Face tissue pressure in prone positioning: a comparison of three face pillows while in the prone position for spinal surgery

Safety and usability of proning pillows in intensive care: A scoping review

OBJECTIVES

Proning is an established technique for the care of intubated patients with severe respiratory failure. Positioning devices used to support the head and body of patients placed in the prone position are often associated with the formation of pressure injuries. Despite robust literature on the prevention and monitoring of pressure injuries, little is described about the role of proning pillows on pressure injuries. The objective of this review is to understand the extent of evidence pertaining to the safety and usability of different types of proning pillows in the intensive care setting.

REVIEW METHOD

A scoping review of the literature was completed using predefined search terms in three databases and identified 296 articles. An additional 26 were included from reference lists. Twenty studies are included in the analysis; most were published in the past 3 years, with >50% in surgical settings.

DATA SOURCES

Three databases were searched: PubMed, Scopus, and EMBASE.

REVIEW METHODS

The review followed the PRISMA Extension for Scoping Reviews, and data were reviewed using Covidence.

RESULTS

The most prevalent proning pillow is a standard, noncontoured foam head positioner. It is responsible for the majority of facial pressure injuries in all settings of care. Memory foam pillows and helmet-based systems offer improved surface pressure distribution, although their usability in the intensive care setting remains poorly studied. Inflatable air-cell-based devices present an alternative, but the lack of supporting research and the costs may explain their poor uptake. Several articles proposed the use of pressure sensor systems to evaluate devices. We propose a set of ergonomic parametres to consider when choosing or designing a positioning device for proned patients.

CONCLUSION

The evidence pertaining to the safety and usability of proning pillows in the intensive care setting is scarce, which provides opportunities for future research to improve the efficacy in the prevention of pressure injuries and the user experience.

The effect of prone positioning on pressure injury incidence in adult intensive care unit patients: A meta-review of systematic reviews

OBJECTIVE

Numerous systematic reviews have examined the impact of prone positioning on outcomes, including pressure injury (PI). The objective of this meta-review was to synthesise the evidence on the effect of prone positioning on the incidence and location of PIs in adult intensive care unit patients.

REVIEW METHOD

This is a meta-review of published systematic reviews. Five databases were searched; data were extracted by three authors and adjudicated by a fourth. The AMSTAR-2 tool was used to quality appraise the selected articles, which was completed by three authors with a fourth adjudicating.

RESULTS

Ten systematic reviews were synthesised. The cumulative incidence of PI in 15,979 adult patients ranged from 25.7% to 48.5%. One study did not report adult numbers. Only one review reported the secondary outcome of PI location. PIs were identified in 13 locations such as the face, chest, iliac crest, and knees. Using the AMSTAR-2, three reviews were assessed as high quality, six as moderate quality, and one as low quality.

CONCLUSION

The high incidence of PI in the prone position highlights the need for targeted preventative strategies. Care bundles may be one approach, given their beneficial effects for the prevention of PI in other populations. This review highlights the need for proactive approaches to limit unintended consequences of the use of the prone position, especially notable in the current COVID-19 pandemic.

Prone position pressure sores in the COVID-19 pandemic: The Madrid experience

BACKGROUND

In the context of the COVID-19 pandemic, prone position (PP) has been frequently used in the intensive care units to improve the prognosis in patients with respiratory distress. However, turning patients to prone imply important complications such as pressure ulcers. The aim of this paper is to describe the prevalence and characteristics of prone-positioning pressure sores (PPPS) and analyze the related risk factors.

METHODS

A case-control study was performed in Gregorio Maranon hospital in Madrid during the COVID-19 pandemic between April and May 2020. We enrolled 74 confirmed COVID-19 patients in critical care units with invasive mechanical ventilation who were treated with pronation therapy. There were 57 cases and 17 controls. Demographic data, pronation maneuver characteristics and PPPS features were analyzed.

RESULTS

In the case group, a total number of 136 PPPS were recorded. The face was the most affected region (69%). Regarding the severity, stage II was the most frequent. The main variables associated with an increased risk of PPPS were the total number of days under pronation cycles, and PP maintained for more than 24 h. The prealbumin level at admission was significantly lower in the case group. All of the ulcers were treated with dressings. The most frequent acute complication was bleeding (5%).

CONCLUSIONS

According to our study, PPPS are related to the characteristics of the maneuver and the previous nutritional state. The implementation of improved positioning protocols may enhance results in critical patient caring, to avoid the scars and social stigma that these injuries entail.

