The effectiveness of massage with and without dimethyl sulfoxide in preventing pressure ulcers: a randomized, double-blind cross-over trial in patients prone to pressure ulcers

Background

Although guidelines advise against massage, it is one of the methods widely regarded and used by nurses to prevent pressure ulcers (PU).

Objectives

The purpose of this study was to examine the effectiveness of different variations of massage in preventing pressure ulcers.

Methods

A randomized, double-blind cross-over design, in which patients of nursing homes who are prone to PU underwent two of the three possible interventions; ‘position changes only’, ‘massaging with an indifferent cream’ and ‘massaging with a dimethyl sulfoxide (DMSO) cream’.

Results

The results of three interventions did not differ significantly. DMSO did not fulfil the expectations raised by literature and a previous pilot-study.     

Efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with disorders of the spinal cord: A randomized double-blind controlled trial

OBJECTIVE: To study the efficacy of multiwavelength light therapy in the treatment of pressure ulcers in subjects with spinal cord disorders. DESIGN: Randomized controlled trial. SETTING: Neurologic rehabilitation ward of a referral center in India. PARTICIPANTS: Thirty-five subjects with spinal cord injury, with 64 pressure ulcers (stage 2, n=55; stage 3, n=8; stage 4, n=1), were randomized into treatment and control groups. One subject refused consent. Mean duration of ulcers in the treatment group was 34.2+/-45.5 days and in the control group, 57.1+/-43.5 days. INTERVENTIONS: Treatment group received 14 sessions of multiwavelength light therapy, with 46 probes of different wavelengths from a gallium-aluminum-arsenide laser source, 3 times a week. Energy used was 4.5 J/cm(2). Ulcers in the control group received sham treatment. MAIN OUTCOME MEASURES: Healing of the ulcer, defined as the complete closure of the wound with healthy scar tissue, time taken for the ulcer to heal, and stage of the ulcer and Pressure Sore Status Tool score 14 days after last treatment. RESULTS: There was no significant difference in healing between the treatment and control groups. Eighteen ulcers in treatment group and 14 in control group healed completely ( P =.802). Mean time taken by the ulcers to heal was 2.45+/-2.06 weeks in the treatment group and 1.78+/-2.13 weeks in the control group ( P =.330). Time taken for stage 3 and 4 ulcers to reach stage 2 was 2.25+/-0.5 weeks in treatment group and 4.33+/-1.53 weeks in control group ( P =.047). CONCLUSIONS: Multiwavelength light therapy from a gallium-aluminum-arsenide laser source did not influence overall healing pressure ulcers. Limited evidence suggested that it improved healing of stage 3 and 4 pressure ulcers.     

Lessons learned while conducting research on prevention of pressure ulcers in veterans with spinal cord injury

OBJECTIVE: To describe the challenges of conducting a large randomized controlled trial (RCT) to assess the effectiveness of an intervention to prevent recurrent pressure ulcers among a high-risk population of subjects with spinal cord injury (SCI). DESIGN: Prospective multisite, randomized design comparing outcomes of patients who received individualized education and structured telephone counseling follow-up with those of patients receiving customary care. This study was stopped early because of unanticipated recruitment problems. SETTING: Six Veterans Affairs SCI specialty centers. PARTICIPANTS: Veterans (N=150) treated for stage III or IV pelvic pressure ulcers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Recurrence (defined as new skin breakdown in the pelvic area) and time to recurrence. The study was stopped early because of slow recruitment, so the focus of this study is lessons learned, not the main planned outcome measures. RESULTS: Subject recruitment did not meet original expectations because almost 50% of those enrolled left the hospital with the study ulcer unhealed (having a healed ulcer was a requirement for participation). No significant differences were observed between groups on rate of or time to recurrence at the time the study was stopped. Among the 6 sites, variability in ulcer management (eg, length of stay, receipt of medical vs surgical treatment, sitting tolerance before discharge) and time to recurrence (median, 4mo) were observed. CONCLUSIONS: RCTs in real-world settings are the most robust method of assessing the effectiveness of prevention strategies. However, in complex, rapidly changing health care organizations, blinding is infeasible, it may be impractical to control for every variable that influences a study's outcome, and any assumptions that usual care is static are probably mistaken. Investigators must be prepared to use innovative approaches to maintain the integrity of the study design, including flexibility in inclusion and exclusion criteria to support accrual, obtaining a better understanding of the important aspects of usual care that may need to be standardized, continuous improvement within the intervention arm, and anticipation and minimization of risks from organizational changes. With attention to these delivery system issues and the usual design features of randomized trials, we believe real-world care settings can serve as important laboratories to test pressure ulcer prevention strategies in this population.     

