Pressure Ulcers in Pediatric Patients With Spinal Cord Injury: A Review of Assessment, Prevention, and Topical Management

Is in-Shoe Microclimate a Neglected Contributor in the Pathway to Diabetic Foot Ulceration?

The identification of the key contributing factors which predispose the foot to ulceration, increasing the risk of recurrence and slow wound healing in diabetes mellitus (DM), has led to some significant research studies over the last 30 years, providing valuable insight into the mechanism leading to diabetic foot ulceration (DFU). Although, these contributory factors are similar to those identified in pressure ulceration occurring in other parts of the body (such as "bed pressure sores') where magnitude and/or duration of mechanical stress in the presence of sensory deficits are key causal factors, research investigating pressure ulceration has also included measurement of temperature and relative humidity at the interface between the skin and supporting surface. The possible influence of these parameters (in-shoe temperature and humidity) does not appear frequently in diabetic foot ulceration research. Referred to as "microclimate", this has an important role in the pathway to tissue breakdown evidenced in pressure ulcer research and may be particularly relevant in countries with warm and humid climates. As the microclimate is influential in the ulceration pathway for other body sites, its role in the DFU causal pathway justifies further investigation.

Needs and Research Priorities for Young People with Spinal Cord Lesion or Spina Bifida and Their Caregivers: A National Survey in Switzerland within the PEPSCI Collaboration

The aim of this study was to describe the needs and research priorities of Swiss children/adolescents and young adults (from here, “young people”) with spinal cord injury/disorder (SCI/D) or spina bifida (SB) and their parents in the health and life domains as part of the international Pan-European Pediatric Spinal Cord Injury (PEPSCI) collaboration. Surveys included queries about the satisfaction, importance, research priorities, quality of life (QoL), and characteristics of the young people. Fifty-three surveys with corresponding parent-proxy reports were collected between April and November 2019. The self-report QoL sum scores from young people with SCI/D and SB were 77% and 73%, respectively. Parent-proxy report QoL sum scores were lower, with 70% scores for parents of young people with SCI/D and 64% scores for parents of young people with SB. “Having fun”, “relation to family members”, and “physical functioning” were found to be highly important for all young people. “Physical functioning”, “prevention of pressure injuries”, “general health”, and “bowel management” received the highest scores for research priority in at least one of the subgroups. As parents tend to underestimate the QoL of their children and young people prioritized research topics differently, both young peoples’ and caregivers’ perspectives should be included in the selection of research topics.

Predictive efficacy of the Braden Q Scale for pediatric pressure ulcer risk assessment in the PICU: a meta-analysis

BACKGROUND

Risk assessment is recommended as the foremost step in the prevention of pressure ulcers. This study aimed to evaluate the predictive efficacy of the Braden Q Scale for the assessment of pediatric pressure ulcer risk in the pediatric intensive care unit (PICU).

METHODS

Six databases were searched. A meta-analysis was performed using Meta DiSc 1.4.

RESULTS

Seven studies were included, with a total of 1273 cases and 72 pressure ulcers. The meta-analysis showed that the pooled sensitivity and specificity of the Braden Q Scale for PICU patients were 0.72 and 0.60 (95% confidence interval (CI): 0.60-0.82; 0.57-0.63), respectively. The pooled positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 1.69, 0.62, and 3.34 (95% CI: 1.18-2.42; 0.40-0.94; 1.47-7.61), respectively. The area under the curve of summary receiver operating characteristics was 69.18%, and the Q index was 0.6464.

CONCLUSION

The Braden Q Scale predicted pressure ulcer risk in the PICU with moderate accuracy. More testing for the Braden QD Scale's performance is needed, taking into account the impact of the interventions. In the future, it will be necessary to look for and improve pediatric pressure ulcer risk assessment tools.

Effect of Pressure Injury Prevention Guides Used In a Pediatric Intensive Care

The aim of this study was to determine the effectiveness of a pressure injury prevention guide used in a pediatric intensive care unit (PICU) on the occurrence of pressure injuries. The design is a pre-post intervention with a control group and a prospective intervention group. Pressure injuries occurred on 9.4% of children in the nontreatment group, and in 3.6% of children in the treatment group. There was a statistically significant difference in the occurrence of pressure injuries between the nontreatment group and the treatment group (p = .033). The average Braden Q pressure injury score was 12.20 ± 2.280 at the beginning of the intensive care hospitalization, and 13.73 ± 3.312 at discharge in the treatment group (p < .001). The results show that the risk of pressure injuries was reduced and pressure injuries occurred later when an evidence-based pressure injury prevention guide was used.