Incidence and risk factors of medical device-related pressure injuries among patients undergoing prone position spine surgery in the operating room

AIM

We aimed to investigate the incidence rate and risk factors of medical device-related pressure injuries (MDRPIs) among patients undergoing prone position spine surgery.

MATERIALS AND METHODS

This was a prospective observational study of 147 patients who underwent spine surgery in an orthopaedic hospital in Korea. The incidence of MDRPI according to intrinsic and extrinsic factors was assessed using the independent t-, χ² -, or Fisher's exact tests. A logistic regression analysis was performed exclusively for MDRPI areas with an incidence rate >5%.

RESULTS

The mean incidence rate of overall MDRPI was 27.4%, while that of MDRPI by Wilson frame, bi-spectral index, and endotracheal tube (ETT) was 56.5%, 52.4%, and 9.5%, respectively. The risk factors under Wilson frame were operation time and body mass index classification. Compared to their normal weight counterparts, those who were underweight, overweight, and obese had a 46.57(95% CI: 6.37-340.26), 3.96 (95% CI: 1.13-13.86), and 5.60 times (95% CI: 1.62-19.28) higher risk of developing MDRPI, respectively. The risk factors by bi-spectral index were sex, operation time, and the American Society of Anaesthesiologists classification. Compared to ETT intubation of <2 h, the risk of MDRPI increased by 7.16 times (95% CI: 1.35-38.00) and 7.93 times (95% CI: 1.45-43.27) for<3 and ≥3 h' duration, respectively.

CONCLUSION

The difficulty of device repositioning can increase the incidence of MDRPI, and prolonged surgery was a significant risk factor. Thus, appropriate planning and correct equipment utilization is needed during prone position spine surgeries.

Complications of prone positioning in patients with COVID-19: A cross-sectional study

OBJECTIVE

To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers.

METHODS

Cross-sectional study conducted in the hub COVID-19 centre in Milan (Italy), between March and June 2020. All patients with COVID-19 admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning were included. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression.

RESULTS

A total of 219 proning cycles were performed on 63 patients, aged 57.6 (10.8) and predominantly obese males (66.7%). The main complications recorded were: prone-related pressure ulcers (30.2%), bleeding (25.4%) and medical device displacement (12.7%), even if no unplanned extubation was recorded. The majority of patients (17.5%) experienced bleeding of upper airways. Only 15 prone positioning cycles (6.8%) were interrupted, requiring staff to roll the patient back in the supine position. The likelihood of pressure ulcers development was independently associated with the duration of prone positioning, once adjusting for age, hypoxemic level, and nutritional status (OR 1.9, 95%CI 1.04-3.6).

CONCLUSION

The use of prone positioning in patients with COVID-19 was a safe and feasible treatment, also in obese patients, who might deserve more surveillance and active prevention by intensive care unit staff.

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.

Effect of Two Regimens of Fluid Administration on Airway Edema in Prone-Position Surgery

Background:

Surgeries in prone position expose a patient to multitude of complications including laryngeal edema which may be related to the volume of fluid administered. Administering larger volumes of fluid intraoperatively may contribute to significant tissue edema, leading many anesthesiologists to practice a restrictive fluid infusion strategy. Although previous studies have compared fluid infusion strategies, changes in airway dimensions leading to airway edema have not been extensively investigated. Here, we compared two fluid infusion regimens in patients undergoing spine surgery in the prone position, and assessed their association with airway edema by means of the cuff leak test (CLT).

Aims:

The aim of this study was to test the hypothesis whether a larger volume of crystalloid administration in spine surgeries performed in prone position would result in greater chances of airway edema, than would a restricted infusion policy, utilizing the CLT.

Materials and Methods:

After ethical committee approval, thirty patients, aged 21–60 years, American Society of Anesthesiologists Status I or II, scheduled for elective spine surgery in the prone position, were selected. Group 1 (restrictive group) received 3 mL.kg ^{− 1}.h ^{− 1}, whereas Group 2 (permissive group) received 5 mL.kg ^{− 1}.h ^{− 1} of crystalloids plus urine output replacement. The airway edema was assessed by CLT which was performed soon after intubation (T1) and before extubation (T2). Cuff leak volume (CLV) was calculated from the difference in tidal volumes before (VT_i) and after cuff deflation (VT_e). Airway edema was evaluated by calculating the differences in the CLV at T1 and T2 (ΔCLV); the more the value of Δ CLV which means greater difference between these two points, the more the decrease in laryngeal lumen, signifying an increased risk of airway edema.

