[Pressure sores-A multilayered challenge]

Pressure sores occur when soft tissue of the skin, subcutaneous fat tissue or musculature is exposed to pressure or friction over a long period of time, which leads to local ischemia with subsequent necrosis. All areas of the skin lying over bones with only a thin layer of soft tissue are predilection sites. In older patients the risk factors for the development of a pressure sore must be systematically documented at admission and during the course of the disease. Accordingly, the necessary prophylactic procedures must be initiated. The classification of the European Pressure Ulcer Advisory Panel (EPUAP) is used to describe a pressure sore. For the differential diagnosis, incontinence-associated dermatitis and a manifest peripheral artery occlusive disease must be excluded. The treatment consists of positioning procedures and local and systemic supportive wound treatment. In cases of deep pressure sores, coverage by plastic surgery can effectively accelerate healing. The multiprofessional geriatric team has the appropriate prerequisites for comprehensive treatment of pressure sores.

The Risk Factors-Based Nursing Case Management Could Effectively Reduce the Incidence of Pressure Sores in Hospitalized Patients

BACKGROUND

To explore the effects of risk factors-based nursing management on the occurrence of pressure sores in hospitalized patients.

METHODS

From Jan 2018 to Jun 2018, 289 hospitalized patients were divided into pressure sores group [100] and control group [189] for retrospective analysis. Overall, 260 hospitalized patients from Jun 2018 to Dec 2018 were followed up for nursing intervention. Overall 130 patients received risk factors-based nursing case management were in the intervention group, whereas 130 patients who received routine nursing care were in the control group. The chi-square test and t-test were used to compare the count data and the measurement data between groups, respectively.

RESULTS

Age, body weight and proportions of patients with impaired nutritional intake, diabetes or stroke in pressure sores group were higher than those in normal group (P<0.05). Hospital stay and operative time in pressure sores group was longer than those in normal group (P<0.05). The frequency of assistant activity in pressure sores group was significantly lower than that in control group (P<0.05).In addition, the score of uroclepsia in pressure sores group was lower than that in normal group (P<0.05). Patients in the intervention group showed lower risk for pressure sores and more satisfied than patients in control group (P<0.001).

CONCLUSION

Advanced age, high body weight, diabetes and stroke, long hospital stay, long operative time, poor nutritional status and severe uroclepsia were independent risk factors of pressure sores. Risk factors-based nursing case management can effectively reduce the occurrence and risk of pressure sores for hospitalized patients.

Perioral pressure ulcers in patients with COVID-19 requiring invasive mechanical ventilation

Background

Facial pressure ulcers are a rare yet significant complication. National Institute for Health and Care Excellence (NICE) guidelines recommend that patients should be risk-assessed for pressure ulcers and measures instated to prevent such complication. In this study, we report case series of perioral pressure ulcers developed following the use of two devices to secure endotracheal tubes in COVID-19 positive patients managed in the intensive care setting.

Methods

A retrospective analysis was conducted on sixteen patients identified to have perioral pressure ulcers by using the institutional risk management system. Data parameters included patient demographics (age, gender, comorbidities, smoking history and body mass index (BMI)). Data collection included the indication of admission to ITU, duration of intubation, types of medical devices utilised to secure the endotracheal tube, requirement of vasopressor agents and renal replacement therapy, presence of other associated ulcers, duration of proning and mortality.

Results

Sixteen patients developed different patterns of perioral pressure ulcers related to the use of two medical devices (Insight, AnchorFast). The mean age was 58.6 years. The average length of intubation was 18.8 days. Fourteen patients required proning, with an average duration of 5.2 days.

Conclusions

The two devices utilised to secure endotracheal tubes are associated with unique patterns of facial pressure ulcers. Measures should be taken to assess the skin regularly and avoid utilising devices that are associated with a high risk of facial pressure ulcers. Awareness and training should be provided to prevent such significant complication.

Level of evidence: Level IV, risk/prognostic study.

Knowledge and attitudes of nurses in a major public hospital in Cyprus towards pressure ulcer prevention

STUDY AIM

The main aim of the study was to identify the knowledge and attitudes of nurses towards pressure ulcer prevention in a major public hospital in Cyprus.

