Investigating the effects of cervical collar design and fit on the biomechanical and biomarker reaction at the skin

The use of a protein network analysis to explore the complexity of early skin inflammation after oronasal mask application- A pilot study

Medical devices, such as non-invasive ventilation masks, save lives in health care settings but can be a cause of tissue injuries due to the pressure and shear loads on skin and soft tissue. These pressure injuries could be painful for the individual and cause a significant economic impact on healthcare providers. In the etiology of device related pressure ulcers, inflammation plays an important role. However, the exact nature and timing of inflammatory biomarker upregulation is still unknown in the early stages of skin damage. This study aimed to explore the inflammatory profile of vulnerable skin sites following non-invasive mask application on a convenience sample of eleven hospital patients. Seventy-one inflammatory proteins were explored from sebum sampled at the skin surface after oronasal mask application. A multivariate analysis to investigate differences between loaded and control site was conducted, with a protein network analysis used to explore interactions in the early inflammation. The study revealed that 21 cytokines and chemokines were important for the separation between loaded and control site. These proteins were associated with remodeling of tissue, vascular wound healing and/or cell death.

Biomechanical design optimization and experimental verification of Bezier curve based two-sectional cervical pillow with variable-density cellular structure

The fundamental function of an optimal cervical pillow is to provide sufficient support to maintain normal spinal alignment and minimize biological stress on the contact surface throughout sleep. The recent advancements in cervical pillows have mainly focused on the subjective and objective evaluations of support comfort, as well as the relationship between pillow height and cervical vertebrae posture. However, only a few studies have addressed shape design guidelines and mechanical performances of the pillows themselves. In this study, a two-sectional contour cervical pillow comprising an arc and a Bezier curve is designed to support the head and neck. The design of the arc-shaped neck section incorporates the Cobb's angle and Borden value from healthy individuals to reflect the consistency of normal cervical anatomical features. The Bezier curve-based head section takes the head length and neck depth into account as significant individual differences. Static analysis and lattice optimization are performed in ANSYS Workbench to develop a variable-density cellular structure, aimed at improving air permeability and reducing the risk of pressure ulcers associated with the cervical pillow. The rapid prototyping technique fused deposition modeling (FDM) and thermoplastic material polylactic acid (PLA) are employed for fabricating different cellular structures. The results demonstrate that the neck section experiences less stress and greater deformation in comparison to the head section, indicating good comfort and support provided by the designed cervical pillow. Additionally, the compressive, bending, and cushion properties of the 3D-printed cervical pillow with variable-density cellular structure are experimentally validated, further confirming its effectiveness.

A bioengineering investigation of cervical collar design and fit: Implications on skin health

BACKGROUND

Cervical collars restrict cervical spine movement to minimise the risk of spinal cord injury. Collars apply mechanical loading to the skin putting it at risk of skin damage. Indeed, cervical collar-related pressure ulcers are unacceptably prevalent, especially at the occiput, mandibles, and chin. Collar design and fit are often key considerations for prevention.

METHODS

This comprehensive study evaluated four commercial prehospital and acute care cervical collars. Pressure, microclimate, transepidermal water loss and skin hydration were measured at the interface between the device and the skin. Range of motion restriction was measured to evaluate effective immobilisation. Head, neck, and shoulder morphology was evaluated using three-dimensional scans.

FINDINGS

The occiput experienced significantly higher interface pressures than the chin and mandibles for most collar designs. Interface pressure at the occiput was significantly higher for the Stiffneck extrication collar compared to the other collar designs. The Stiffneck collar also provided the most movement restriction, though not significantly more than other designs. Relative humidity at the device skin interface was significantly higher for the Stiffneck and Philadelphia collars corresponding to closed cell foam padding, in contrast to the open cell foams lined with permeable fabric used in the other collars. Collar discomfort correlated with both occipital pressure and skin humidity.

INTERPRETATION

The occiput is at increased risk of cervical collar-related pressure ulcers during supine immobilisation, especially for Stiffneck extrication collars. Lined open-cell foams could be used to minimise skin humidity and increase comfort.