Results:

Decrease in laryngeal lumen was observed in patients who received permissive fluid regimen than that of the restrictive group, signifying more chances of airway edema in the former group. In addition, a poor correlation was found between the duration of anesthesia and development of airway edema in our study group.

Conclusions:

Because surgeries in the prone position are at risk of airway edema, restrictive fluid regimen strategy should be preferred over the liberal one as there are more chances of reduction in laryngeal lumen dimensions with permissive fluid infusions.

Pressure Injury Prevention in COVID-19 Patients With Acute Respiratory Distress Syndrome

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12–16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.

Plan de cuidados de enfermería para la prevención de úlceras por presión secundarias a la posición prono en pacientes COVID-19

Introducción: La posición prono (PP) es una alternativa terapéutica ampliamente recomendada e implementada en los pacientes con COVID-19. Sin embargo, aunque es un procedimiento no invasivo, es complejo y se asocia con eventos adversos como las úlceras por presión (UPP). Nuestro objetivo es proponer un plan de cuidados de enfermería basado en el lenguaje estandarizado NANDA-I, NIC, NOC para la prevención de las UPP secundarias a la PP en la enfermedad de COVID-19. Síntesis del contenido: En los pacientes con COVID-19, además de factores de riesgo propios del paciente como la edad avanzada y la presencia de comorbilidades, la PP contribuye a la presencia de los diagnósticos de enfermería de riesgo de úlcera por presión [00249], de deterioro de la integridad cutánea [00047] y tisular [00248]. Por su parte, la intervención de enfermería prevención de úlceras por presión [3540], es clave para minimizar el desarrollo de esta complicación, mejorar la calidad de la atención y el pronóstico en este tipo de pacientes. Finalmente, para determinar la efectividad del cuidado de enfermería se proponen los resultados NOC consecuencias de la inmovilidad: fisiológicas [0204] e integridad tisular: piel y membranas mucosas [1101]. Conclusión: La PP es una terapia coadyuvante recomendada para el manejo de los pacientes con COVID-19 críticamente enfermos, debido a que optimiza la función pulmonar, sin embargo está asociada a eventos adversos como las UPP. Este artículo presenta recomendaciones basadas en una revisión narrativa para facilitar la implementación de cuidados de enfermería preventivos que reduzcan su frecuencia en esta población.

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.

COVID-19 disease: assessment of a critically ill patient

With the major scale up of critical care services to respond to the increasing numbers of patients with severe COVID-19 infection, nurses need to be able to rapidly assess patients. While many patients present with signs of viral pneumonia and may develop respiratory failure, it is essential that the subsequent systemic complications are also recognized. Due to the unprecedented numbers of patients requiring critical care, many of them will initially have to be managed in emergency departments and acute wards until a critical care bed becomes available. In this article, the assessment of a patient with suspected or confirmed severe COVID-19 has been presented initially from a ward perspective, followed by that of critical care, using the Airway, Breathing, Circulation, Disability and Exposure (ABCDE) approach. This article has been specifically designed to enable nurses to systematically assess patients and prioritise care.

Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency

OBJECTIVE

Pressure ulcers (PUs) involve the destruction of skin and underlying tissue due to prolonged pressure and shear forces. These ulcers are painful and significantly reduce a person's quality of life. PUs are also expensive to manage and impact negatively on the achievement of cost-effective, efficient care delivery.

METHOD

Prone positioning is a postural therapy that aims to enhance respiratory function through increasing oxygenation levels. In contemporary clinical practice, ventilation in the prone position is indicated for patients with severe acute respiratory distress syndrome. However, despite its advantages in terms of respiratory function, several studies have examined complications of prone position ventilation and have identified PUs (facial PUs as well as PUs on other weight-bearing areas of the body) as a frequent complication in patients who are already in a precarious medical situation. International data suggest that up to 57% of patients nursed in the prone position develop a PU. The aim of this clinical review is to identify and review evidence-based recommendations developed to facilitate the selection and application of preventive interventions aimed at reducing PU development in patients ventilated in the prone position. Given the current COVID-19 crisis, this review is timely as intensive care unit (ICU) patients with COVID-19 require ventilation in the prone position at a level that is disproportionate to the general intensive care population. Up to 28% of patients admitted to the ICU with confirmed infection due to severe COVID-19 are cared for in the prone position. The scope of this review is limited to adult individuals only.

