standard preventive interventions. The findings warrant further investigation of additional preventative interventions in the OR specific to high-risk populations.

Topical phenytoin for treating pressure ulcers

BACKGROUND

Pressure ulcers are common in clinical practice and pose a significant health problem worldwide. Apart from causing suffering to patients, they also result in longer hospital stays and increase the cost of health care. A variety of methods are used for treating pressure ulcers, including pressure relief, patient repositioning, biophysical strategies, nutritional supplementation, debridement, topical negative pressure, and local treatments including dressings, ointments and creams such as bacitracin, silver sulphadiazine, neomycin, and phenytoin. Phenytoin is a drug more commonly used in the treatment of epilepsy, but may play an important role in accelerating ulcer healing.

OBJECTIVES

To assess the effects of topical phenytoin on the rate of healing of pressure ulcers of any grade, in any care setting.

SEARCH METHODS

In September 2016, we searched the following electronic databases to identify relevant randomized clinical trials: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid Embase; and EBSCO CINAHL Plus. We handsearched conference proceedings from the European Pressure Ulcer Advisory Panel, European Wound Management Association and the Tissue Viability Society for all available years. We searched the references of the retrieved trials to identify further relevant trials. We also searched clinical trials registries to identify ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) addressing the effects (both benefits and harms) of topical phenytoin on the healing of pressure ulcers of any grade compared with placebo or alternative treatments or no therapy, irrespective of blinding, language, and publication status.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted information on participants, interventions, methods and results and assessed risk of bias using Cochrane methodological procedures. For dichotomous variables, we calculated the risk ratio (RR) with 95% confidence interval (CI). For continuous variables, we calculated the mean difference with 95% CI. We rated the quality of the evidence by using Grading of Recommendations, Assessment, Development and Evaluation approach (GRADE).

MAIN RESULTS

Three small RCTs met our inclusion criteria and included a total of 148 participants. These compared three treatments with topical phenytoin: hydrocolloid dressings, triple antibiotic ointment and simple dressings. In the three RCTs, 79% of participants had grade II ulcers, and 21% of participants had grade I ulcers; no participants had grade III or IV ulcers. Two RCTs had a high risk of bias overall and the other RCT was at unclear risk of bias due to poor reporting. Two RCTs had three intervention arms and the other had two intervention arms.Two studies compared topical phenytoin with hydrocolloid dressing (84 participants analysed). The available data suggest that hydrocolloid dressings may improve ulcer healing compared to topical phenytoin (39.3% ulcers healed for phenytoin versus 71.4% ulcers healed for hydrocolloid dressings (RR 0.55, 95% CI 0.33 to 0.92; 56 participants, 1 study; low quality evidence). We downgraded the evidence twice: once due to serious limitations (high risk of bias) and once due to the small sample size and small number of events. Two studies compared topical phenytoin with simple dressings (81 participants analysed). From the available data, we are uncertain whether topical phenytoin improves ulcer healing compared to simple dressings (39.3% ulcers healed for phenytoin versus 29.6% ulcers healed for the simple dressing (RR 1.33, 95% CI 0.63 to 2.78; 55 participants, 1 study; very low quality evidence). This evidence was downgraded once due to serious limitations (high risk of bias) and twice due to the low number of outcome events and resulting wide CI which included the possibility of both increased healing and reduced healing. We therefore considered it to be insufficient to determine the effect of topical phenytoin on ulcer healing. One study compared topical phenytoin with triple antibiotic ointment, however, none of the outcomes of interest to this review were reported. No adverse drug reactions or interactions were detected in any of the three RCTs. Minimal pain was reported in all groups in one trial that compared topical phenytoin with hydrocolloid dressings and triple antibiotic ointment.

AUTHORS' CONCLUSIONS

This review has considered the available evidence and the result shows that it is uncertain whether topical phenytoin improves ulcer healing for patients with grade I and II pressure ulcers. No adverse events were reported from three small trials and minimal pain was reported in one trial. Therefore, further rigorous, adequately powered RCTs examining the effects of topical phenytoin for treating pressure ulcers, and to report on adverse events, quality of life and costs are necessary.

The Relationship Between Length of Surgery and the Incidence of Pressure Ulcers in Cardiovascular Surgical Patients: A Retrospective Study

OBJECTIVE

The aim of this study was to investigate the relationship between the length of surgery and the incidence of pressure ulcers (PrUs) in cardiovascular surgical patients.