MATERIAL AND METHODS

A descriptive and cross-sectional study design was used to collect the data between December 2014 and February 2015, the sample consisted of n = 102 nurses employed in a major public hospital in Cyprus. Customised and standardised Pressure Ulcer Knowledge Test and an attitudes Likert questionnaire was used to investigate both parameters. Descriptive and inferential statistics, parametric (t-test), non-parametric tests (Mann-Whitney U) and Pearson test was applied. Statistical significance was set at p = 0.05.

RESULTS

The majority of the participants (44.1%) n = 45 were employed in the intensive care unit, were female (61.8%) n = 63, registered nurses (93.1%) n = 95, had more than 5 years of experience (59.4%) n = 32 and 10.8% (n = 11) had a postgraduate title. The mean value regarding the knowledge questionnaire was 16.16, IQR: 17(15-18) correct answers 77%. In the attitudes questionnaire the median value was 41.82, IQR: 43 (40-46). Knowledge and attitudes correlated positively and statistically significantly (Pearson's R = 0,223, p = 0,019).

CONCLUSION

The result suggests that nurses had relatively inadequate knowledge levels and positive attitudes, attitudes and knowledges correlated statistically significantly and positively. It is proposed that through the development of educational programs and the frequent measurement of the two parameters further improvement can be achieved.

Effect of stratified nursing intervention in preventing pressure ulcers in patients with advanced cancer in department of gastroenterology

AIM

To explore the preventive effect of stratified nursing intervention based on risk factors of pressure ulcers in patients with advanced cancer in department of gastroenterology.

METHODS

One hundred and ten advanced cancer patients admitted to Beijing Pinggu Hospital from January 2016 to December 2017 were selected, and they were equally divided into a control group and an observation group according to the nursing regimen. The control group was given conventional nursing intervention, and the observation group was given stratified nursing intervention based on the pressure ulcer risk factor assessment. After 1 mo of nursing, the incidence and grade of pressure ulcers were evaluated using the National Pressure Ulcer Advisory Panel (2007), Braden pressure ulcer score was used to evaluate perceived ability, activity ability, mobility, nutrition intake, and humidity, and a questionnaire survey was used to evaluate the satisfaction to nursing care and the preventive effect on pressure ulcers.

RESULTS

The number of cases with pressure ulcer was significantly lower in the observation group than in the control group (6 vs 13, P < 0.05). The incidence of grade Ⅰ pressure sores in the observation group was higher than that in the control group (P < 0.05), but the incidence of grades Ⅱ, Ⅲ, and Ⅳ pressure sores in the observation group was significantly lower than that in the control group (P < 0.05). The observation group was better than the control group with regard to nursing, activity, mobility, nutrition, and humidity (P < 0.05). In the observation group, the satisfaction to stratified nursing intervention was 98.18%, which was significantly higher than that in the control group (90.91%, P < 0.05).

CONCLUSION

Stratified nursing intervention is helpful to reduce the incidence of pressure ulcers, improve Braden pressure sore score, and increase the satisfaction with nursing in patients with advanced digestive cancer.

Quantifying the in vivo quasi-static response to loading of sub-dermal tissues in the human buttock using magnetic resonance imaging

BACKGROUND

The design of seating systems to improve comfort and reduce injury would benefit from improved understanding of the deformation and strain patterns in soft tissues, particularly in the gluteal region.

METHODS

Ten healthy men were positioned in a semi-recumbent posture while their pelvic and thigh region was scanned using a wide-bore magnetic resonance imaging (MRI) scanner. Independent measurements of deformation for muscles and fat were taken for the transition from non-weight-bearing to weight-bearing loads in three stages. A weight-bearing load was achieved through having the subject supported by a flat, rigid surface. A non-weight-bearing condition was achieved by removing the support under the left buttock, leaving all soft tissue layers undeformed. An intermediate condition partially relieved the subject's left buttock by lowering the support relative to the pelvis by 20mm, which left the buttock partially deformed. For each of these conditions, the thicknesses of muscle and fat tissues below the ischial tuberosity and the greater trochanter were measured from the MRI data.