RESULTS

The skin assessment should be undertaken before proning and following positioning the patient back into the supine position. Although it is essential to keep the skin clean and moisturised, using pH-balanced cleansers, there is inconsistency in terms of the evidence to support the type of moisturiser. Use of positioning devices in addition to repositioning is recommended to offload pressure points on the face and body. Further, using dressings such as hydrocolloids, transparent film and silicone may be of benefit in decreasing facial skin breakdown.

CONCLUSION

Given the importance of PU prevention in this cohort of patients, adopting a focused prevention strategy, including skin assessment and care, offloading and pressure redistribution, and dressings for prevention may contribute to a reduction in the incidence and prevalence of these largely preventable wounds.

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.

Incidence of Pressure-Related Skin Injuries in Patients Operated for Spine Surgery in Prone: A Retrospective Analysis of 307 Patients

Background:

Spine surgery in prone position frequently results in pressure skin lesions (PSLs). No study from Arabic world has published their incidence in literature.

Methods:

We retrospectively analyzed patients who underwent prone position spine surgery from December 1, 2017, to November 30, 2018. They received standardized anesthesia care and were made prone on Jackson table. The face was supported on a nonface contoured foam device, whereas the chest and pelvis were supported on soft cushions. Following completion of surgery, they were turned supine and their skin was inspected for any skin lesions. The lesions were categorized into five grades depending on severity.

Results:

Data of 307 patients were analyzed. Their mean age and weight was 41.5 years and 71 kg, respectively. The mean duration of prone positioning was 470 min. One hundred and three PSLs were observed in 45 patients (14.7%), giving a PSL incidence of 43.7% in affected patients. Majority of patients (18, 40%) with lesions remained in prone position between 421 and 600 min. Multiple lesions were observed in 53.3% of the affected patients. The highest number of patients (21, 46.7%) had one lesion only and it was restricted to face. All lesions were of Grade I, II, or III. Body weight >71 kg was more prone to developing PSLs. Females were more prone to PSLs.

Conclusion:

PSLs in prone position spine surgery occur frequently, and their incidence is proportional to the duration of positioning and weight of the patients. Face is the most commonly affected area.

Lateral Position versus Prone Position for Cervical Laminoplasty: A Retrospective Comparative Study

Purpose

To examine the safety of lateral decubitus positions for cervical laminoplasty.

Patients and Methods

A retrospective comparative study was conducted on the safety between the lateral and prone positions in cervical laminoplasty. After screening, 466 patients who underwent cervical laminoplasty at a single medical center were enrolled and categorized into the lateral (n=229) and prone (n=237) groups. Data on positioning time, surgical time, blood loss, complication rates, and surgical outcomes were collected and compared between the two groups. The patients were further divided into underweight, normal weight, overweight, and obesity subgroups according to their body mass index, and the collected data were compared between the lateral and prone groups.

Results

The lateral group had a lower incidence of facial pressure ulcers (2.18%) than the prone group (11.39%). However, positioning time, surgical time, blood loss, and surgical outcomes were not significantly different between the two groups. In the subgroup analysis, no significant difference in positioning time, operative time, and blood loss was observed in the underweight, normal weight, and overweight patients between the two groups, but in the obesity subgroup, the lateral group had a significantly shorter positioning time (15.23±6.44 vs 21.63±9.43 min, P=0.045) and operative time (140.16±40.48 vs 178.62±51.82 min, P=0.037) and lesser blood loss (285.31±171.75 vs 430.46±189.84 mL, P=0.044) than the prone group.

Conclusion

The lateral position is as safe as the prone position for cervical laminoplasty, but it has advantages over the prone position for patients with obesity.

LumbarIschemic Optic NeuropathyComplicating Spine Surgery-A Case Report

Introduction

Post-operative vision loss (POVL),i.e., blindness is an uncommon complication of any major surgery. In orthopedics, it is encountered mostly in spine surgery. POVL may be due to various pathologies such asischemic optic neuropathy (ION) and central retinal artery occlusion. A rise in intraocular pressure is one of the contributing factors. ION associated with lumbar spine surgery has been designated as lumbar ION. Even though its incidence is as low as 0.02%, once occurs, the consequence is disastrous. Our case of POVL due to posterior ION has certain distinct features which differentiate it from the routine cases reported in literature.

