Variations in sacral oedema levels over continuous 60-degree head of bed elevation positioning in healthy adults: An observational study

BackgroundSubepidermal moisture (SEM) scanning is a novel technology that measures changes in localised oedema. Accumulation of subepidermal oedema is associated with early tissue damage that may lead to a pressure injury.AimThe primary study objective was to observe the variations in sacral subepidermal oedema levels over a continuous period of 60-degree head of bed elevation positioning.MethodsHealthy adult participants were recruited in this prospective observational study. Participants were positioned at 60-degree head of bed elevation for 120 min and sacral SEM measurements were collected at baseline and in 20 min increments.ResultsA total of 20 participants with a mean age of 39.3 years (SD = 14.7) were recruited. The mean SEM delta value increased 6.3% from 0.46 SEM delta at baseline to 0.49 SEM delta after 120 min, however these differences are not statistically significant (p = .21). There were also no significant findings between SEM delta variations and demographic factors.ConclusionIn a sample of healthy individuals, 120 min of continuous loading with a 60-degree head of bed elevation did not lead to a significant change in sacral subepidermal oedema levels. Further research on the response of healthy adult tissue under external forces associated with different angles of head of bed positioning may further contribute to our understanding pressure injury prevention.     

Effects of cycle periods and pressure amplitudes of alternating pressure on sacral skin blood flow responses

BackgroundThere are no guidelines on selecting alternating pressure (AP) configurations on increasing sacral skin blood flow (SBF).AimThe specific aims were to compare different cycle periods and pressure amplitudes of AP on sacral SBF responses in healthy people to establish the efficacy and safety of the protocols.MethodsTwo studies were tested, including the cycle period study (8 2.5-min vs 4 5-min protocols) and the pressure amplitude study (75/5 vs 65/15 mmHg protocols). Sacral SBF was measured using laser Doppler flowmetry (LDF) in 20 participants. AP loads were randomly applied using an indenter through the rigid LDF probe. Each protocol included a 10-min baseline, 20-min AP and 10-min recovery periods. A 30-min washout period was provided. The SBF response was normalized to the baseline SBF of each condition of each participant.ResultsFor the cycle period study, the 4 5-min cycle protocol partially restored more SBF than the 8 2.5-min cycle protocol at the low-pressure phase (0.87 ± 0.04 vs 0.71 ± 0.03, p < 0.05) and at the high-pressure phase (0.25 ± 0.03 vs 0.19 ± 0.03, p < 0.05). For the pressure amplitude study, the 75/5 mmHg protocol partially restored more sacral SBF than the 65/15 mmHg protocol at the low-pressure phase (0.87 ± 0.1 vs 0.25 ± 0.03, p < 0.05) but not at the high-pressure phase (0.23 ± 0.02 vs 0.21 ± 0.02, non-significant).ConclusionThis study demonstrated that 1) a cycle period of 5 min was better than 2.5 min and 2) a pressure amplitude of 75/5 mmHg was better than 65/15 mmHg. The finding provides insights for selecting the AP configurations for increasing SBF.     

Sacral interface pressure can be alleviated by repositioning with a small-angle change using an automated bed in patients with spinal cord injury

Aim of the studyThis study aimed to compare interface pressure and total contact area of the sacral region in different positions, including small-angle changes, in patients with spinal cord injury (SCI). Furthermore, we analyzed the clinical factors influencing pressure to identify the pressure injury (PI) high-risk group.Materials and methodsAn intervention was conducted for patients with paraplegia (n = 30) with SCI. In the first and second trials, interface pressure and total contact area of the sacral region were recorded from large- and small-angled positions using the automatic repositioning bed, which can change the angle of the back, lateral tilt, and knee.ResultsPositions with back raised ≥45° showed significantly higher pressure on the sacrum than most other positions. The pressure and contact area differences were statistically insignificant for combinations of small-angled changes <30°.Additionally, the duration of injury (β = 0.51, p = 0.010) and neurological level of injury (NLI) (β = −0.47, p = 0.020) were significant independent predictors of average pressure. Similarly, the duration of injury (β = 0.64, p = 0.001), the Korean version of the spinal cord independence measure-III (β = −0.52, p = 0.017), and body mass index (BMI; β = −0.34, p = 0.041) were significant independent predictors of peak pressure.ConclusionsFor repositioning, combinations of small-angle changes <30° effectively reduce pressure on the sacral region in patients with SCI. Lower BMI, longer duration of injury, lower functioning score, and NLI ≥ T7 are predictors of high sacral pressures, which increase the risk for PI. Therefore, patients with these predictors require strict management.     

