Pressure ulcer development in the operating room. Nursing implications

A modified park bench position: the "Dormeuse" position

BACKGROUND

Because of the restricted volume of the cisternal space, proper patient positioning on the operating table is of utmost importance during surgery by retrosigmoid approaches. Three positions are commonly used: supine, with the head rotated to the side contralateral to the lesion; the semi-sitting position; and the park bench position. Each position has advantages and disadvantages, and the surgeon should choose the one best suited to the individual patient and the pathology to be treated.

METHODS

We describe a modified park bench position that we call the Dormeuse position.

CONCLUSION

The Dormeuse position guarantees decrease in the posterior fossa pressure and allows optimal neural and vascular manipulation and control of any aspect of the cerebellopontine angle.

Perioperative factors and pressure ulcer development in postoperative ICU patients: a retrospective review

OBJECTIVE

To identify variables during surgery that may contribute to the development of pressure ulcers (PUs) in postoperative, intensive care unit (ICU) patients within 72 hours of admission, as well as over their entire ICU admission. Furthermore, to investigate how these variables may impact on the number of PUs acquired.

METHOD

In a three-year retrospective audit, from 1 January 2014 to 31 December 2016, data from the electronic medical records of 3484 postoperative ICU patients in a major Australian metropolitan public hospital were retrieved and analysed to investigate associations between perioperative variables and PU occurrence.

RESULTS

A total of 69 ICU admissions (1.98%) out of 3484 resulted in at least one PU developing within the ICU. No specific variables were associated with the development of a PU within 72 hours of the patient's ICU admission. Multiple regression Cox analysis showed that length of time in the operating theatre (OT) (p=0.045), surgical specialty (p<0.001), 1-4 hypotensive episodes (p=0.017) and >5 hypotensive episodes (p<0.0005) were significantly associated with PU risk. Multivariable negative binomial regression demonstrated APACHE II score (p<0.01), OT time (p<0.01) and surgical specialty (p<0.01) were associated with PU number.

CONCLUSION

There are many risks to skin integrity at the perioperative period, and these risks may exert their effect well into the ICU admission period. It is imperative to identify and mitigate these factors in order to reduce PU incidence, morbidity and mortality.

Pressure Ulcers: Factors Contributing to Their Development in the OR

The prevention of health care-associated pressure ulcers (HAPUs) is an important quality measure because HAPUs are considered a never event. The literature suggests that the prevalence rate of pressure ulcers is 8.5% or higher among patients who undergo surgical procedures that last longer than three hours. We performed a retrospective chart review to determine what factors contribute to the development of pressure ulcers in patients who undergo surgical procedures. The sample population included patients who acquired a pressure ulcer that was not present at admission and developed during their postoperative hospital stay. The project revealed consistent risk factors that may contribute to the development of pressure ulcers in patients who have undergone surgical procedures. These findings can drive the implementation of preventive measures to reduce the occurrence of HAPUs associated with surgical procedures.

Risk factors associated with intraoperatively acquired pressure ulcers in the park-bench position: a retrospective study

Patients undergoing surgery in the park-bench position are at high risk of developing intraoperatively acquired pressure ulcers (IAPUs). The purpose was to examine retrospectively risk factors associated with IAPUs in the park-bench position. This study was conducted at a general hospital during the period of September 2010 to September 2012. Twenty-one potential risk factors were evaluated using data obtained from the hospital database. IAPUs developed in 30 of 277 patients (11%). Perspiration was statistically found to be independently associated with IAPUs [OR 3·09, 95% confidence interval (Cl) 1.07-8·58, P = 0·037]. A length of surgery of more than 6 hours was identified to be likely associated with IAPUs (OR 2·64, 95% Cl 0·84-9·08, P = 0·095) compared with less than 6 hours. Furthermore, there was an interaction between the length of surgery and the core temperature; that is, when the length of surgery was more than 6 hours, a core temperature of more than 38·1°C at the end of surgery had a higher odds ratio (8·45, 95% Cl 3·04-27·46, P < 0·001) than that at a lower core temperature (3·20, 95% Cl 1·23-8·78, P = 0·017). These results suggest that perspiration and core temperature are preventable causative factors of pressure ulcers, even under conditions of prolonged surgery in the park-bench position.

