Impact of diabetes on the risk of bedsore in patients undergoing surgery: an updated quantitative analysis of cohort studies

Risk factors predicting hospital-acquired pressure injury in adult patients: An overview of reviews

BACKGROUND

Hospital-acquired pressure injuries remain a significant patient safety threat. Current well-known pressure injury risk assessment tools have many limitations and therefore do not accurately predict the risk of pressure injury development over diverse populations. A contemporary understanding of the risk factors predicting pressure injury in adult hospitalised patients will inform pressure injury prevention and future researchers considering risk assessment tool development may benefit from our summary and synthesis of risk factors.

OBJECTIVE

To summarise and synthesise systematic reviews that identify risk factors for hospital-acquired pressure injury development in adult patients.

DESIGN

An overview of systematic reviews.

METHODS

Cochrane and the Joanna Briggs Institute methodologies guided this overview. The Cochrane library, CINAHL, MEDLINE, and Embase databases were searched for relevant articles published in English from January 2008 to September 2022. Two researchers independently screened articles against the predefined inclusion and exclusion criteria, extracted data and assessed the quality of the included reviews using "a measurement tool to assess systematic reviews" (AMSTAR version 2). Data were categorised using an inductive approach and synthesised according to the recent pressure injury conceptual frameworks.

RESULTS

From 11 eligible reviews, 37 risk factors were categorised inductively into 14 groups of risk factors. From these, six groups were classified into two domains: four to mechanical boundary conditions and two to susceptibility and tolerance of the individual. The remaining eight groups were evident across both domains. Four main risk factors, including diabetes, length of surgery or intensive care unit stay, vasopressor use, and low haemoglobin level were synthesised. The overall quality of the included reviews was low in five studies (45 %) and critically low in six studies (55 %).

CONCLUSIONS

Our findings highlighted the limitations in the methodological quality of the included reviews that may have influenced our results regarding risk factors. Current risk assessment tools and conceptual frameworks do not fully explain the complex and changing interactions amongst risk factors. This may warrant the need for more high-quality research, such as cohort studies, focussing on predicting hospital-acquired pressure injury in adult patients, to reconsider these risk factors we synthesised.

REGISTRATION

This overview was registered with the PROSPERO (CRD42022362218) on 27 September 2022.

Incidence and risk factors of pressure injuries in critically ill patients with COVID-19

OBJECTIVE

to analyze pressure injury (PI) incidence and risk factors in patients with COVID-19 admitted to an Intensive Care Unit and characterize the identified PIs.

METHOD

a retrospective cohort study, consisting of 668 patients, carried out between March 2020 and February 2021. Clinical/demographic and PI variables were collected from medical records and electronic database. Data were analyzed using descriptive and inferential statistics. Logistic regression was performed to analyze risk factors for PI.

RESULTS

PI incidence was 30.2% (n=202), with the majority located in the sacral region (52.9%) and in stage 1 (39%). Risk factors were age (p<0.001), Diabetes Mellitus (p=0.005), length of stay (p<0.001), immunosuppression (p=0.034), nutritional risk (p=0.015) and mechanical ventilation (p<0.001).

CONCLUSION

PI incidence in critically ill patients with COVID-19 was high.

Assessment of the risk factors for intraoperative pressure injuries in patients

AIM

This study was conducted to assess the risk factors for pressure injuries in patients during surgery.

METHODS

In this descriptive cross-sectional study, the risk of pressure injuries during surgery was evaluated in 250 patients in a university hospital. Data were collected through a Patient Descriptive Information Form (PDIF) and the 3S Intraoperative Pressure Injury Risk Assessment Scale (IPIRAS).

RESULTS

The mean age of the patients was 44.15 ± 17.00, and 52.4% were female. In addition, it was determined that the mean 3S IPIRAS score was higher in patients who were male, were aged ≥60 years, were obese, had a chronic disease, and had low serum albumin and hemoglobin levels (p < .05). During the surgery of the patients included in the study, support surfaces were used in 67.6%, positioning aids were used in 82.4%, and 55.6% had normal skin. Patients who underwent CVS procedures for more than 6 h, did not use support surfaces during surgery, had moist skin, or used vasopressors had higher and significantly different mean 3S IPIRAS scores (p < .05).