A quantitative analysis of microcirculation in sore-prone pressure areas on conventional and pressure relief hospital mattresses using laser Doppler flowmetry and tissue spectrophotometry

BackgroundPressure ulcers are associated with severe impairment for the patients and high economic load. With this study we wanted to gain more insight to the skin perfusion dynamics due to external loading. Furthermore, we evaluated the effect of different types of pressure relief mattresses.MethodsA total of 25 healthy volunteers were enrolled in the study. Perfusion dynamics of the sacral and the heel area were assessed using the O2C-device, which combines a laser light, to determine blood flow, and white light to determine the relative amount of hemoglobin. Three mattresses were evaluated compared to a hard surface: a standard hospital foam mattress bed, a visco-elastic foam mattress, and an air-fluidized bed.ResultsIn the heel area, only the air-fluidized bed was able to maintain the blood circulation (mean blood flow of 13.6 ± 6 versus 3.9 ± 3 AU and mean relative amount of hemoglobin of 44.0 ± 14 versus 32.7 ± 12 AU.) In the sacral area, all used mattresses revealed an improvement of blood circulation compared to the hard surface.ConclusionThe results of this study form a more precise pattern of perfusion changes due to external loading on various pressure relief mattresses. This knowledge may reduce the incidence of pressure ulcers and may be an influencing factor in pressure relief mattress selection.     

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

ObjectivesThis study aimed to validate the skin temperature on sacral region and vascular attributes as early warning signs of pressure injury.MethodsTotally 415 patients admitted to the adult intensive care unit from August 2018 to April 2019 were prospectively screened. Daily blood pressure and blood glucose affecting vascular attributes and the relative skin temperature of sacral region were measured for 10 consecutive days. Collect the changes of these indicators during the occurrence of pressure injury. The optimal cut-off values of indicators were determined by X-tile analysis. The risk ratios of indicators associated with pressure injury were compared using the Cox proportional hazards regression model.ResultsThere were no obvious interactions among blood pressure, blood glucose and relative skin temperature (P > 0.05). The optimal cutoff value for above indicators was 63.5 mmHg, 9.9 mmol/L and −0.1 °C, respectively. The incidence of pressure injury peaked on the 4th and 5th day after hospitalization when categorizing the patients into low- and high-risk groups according to the cutoff values (P < 0.05). Based on relative skin temperature, patients in the high-risk group were more likely to develop pressure injury (hazard ratio = 6.36, 95% confidence interval = 3.91, 10.36), when compared to the other two indicators of blood pressure and blood glucose.ConclusionStringent skin temperature and vascular attributes measurements were necessary for preventing pressure injury. Nursing measures should be taken according to warning sings to reduce the incidence of pressure injury.     

Associations between skin structural and functional changes after loading in healthy aged females at sacral and heel skin: A secondary data analysis

Aim of the studyMechanical loading causes skin occlusion and deformation, which influences structural and functional skin properties. Aims of the study were to measure structural and functional skin parameters after loading at the sacral and heel skin and to describe possible associations.Material and methodsA secondary data analysis based on a clinical trial with n = 15 aged women was conducted. Changes of transepidermal water loss, stratum corneum hydration, epidermal hydration, erythema, temperature, structural stiffness, elastic recovery, elastic function, and mean roughness after 120 min loading were described and compared. Spearman's rho (r_s) was used to estimate possible associations.ResultsLoading caused an increase of transepidermal water loss, stratum corneum and epidermal hydration, erythema and temperature at sacral and heel skin. There was a decrease of median roughness at the heel skin surface (-8.5 (IQR -10.5 to 5.5) μm). Strongest positive associations were observed between changes of elastic function and elastic recovery (r_s = 0.9 at heel and sacral skin) and between changes of epidermal and stratum corneum hydration at both skin areas (r_s = 0.7 at sacral skin and r_s = 0.5 at the heel).ConclusionTwo hours loading on a standard foam mattress leads to skin occlusion at the skin surface and mechanical deformation. Skin occlusion seems primarily to increase temperature, stratum corneum and epidermal hydration that may affect mechanical skin properties. Mechanical deformation seems to be responsible for the erythematous response of the dermal skin layer.     

