Pressure ulcers attributable to the

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1 Ten top tips: preventing pressure ulcers in the surgical patient Authors: Joyce Black, Debra Fawcett and Susan Scott Joyce Black is Associate Professor of Nursing, University, Nebraska Medical Center, Omaha, Nebraska; Debra Fawcett is Manager Infection Prevention and Control, Eskenazi Health Indianapolis, Indiana; Susan Scott is Educator, The University of Tennessee Health Science Center Office of Graduate Medical Education, Memphis, Tennessee Pressure ulcers attributable to the operating room (OR) are not uncommon; they account for up to 45% of all hospitalacquired pressure ulcers [1].The incidence of pressure ulcers occurring during surgery was addressed in international pressure ulcer guidelines in 2014 [1], reflecting the research and work that has been done in this area [2-3]. Prevention begins before surgery, continues in the OR and is imperative during recovery from anaesthesia and the operation. These top tips cover each of these stages of the surgical journey and the considerations required to prevent pressure ulcers in the surgical patient. 1Understand the epidemiology and presentation of pressure ulcer development in the operating room Pressure ulcers in the OR usually develop as a result of improper body positioning, increased time on the OR bed, inadequate padding of bony prominences and also possibly from incorrect use of positioning devices. Other factors that may contribute to a pressure ulcer in the OR include heat, shear forces, skin moisture and friction. The patient s absolute immobility and anaesthetised state during surgery create a unique timeframe of very high risk. However, pressure ulcers can often be incorrectly diagnosed as a burn or attributed to the postoperative period [4]. Many pressure ulcers that develop in the OR follow a pattern of evolution, so recognising the classic presentation associated with pressure damage acquired during surgery helps to identify their origin. Deep tissue injury appears purple or maroon in colour at approximately 48 hours after the pressure episode [Figure 1]. Blisters develop hours later (Black, unpublished data). Therefore, if purple tissue is present two days after surgery, this may be a key indication that the ulcer started during surgery. In addition, the location of the ulcer should be examined to determine if it correlates to the position the patient was in during surgery [5-7]. For example, if the patient was supine, and of normal body weight, ulcers tend to develop on the soft tissue of the buttocks rather than the sacrum or coccyx [Figure 2]. The sacrum and coccyx ulcerate in patients who are in a sitting position with the head of the bed elevated during surgery. If the patient is positioned prone for the operation, pressure ulcers may develop on the face, clavicles, ribs, anterior pelvis, or knees. Patients in the lithotomy position may develop ulcers on the lower portion of the sacrum and coccyx. Pressure ulcers can also develop on the heels. In a study by Schoonhoven [8], 37% of patients developed heel ulcers during cardiac surgery. Therefore identifying the timing of the first appearance of deep tissue injury and the anatomical location of the pressure ulcer can alert staff to pressure damage caused in the OR [5]. The duration of surgery is a major risk factor. Studies have shown that operations over 3 hours are associated with a higher risk of pressure ulcers, with Tschannen [9] finding that the risk rises for every hour of additional time in the OR. Schoonhoven et al [8] found that for every 30 minutes of anaesthesia after 4 hours, the risk of pressure ulcer development increased by 33%. Shaw et al [6] reported that the odds of developing pressure ulcers during general anesthesia is 4.8 times greater than under local anesthesia. Identify patients at high risk of pressure 2 ulcer development Assessing for risk of pressure ulcers before surgery is an important first step. When patients are identified as at risk, additional interventions can be put into place to reduce pressure ulcer risk [10]. Although there is not a validated pressure ulcer risk assessment tool specific to surgical patients, the use of a screening tool in conjunction with use of the Braden Scale for Predicting Pressure Sore Risk may reduce pressure ulcer incidence [11]. In a study of 7000 surgical patients, the incidence rate of hospitalacquired pressure ulcers dropped from 3.37% to 0.89% (p=0.0004) over an 18-month period following implementation of a screening tool in combination with the Braden Score (Scott, unpublished data). Risk factors before, during and after surgery are outlined in Box 1. Assess the patient s skin before surgery 3 The condition of the skin before any procedure should be known in order to plan for special pressure redistribution during the operation. Any skin injury on body areas that will be subjected to pressure during the operation should be noted. Assessment should be done 14 Wounds International 2014 Vol 5 Issue 4 Wounds International