A study of a pathway to reduce pressure ulcers for patients with a hip fracture

Due to an ageing population the numbers of patients with hip fractures are increasing. They often suffer from concomitant diseases and are therefore prone to be affected by complications such as pressure ulcers. The prevention of pressure ulcers among patients with a hip fracture is crucial. The aim of this study was to improve the quality of care and patient safety in patients with a hip fracture. A new evidence based clinical pathway was introduced to prevent hospital acquired pressure ulcers. Furthermore, the purpose was to bring attention to pressure ulcer prevention and to facilitate changes in clinical practice to improve quality of care and patient safety. A total of 478 patients with a hip fracture were consecutively included between April 2003 and March 2004. The new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. In the intervention group, hospital acquired pressure ulcers decreased by 50% (p < 0.007). It is possible to reduce the development of hospital acquired pressure ulcers among elderly patients with a hip fracture even though it is not possible to eliminate the effect of factors such as increased age and the patients’ medical status which are often the two main risk factors.     

Impact of sitting time on seat-interface pressure and on pressure mapping with multiple sclerosis patients

Crawford SA, Stinson MD, Walsh DM, Porter-Armstrong AP. Impact of sitting time on seat-interface pressure and on pressure mapping with multiple sclerosis patients. Arch Phys Med Rehabil 2005;86:1221-5.

Objective

To examine changes in seat-interface pressure with multiple sclerosis (MS) patients.

Design

Case series.

Setting

Multiple Sclerosis Society’s Resource Centre and community.

Participants

Convenience sample of 15 MS wheelchair users and 12 MS non-wheelchair users.

Intervention

Interface pressure was measured for 8 minutes using the Force Sensing Array pressure mapping system.

Main Outcome Measures

Number of activated sensors, standard deviation, average and maximum pressures.

Results

With the wheelchair users, significant decreases were found in the standard deviation and average and maximum pressures during 0 to 2 minutes of sitting (P<.01). Average pressure was the only parameter to show a significant decrease in the non-wheelchair users (P<.01) during 0 to 2 minutes. Significant increases were found in all output parameters during 2 to 4 minutes with both groups (P<.05). Non-wheelchair users showed no significant changes in the output parameters after 4 minutes, but wheelchair users showed significant continued increases in the output parameters from 4 to 8 minutes (P<.05).

Conclusions

Because no significant changes in interface pressure occurred after 4 minutes of sitting with the non-wheelchair users, 4 minutes may be a reasonable sitting time before interface pressure is recorded with this group. Significant changes in interface pressure continued up to 8 minutes with the wheelchair users, therefore 8 minutes or beyond may be a reasonable sitting time before recording with this group.     

Alternating pressure air mattresses as prevention for pressure ulcers: a literature review