Incidence and risk factors for pressure injury in hospitalized non-small cell lung cancer patients: A retrospective observational study

AimThis study aimed to identify the incidence and risk factors for pressure injury in patients hospitalized for non-small cell lung cancer (NSCLC).MethodsThis retrospective observational study was conducted in 645 adults who were hospitalized for NSCLC. Clinicopathological characteristics were compared between NSCLC patients with pressure injury and those without pressure injury.ResultsAmong total 645 patients, 180 patients showed pressure injury with an incidence of 27.9%. Patients with pressure injury showed increased serum C-reactive protein (CRP) levels (P < 0.001), increased neutrophil-lymphocyte ratio (P = 0.002), and increased platelet-lymphocyte ratio (P = 0.001) more often. Increase in serum CRP levels at the time of admission was the major risk factor for development of pressure injury in NSCLC patients (OR = 2.20; 95% CI [1.40–3.45]; P = 0.001). Also, among major inflammatory markers, serum CRP levels at the time of admission showed weak negative correlation with the period from admission to the development of pressure injury (r = −0.216, P = 0.004).ConclusionBy checking serum CRP levels at the time of admission, the NSCLC patients at high risk for the development of pressure injury can be identified in advance and the occurrence of pressure injury can be reduced by applying more active preventive nursing care.Clinical trial registration numberKCT0006570.     

Comparison of interface pressures in two dynamic pressure ulcer prevention supports (NIMBUS 3 and SUMMIT): A randomized controlled trial

BackgroundPressure ulcers are a risk for bedridden patients and various supports exist to prevent them. The Pressure Relief Index (PRI) evaluates pressure relief of dynamic mattresses over time. This study compared the PRI of the SUMMIT mattress (AKS-France) and the NIMBUS 3 (HNE Medical).MethodsIn this non-blinded, randomized, crossover, non-inferiority study, patients aged ≥60 with a BMI of 16–35 kg/m2, predominantly confined to bed, able to walk with aid and with pelvic symmetry were recruited from a hospital rehabilitation department from March–April 2012. Exclusion criteria included past or present pressure ulcers, inability to remain supine and deep vein thrombosis. Peak pressures of the sacrum were recorded at 0.1 Hz during a single complete 10-min inflating cycle on both mattresses, with the order determined via electronic randomization allocation.ResultsThirty-one subjects were included and randomized; with 14 finally analyzed in the SUMMIT-NIBMUS 3 order group and 16 in the NIMBUS 3-SUMMIT group. The difference in PRI <30 mmHg between the two mattresses was 13.2% [0.3–26.1] (p < 0.05), allowing a non-inferiority - superiority switch. The SUMMIT mattress demonstrated a significantly higher percentage of time <30 mmHg (p = 0.0454). No significant difference in mean minimal pressure was seen (p = 0.3231) and mean maximal pressure was in favor of SUMMIT mattress (p = 0.0096). BMI did not affect pressure profile. There were no adverse events.ConclusionsEvaluated by the PRI, the SUMMIT mattress had a better interface pressure profile than the NIMBUS 3 in older patients. The PRI is a promising tool for clinical decision-making and research, warranting validation.     

Patterns and associations of structural and functional cutaneous responses during loading at heel and sacral skin in aged females: A reanalysis of clinical study data

Aim of the studyThe aim of this study was to explore possible interrelationships and cutaneous response patterns at the heel and sacral skin due to prolonged loading.Materials and methodsSkin stiffness, elasticity, roughness and transepidermal water loss, stratum corneum hydration, erythema, and temperature of n = 20 aged females (mean age 69.9 years) were measured before and after 90 and 150 min loading in supine position. Delta values were calculated and correlated using Spearman's rho. Strengths and directions of associations and similar patterns were subsequently identified for the heel and sacrum areas.ResultsAt the sacral area decreased stiffness (Uf) was associated with increased TEWL and there was a positive relationship between mean roughness (Rz) and erythema. At the heel there was a positive association between TEWL and decreasing stiffness (Uf).ConclusionsOur results indicate a dynamic interaction between skin changes during loading and different physiological response patterns for sacral and heel skin. There seems to be close association between transepidermal water loss and stiffness changes during loading.     

Upright vs. supine shape-capturing comparison for custom-contoured cushions

AimsThis study aims to explore best practices of shape capturing methods for creating custom-contoured wheelchair cushions for the purpose of reducing pressure injury risk.Materials and methodsPressure redistribution qualities were measured by peak pressure index (PPI) and compared between custom-contoured seating systems molded in supine vs. upright shape-capturing positions. Subjects consisted of 14 able-bodied participants in a within-subjects comparison.ResultsA Wilcoxon signed-rank test and paired t-test were calculated to compare the mean differences of the PPI between shape-capturing positions. Supine shape-capturing resulted in a statistically significant lower PPI compared to upright (z = 2.040, p < . 05) (t = −2.28, p < .05).ConclusionShape-capturing in the supine position provided greater pressure distribution as opposed to an upright position. Creating custom-contoured cushions molded in a supine position can reduce the risk of pressure injury to the patient.     