Adjustability and Adaptability Are Critical Characteristics of Pediatric Support Surfaces

Significance: Pressure ulcers (PUs) in newborns and children are remarkably different from those in adults, both in their possible causal factors and in the etiology and biomechanical pathways for tissue damage. Recent Advances: Pediatric muscle and fat tissue structures are overall softer than those of adults, making newborns and young children more susceptible to deformation-inflicted injuries at their weight-bearing soft tissues. Critical Issues: The unique medical environment of neonatal and pediatric intensive care units, which is overloaded with medical devices, wiring, tubing, electrodes, and so on, is, in fact, an extrinsic risk factor for device-related PUs, since accidently misplaced tubes, wires, or electrodes can become trapped between the skin and the mattress, causing large sustained soft tissue deformations around them. Future Directions: Mattresses that are being used in neonatal and pediatric intensive care units must be able to respond to frequent movements and changing positions and also be able to effectively adapt and conform around such misplaced tubing or wires, which might contact the body and deform soft tissues. We used computer simulations of a tube caught under a preterm neonate's arm in a supine position to illustrate what adaptability of the support surface means in such cases. Our present simulations indicate that an air-cell-based technology provides considerably better protection against PUs in such cases, as the air-cells are able to locally buckle and conform around objects that are stiffer than the pediatric tissues (e.g., wires, tubes, electrodes), which minimizes exposure to tissue deformations.

Dressings and Products in Pediatric Wound Care

Significance: The increasing complexity of medical and surgical care provided to pediatric patients has resulted in a population at significant risk for complications such as pressure ulcers, nonhealing surgical wounds, and moisture-associated skin damage. Wound care practices for neonatal and pediatric patients, including the choice of specific dressings or other wound care products, are currently based on a combination of provider experience and preference and a small number of published clinical guidelines based on expert opinion; rigorous evidence-based clinical guidelines for wound management in these populations is lacking. Recent Advances: Advances in the understanding of the pathophysiology of wound healing have contributed to an ever-increasing number of specialized wound care products, most of which are predominantly marketed to adult patients and that have not been evaluated for safety and efficacy in the neonatal and pediatric populations. This review aims to discuss the available data on the use of both more traditional wound care products and newer wound care technologies in these populations, including medical-grade honey, nanocrystalline silver, and soft silicone-based adhesive technology. Critical Issues: Evidence-based wound care practices and demonstration of the safety, efficacy, and appropriate utilization of available wound care dressings and products in the neonatal and pediatric populations should be established to address specific concerns regarding wound management in these populations. Future Directions: The creation and implementation of evidence-based guidelines for the treatment of common wounds in the neonatal and pediatric populations is essential. In addition to an evaluation of currently marketed wound care dressings and products used in the adult population, newer wound care technologies should also be evaluated for use in neonates and children. In addition, further investigation of the specific pathophysiology of wound healing in neonates and children is indicated to promote the development of wound care dressings and products with specific applications in these populations.

The effects of phenol neurolysis of the obturator nerve on the distribution of buttock-seat interface pressure in spinal cord injury patients with hip adductor spasticity

OBJECTIVES

Hip adductor spasticity may adversely effect shear-force and pressure distribution on the buttocks, where ulcerations most frequently appear in patients with spinal cord injury (SCI). Phenol neurolysis of the obturator nerve (ON) is commonly used to manage hip adductor spasticity. This study aimed to determine the effects on the distribution of buttock-seat interface pressure (BSIP) in a group of SCI patients with adductor spasticity that underwent ON blockade with phenol.

METHODS

We reviewed the records of SCI patients that were admitted to our clinic between January 2009 and December 2009. BSIP values (obtained with an X-sensor 48) and hip adductor spasticity levels of SCI patients with hip adductor spasticity that underwent ON blockade with phenol were collected. BSIP distributions of the patients were divided into two portions: first one is the BSIP distribution at the pressure ≤37 mm Hg, and the second one is at the pressure >37 mm Hg.

RESULTS

The study included 20 SCI patients (19 males and 1 female), with a mean age of 42.85±13.24 years. Although the percentage of BSIP distribution at ≤37 mm Hg range increased significantly (P<0.001), after ON neurolysis, BSIP distribution at >37 mm Hg range decreased significantly (P<0.001). In addition, mean hip adductor spasticity decreased significantly after ON neurolysis (P<0.001).

CONCLUSION

Phenol neurolysis of the ON is a promising treatment for the management of hip adductor spasticity in SCI patients and also has positive effects on BSIP, which has a crucial function in the development of pressure ulcers.