Spatial and temporal changes in biophysical skin parameters over a category I pressure ulcer

In acute care facilities, the detection of pressure ulcers (PUs) relies on visual and manual examination of the patient's skin, which has been reported to be inconsistent and may lead to misdiagnosis. In skin and wound research, various biophysical parameters have been extensively employed to monitor changes in skin health. Nonetheless, the transition of these measures into care settings as part of a routine clinical assessment has been limited. This study was designed to examine the spatial and temporal changes in skin biophysical parameters over the site of a category I PU, in a cohort of hospitalised patients. Thirty patients, each presenting with a category I PU, were enrolled in the study. Skin integrity was assessed at the PU-compromised site and two adjacent areas (5 and 10 cm away). Data was collected over three sessions to examine both temporal differences and longitudinal changes. Skin integrity was assessed using two biophysical parameters, namely, transepidermal water loss (TEWL) and stratum corneum (SC) hydration. In addition, the influence of intrinsic factors, namely, incontinence and mobility status, on the parameters was evaluated. TEWL values at the sites compromised by PU were statistically significantly greater (P < .001) than corresponding values at the adjacent control sites at 5 and 10 cm, which were consistent with a normative range (<20 g/h/m2 ). By contrast, SC hydration values did not reveal clear distinctions between the three sites, with high inter-patient variation detected at the sites. Nevertheless, individual profiles were consistent across the three sessions, and the PU site was observed to be either abnormally dry or overhydrated in different individuals. No consistent temporal trend in either parameter was evident. However, intrinsic factors were shown to influence the parameters, with females, bedridden and incontinent patients presenting significantly higher TEWL and SC hydration values (P < .05). TEWL was able to identify differences in skin responses at skin sites compromised with a category I PU when compared to healthy adjacent skin sites. Accordingly, this parameter could be included in the clinical assessment for the identification of PU risk. Further studies are required to elucidate the role of hydration and skin barrier function in the development of PUs and their ability to monitor temporal changes in skin integrity.

Patterns of change in prehospital spinal motion restriction: A retrospective database review

BACKGROUND

Acute management of trauma patients with potential spine injuries has evolved from uniform spinal immobilization (SI) to spinal motion restriction (SMR). Little research exists describing how these changes have been implemented. This study aims to describe and analyze the practice of SMR in one emergency medical services (EMS) agency over the time frame of SMR adoption.

METHODS

This was a retrospective database review of electronic patient care reports from 2009 to 2020. The effects of key practice changes (revised documentation and a collar-only treatment option) were analyzed in an interrupted time series using the rate of SI/SMR as the primary outcome. Secondary outcomes included patient age, sex, acuity, mechanism of injury, treatment provided, cervical collar size, and positioning. These were assessed for changes from year to year by Poisson regression. Associations between patient and treatment characteristics were investigated with binomial logistic regression.

RESULTS

There were 25,747 instances of SI/SMR included. Among all patients, the median age was 40 (interquartile range 24-56), 58% (14,970) were male, and 20% (5062) were high-acuity. The rate of SI/SMR declined from 31.2 to 12.7 treatments per 100 trauma calls per month. The proportion of high-acuity patients increased by 9.6% per year on average (95% CI 8.7%-10.0%). When first available, collar-only treatment was provided to 47% of patients, rising by 6.3% per year (95% CI 3.2%-9.5%) to 60% in 2020. Collar-only treatment (compared to board-and-collar) was more likely to be applied to low-acuity patients (as compared to high): odds ratio 3.01 (95% CI 2.64-3.43).

CONCLUSIONS

This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.

Neck Collar Assessment for People Living With Motor Neuron Disease: Are Current Outcome Measures Suitable?

A majority of people living with motor neuron disease (MND) experience weakness of the neck and as a result, experience head drop. This exacerbates problems with everyday activities (eating, talking, breathing, etc). Neck collars are often used to support head drop; however, these are typically designed for prehospitalization settings to manage and brace the cervical region of the spine. As a result, it has been recorded that people living with MND often reject these collars for a variety of reasons but most notably because they are too restricting. The current standardized outcome measures (most notably restricting cervical range of motion) used for neck collars are summarized herein along with whether they are suitable for a bespoke neck collar specifically designed for people living with MND.

The role of proinflammatory cytokines in the detection of early pressure ulcer development: a systematic review

OBJECTIVE

Pressure ulcers (PUs) commonly occur over bony prominences and are notoriously difficult to treat. Proinflammatory cytokines are substances that initiate the inflammatory process preceding PU development. The aim of this review was to assess whether the increased presence of proinflammatory cytokines could potentially be used as an early detection system for PU development.