FINDINGS

In this dataset, the greatest soft tissue deformation took place below the ischial tuberosity, with muscles (mean=17.7mm, SD=4.8mm) deforming more than fat tissues (mean=4.3mm, SD=5.6mm). Muscles deformed through both steps of the transition from weight-bearing to non-weight-bearing conditions, while subcutaneous fat deformed little after the first transition from non-weight-bearing to partial-weight-bearing. High inter-subject variability in muscle and fat tissue strains was observed.

INTERPRETATION

Our findings highlight the importance of considering inter-subject variability when designing seating systems.

Morfeo Study II: Clinical Course and Complications in Patients With Long-Term Disorders of Consciousness

BACKGROUND

The life expectancy of patients with disorders of consciousness (DOCs) is ever-increasing, but little is known about their clinical course over late stages. Several issues (premorbid conditions, complications and pressure sores) are to be considered for their effect on clinical outcome, risk of death and recovery of functional performance. Unfortunately, in late stages of long-term rehabilitation, these aspects are still more neglected than in acute and postacute stages. The aim of this study was to investigate the clinical course and the complications of patients in the late stages of DOCs and to explore the relationship between mortality and specific biomarkers.

MATERIALS AND METHODS

A total of 112 patients, admitted over 10 years in a dedicated ward, were retrospectively studied. Sociodemographic data, preadmission and inpatient clinical features were collected. Disability Rating Scale scores, complications including pressure sores and blood markers were assessed monthly. Data were analyzed through descriptive statistics and correlations using SPSS.

RESULTS

Most patients were men older than 50 years with a nontraumatic etiology and a history of hypertension (42.86%). The most common complication was pneumonia (76.79%). No association was found between sex and mortality or between etiology and mortality (P > 0.05). Mortality correlated significantly with sepsis (ρ = 0.253), albumin (ρ = -0.558), hemoglobin (ρ = -0.354) and white blood cells (ρ = 0.243). Only 42% of patients remained unchanged at Disability Rating Scale evaluation.

CONCLUSIONS

These data confirmed that DOCs are not static conditions and they require ongoing monitoring and assessment of clinical status, level of consciousness and laboratory biomarkers.

Improving outcomes following reconstruction of pressure sores in spinal injury patients: A multidisciplinary approach

BACKGROUND AND AIM

Pressure sore treatment in spinal injury patients is challenging. A multidisciplinary approach with joint management by the plastic surgery and spinal injury teams was initiated at our institution in 2005 to improve patient care and surgical outcomes following reconstruction. This study assessed the surgical outcomes following reconstruction using the team approach and to compare inpatient stay and readmissions for complications before and after the multidisciplinary protocol was introduced.

METHODS

A retrospective review of consecutive patients in the multidisciplinary pressure sore clinic was performed. Data were collected on patient demographics, reconstructive techniques, surgical outcomes and readmission for any complications.

RESULTS

In total, 45 patients with 60 pressure sores (grade 3 or 4) were reviewed in the joint clinic between 2005 and 2011. The majority of patients were paraplegic (78%), while the remaining 22% were tetraplegic. Ischial sores were the most common (45%) followed by trochanteric (23%) and sacral (20%) sores. Multiple sores were noted in 44% of patients. Flap reconstruction was required in 32 patients (71%); after a mean follow-up time of 33 months (range 25-72 months), there were three (9%) major complications (two recurrences of pressure sores and one sinus) and seven (22%) minor complications. After introduction of patient care pathways through the multidisciplinary approach, the rate of readmission for complications decreased from 14% to 5.5% and inpatient stay upon readmission reduced from 65 to 45 days.

CONCLUSIONS

Implementation of a multidisciplinary approach was key to optimising surgical outcomes, achieving a low recurrence rate (6%) and reducing readmissions.

[Plastic surgery treatment techniques for interdisciplinary therapy of pressure sores]

Pressure sores in geriatric patients represent a challenge for all disciplines involved in the treatment process; however, the prerequisite for successful treatment is the elaboration of an interdisciplinary treatment concept. The treatment goals should be adapted to the individual needs of the patients including the life situation, general condition and local findings. In addition to general basic operative techniques, such as wound cleansing and conditioning, plastic and reconstructive surgery provides a wide range of highly specialized operative techniques for the treatment of these patients by which a definitive defect coverage can be achieved. The aim of this article is to raise awareness for these complex and highly specialized procedures for all disciplines participating in the treatment in order to improve the interdisciplinary cooperation and ultimately the quality of treatment.

A composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region

BACKGROUND AND AIM

Gigantic pressure sores pose a daunting challenge for plastic surgeons. This paper presents a composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region.

METHODS

In this anatomical study, 30 embalmed cadaveric lower limbs were used for dissection to observe the musculocutaneous perforators of the inferior gluteal artery and the longitudinal nutritional vascular chain of the posterior femoral cutaneous nerve. In this clinical study, eight patients underwent surgical harvest of the composite gluteofemoral flap for coverage of grade IV sacrococcygeal pressure sores. The size of the pressure sores ranged between 16 × 9 cm and 22 × 10 cm.

RESULTS

The inferior gluteal artery was present in 26 cases and absent in four cases. It gave off two to four musculocutaneous branches with a diameter larger than 0.5 mm to the gluteus maximus. A direct cutaneous branch was given off at the inferior margin of the gluteus maximus, serving as a nutritional artery for the posterior femoral cutaneous nerve. The size of the flap harvested ranged between 22 × 9 cm and 32 × 10 cm. Flaps in seven patients survived uneventfully and developed epidermal necrosis at the distal margin in one case. An average 2-year follow-up revealed no recurrence of pressure sores.

CONCLUSION

The composite gluteofemoral flap, being robust in blood supply, simple in surgical procedure, and large in donor territory, is an important addition to the armamentarium.

Prospective and randomised evaluation of the protease-modulating effect of oxidised regenerated cellulose/collagen matrix treatment in pressure sore ulcers

In chronic wounds, excess levels and activity of proteases such as elastase and plasmin have been detected. Oxidised regenerated cellulose/collagen matrix (ORC/collagen matrix) has been reported to ameliorate the wound microenvironment by binding and inactivating excess proteases in wound exudates. In this study, the levels and activity of elastase and plasmin in wound exudates of pressure sore ulcers were measured to determine the beneficial effect of ORC/collagen matrix treatment compared with control treatment with a foam dressing. A total of 33 patients with pressure sores were enrolled in the study and were followed up for 12 weeks after treatment. Ten control patients were treated with a foam hydropolymer dressing (TIELLE^® , Systagenix), and the remaining 23 patients were treated with ORC/collagen matrix plus the foam dressing (TIELLE^® , Systagenix) on top. Wound assessments were carried out over 12 weeks on a weekly basis, with dressing changes twice a week. Ulcers were photographed and wound exudates were collected on admission and at days 5, 14 and then every 14 days to provide a visual record of any changes in appearance of the ulcer and healing rate and for biochemical analysis of the wound. The levels and activity of elastase and plasmin were measured in wound exudates. Statistical analysis was performed using ANOVA and Bonferroni's post hoc test with P-values <0·05 considered to be significant. Compared with controls, ORC/collagen matrix-treated pressure sore wounds showed a significant faster healing rate, which positively correlated with a decreased activity of elastase and plasmin in wound exudates. No signs of infection or intolerance to the ORC/collagen matrix were observed.

Medical complication in adults with spina bifida

SETTING

Cohort study.

INTRODUCTION

Spina bifida (SB) is a congenital malformation affecting the central nervous system (CNS) and is one of the most prevalent CNS disorders in children. Hydrocephalus (HC) is present in 80% of newborns with SB. The aim of the present study was to analyze the medical complications and to relate the complications to age at examination, the level of injury, AIS grade and presence of HC in adults with SB.

MATERIALS AND METHODS

SB patients were recruited from the Spinalis out-patient clinic at the Karolinska University Hospital at their annual follow-up. The patients underwent a thorough general and neurological examination and background data including medical complications were retrieved from the medical files.