CONCLUSIONS

According to the results, all surgical patients were at risk for pressure injury in the intraoperative period. In addition, it was found that male gender was associated with risk factors and that being aged ≥60 years, obesity, chronic disease, low serum hemoglobin and albumin levels, CVS, operations lasting more than 6 h, moist skin, vasopressor drugs, and not using support surfaces during surgery increased the risk of pressure injuries significantly.

Retrospective study on the factors influencing the severity of pressure injuries among intensive care unit patients

AIMS AND OBJECTIVES

This study investigated the factors of pressure injuries in patients in intensive care units (ICU).

BACKGROUND

Pressure injuries among patients in ICUs can be prevented by the early assessment of risk factors and taking appropriate preventative measures.

DESIGN

A retrospective study.

METHODS

ICU patients who suffered from pressure injuries between January 2016 and August 2018 at a hospital in Taiwan were selected. Patient medical histories and data associated with pressure injuries and medical treatment were collected from electronic medical records. A total of 256 patients were included in our analysis. The study adhered to the STROBE checklist.

RESULTS

A multivariate model of multinomial logistic regression analysis indicated that when compared to Stage 1 pressure injuries, Stage 2-4 pressure injuries were associated with albumin levels. Patients with lower albumin levels were at greater odds of Stage 2-4 pressure injuries than Stage 1 pressure injuries. In addition, when compared to unstageable pressure injuries or deep tissue injuries, Stage 1 pressure injuries were associated with the use of fentanyl and haemoglobin levels. Patients using fentanyl were more likely to suffer from unstageable pressure injuries, and those with lower haemoglobin levels were more likely to suffer from unstageable pressure injuries or deep tissue injuries.

CONCLUSION

When patients were simultaneously on ventilators and taking midazolam or fentanyl, the incidence of pressure injuries with greater severity became higher. Furthermore, ICU patients with lower albumin and haemoglobin levels were more likely to suffer from pressure injuries of greater severity.

RELEVANCE TO CLINICAL PRACTICE

For critically ill patients on ventilators, it is recommended to devise a means of assessing each patient daily as well as systematically reduce their dosage of midazolam or fentanyl. Furthermore, regularly monitoring albumin and haemoglobin levels to understand their nutritional status is necessary.

Adipose Tissue in Peripheral Obesity as an Assessment Factor for Pressure Ulcers

Scope and Significance: Pressure ulcers are very difficult to treat and pose an economic burden, just below cancer and cardiovascular illness, at 4.82 billion U.S. dollars. It is important to understand the pathophysiology of the condition, risk stratification, and ways of preventing it. Prevention forms the most important aspect of their management. The authors systematically evaluated the existing risk prediction scales and explored the evidence from literature regarding the role of additional factors including body mass index, obesity, subcutaneous tissue thickness, and skin integrity in pressure ulcers. With this review it is hoped that the future management of pressure ulcers will concentrate on the preventable and alterable factors in its pathophysiology. Translational Relevance: The review focuses on how adipose tissue thickness can predict the occurrence of pressure ulcer. If adequately proved that a definite thickness of peripheral adipose tissue is efficient in prevention of pressure ulcers, then methods of maintaining the thickness of this tissue will be the next effective strategy in the management of this chronic issue. Clinical Relevance: The review addresses the management of pressure ulcers to wound care providers and emphasize on confounding parameters of obesity, subcutaneous tissue thickness, and skin integrity during the treatment regimen of pressure ulcers. Objectives: The main objective of this review is to draw a consensus concerning the role of adipose tissue in pressure ulcers, based on the published research. A review of the various preexisting predictive scales for pressure ulcers is a secondary objective to highlight the shortcomings in ulcer management. This review finally aims in the future at paving a way to refine our prognosticating scales for pressure sores based on these results. Accurate preventative injury risk scales are needed so that preventative resources can be directed to the patients for whom they are the most appropriate.