METHOD

A systematic search of publications using MEDLINE, CINAHL, and Cochrane databases was conducted in August 2020. Data were extracted and a narrative synthesis was undertaken. The evidence-based librarianship (EBL) checklist assessed the methodological quality of the included studies. The systematic review included original research studies, prospective design, and human studies written in English. Retrospective studies, animal studies, conference papers, opinion papers and qualitative methodology were excluded. No restrictions on the date of publication and study setting were applied.

RESULTS

The six studies included were conducted between 2015 and 2019, 50% (n=3) used an experimental study design. The mean sample size was 15 participants (standard deviation=1.72). A total of seven proinflammatory cytokines were analysed. Statistically significant differences were found among inflammatory mediators. Overall results showed that the concentration of interleukin (IL)-1α significantly increased in each study. The EBL score varied between 77-88%. In total, 100% (n=6) of the studies scored ≥75%, reflecting validity.

CONCLUSION

It is not yet certain that monitoring proinflammatory cytokines represents a noninvasive method that could potentially direct preventative measures to those who are identified as at high risk for developing PUs. IL-1α potentially may be elevated for other health conditions, not just PUs. Future studies are therefore recommended.

Partial vs full glottic view with CMACTM D blade intubation of airway with simulated cervical spine injury: a randomized controlled trial

PURPOSE

A previous study reported a shorter time to tracheal intubation by reducing percentage of glottic opening (POGO) view to <50% when intubating a normal adult airway using the Glidescope^TM blade. We evaluate the efficacy of reducing POGO to <50% when intubating patients with rigid cervical immobilization using CMAC^TM D blade.

METHODS

One hundred and four adult patients were randomized to group POGO 100% or POGO <50% . Laryngoscopy was performed by advancing tip of the D blade at vallecula. POGO 100% was achieved by exerting upward force to displace epiglottis until glottic opening from the anterior commissure to inter arytenoid notch. POGO < 50% was acquired by withdrawing the D blade tip dorsally from vallecula. The primary outcome was time to intubation.

RESULTS

The median time (IQR) to successful intubation was 29 (25-35) seconds for group POGO < 50% and 34 (28-40) seconds for group with POGO 100% (difference in medians, 5 seconds; 95% confidence interval, 2 to 8, p = 0.003). Complications were minor.

CONCLUSION

Using the CMAC^TM D blade with a reduced POGO in patients with cervical spine immobilization resulted in faster tracheal intubation.

TRIAL REGISTRATION

The trial is registered at ClinicalTrial.gov (CT.gov identifier: NCT04833166).

Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust

BACKGROUND

Spinal assessment and immobilisation has been a topic of debate for many years where, despite an emerging evidence base and the delivery of new guidance overseas, little has changed within UK pre-hospital practice. Since 2018, South East Coast Ambulance Service NHS Foundation Trust has spent time working with local trauma networks and expertise from within the region and international colleagues to develop a set of C-spine assessment and immobilisation guidelines that reflect the current best available international evidence and significant changes in international pre-hospital practice from settings such as Scandinavia and Australasia.

METHODS

A specialist group was commissioned to review the topic of pre-hospital spinal immobilisation and explore potential for evidence-based improvement. In conjunction with local trauma networks, subject matter experts and a thorough review of recent literature, a series of recommendations were made in order to improve spinal care within the authoring trust.

RESULTS

Seven recommendations were made, and an updated set of guidelines produced. These included the removal of semi-rigid collars from pre-hospital spinal immobilisation; the creation of two tiers of patients to ensure that the high-risk and low-risk populations are considered separately and an accompanying decision tool to safeguard both cohorts; an increased emphasis on the risk of spinal injury in the frail and older patient; an emphasis on spinal motion restriction rather than rigid immobilisation; an increased emphasis on self-extrication; and the use of a marker for emergency departments.

SUMMARY

An updated set of guidance has been produced using a combination of specialist and expert opinion alongside a literature review with close involvement of key stakeholders, both public and professional. The new guidance helps to ensure a patient-centred approach where each person is considered an individual with their risk of injury and management measures tailored to their specific needs.

Paramedic attitudes towards prehospital spinal care: a cross-sectional survey

BACKGROUND

The optimal application of spinal motion restriction (SMR) in the prehospital setting continues to be debated. Few studies have examined how changing guidelines have been received and interpreted by emergency medical services (EMS) personnel. This study surveys paramedics' attitudes, observations, and self-reported practices around the treatment of potential spine injuries in the prehospital setting.