METHODS

A retrospective analysis was performed among consecutive patients with cardiac surgery in 2012. Propensity score matching was used to control differences in the baseline characteristics between with and without surgery-related pressure ulcer (SRPU) groups.

RESULTS

A total of 286 patients with cardiac surgery were included in the study: 47 patients developed 57 SRPUs, with incidence of 16.4% (95% confidence interval, 12.3%-21.2%); 97.9% of SRPUs were Stage I, and the other 2.1% were Stage II. After propensity score matching, statistically significant difference of the length of surgery between the 2 groups was found (195 minutes [30-330 minutes] vs 240 minutes [125-675 minutes], P = .003). However, the length of cardiopulmonary bypass was found to be not statistically significantly different between the 2 groups (37 minutes [15-144 minutes] vs 44 minutes [16-107 minutes], P = .830). The curve fitting showed the SRPU incidence increased gradually with the extension of length of surgery.

CONCLUSIONS

The authors' retrospective analysis showed the length of surgery was an important risk factor for PrUs in cardiovascular surgical patients, but not the length of cardiopulmonary bypass. The incidence of SRPUs increased gradually with the extension of length of surgery.

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.

A longitudinal study of the incidence of pressure sores and the associated risks and strategies adopted in Italian operating theatres

To explore the incidence of intraoperative pressure sores, the associated risk factors and the preventive strategies adopted by nurses, we adopted a longitudinal study in a 900-bed teaching hospital with multiple operating theatres, located in the North of Italy. Patients who underwent major surgery were evaluated four times: at the moment of operating theatre admission, at operating theatre discharge, and on their third and sixth postoperative day. Of the patients included (n = 102) who had an average age of 62.3 years (range 20-87), 12.7% (13/102) developed a pressure ulcer in the operating theatre; 46.1% (6/13) of these ulcers were still present on the third postoperative day. Some health conditions (diabetes mellitus, cardiac diseases) and intra-operative factors (lying on the operating table for more than 6.15 hours, intraoperative hypothermia) are associated with the occurrence of pressure sores.

Pressure ulcer prevalence and risk factors during prolonged surgical procedures

Pressure ulcer formation related to positioning while in the OR increases the length of hospital stay and hospital costs, but there is little evidence documenting how positioning devices used in the OR influence pressure ulcer development when examined with traditional risk factors. The aim of this prospective cohort study was to identify the prevalence of and risk factors associated with pressure ulcer development among patients undergoing surgical procedures lasting longer than three hours. Participants included all adult same-day admission patients scheduled for a three-hour surgical procedure during an eight-month period (N = 258). Data were gathered preoperatively, intraoperatively, and postoperatively on pressure ulcer risk factors. Bivariate analyses indicated that the type of positioning (ie, heels elevated) (χ(2) = 7.897, P = .048), OR bed surface (ie, foam table pad) (χ(2) = 15.848, P = .000), skin assessment in the postanesthesia care unit (χ(2) = 41.652, P = .000), and male gender (χ(2) = 6.984, P = .030) were associated with pressure ulcer development. Logistic regression analyses indicated that the use of a foam pad (β = 2.691, P = .024) and a lower day-one Braden score (β = .244, P = .003) were predictive of pressure ulcers.

Skin Care Intervention for Patients Having Cardiac Surgery

• Background Pressure ulcers are a major problem after cardiovascular surgery, occurring in 9.2% to 38% of patients.

• Objectives To determine the effectiveness of a skin care intervention program in preventing development of ulcers or progression from one stage to another and to determine the extent to which selected risk factors were associated with development and progression of pressure ulcers.

• Methods A simple interrupted time series design was used. The protocol involved interrelated assessment, staging, and type of intervention provided. The Braden Scale was used to determine risk for skin breakdown.

• Results Of the 351 patients in the study, 327 (93%) maintained skin integrity and 24 (7%) had skin breakdown. Breakdown by stages was as follows: stage 1, 62% (n = 15); stage 2, 29% (n = 7); stage 3, 4% (n = 1); and stage 4, 4% (n = 1). Age, sex (female), and heart failure were statistically significant risk factors for breakdown (P = <.001, .02, and .02, respectively). The mean scores on the Braden Scale of the breakdown group differed significantly from those of the skin integrity group from days 2 through 5 after surgery (P = .01). Seventeen (71%) of the breakdowns occurred during the first 4 days after surgery.

• Conclusions Skin assessments and nursing interventions should be increased on the day of surgery and the first to fifth postoperative days, including multiple assessments and skin care focused on maintaining skin integrity.