Associated Risk Factors and Barriers of Pressure Injury Wound Healing Process: A Retrospective Study of Single-Center Experience

<b><i>Introduction:</i></b> Pressure injuries, particularly those involving dressings, are associated with high rates of morbidity, mortality, and costs. Furthermore, it has a significant impact on patients, family members, and health care systems, increasing pain symptoms, wound odor, hospital stay duration, and even mortality, all of which have a negative impact on quality of life. In the medical literature, a number of variables have been identified that predispose patients to poor wound healing. Diabetes mellitus, venous insufficiency, peripheral artery disease, tobacco smoking, low serum albumin, and inflammatory disorders are among the causes. <b><i>Objectives:</i></b> The main aim of this study was to identify risk factors and barriers that may confer on poor wound healing. <b><i>Methods:</i></b> This is a retrospective study, which was carried out in Dubai Hospital, Dubai Health Authority (DHA), for the period June 2020 until December 2020. <b><i>Result:</i></b> The present study consisted of 146 patients. Paired <i>t</i> test revealed statistically significant improvement in pressure injury healing in terms of length and width at discharge compared to pressure injury (<i>p</i>&#x3c; 0.05). On the other hand, depth improvement was not statistically significant (<i>p</i>&#x3e; 0.05). χ² test revealed a statistically significant relationship between pressure injury healing and low albumin levels, diabetes, and advanced age (<i>p</i> &#x3c; 0.05), while there was no statistically significant association between the location of the pressure injury and the healing process (<i>p</i>&#x3e; 0.05). Furthermore, there was no statistically significant relationship between Braden category, length of stay, or patient hospitalization and pressure injury healing (<i>p</i>&#x3e; 0.05). <b><i>Conclusion:</i></b> The healing process might be influenced by single or multiple factors. The findings of this retrospective study revealed that low albumin levels, diabetes patients, and age all had an impact on the healing of pressure injuries. When planning and implementing a complete pressure injury treatment strategy, health care practitioners should keep these things under consideration. On the other hand, pressure injury’s location, Braden category, length of stay, and patient hospitalization did not reveal a significant effect on wound healing, despite the fact that other studies showed an effect of these factors on the healing process.

The emerging translational potential of GDF11 in chronic wound healing

Chronic skin wounds impose immense suffers and economic burdens. Current research mainly focuses on acute wound management which exhibits less effective in chronic wound healing. Growth differentiation factor 11 (GDF11) has profound effects on several important physiological processes related to chronic wound healing, such as inflammation, cell proliferation, migration, angiogenesis, and neurogenesis. This review summarizes recent advances in biology of chronic wounds and the potential role of GDF11 on wound healing with its regenerative effects, as well as the potential delivery methods of GDF11. The challenges and future perspectives of GDF11-based therapy for chronic wound care are also discussed.

The Translational Potential of this Article: This review summarized the significance of GDF11 in the modulation of inflammation, vascularization, cell proliferation, and remodeling, which are important physiological processes of chronic wound healing. The potential delivery methods of GDF11 in the management of chronic wound healing is also summarized. This review may provide potential therapeutic approaches based on GDF11 for chronic wound healing.

Construction of a Risk Prediction Model for Intraoperative Pressure Injuries: A Prospective, Observational Study

PURPOSE

To explore the incidence and risk factors of intraoperatively acquired pressure injuries (IAPIs) in patients transferred to the intensive care unit (ICU) after surgery and establish a risk factor prediction model for IAPIs for guiding clinical intervention.

DESIGN

A prospective, observational study was conducted.

METHODS

This study was conducted in the West China Hospital of Sichuan University. A total of 648 patients who were transferred to the ICU after surgery were recruited from May 1, 2019, to October 30, 2020. Data were collected preoperatively, intraoperatively, and postoperatively (3 days after transfer to the ICU). The enrolled patients underwent well-developed preventive measures to prevent IAPIs in the operating room and ICU. A sociodemographic and clinical characteristic questionnaire, the Braden pressure injuries risk assessment scale, the activity of daily living scale, and the Nutrition Risk Screening-2002 were used. Descriptive, bivariate, and logistic regression analyses were conducted.