METHODS

This was a cross-sectional survey of a North American EMS agency. After development and piloting, the final version of the survey contained four sections covering attitudes towards 1) general practice, 2) specific techniques, 3) assessment protocols, and 4) mechanisms of injury (MOI). Questions used Likert-scale, multiple-choice, yes/no, and free-text responses. Exploratory factor analysis (EFA) was used to identify latent constructs within responses, and factor scores were analyzed by ordinal logistic regression for associations with demographic characteristics (including qualification level, gender, and years of experience). MOI evaluations were assessed for inter-rater reliability (Fleiss' kappa). Inductive qualitative content analysis, following Elo & Kyngäs (2008), was used to examine free-text responses.

RESULTS

Two hundred twenty responses were received (36% of staff). Raw results indicated that respondents felt that SMR was seen as less important than in the past, that they were treating fewer patients than previously, and that they follow protocol in most situations. The EFA identified two factors: one (Judging MOIs) captured paramedics' estimation that the presented MOI could potentially cause a spine injury, and another (Treatment Value) reflected respondents' composite view of the effectiveness, importance, and applicability of SMR. Respondents with advanced life support (ALS) qualification were more likely to be skeptical of the value of SMR compared to those at the basic life support (BLS) level (OR: 2.40, 95%CI: 1.21-4.76, p = 0.01). Overall, respondents showed fair agreement in the evaluation of MOIs (k = 0.31, 95%CI: 0.09-0.49). Content analysis identified tension expressed by respondents between SMR-as-directed and SMR-as-applied.

CONCLUSION

Results of this survey show that EMS personnel are skeptical of many elements of SMR but use various strategies to balance protocol adherence with optimizing patient care. While identifying several areas for future research, these findings argue for incorporating provider feedback and judgement into future guideline revision.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

Comparison of cervical motion restriction and interface pressure between two cervical collars

Background Cervical collar treatment is widespread amongst a broad range of ages and conditions. However, these devices are associated with a known correlation between collar usage and adverse effects such as pressure ulcers, infections, exacerbated spinal injury, and higher morbidity. The objective of this study was to determine if the ability of a newly developed DJO Procare XTEND 174 collar to restrict cervical spine motion was similar to that of the previously studied Össur Miami J collar and to determine if this was done while producing similar tissue interface pressures. Methods Three-dimensional kinematic data were obtained for twelve healthy volunteer participants (6 female, 6 male) using a 10-camera infrared motion capture system. Cervical range of motion in each plane was calculated using angles between head and thorax rigid-body axes. Tissue interface pressure was measured between the head and the collar with three flexible pressure sensor pads over the anterior mandibles and occiput. The distribution of interface pressures was obtained in both the seated and supine positions. Findings Both collars significantly restricted range of motion in all movement directions (p < 0.001) compared to no collar. There were no significant differences in restrictiveness nor in tissue interface pressures between the collars. Both collars exhibited similar range of motion restriction and similar interface pressures. Interpretation Our data indicate that the newly developed Procare XTEND 174 collar is not statistically different from the scientifically recognized Miami J benchmark collar regarding cervical range of motion restriction in all three planes and tissue interface pressure.

Clinical outcomes in patients admitted to hospital with cervical spine fractures or with hip fractures

Patients admitted with a cervical fracture are twice as likely to die within 30 days of injury than those with a hip fracture. However, guidelines for the management of cervical fractures are less available than for hip fractures. We hypothesise that outcomes may differ between these types of fractures. We analysed 1359 patients (406 men, 953 women) with mean age of 83.8 years (standard deviation = 8.7) admitted to a National Health Service hospital in 2013-2019 with a cervical (7.5%) or hip fracture (92.5%) of similar age. The association of cervical fracture (hip fracture as reference), hospital length of stay (LOS), co-morbidities, age and sex with outcomes (acute delirium, new pressure ulcer, and discharge to residential/nursing care) was assessed by stepwise multivariate logistic regression. Acute delirium without history of dementia was increased with cervical fractures: odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.3-4.7, age ≥ 80 years: OR = 3.5 (95% CI = 1.9-6.4), history of stroke: OR = 1.8 (95% CI = 1.0-3.1) and ischaemic heart disease: OR = 1.9 (95% CI = 1.1-3.6); pressure ulcers was increased with cervical fractures: OR = 10.9 (95% CI = 5.3-22.7), LOS of 2-3 weeks: OR = 3.0 (95% CI = 1.2-7.5) and LOS of ≥ 3 weeks: OR = 4.9, 95% CI = 2.2-11.0; and discharge to residential/nursing care was increased with cervical fractures: OR = 3.2 (95% CI = 1.4-7.0), LOS of ≥ 3 weeks: OR = 4.4 (95% CI = 2.5-7.6), dementia: OR = 2.7 (95% CI = 1.6-4.7), Parkinson's disease: OR = 3.4 (95% CI = 1.3-8.8), and age ≥ 80 years: OR = 2.7 (95% CI = 1.3-5.6). In conclusion, compared with hip fracture, cervical fracture is more likely to associate with acute delirium and pressure ulcers, and for discharge to residency of high level of care, independent of established risk factors.