The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis

This meta-analysis investigated the effectiveness of a pressure-relieving intervention on the incidence of heel pressure ulcers in a variety of settings. Literature searches of Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, EMBASE and Cochrane databases were conducted for English-language articles that investigated the effect of pressure relief interventions with or without concurrent prevention programs on the number of heel ulcers occurring on adult humans in a controlled clinical design. Full articles were selected from citations based upon consensus between at least two independent reviewers. Methodological quality of each study was assessed using the Jadad and PEDro scales. A quantitative analysis was performed to determine and compare relative risk (RR) between pressure relief programs/devices that were classified according to similarity of interventions. Fourteen studies that involved a total of 1457 subjects were selected from a total of 105 full articles reviewed. Pressure-reducing/relieving surfaces were associated with a significantly lower incidence of heel ulcers compared with standard hospital mattresses (RR = 0.50, 95% CI = 0.26-0.93, P < 0.03). Foam mattresses also significantly reduced the risk of developing heel ulcers. There is evidence to support the use of certain air or foam mattresses/overlays in the prevention of heel pressure ulcers when compared with a standard hospital mattress. There is insufficient research available at this time to determine if heel-protective devices can prevent heel pressure ulcers. These results need to be interpreted with caution given the relatively low number and poor quality of research articles available to date.

[Decubitus ulcer and nutritional status: literature review]

In order to better understand aspects related to the nutritional assessment of patients in risk for pressure ulcers, we reviewed the national and international literature indexed on Medline and LILACS bibliographic databases, from 1987 to 2001. The aim of this research was to investigate the knowledge production on pressure ulcers and nutritional status, as well as to learn about the authors and the publication focus. We concluded that patients in risk for pressure ulcers can be early identified based on nutritional assessment, including biochemical data, anthropometric evaluation, clinical data, diet history and energetic consumption. The alterations are frequent in elderly patients, hospitalized patients, patients with a chronic disease such as a vascular cerebral accident, cancer and spinal cord injury.

The incidence of pressure ulcers in surgical patients: a sample hospital in Turkey

AIM

This research was conducted for the purpose of determining the incidence of surgery-related pressure ulcer formation.

BACKGROUND

Patients undergoing surgery are prone to develop pressure ulcers during surgery. Pressure ulcer incidence in surgery population is reported between 3.5% and 29.5%. Some of these factors that occur during surgery are being under pressure for a long time, remaining wet, and metabolic and circulatory changes related to the surgery and anaesthesia.

DESIGN

The research was conducted as a prospective-analytic-descriptive study with 84 patients who agreed to participate in the study and who were 20 years old or older, having elective surgery, having a surgical procedure lasting two or more hours under general anaesthesia, and who had no risk for pressure ulcer development before surgery according to the Braden Pressure Ulcer Risk Assessment Scale. Research data were obtained using a Data Collection Form that has places for pre-, intra- and postoperative factors that may be related to surgery-related pressure ulcer development; a Body Mass Index Data Form and the Braden Pressure Ulcer Risk Assessment Scale. The Braden Pressure Ulcer Risk Assessment Scale was used to determine that patients had no risk for pressure ulcer development pre- and postoperatively and it was used for the purpose of establishing the patients risk status and areas at risk. Patients were monitored for pressure ulcers until the sixth postoperative day and risk status and areas at risk were determined. Data obtained in the research were analysed using percentage, chi-squared, McNemar and Cohen's Kappa tests for reliability between dependent groups.

RESULTS

At the conclusion of the research, the findings obtained showed that 54.8% of the patients (n = 46) were observed to have Stage 1 pressure ulcers. A total of 41.3% of the patients had pressure ulcers in more than one region and 56.5% of these were of the erythema type. During the six-day postoperative monitoring, 97.9% of the pressure ulcers were observed in the first three days.