FINDINGS

The incidence rate of IAPIs within 3 days was 18.67%. The Braden pressure injuries score, preoperative fasting blood glucose level, emergency surgery, and types of vasoactive drugs in the ICU were significant factors for increased risk. The risk factor prediction model was established using the perioperative Braden pressure injuries score (P = 0.027, odds ratio [OR] = 0.901), preoperative fasting blood glucose level (P = 0.027, OR = 1.111), emergency surgery (P < 0.01, OR = 5.054), types of vasoactive drugs in the ICU (P = 0.038, OR = 1.668), and surgery time (P = 0.021, OR = 2.434). The area under the receiver operating characteristic curve was 0.74; 95% confidence interval was 0.671 to 0.810; sensitivity was 0.635; specificity was 0.860; and the Youden index was 0.495.

CONCLUSIONS

In patients transferred to the ICU after surgery, high fasting blood glucose level before surgery, emergency surgery, types of vasoactive drugs, and surgery time should be treated as predisposing factors in the prevention and control of IAPIs. However, the predictive effect of the perioperative Braden pressure injuries risk assessment scale on the risk of IAPIs needs to be further verified.

The risk of surgery-related pressure ulcer in diabetics: A systematic review and meta-analysis

Background and objective

Postoperative pressure ulcers are known as the most important quality indicators of intraoperative care that create critical and costly complications during hospital care. Accordingly, this study was performed to determine the risk factor for diabetes in postoperative pressure ulcers.

Materials and methods

The present study is a systematic review of PubMed, Scopus and the Web of Science databases with using standardized keywords of the performed English language articles between Jan 2010 to Jan 2020. The articles were searched independently by two related researchers to avoid possible biases. Then, all collected articles were reviewed, and articles with inclusion criteria were evaluated using a data collection table. It should be noted that the data were analyzed using STATA software version 11.1.

Results

Overall, the results showed that 19724 patients were identified from 15 studies conducted in Asia (six), the America (four), Europe (four), and Australia (one) from 1989 to 2019. The results showed that patients with diabetes were more likely to experience surgery-related pressure ulcers than patients without diabetes (The odds ratio of 1.52; the 95% confidence interval: 1.25–1.85).

Conclusion

In general, patients with diabetes increased the risk of surgery-related pressure ulcers about 1.5 times more than others. Accordingly, the reduction of surgery-induced pressure ulcers should be more extensively considered in patients with diabetes.

What is already known about the topic?•

Diabetes as a preoperative comorbidity should be added to risk assessment instruments for perioperative pressure ulcers, which may increase the accuracy of the prediction.

•

The excess risk of pressure ulcers associated with pre-existing diabetes was significantly higher in patients undergoing surgery, specifically in patients receiving cardiac surgery.

What this paper adds.•

Diabetes increases the risk of surgery-related pressure ulcers about 1.5 times. Therefore, it is necessary to provide Planned Cares to prevent, overcome, and decrease surgery-related pressure ulcers in patients with diabetes.

•

Previous meta-analysis reported that the risk of surgery-related pressure ulcers in diabetic patients was higher than non-diabetic patients in cardiac surgeries, while evidence for this claim was not observed in this study. Considering the long duration of liver resection surgery, the risk of pressure ulcers is higher than heart surgery

•

It is advised that standard wound measuring tools will apply for measuring wounds in the next prospective studies. It is also better to evaluate pressure ulcers at a specific time after surgery toward more carefully investigate the issue.

Skin temperature and vascular attributes as early warning signs of pressure injury

OBJECTIVES

This study aimed to validate the skin temperature on sacral region and vascular attributes as early warning signs of pressure injury.

METHODS

Totally 415 patients admitted to the adult intensive care unit from August 2018 to April 2019 were prospectively screened. Daily blood pressure and blood glucose affecting vascular attributes and the relative skin temperature of sacral region were measured for 10 consecutive days. Collect the changes of these indicators during the occurrence of pressure injury. The optimal cut-off values of indicators were determined by X-tile analysis. The risk ratios of indicators associated with pressure injury were compared using the Cox proportional hazards regression model.

