Heel blood flow during loading and off-loading in bedridden older adults with low and normal ankle-brachial pressure index: a quasi-experimental study

Heel Pressure Injuries: Consensus-Based Recommendations for Assessment and Management

Significance: A systematic approach to develop experts-based recommendations could have a favorable impact on clinical problems characterized by scarce and low-quality evidence as heel pressure ulcers. Recent Advances: A systematic approach was used to conduce a formal consensus initiative. A multidisciplinary panel of experts identified relevant clinical questions, performed a systematic search of the literature, and created a list of statements. GRADE Working Group guidelines were followed. An independent international jury reviewed and voted recommendations for clinical practice. Consent was developed according to Delphi rules and GRADE method was used to attribute grade of strength. Critical Issues: The extensive search of the literature retrieved 42 pertinent articles (26 clinical studies, 7 systematic reviews or meta-analysis, 5 other reviews, 2 consensus-based articles, and 2 in vitro studies). Thirty-five recommendations and statements were created. Only 1 of 35, concerning ankle-brachial pressure index reliability in diabetic patients, was rejected by the panel. No sufficient agreement was achieved on toe brachial index test to rule out the orphan heel syndrome, removing dry eschar in adult patients without vascular impairment, and using an antimicrobial dressing in children with infected heel pressure injuries. Eleven recommendations were approved with a weak grade of strength. Experts strongly endorsed 20 recommendations. Offloading, stages I and II pressure injuries, and referral criteria were areas characterized by higher level of agreement. Future Directions: We believe that the results of our effort could improve practice, especially in areas where clear and shared opinions emerged. Barriers and limits that could hinder implementation are also discussed in the article.

Subepidermal moisture detection of heel pressure injury: The pressure ulcer detection study outcomes

We examined subepidermal moisture (SEM) and visual skin assessment of heel pressure injury (PrI) among 417 nursing home residents in 19 facilities over 16 weeks. Participants were older (mean age 77 years), 58% were female, over half were ethnic minorities (29% African American, 12% Asian American, 21% Hispanic), and at risk for PrI (mean Braden Scale Risk score = 15.6). Blinded concurrent visual assessments and SEM measurements were obtained at heels weekly. Visual skin damage was categorised as normal, erythema, stage 1 PrI, deep tissue injury (DTI) or stage 2 or greater PrI. PrI incidence was 76%. Off-loading occurred with pillows (76% of residents) rather than heel boots (21%) and often for those with DTI (91%). Subepidermal moisture was measured with a device where higher readings indicate greater moisture (range: 0-70 tissue dielectric constant), with normal skin values significantly different from values in the presence of skin damage. Subepidermal moisture was associated with concurrent damage and damage 1 week later in generalised multinomial logistic models adjusting for age, diabetes and function. Subepidermal moisture detected DTI and differentiated those that resolved, remained and deteriorated over 16 weeks. Subepidermal moisture may be an objective method for detecting PrI.

Effects of different heel angles in sleep mode on heel interface pressure in the elderly

BACKGROUND

The heels are one of the most common sites of pressure ulcers, and the incidence rate in the elderly aged 70 years or older is high. Although there is literature on heel interface pressure, the heel interface pressure of the elderly in different postures has not yet been explored, which will be investigated in this study, as well as the effects of different foot positions. Their skin conditions will also be examined.

METHODS

Twenty-five females and twenty-six males, 70 years old or older, are evaluated while lying down, with only their naked foot in its natural position on a mattress, as well as placed on a standard or pressure-relieving mattress in different positions. The moisture, sebum content, and elasticity of the skin of the heel are tested.

FINDINGS

The heel of most of the participants is positioned at a 60°-69° or 90°-99° angle to the support surface. The heel interface pressure is the greatest when the foot is upright. The age, weight, and body mass index have no significant impacts. The moisture and sebum content are extremely low while elasticity is normal.

INTERPRETATION

The relaxed position of the foot is in neutral external rotation and upright positions. A greater amount of pressure is experienced when the foot is upright. The pressure-relieving mattress is more effective for reducing heel pressure but may not apply to all cases. Finally, the skin of the heel is dry and lacks sebum, which implies greater risk of developing heel sores.