2 Box 1. Pressure ulcer risk factors in the surgical patient Risk factors before surgery [10, 24] Operation planned for 3 hours or more Age > 62 years Albumin <3.5g/dl American Society of Anaesthesiologists s score >3 Cardiopulmonary bypass Operations requiring prone positioning Diabetes [25] Trauma, orthopaedic, vascular, transplant or bariatric procedures [10] Body mass index <19 or >40 Risk factors during surgery include: Increased hypotensive episodes during surgery Low core temperature during surgery Use of vasopressors [25] Figure 1. This deep tissue injury occurred during open heart surgery and was discovered 48 hours after the operation. Note the classic presentation of deep purple intact tissue. Risk factors after surgery include: Reduced mobility on first postoperative day Use of vasopressors [25] before surgery, while the patient is conscious (if possible) so that any complaints of pain can be ascertained. Findings of abnormal skin or highrisk areas, such as previously healed pressure ulcers, should be communicated to the staff in the OR [12]. Consider preoperative use of additional 4 protection on high-risk body areas Once high-risk areas are identified, foam and gel cushions or multi-layer soft silicone foam dressings should be applied pre-operatively to protect these areas [7, 13]. Protection of the sacrum or buttocks when a patient will be in a supine position for operative cases of 2 hours or more should be considered before surgery. In addition, special consideration of the need for localised protection of the head, clavicles, ribs and iliac crest for such cases is also recommended [5,7]. Research on the use of multi-layer soft silicone foam dressings, such as Mepilex Border sacral dressings (Mölnlycke Health Care), placed in vulnerable anatomical locations before surgery has shown a reduction in the number of ORacquired pressure ulcers [13-14]. When selecting pads and positioning devices before surgery, the intended use and the manufacturer s instructions for use must be adhered to. Use appropriate operating room table 5 padding and equipment Several studies [4, 15-16] have indicated that the standard operating room table pad (2-inch-thick Figure 2. This deep tissue injury (DTI) pressure ulcer developed during surgery in the supine position. The location of the ulcer on the buttocks cheeks, rather than the sacrum, indicates that the patient was supine at the time of the pressure. The blistered phase of DTI is seen about hours after the pressure event. elastic foam covered with black conductive laminated vinyl fabric) may contribute to pressure ulcer development during surgery. Using high-specification OR table pads in every room is one strategy to reduce risk of ulceration. These pads may include multilayering foams of various grades and types. The design considers indentation load deflection, density of foam, depth, and a mattress cover that allows for immersion while providing infection control features such as ease of cleaning, waterproofing and/or welded seams, and fire retardant properties. There is limited research on active support surfaces in the OR; however, a laser Doppler study confirmed reduced capillary occlusion with fluid immersion therapy when compared to non-powered foam and gel devices [17]. The weight of the patient must always be considered; as most foam pads have a weight limit of 115 kg. However, some viscoelastic foam mattresses can support up to 315 kg. Staff must be mindful of the fact that the number of pads, sheets, blankets and warming/cooling blankets placed between the patient and the procedure bed mattress interferes with the pressure Wounds International 2014 Vol 5 Issue 4 Wounds International

3 Clinical practice Figure 3. Burns can develop from instruments. This burn behind the leg occurred when a knee flexion device was autoclaved just before use on the patient. redistribution properties of the mattress [1,18]. During surgery, the use of towels, sheet rolls, IV fluid bags and blankets for padding must be avoided, as they do not reduce pressure. Appropriate padding should be placed between the patient and surgical devices such as stirrups and extremity holders. Pillows and molded-foam devices may produce only a minimum amount of pressure redistribution and are less effective during long procedures [7]. Practice safe patient handling during 6 transfers and positioning Correct patient positioning and transfer is critical in pressure ulcer prevention, and requires a team effort [19]. Team members must understand the positional needs of the operation, and have knowledge of the positional devices, pressurereducing surfaces, and the correct equipment available to protect the patient [2,20]. Staff should complete training and competency validation to ensure this. Lateral transfer devices such as frictionreducing sheets, slider boards and air-assisted transfer devices, should be used for supineto-supine patient transfer. Soft tissue can be distorted from pressure, shear, and friction, so adequate personnel to move the patient while positioning are required to prevent shear and friction. Incorrect body alignment can also cause decreased blood flow to areas affected and increase the potential for pressure ulcers [1]. Know how to protect the occiput and heels 7 from pressure damage during surgery The occiput may ulcerate during long procedures and this can be prevented by use of a gel pad under the occiput, by lifting the occiput from the operating table or by repositioning the head, if possible, during surgery. Heels also require particular prevention strategies; staff should ensure that the heels are free of the operating table surface. For those patients who will not likely need heeloffloading devices after surgery, a foam dressing to the heel prior to the operation should be considered. For those requiring heeloffloading devices, these should be used in the OR. Schoonhoven found the highest incidence of OR-acquired ulcers on the heels [8]. Heel off-loading devices, such as Prevalon Boot (Sage Products) and the HeelLift (DM Systems) are preferable for immobilised individuals since they reduce interface pressure and can provide distribution of the weight of the leg along the calf while floating the heels. Most operating tables alone are not adequate to reduce interface pressure at the heel. Hyperextension of the knee must be avoided as it can obstruct the popliteal vein and predispose an individual to deep vein thrombosis. Therefore positioning the knees in slight flexion when off-loading the heels is advised [1,21-22]. Use careful positioning of operating room 8 equipment After positioning the patient, the perioperative team should monitor the patient to ensure that there is no pressure occurring from equipment used during surgery, which can have serious consequences [Figure 3]. As the patient is positioned and draped, the scrub team will move the back tables and instrument tray or mayo stand into position. Care must be taken to ensure that the mayo stand does not lie on the toes or legs. During the course of surgery the surgeon may raise the bed for better visualisation or better access. As the bed is raised the mayo stand should also be raised so that it does not rest on toes or legs, which would cause an increase in pressure from above. All potential points of pressure should be monitored when repositioning the patient during surgery. It should be noted here that pressure can also occur from scrub team members leaning on the patient, which increases the risk of tissue and nerve damage in the surgical patient. 9Continue pressure ulcer prevention after surgery, and include skin status and risk factors for pressure ulcers in patient transfer communication Pressure ulcer prevention must continue after surgery, especially while the patient is sedate or medicated for pain. Team members must collaborate to ensure that risk factors related to pressure injuries are conveyed efficiently and correctly to staff looking after the patient postoperatively, to create a proactive approach to prevention. Handover communication should 16 Wounds International 2014 Vol 5 Issue 4 Wounds International