RESULTS

127 of 157 (82%) SB patients (114 with MMC and 13 SB occulta) with a mean age of 34 years were included. Half of the patients had a complete SCI and a lumbar level was most common. Nearly 60% of the patients had HC. 88 patients (69%) suffered from at least one medical complication. Urinary tract infection (UTI), scoliosis and pain were the most common complications found in 46%, 30% and 28% of the patients, respectively. Less common complications were epilepsy, pressure ulcers (PU) and spasticity.

DISCUSSION

SB gives a disability including motor, sensory dysfunctions and the patients suffer from a high frequency of medical complications like UTI, scoliosis, pain, and epilepsy. Data gives basis for adequate routines for medical examination at the follow-up.

Medical device-related hospital-acquired pressure ulcers in children: an integrative review

The management, cost, physical and emotional suffering associated with pressure ulcers have a significant impact on the health status of patients-especially infants and children. The purpose of this integrative review was to identify factors associated with medical device-related (MDR) hospital acquired pressure ulcers (HAPUs) in the pediatric population. Pediatric MDR HAPUs are becoming more prevalent and require further exploration in terms of describing devices which cause injury and preventive interventions to improve patient outcomes. Opportunities to uncover new methods for addressing this important problem and to inform and advance the state of the science in this evolving area exist.

The occurrence of adverse events potentially attributable to nursing care in medical units: cross sectional record review

BACKGROUND

Ensuring the safety of hospitalized patients remains a major challenge for healthcare systems, and nursing services are at the center of hospital care. Yet our knowledge about safety of nursing care is quite limited. In fact, most earlier studies examined one, or at most two, indicators, thus presenting an incomplete picture of safety at an institutional or broader level. Furthermore, methodologies have differed from one study to another, making benchmarking difficult.

OBJECTIVES

The aim of this study was to describe the frequencies of six adverse events widely considered in the literature to be nursing-sensitive outcomes and to estimate the degree to which these events could be attributed to nursing care.

METHOD

Cross-sectional review of charts of 2699 patients hospitalized on 22 medical units in 11 hospitals in Quebec, Canada. The events included: pressure sores, falls, medication administration errors, pneumonias, urinary infections, and inappropriate use of restraints. Experienced nurse reviewers abstracted patients' charts based on a grid developed for the study.

RESULTS

Patient-level risk for at least one of these six adverse events was 15.3%, ranging from 9% to 28% across units. Of the 412 patients who experienced an event, 30% experienced two or more, for a total of 568 events. The risk of experiencing an adverse event with consequences was 6.2%, with a unit-level range from 3.2% to 13.5%. Abstractors concluded that 76.8% of the events were attributable to nursing care.

CONCLUSION

While the measurement approach adopted here has limitations stemming from reliance on review of documentation, it provided a practical means of assessing several nursing-sensitive adverse events simultaneously. Given that patient safety issues are so complex, tracking their prevalence and impact is important, as is finding means of evaluating progress in reducing them.

A numerical study to analyse the risk for pressure ulcer development on a spine board

BACKGROUND

Spine boards are used to immobilise accident victims suspected of having spinal injury. Guidelines about the maximum time patients remain on the board are often exceeded and on occasions may lead to pressure ulcers. Etiological research has shown that two processes ultimately lead to pressure ulcers:"Ischemic damage" which takes several hours to initiate and "deformation damage" at high strains. The latter process is very quick and the first signs of cell damage are already evident within minutes. Thus in order to minimise the risk of pressure ulcer development during prolonged loading, a new soft-layered long spine board has been designed.

METHODS

A subject specific numerical approach has been adopted to evaluate the prototype spine board in comparison to a conventional spine board, with reference to the estimated strains in the soft tissues adjacent to the sacrum in the supine position. The model geometry is derived from magnetic resonance images of three human volunteers in an unloaded situation. The loaded images are used to "tune" the material parameters of skin, fat and muscle. The prediction of the deformed contours on the soft-layered board is used to validate the model.

FINDINGS

Comparison of the internal strains in muscle tissue near the spine showed that internal strains on the soft-layered board are reduced and maximum strains are considerably less than the threshold at which deformation damage is possible. By contrast, on the rigid spine board this threshold is exceeded in all cases.

INTERPRETATION

The prototype comfort board is able to reduce the risk for deformation damage and thus reduces the risk of developing pressure ulcers.