Effects of skin moisturizer on the skin barrier dysfunction model: An evaluation of the heel via tape-stripping in healthy,young adults

BackgroundThis study seeks to establish the skin barrier dysfunction model at the heel via tape-stripping (TS) by evaluating the skin moisturizing effects.Materials and methodsNineteen young, female participated in the study. A sequence of TS was performed at the heel and trans-epidermal water loss (TEWL), stratum corneum (SC) hydration, and surface pH were measured. Following TS, the subjects were divided into three groups: moisturizer, emollient, and overcoat. These agents were applied daily at night, and the skin parameters were measured the next morning for a week.ResultsThe TEWL value of TS immediately and 5 min after TS were significantly higher than what was obtained before TS, while the SC hydration after TS was significantly lower than what was obtained before TS. However, there were no significant differences in the skin parameters among the three agents on day 7 after application, with the two-way ANOVA showing no interaction among the agents and number of days.ConclusionThe skin barrier dysfunction model at the heel was established by TS in healthy, young adults. However, the physiological function of the skin at the heel did not change drastically and showed no differences even after continuous application for 7 days.     

Risk factors for the development and evolution of deep tissue injuries: A systematic review

AimsThe aim of this systematic review is to identify the current epidemiological evidence indicating the unique risk factors for deep tissue injury (DTI) compared to grade I-IV pressure injury (PI), the proportion of DTI which evolve rather than resolve and the anatomical distribution of DTI.MethodsA systematic literature search was undertaken using the MEDLINE and CINAHL Plus databases using the search terms ‘Deep tissue injury OR DTI [Title/abstract]’. A google scholar search was also conducted in addition to hand searches of relevant journals, websites and books which were identified from reference lists in retrieved articles. Only peer-reviewed English language articles published 2009–2021 were included, with full text available online.ResultsThe final qualitative analysis included nine articles. These included n = 4 retrospective studies, n = 4 prospective studies and n = 1 animal study.ConclusionThe literature indicates that the majority of DTI occur at the heel and sacrum although in paediatric patients they are mainly associated with medical devices. Most DTI are reported to resolve, with between 9.3 and 27% deteriorating to full thickness tissue loss.Risk factors unique to DTI appear to include anaemia, vasopressor use, haemodialysis and nicotine use although it is unclear if these factors are unique to DTI or are shared with grade I-IV PI. Factors associated with deterioration include cooler skin measured using infrared thermography and negative capillary refill. With 100% of DTI showing positive capillary refill in one study resolving without tissue loss (p = 0.02) suggesting this may be an effective prognostic indicator.More prospective studies are required focusing on establishing causal links between risk factors identified in earlier retrospective studies. Ideally these should use statistically powered samples and sufficient follow up periods allowing DTI outcomes to be reached. Further work is also needed to establish reliable diagnostic criteria for DTI in addition to more studies in the paediatric population.     

Translation and validation of the ELPO for Turkish population: Risk assessment scale for the development of pressure injuries due to surgical positioning

Aim of the studyThis study was conducted to translate the ELPO risk assessment scale for the development of pressure injuries due to surgical positioning to Turkish and to test its validity and reliability in the Turkish Population.Materials and methodsThe data were collected using the patient identification form, the risk assessment scale for the prevention of injuries due to surgical positioning, and the Braden Scale. This scale consisted of a total of seven items, each of which contained five sub-items. It is rated between 1 and 5 in the Likert type. The total score of the scale ranges between 7 and 35. The risk of developing pressure injuries increases in patients as the score increases.ResultsA total of 184 patients were included in the study sample. The mean age of the group was 55.96 ± 17.90, and the content validity index was 0.944. The sensitivity of the test was 60%, the specificity was 66%, and the accuracy was 66%. There was a negative, weak, statistically significant correlation between the total scores of the risk assessment scale for the prevention of injuries due to surgical positioning and the Braden scale. The mean total score of the scale was 18.45 ± 2.96 (12–26) and 35.9% (n = 66) of the group were at high risk.ConclusionsThe ELPO, which includes the risks specific to patients during surgery, can be used as an assessment scale for the development of pressure injury due to surgical positioning for Turkish population.     