Cervical Spine Immobilization in Patients With a Geriatric Facial Structure: The Influence of a Geriatric Mandible Structure on the Immobilization Quality Using a Cervical Collar

INTRODUCTION

Demographic changes have resulted in an increase in injuries among geriatric patients. For these patients, a rigid cervical collar is crucial for immobilizing the cervical spine. However, evidence suggests that patients with a geriatric facial structure require a different means of immobilization than patients with an adult facial structure. This study aimed to analyze the remaining motion of the immobilized cervical spine based on facial structure.

MATERIALS AND METHODS

This study was performed on 8 fresh human cadavers. Facial structure was evaluated via ascertaining the mandibular angle by computer tomography. A mandibular angle below 130°, belongs to the adult facial structure group (n = 4) and a mandibular angle above 130°, belongs to the geriatric facial structure group (n = 4). The flexion and lateral bending of the immobilized cervical spine were analyzed in both groups using a wireless motion tracker system.

RESULTS

A flexion of up to 19.0° was measured in the adult facial structure group. The mean flexion in the adult vs. geriatric facial structure groups were 14.5° vs. 6.5° (ranges: 9.0-19.0 vs. 5.0-7.0°), respectively. Thus, cervical spine motion was (p = 0.0286) significantly more reduced in the adult facial structure group. No (p = 0.0571) significant difference was oberserved in the mean lateral bending of the adult facial structure group (14.5°) compared to the geriatric facial structure group (7.5°).

CONCLUSION

Emergency medical service personnel should therefore follow current guidelines and recommendations and perform cervical spine immobilization with a cervical collar, including in patients with a geriatric facial structure.

The Influence of Cervical Spine Angulation on Symptoms Associated With Wearing a Rigid Neck Collar

Introduction:

Rigid cervical spine collars can be used to maintain the position of the cervical spine following injury or surgery. However, they have been associated with difficulty swallowing, pressure sores and pain, particularly in older patients. We aimed to investigate the relationship between cervical spine angulation, a rigid neck collar and neck pain in healthy young and older adults.

Methods:

Twenty healthy young adults aged 25 ± 3 years and 17 healthy older adults aged 80 ± 8 years were tested. Magnetic resonance imaging scans of their cervical spines were taken before and after the rigid neck collar was worn for 1 hour. Measurement of vertebral angulation involved digitization of the scans and joint angle calculations using image processing software. Pain was quantified before and after the collar was worn, using a visual analogue scale.

Results:

Pain scores increased in the young group after the collar was worn (p = 0.001). The older group showed no difference in pain score after the collar was worn. Statistical tests showed no significant correlations between the change in cervical angles and the change in pain scores after the collar was worn.

Discussion:

The aging process may contribute to the changing distribution of subcutaneous tissue and increase risk of symptoms associated with wearing a collar. Oesophageal compression is not a result of collar use.

Conclusion:

There is no correlation between cervical spine vertebrae angulation and symptoms associated with wearing a neck collar. Generally, older individuals have greater cervical lordosis angles, and more straight and lordotic neck shapes. Older individuals may be more prone to skin-interface pressures from the neck collar than younger individuals.

Indentation marks, skin temperature and comfort of two cervical collars: A single-blinded randomized controlled trial in healthy volunteers

BACKGROUND

Collar-related pressure ulcers (CRPU) are a problem in trauma patients with a suspicion of cervical cord injury patients. Indentation marks (IM), skin temperature (T_sk) and comfort could play a role in the development of CRPU. Two comparable cervical collars are the Stifneck® and Philadelphia®. However, the differences between them remain unclear.

AIM

To determine and compare occurrence and severity of IM, T_sk and comfort of the Stifneck® and Philadelphia® in immobilized healthy adults.