RESULTS

There were no obvious interactions among blood pressure, blood glucose and relative skin temperature (P > 0.05). The optimal cutoff value for above indicators was 63.5 mmHg, 9.9 mmol/L and -0.1 °C, respectively. The incidence of pressure injury peaked on the 4th and 5th day after hospitalization when categorizing the patients into low- and high-risk groups according to the cutoff values (P < 0.05). Based on relative skin temperature, patients in the high-risk group were more likely to develop pressure injury (hazard ratio = 6.36, 95% confidence interval = 3.91, 10.36), when compared to the other two indicators of blood pressure and blood glucose.

CONCLUSION

Stringent skin temperature and vascular attributes measurements were necessary for preventing pressure injury. Nursing measures should be taken according to warning sings to reduce the incidence of pressure injury.

Efficacy and Safety of Ginkgo Leaf Extract and Dipyridamole Injection for Ischemic Stroke: A Systematic Review and Meta Analysis

Objective: Ginkgo leaf extract and dipyridamole injection (GDI), a kind of Chinese medicine preparation, has been considered as a promising supplementary treatment for ischemic stroke. The aim of this study was to systematically evaluate the clinical efficacy and safety of GDI mediated therapy for ischemic stroke.

Methods: PubMed, Cochrane Library, Medline, Embase, Web of Science, Wanfang database, Chinese Scientific Journal Database (VIP), China National Knowledge Infrastructure (CNKI) and Chinese Biological Medicine Database (CBM), were searched systematically for clinical trials of conventional treatments combined with GDI for ischemic stroke. The reported outcomes including overall response, hemorrheology and blood lipid indexes, and adverse events were systematically investigated.

Results: Data from thirty-nine trials including 3,182 ischemic stroke patients were involved. The results indicated that, compared with conventional treatments alone, the combination of conventional treatments with GDI obviously improved the overall response (odds ratio [OR] = 4.14, 95% confidence interval [CI] = 3.26–5.25, P < 0.00001), neurological status (National Institutes of Health Stroke Scale, OR = −3.13, 95% CI = −3.98 to −2.28, P < 0.00001) and activity of daily living (Barthel Index score, OR = 14.10, 95% CI = 9.51–18.68, P < 0.00001) of patients. Moreover, the hemorheology and blood lipids indexes of ischemic stroke patients were also significantly ameliorated after the combined therapy (P < 0.01). The frequency of adverse events did not differ significantly between the two groups (P > 0.05).

Conclusion: Evidence from the meta-analysis suggested that the combination of conventional treatments and GDI is safe and more effective in treating ischemic stroke than conventional treatments alone. Therefore, GDI mediated therapy could be recommended as an adjuvant treatment for ischemic stroke.

Efficacy and safety of sodium cantharidinate and vitamin B6 injection for the treatment of digestive system neoplasms: a meta-analysis of randomized controlled trials

Objective

To systematically evaluate the efficacy and safety of sodium cantharidinate and vitamin B6 (SC/B6) combined with conventional medical treatment (CMT) for the treatment of patients with advanced digestive system neoplasms (DSNs).

Methods

The Cochrane Library, Embase, PubMed, Web of Science, Chinese Scientific Journal Database (VIP), China National Knowledge Infrastructure, and Wanfang databases were searched for clinical trials using SC/B6 for DSNs. Outcome measures, including therapeutic efficacy, quality of life (QoL), and adverse events, were extracted and systematically evaluated.

Results

Data from 24 trials including 1,825 advanced DSN patients were included. Compared with CMT alone, its combination with SC/B6 significantly improved the patients’ overall response rate (OR =2.25, 95% CI =1.83–2.76, P<0.00001), disease control rate (OR =2.41, 95% CI =1.85–3.15, P<0.00001), and QoL improvement rate (OR =2.75, 95% CI =2.13–3.55, P<0.00001). Moreover, adverse events caused by chemotherapy, including leukopenia, nausea and vomiting, gastrointestinal side effects, hepatotoxicity, diarrhea, transaminase disorder, myelosuppression, anorexia, and anemia, were significantly alleviated (P<0.05) when SC/B6 was applied to DSN patients. Nephrotoxicity, thrombocytopenia, hand-foot syndrome, and oral mucositis were not significantly alleviated in patients receiving combination therapy (P>0.05).