Case Report

Our case is a 33-year-old gentleman who underwent revision lumbar spine surgery, for L3-L4 disc protrusion (recurrence) and L4-L5 disc protrusion with bilateral foot drop, in the form of posterior decompression, pedicle screw fixation from L3 to L5, and two-level transforaminal lumbar interbody fusion using cages. The patient developed POVL involving one eye which was diagnosed on operating table itself (immediately after extubation). Immediate appropriate treatment was initiated with the cooperation of ophthalmologist. The patient subsequently recovered, from no perception of light, to a visual acuity of 6/24, and is doing well regarding vision as well as neurology.

Conclusion

Since POVL is an avoidable complication, knowledge regarding POVL and its contributing factors can lead to the prevention of the development of this complication. Moreover, since POVL has poor prognosis for recovery, prevention is the key. Since POVL can occur after any major surgery (apart from orthopedics), its knowledge can help surgeons in other specialties also.

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.

Supercapacitive Iontronic Nanofabric Sensing

The study of wearable devices has become a popular research topic recently, where high-sensitivity, noise proof sensing mechanisms with long-term wearability play critical roles in a real-world implementation, while the existing mechanical sensing technologies (i.e., resistive, capacitive, or piezoelectric) have yet offered a satisfactory solution to address them all. Here, we successfully introduced a flexible supercapacitive sensing modality to all-fabric materials for wearable pressure and force sensing using an elastic ionic-electronic interface. Notably, an electrospun ionic fabric utilizing nanofibrous structures offers an extraordinarily high pressure-to-capacitance sensitivity (114 nF kPa^-1 ), which is at least 1000 times higher than any existing capacitive sensors and one order of magnitude higher than the previously reported ionic devices, with a pressure resolution of 2.4 Pa, achieving high levels of noise immunity and signal stability for wearable applications. In addition, its fabrication process is fully compatible with existing industrial manufacturing and can lead to cost-effective production for its utility in emerging wearable uses in a foreseeable future.

Marginal Hospital Cost of Surgery-related Hospital-acquired Pressure Ulcers

BACKGROUND

Patients who develop hospital-acquired pressure ulcers (HAPUs) are more likely to die, have longer hospital stays, and are at greater risk of infections. Patients undergoing surgery are prone to developing pressure ulcers (PUs).

OBJECTIVE

To estimate the hospital marginal cost of a HAPU for adults patients who were hospitalized for major surgeries, adjusted for patient characteristics, comorbidities, procedures, and hospital characteristics.

RESEARCH DESIGN AND SUBJECTS

Data are from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and the Medicare Patient Safety Monitoring System for 2011 and 2012. PU information was obtained using retrospective structured record review from trained MPMS data abstractors. Costs are derived using HCUP hospital-specific cost-to-charge ratios. Marginal cost estimates were made using Extended Estimating Equations. We estimated the marginal cost at the 25th, 50th, and 75th percentiles of the cost distribution using Simultaneous Quantile Regression.

RESULTS

We find that 3.5% of major surgical patients developed HAPUs and that the HAPUs added ∼$8200 to the cost of a surgical stay after adjusting for comorbidities, patient characteristics, procedures, and hospital characteristics. This is an ∼44% addition to the cost of a major surgical stay but less than half of the unadjusted cost difference. In addition, we find that for high-cost stays (75th percentile) HAPUs added ∼$12,100, whereas for low-cost stays (25th percentile) HAPUs added ∼$3900.

CONCLUSIONS

This paper suggests that HAPUs add ∼44% to the cost of major surgical hospital stays, but the amount varies depending on the total cost of the visit.

The prone position during surgery and its complications: a systematic review and evidence-based guidelines

Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.

Support surfaces for pressure ulcer prevention

BACKGROUND

Pressure ulcers (i.e. bedsores, pressure sores, pressure injuries, decubitus ulcers) are areas of localised damage to the skin and underlying tissue. They are common in the elderly and immobile, and costly in financial and human terms. Pressure-relieving support surfaces (i.e. beds, mattresses, seat cushions etc) are used to help prevent ulcer development.

OBJECTIVES

This systematic review seeks to establish:(1) the extent to which pressure-relieving support surfaces reduce the incidence of pressure ulcers compared with standard support surfaces, and,(2) their comparative effectiveness in ulcer prevention.