CONCLUSION

The study made clear that surgery-related pressure ulcers are an important problem.

RELEVANCE TO CLINICAL PRACTICE

(i) Determining the incidence of pressure ulcers during surgery in Turkey; (ii) For nurses to be able to prevent surgery-related pressure ulcers, it is necessary for them to direct their care by knowing factors that have a role in the development of pressure ulcers during surgery therefore this study will be to call Turkish nurse's attention to pressure ulcers during surgery.

Predicting and preventing pressure ulcers in surgical patients

Pressure ulcers, regardless of their origin, represent negative outcomes for patients, including pain, additional treatments and surgery longer hospital stays, disfigurement or scarring, increased morbidity, and increased costs. The or is a high-risk environment for the development of pressure ulcers. Preoperative identification of patients at risk for pressure ulcer development is imperative if cost-effective, evidence-based preventive measures are to be implemented. This article presents a review of the literature pertaining to pressure ulcer development in surgical patients. Recommendations for future research and implications for practice are provided.

An integrative review of pressure relief in surgical patients

Effective patient positioning has been an important issue throughout the history of the nursing profession. Pressure ulcers result from prolonged pressure, which causes skin, tissue, or muscle damage. Surgical patients present a unique challenge in preventing pressure ulcers because they are immobile and unable to perceive the discomfort of prolonged pressure. The purpose of this integrative review is to examine risk factors associated with pressure ulcer development in surgical patients and to examine pressure-relieving support surfaces to determine if they significantly reduce intraoperative tissue pressure and result in a lower incidence of postoperative pressure ulcers. Most of the research focuses on long-term care units, with little attention given to the acute care setting. Although the pathophysiology and etiology of pressure ulcers are well documented by years of research, the OR as an etiologic factor is largely undefined.

Etiology and incidence of pressure ulcers in surgical patients

This experimental study was designed to identify the etiology of pressure ulcers in a surgical sample and to evaluate a special OR mattress overlay in preventing pressure ulcer development. Surgical patients (N = 413) were randomized to receive "usual perioperative care" or the new mattress overlay. Over six postoperative days, 89 patients (21.5%) developed pressure ulcers, primarily stage I. Only 2% developed stage II or IV ulcers. Patients with ulcers were statistically older, had diabetes, were smaller in body mass, had lower Braden Scale scores on admission, and used the new mattress overlay (P < .02). Pressure ulcers that presented as "burns" or ecchymosis did not deteriorate to stage III or IV ulcers during the study. The mattress overlay was not effective in preventing pressure ulcer development.

Pressure sore formation in the operating theatre: 1

While theatre nurses strive to master increasingly sophisticated equipment and techniques they must also endeavour to ensure that the quality of fundamental nursing care has positive outcomes for the patient. According to Land (1995), pressure area care is such a fundamental nursing activity that many health professionals do not recognize the importance of keeping abreast of new developments. A review of the literature concerning pressure sore formation suggests that, far from being a ward-based problem, all surgical patients experience a critical period during which they are most susceptible to pressure injury--the time spent on the operating table. This article, the first of two parts, outlines the pathophysiology of pressure sores and the contributory factors present within the operating theatre. The second part suggests nursing interventions to reduce the incidence of pressure sore formation during the perioperative phase.

Intraoperative positioning of surgical patients

All perioperative team members are responsible for the safe positioning of surgical patients. Circulating nurses coordinate the positioning of patients during intraoperative periods of care. Skilled perioperative nursing interventions afford patients safe and comfortable positioning during surgery, ensure optimal exposures of surgical sites, and prevent postoperative complications (e.g., pressure injuries, neuropathies, cardiovascular and respiratory compromises). Perioperative nurses should have a working knowledge of anatomy and physiology, patient risk factors, injury mechanisms, potential complications, and positioning devices before placing patients in required perioperative positions.