Conclusion

The combination of SC/B6 and CMT is more effective in treating DSNs than CMT alone. This combination alleviates the adverse effects associated with chemotherapy and improves the QoL of DSN patients, and its application in the clinic is worth promoting.

Transcatheter hepatic arterial chemoembolization plus cinobufotalin injection adjuvant therapy for advanced hepatocellular carcinoma: a meta-analysis of 27 trials involving 2,079 patients

Objective

The aim of this study was to systematically investigate the safety and efficacy of the combination of transcatheter hepatic arterial chemoembolization (TACE) and cinobufotalin injection for advanced hepatocellular carcinoma (HC).

Methods

Clinical trials were searched from Web of Science, Cochrane Library, PubMed, Embase, Chinese Medical Citation Index (CMCI), China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), and Wanfang database. Outcome measures including therapeutic efficacy, quality of life, liver function, immune function, and adverse events were extracted and evaluated.

Results

After final assessment, 27 studies including 2,079 advanced HC patients were involved in this study. Compared with TACE alone, the combination of TACE with cinobufotalin injection adjuvant therapy significantly prolonged the patients’ 1-, 1.5-, 2-, and 3-year overall survival (OS) rate (1-year OS, OR=2.84, 95% CI=2.20–3.67, P<0.00001; 1.5-year OS, OR=3.57, 95% CI=1.92–6.66, P<0.0001; 2-year OS, OR=3.17, 95% CI=2.36–4.25, P<0.00001; 3-year OS, OR=2.88, 95% CI=1.82–4.57, P<0.00001). The combined therapy also improved patients’ overall response rate (ORR; OR=1.86, 95% CI=1.54–2.24, P<0.00001), disease control rate (DCR; OR=2.05, 95% CI=1.59–2.64, P<0.00001), and quality of life improved rate (QIR; OR=3.45, 95% CI=2.52–4.72, P<0.00001). Moreover, the immune function and liver function of HC patients were all significantly enhanced after the combined therapy of TACE and cinobufotalin injection (CD3⁺, P=0.001; CD4⁺, P=0.0006; CD4⁺/CD8⁺, P=0.03; natural killer [NK] cell, P=0.01; total bilirubin [TBIL], P=0.003; alanine aminotransferase [ALT], P<0.00001; aspartate aminotransferase [AST], P<0.00001). No serious adverse events occurred during cinobufotalin injection-mediated therapy.

Conclusion

The combination of TACE and cinobufotalin injection adjuvant therapy is safe and more effective for end-stage HC treatment than TACE alone.

Increased risk of hospital-acquired foot ulcers in people with diabetes: large prospective study and implications for practice

AIMS

Diabetes increases the risk of costly and potentially preventable hospital-acquired pressure ulceration. Given that peripheral arterial disease and neuropathy, important risk factors for foot ulceration, are more common in people with diabetes, their risk of hospital-acquired foot ulceration (HAFU) in particular may be even greater. This study aims to determine this risk.

METHODS

Using data collected over 2 years from all admissions to the Ipswich Hospital NHS Trust, we conducted a prospective multilevel regression analysis of the risk of HAFU in 5043 admissions of people with diabetes versus 23 599 without diabetes. Patients over 50 years who developed HAFU at least 48 hours after admission were included in analyses. Progressive adjustment for important risk factors and subgroup analyses were conducted to compare patients with and without diabetes.

RESULTS

There were significant differences between patients with and without diabetes among a range of covariates including sex, Comorbidity Score, and length of stay (p value <0.001). After progressive adjustment for age, sex, and other risk factors, there persisted a significant increase risk of HAFU in people with diabetes (OR 2.24; 95% CI 1.80 to 2.69). There were no substantial differences between clinically relevant subgroups.

CONCLUSIONS

These analyses demonstrate at least a twofold increase in the risk of HAFU in patients with diabetes and suggest further work should focus on specific processes to detect those inpatients with diabetes at increased risk, in whom preventative measures may reduce the prevalence of this costly complication.