SEARCH METHODS

In April 2015, for this fourth update we searched The Cochrane Wounds Group Specialised Register (searched 15 April 2015) which includes the results of regular searches of MEDLINE, EMBASE and CINAHL and The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 3).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised trials, published or unpublished, that assessed the effects of any support surface for prevention of pressure ulcers, in any patient group or setting which measured pressure ulcer incidence. Trials reporting only proxy outcomes (e.g. interface pressure) were excluded. Two review authors independently selected trials.

DATA COLLECTION AND ANALYSIS

Data were extracted by one review author and checked by another. Where appropriate, estimates from similar trials were pooled for meta-analysis.

MAIN RESULTS

For this fourth update six new trials were included, bringing the total of included trials to 59.Foam alternatives to standard hospital foam mattresses reduce the incidence of pressure ulcers in people at risk (RR 0.40 95% CI 0.21 to 0.74). The relative merits of alternating- and constant low-pressure devices are unclear. One high-quality trial suggested that alternating-pressure mattresses may be more cost effective than alternating-pressure overlays in a UK context.Pressure-relieving overlays on the operating table reduce postoperative pressure ulcer incidence, although two trials indicated that foam overlays caused adverse skin changes. Meta-analysis of three trials suggest that Australian standard medical sheepskins prevent pressure ulcers (RR 0.56 95% CI 0.32 to 0.97). 

AUTHORS' CONCLUSIONS

People at high risk of developing pressure ulcers should use higher-specification foam mattresses rather than standard hospital foam mattresses. The relative merits of higher-specification constant low-pressure and alternating-pressure support surfaces for preventing pressure ulcers are unclear, but alternating-pressure mattresses may be more cost effective than alternating-pressure overlays in a UK context. Medical grade sheepskins are associated with a decrease in pressure ulcer development. Organisations might consider the use of some forms of pressure relief for high risk patients in the operating theatre.

Chin necrosis as a consequence of prone positioning in the intensive care unit

Pressure necrosis of the skin is a rarely reported avoidable complication of prone positioning that can be minimised by active collaboration between care teams. We report a case of pressure necrosis of the chin after prone ventilation in the intensive care setting. Such injuries pose a risk of infection, possible need for surgical intervention, and increased costs to the health care system. Pressure necrosis injuries should be diligently guarded against by the careful selection of support devices, frequent turning, and rigorous skin care to minimise extended external compression, particularly on the face and bony prominences.

Proper Patient Positioning and Complication Prevention in Orthopaedic Surgery

➤ The consequences of improper intraoperative positioning can be profound: it not only may cause substantial morbidity but also may be a major area of litigation, particularly when peripheral nerve injury occurs.➤ The ulnar nerve is most likely to be injured secondary to improper positioning. The elbow should be flexed ≤90° and the forearm placed in a neutral or slightly supinated position intraoperatively to minimize pressure in the cubital tunnel.➤ Pressure-related complications, such as pressure ulcers and alopecia, are best avoided by the use of adequate padding. Cushions on the operating-room table and armrest should be emphasized under osseous prominences.➤ Positioning the head in a non-neutral alignment or arm abduction of ≥90° may result in injury to the brachial plexus.➤ The hemilithotomy position increases intracompartmental pressure in the leg on the uninjured side. The risk of well-leg compartment syndrome can be minimized by avoiding this position if possible.

Modified prone position using lateral brace attachments for cervico-dorsal spine surgeries

PURPOSE

The purpose of the study was to propose a method of prone positioning for posterior cervico-dorsal spine surgeries that is easy to achieve without additional equipment and may reduce complications associated with prone positioning in patients.

METHODS

41 patients underwent posterior spine surgeries using our method of prone positioning on a fluoroscopy compatible conventional operation table, and the technical difficulties and complications associated were noted. After induction under general anaesthesia in supine position, cervical tongs were applied. An assembly of two adequately padded cylindrical bolsters and two lateral brace attachments was set on a conventional operating table. The patient was then positioned prone so that the tongs as well as insertion pins of the tongs rest on the lateral brace attachments, with the face and head suspended freely in between. A neutralisation weight was then applied suspended from the tongs to stabilize the head.

RESULTS

The time required for patient positioning was noted and was found to be nearly the same as that required for traditional prone positioning. No problems were noted during patient positioning and with anaesthesia tubing management. All surgeries went well without position related complications except for one patient who developed post-operative macroglossia. All cervical tong pin sites healed without any complications. The fluoroscope easily gained access to the operative areas.