METHODS

This single-blinded randomized controlled trial compared two groups of immobilized participants in supine position for 20 min.

RESULTS

All participants (n = 60) generated IM in at least one location in the observed area. Total occurrence was higher in the Stifneck®-group (n = 95 versus n = 69; p = .002). T_sk increased significantly with 1.0  °C in the Stifneck®-group and 1.3 °C in the Philadelphia®-group (p = .024). Comfort was rated 3 on a scale of 5 (p = .506).

CONCLUSION

The occurrence of IM in both groups was high. In comparison to the Stifneck®, fewer and less severe IM were observed from the Philadelphia®. The T_sk increased significantly with both collars; however, no clinical difference in increase of T_sk between them was found. The results emphasize the need for a better design of cervical collars regarding CRPU.

Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study

Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C-collar) device in situ and are subsequently exposed to device-related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C-collar-related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C-collar were retrieved over a 9-year period. Chi square and t-tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine-year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C-collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024-1.723, P = .033). Time in the C-collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P < .001) were associated with pressure injury development. Patients with C-collar devices are a vulnerable group at risk for pressure injury development because of their immobility and length of ICU stay.

Establishing a measurement array to assess tissue tolerance during loading representative of prosthetic use

BACKGROUND

In the early stages of rehabilitation after primary amputation, residual limb soft tissues have not been mechanically conditioned to support load and are vulnerable to damage from prosthetic use. There is limited quantitative knowledge of skin and soft tissue response to prosthetic loading.

METHODS

An in-vivo protocol was developed to establish suitable measures to assess tissue tolerance during loading representative of early prosthesis use. Ten participants without amputation one participant with trans-tibial amputation were recruited, and pressure applied to their calf in increments from 20 to 60 mmHg. Measurements were recorded at relevant skin sites including interface pressures, transcutaneous oxygen (T_CPO₂) and carbon dioxide (T_CPCO₂) tensions and inflammatory biomarkers.

FINDINGS

At the maximum cuff pressure, mean interface pressures were between 66 and 74 mmHg, associated with decreased T_CPO₂ values. On the release of pressure, the ischaemic response was reversed. Significant upregulation (p < 0.05) in inflammatory biomarker IL-1α and its antagonist IL-1RA were observed at all sites immediately following loading.

INTERPRETATION

The protocol was successful in applying representative prosthetic loads to lower limb tissues and monitoring the physiological response, both in terms of tissue ischemia and skin inflammation. Results indicated that the measurement approaches were sensitive to changes in interface conditions, offering a promising approach to monitor tissue status for people with amputation.

Preventing medical device-related skin damage

While medical technology is continuing to improve healthcare outcomes and quality of life for patients, the number of people affected by medical device-related skin damage is increasing. In many cases, life-preserving medical devices used in interventions such as nasal continuous positive airway pressure or oxygen therapy can cause significant skin damage, with negative consequences including pain, infection and delayed hospital discharge. This article outlines methods that nurses can use to minimise the risk of skin damage, focusing primarily on the prevention of pressure ulcers. It also examines how nurses can work collaboratively with patients, manufacturers and regulatory bodies to reduce the risk of medical device-related skin damage in the future.

Evaluation of a fluidised positioner to reduce occipital pressure injuries in intensive care patients: A pilot study

This pilot study aimed to evaluate the clinical efficacy and feasibility of a fluidised positioning device to reduce occipital pressure injuries (PIs). A post-test design with a historical control group was used in a 54-bed intensive care unit between September 2017 and August 2018. Patients who were receiving either extracorporeal membrane oxygenation, were mechanically ventilated, or had raised intracranial pressure (≥20) were recruited. The intervention consisted of a fluidised positioning device under the patient's head, and a skin assessment every 8 h. Outcome measures included the occurrence of occipital PIs and registered nurses (RNs)' perspectives of the intervention. Data collected from patients in the intervention group were compared with data obtained from the historical control group between May 2016 and April 2017. Sixty-four patients were recruited in the intervention phase and 63 were in the historical control group. Results showed a statistically significant reduction in occipital PIs by 87.7% (16/63; 25.4% historical control vs 2/64; 3.13% interventional group). Bedside RNs provided positive evaluation of the fluidised positioning device. The findings demonstrate that the fluidised positioning device is a feasible and effective intervention in reducing the risk of occipital PIs in intensive care patients, which merits the continuation of use and further evaluation through a larger-scale study.