Prevention of pressure injuries in critically ill children: A preliminary evaluation

AimsTo evaluate a prevention strategy implemented to reduce incidence and severity of positioning related pressure injuries affecting pediatric patients in a pediatric critical care unit. Secondary objective was to evaluate compliance with preventive recommendations.BackgroundThe skin in infants or children has important physiological and anatomical differences compared with adults. Further, factors such as the immaturity of the skin and limited activity and mobility in pediatric critical care unit, along with the pressure exerted by medical devices, increases the risk of pressure ulcers in infants and children. The most effective preventive measures specific to this intensive care population need to be evaluated.Material and methodsQuasi-experimental before-after study with consecutive sampling. The effectiveness of the care bundle implementation was evaluated based on the latest evidence (intervention group) versus the application of non-standardized care (control group). Pediatric patients up to 14 years old at risk of suffering from pressure injuries and who were admitted more than 48 h in a pediatric intensive care unit (level III) participated. For the collection of data, two computer programs and the hospital clinical records of each participant were consulted. The data collection period was 6 months per group (pre and post intervention).ResultsA sample of 110 patients was obtained (50 control group and 60 intervention group). The cumulative incidence in pediatric patients exposed to the risk of pressure injuries was reduced from 16% to 13.3%; and in the subgroup of patients with prolonged stay (≥28 days), the incidence was reduced from 55.55% to 20%. In the intervention group, category III and IV pressure ulcers were completely reduced. In addition, the total number of pressure injuries decreased by 21.43%. The care bandle recommendations with the highest level of adhesion recorded were: skin inspection, application of hyperoxygenated fatty acids and use of a special support surface. The main risk factor found during the study was the prone position (p < 0.05).ConclusionsThe application of a care bundle for prevention can be an effective solution to reduce the number and severity of LPPs in an intensive care unit. The most vulnerable subgroup of patients may benefit from the application of these resources.     

Risk factors associated with heel pressure ulcer development in adult population: A systematic literature review

AimsThe main aim of this systematic literature review was to identify risk factors for development of heel pressure ulcers and quantify their effect.BackgroundPressure ulcers remain one of the key patient safety challenges across all health care settings and heels are the second most common site for developing pressure ulcers after the sacrum.DesignQuantitative systematic review.MethodsData sources: Electronic databases were searched for studies published between 1809 to March 2020 using keywords, Medical Subject Headings, and other index terms, as well as combinations of these terms and appropriate synonyms. Study eligibility criteria: Previous systematic literature reviews, cohort, case control and cross-sectional studies investigating risk factors for developing heel pressure ulcers. Only articles published in English were reviewed with no restrictions on date of publication. Participants: patients aged 18 years and above in any care setting. Study selection, data extraction, risk of bias and quality assessment were completed by two independent reviewers. Disagreements were resolved by discussion.ResultsThirteen studies met the eligibility criteria and several potential risk factors were identified. However, eligible studies were mainly moderate to low quality except for three high quality studies.ConclusionsThere is a paucity of high quality evidence to identify risk factors associated with heel pressure ulcer development. Immobility, diabetes, vascular disease, impaired nutrition, perfusion issues, mechanical ventilation, surgery, and Braden subscales were identified as potential risk factors for developing heel pressure ulcers however, further well-designed studies are required to elucidate these factors. Other risk factors may also exist and require further investigation.Prospero idPROSPERO International prospective register of systematic reviews: CRD42017071459.     

Sacral skin blood flow response to alternating pressure operating room overlay

Pressure injuries resulting from long surgeries may be caused by prolonged ischemia. Operating table surfaces with alternating pressure (AP) features may reduce the risk of ischemia-induced pressure injuries by providing periodic relief of blood flow occlusions. Prior research investigated alternating loading applied with a single isolated rigid indenter and demonstrated increased perfusion. This study quantified effects of an overlay with AP on sacral skin perfusion for individuals lying supine for 60-min while blood flow was monitored. The mean normalized sacral skin blood flow was found to be greater with the AP overlay over an operating table pad compared to the operating pad alone (pad with AP mean SBF?=?1.45?±?1.16, pad without AP mean SBF?=?1.03?±?0.46, p?=?0.10). Peak and average interface pressure at the sacrum was significantly lower during the deflation cycle of the AP surface compared to the operating pad alone (P?<?0.001), suggesting this periodic reduction resulted in higher mean blood flow. Post-hoc regression analysis showed participant body mass index was a significant predictor of the effectiveness of the AP overlay (p?=?0.012). The results suggest risk for pressure injuries due to prolonged ischemia might be mitigated by the addition of an alternating pressure feature on operating table pads for lower BMI patients.