CONCLUSIONS

Our modification appears simple, versatile and reproducible for posterior approach procedures of the cervical and upper dorsal spine in prone position. Also, the method can be easily implemented in most conventional operating room facilities with minimal surgeon effort and without the need for any additional inventory.

Support surfaces for pressure ulcer prevention

BACKGROUND

Pressure ulcers (i.e. bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue. They are common in the elderly and immobile, and costly in financial and human terms. Pressure-relieving support surfaces (i.e. beds, mattresses, seat cushions etc) are used to help prevent ulcer development.

OBJECTIVES

This systematic review seeks to establish: (1) the extent to which pressure-relieving support surfaces reduce the incidence of pressure ulcers compared with standard support surfaces, and, (2) their comparative effectiveness in ulcer prevention.

SEARCH STRATEGY

For this third update we searched: the Cochrane Wounds Group Specialised Register (searched 8 December 2010), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4); Ovid MEDLINE (1950 to November Week 3 2010); Ovid MEDLINE (In-Process & Other Non-Indexed Citations December 07, 2010); Ovid EMBASE (1980 to 2010 Week 48); EBSCO CINAHL (1982 to 3 December 2010), and the reference sections of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised studies, published or unpublished, that assessed the effects of any support surface for prevention of pressure ulcers, in any patient group or setting which measured pressure ulcer incidence.Studies reporting only proxy outcomes (e.g. interface pressure) were excluded. Two review authors independently selected studies.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by another. Where appropriate, estimates from similar studies were pooled for meta-analysis.

MAIN RESULTS

One new trial was included, bringing the total of included studies to 53.Foam alternatives to standard hospital foam mattresses reduce the incidence of pressure ulcers in people at risk (RR 0.40 95% CI 0.21 to 0.74). The relative merits of alternating- and constant low-pressure devices are unclear. One high-quality trial suggested that alternating-pressure mattresses may be more cost effective than alternating-pressure overlays in a UK context.Pressure-relieving overlays on the operating table reduce postoperative pressure ulcer incidence, although two studies indicated that foam overlays caused adverse skin changes. Meta-analysis of three trials indicated that Australian standard medical sheepskins prevent pressure ulcers (RR 0.56 95% CI 0.32 to 0.97). 

AUTHORS' CONCLUSIONS

People at high risk of developing pressure ulcers should use higher-specification foam mattresses rather than standard hospital foam mattresses. The relative merits of higher-specification constant low-pressure and alternating-pressure support surfaces for preventing pressure ulcers are unclear, but alternating-pressure mattresses may be more cost effective than alternating-pressure overlays in a UK context. Medical grade sheepskins are associated with a decrease in pressure ulcer development. Organisations might consider the use of some forms of pressure relief for high risk patients in the operating theatre.

Complications in spinal deformity surgery: issues unrelated directly to intraoperative technical skills

STUDY DESIGN

Literature review of complications unrelated directly to surgical skills involved in spinal deformity surgery.

OBJECTIVE

Highlight complications associated with perioperative issues.

SUMMARY OF BACKGROUND DATA

Complications can arise from mundane events that arise during the operative experience, but are not directly related to surgical skills.

METHODS

Literature reviews that touches on the more common potential complication events that do not involve direct surgical expertise.

RESULTS

The topics of positioning, nutrition, blood loss, comorbidities, OR time, and pulmonary and GI concerns are discussed as basics that could derail a surgical outcome even with an otherwise uneventful surgical technique. The need for vigilance is stressed and the nuances of understanding these are discussed.

CONCLUSION

Mundane events can derail a perfectly executed surgical undertaking. Attention to detail, team work, close monitoring, and checklist type focus will help to improve, focus, and avoid these preventable complications that have nothing to do with direct surgical skills.

[Complications of surgical interventions on the spinal column]

The number of surgical interventions for spinal diseases has greatly increased due to rapid improvements in surgical techniques. The close anatomical relationship between neural and bony structures and the various anatomical approaches to the spinal column lead to a large variety of possible surgical complications. Therefore, it seems helpful to differentiate the complications with respect to their origin. An incorrect positioning of the patient can result in palsy or even blindness. Surgical access to the spine depends on the pathology and the surgical target. Typical complications can be explained by the anatomical situation, such as the vicinity of the esophagus in the anterior approach to the cervical spine or the great vessels in anterior procedures to the lumbar spine. Complication during the surgical manipulation of the spine can be related to either decompression procedures of neural structures or spinal implants. The correction of spinal deformities can result in very specific complications.