4 PRO EN PREVENTION Can you afford the impact of not using our proven prevention? SHEAR PRESSURE MICRO-CLIMATE FRICTION The only dressings supported by results of randomised controlled trials 1,2 Significant reduction in pressure ulcer incidence 3,4,5,* Substantial cost savings 4,6,* Combats 4 extrinsic causes of pressure ulcers 7,8,9,* Find out more References: 1. Kalowes P. et al. Use of a soft silicone, self-adherent, bordered foam dressing to reduce pressure ulcer formation in high risk patients: a randomized clinical trial. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore, Maryland, United States of America Santamaria N. et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International Wound Journal 2013; doi: / iwj Brindle C.T. and Wegelin J.A. Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. Journal of Wound Ostomy & Continence Nursing. 2012; 39(2): Cherry C. and Midyette P. The Pressure Ulcer Prevention Care Bundle: a collaborative approach to preventing hospital-acquired pressure ulcers. Poster presentation at Magnet Research Day, Alabama, United States of America Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. Journal of Wound Ostomy & Continence Nursing 2012;39(2): Padula W. et al. Improving the Quality of Pressure Ulcer Care With Prevention, A Cost-Effectiveness Analysis. Medical Care. 2011; 49(4). 7. Call, E. Pederson, J., Bill, B.Craig Oberg PhD, Martin Ferguson- Pell PhD, Wounds -2013, 25(4): Call, E. Pederson, J., Bill, B. In vitro comparison of the prophylactic properties of two leading commercially available wound dressings. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore, Maryland, United States of America Call, E. Black J., Clark M.,Alves P., Brindle T., Dealey C. Santa Maria, N International Panel Studies Creation of Guidance on Dressing Use in Prevention of Pressure Ulcers poster presentation SAWC spring *In addition to current prevention protocols.

5 include patient status and surgery-specific risk factors, such as hypotension, blood loss, hypothermia, time on the operating table, and surgical position. In addition, if there was an occurrence during the procedure that may lead to potential pressure injuries, this should also be handed over. If at all possible, the patient should be positioned differently to that which was used during surgery; for example, if the operation was done in a supine position attempt to position the patient in a lateral position as soon as possible [1]. Conduct patient safety investigations 10 such as root cause analysis to improve outcomes Pressure ulcer development in surgical patients should be investigated using a systems approach. This should involve the interprofessional team and appropriate stakeholders, such as wound care, ostomy and continence nurses, operating room nurses, post-anaesthesia care unit staff, anaesthesiology staff, surgeons and postoperative nursing staff. The causes and contributing factors may be multifactorial involving assessment, processes, competency, people, environment of care and availability of equipment/devices. A detailed analysis of the perioperative process is essential in developing meaningful improvement strategies [23]. Policies, procedures and education should be developed and reviewed annually. Conclusion Research is needed to determine the history of pressure ulcers that begin in the OR. Many of these ulcers are deep tissue injuries, which can deteriorate rapidly. Refinement of a risk assessment for surgical patients that goes beyond the usual risk assessments would aid those patients at risk. Intervention programmes for various types of surgery position, such as prone and lithotomy positions, would also be helpful to reduce pressure ulcer incidence. WINT References 1.National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. 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J Wound Ostomy Continence Nursing 2012; 39: Spruce L, Van Winklin SA. Back to basics; positioning the patient. AORN Journal 2014; 100(3): Santamaria N, Gerdtz M, Sage S et al. A randomized controlled trial of the effectiveness of soft silicone foam multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. Int Wound J 2013; [Epub ahead of print] 15. Aronovitch SA. Intraoperatively Acquired Pressure Ulcers: Are There Common Risk Factors? Ostomy Wound Manage 2007; 53(2): Moss J, Room C. Best practices for preventing hospital-acquired pressure injuries in surgical patients. Can Oper Room Nurs 2011; 29(1): 6 8, Kohanzadeh S, Breithaupt A, Bondarchulk A et al. Effectiveness of the Biologics Dolphin bed as a tool to improve tissue perfusion in points of compression Division of Plastic Surgery, V.A. 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