OBJECTIVES: The purpose of this paper is to examine and synthesise the literature on alternating pressure air mattresses (APAMs) as a preventive measure for pressure ulcers. DESIGN: Literature review. DATA SOURCES: PubMed, Cinahl, Central, Embase, and Medline databases were searched to identify original and relevant articles. Additional publications were retrieved from the references cited in the publications identified during the electronic database search. RESULTS: Thirty-five studies were included. Effectiveness and comfort of APAMs were the main focuses of the studies evaluating APAMs. Pressure ulcer incidence, contact interface pressure, and blood perfusion were the most frequently used outcome measures to evaluate the effectiveness of APAMs. Fifteen randomised controlled trials (RCTs) analysed the pressure ulcer incidence. One RCT compared a standard hospital mattress with an APAM and found that the APAM was a more effective preventive measure. RCTs comparing APAMs with constant-low-air mattresses resulted in conflicting evidence. There was also no clear evidence as to which type of APAM performed better. All RCTs had methodological flaws. The use of contact interface pressure and blood perfusion measurements to evaluate the effectiveness of APAMs is questionable. Comfort of APAMs was the primary outcome measure in only four studies. Different methods for assessment were used and different types of APAMs were evaluated. Better measures for comfort are needed. A few studies discussed technical problems associated with APAMs. Educating nurses in the correct use of APAMs is advisable. CONCLUSION: Taking into account the methodological issues, we can conclude that APAMs are likely to be more effective than standard hospital mattresses. Contact interface pressure and blood perfusion give only a hypothetical conclusion about APAMs' effectiveness. Additional large, high-quality RCTs are needed. No conclusions can be drawn regarding the comfort of APAMs. A number of technical problems associated with APAMs are related to nurses' improper use of the devices.     

全程信息化管理在压疮高危患者护理中的应用

目的：探讨全程信息化管理体系在压疮高危患者护理中的应用,评价其对压疮高危风险预防管理效果的影响。方法设立压疮管理核心组对全院压疮高危患者的护理实行专科技术指导;构建信息化管理模块,完善压疮高危风险报告表,增设压疮高危风险统计分析表,并实行智能化记录和自动统计;完善并实施压疮高危患者的护理管理流程,加强护理管理者对压疮预防措施落实情况的督查,压疮高危患者从上报到转归的全过程均通过信息系统进行动态实时管理。结果全程信息化管理体系实施后,全院压疮高危患者的压疮发生率为18．98％,较实施前的32．64％显著降低,差异有统计学意义（χ2＝10．032,P＜0．01）;压疮高危患者上报资料正确率为98．15％,与实施前的91．71％相比显著提高,差异有统计学意义（χ2＝9．084,P＜0．01）;护理部进行季度压疮高危风险统计所需时间由6 h 降至20 min。结论应用全程信息化管理体系,可降低压疮高危患者的压疮发生率,提高压疮高危风险上报资料的正确率,提高压疮高危风险统计分析的工作效率,有助于完善压疮预防和控制工作。     

Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention

Rintala DH, Garber SL, Friedman JD, Holmes SA. Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention.

Objective

To test the hypothesis that enhanced education and structured follow-up after pressure ulcer surgery will result in fewer recurrences.

Design

Randomized controlled trial.

Setting

Veterans Affairs medical center.

Participants

Forty-nine veteran men with spinal cord injury or dysfunction were approached on admission for pressure ulcer surgery. Five never had surgery, 2 refused to participate, and one withdrew. Forty-one were randomized into 3 groups. Three participants' ulcers did not heal, so follow-up could not begin.

Interventions

Group 1 received individualized pressure ulcer education and monthly structured telephone follow-up (n=20); group 2 received monthly mail or telephone follow-up without educational content (n=11); and group 3 received quarterly mail or telephone follow-up without educational content (n=10). Follow-up continued until recurrence, death, or 24 months.

Main Outcome Measure

Time to pressure ulcer recurrence.

Results

Group 1 had a longer average time to ulcer recurrence or end of study than groups 2 and 3 (19.6mo, 10.1mo, 10.3mo; P=.002) and had a smaller rate of recurrence (33%, 60%, 90%; P=.007). Survival analysis confirmed these findings (P=.009).

Conclusions

Individualized education and structured monthly contacts may be effective in reducing the frequency of or delaying pressure ulcer recurrence after surgical repair of an ulcer.     

康复新液联合胰岛素治疗糖尿病压疮的效果观察

目的：探讨康复新液联合胰岛素治疗糖尿病压疮的效果。方法将21例Ⅱ～Ⅳ期压疮患者随机分成观察组（11例）和对照组（10例）,观察组采用康复新液100 ml加胰岛素200 U的混合溶液制剂,以无菌纱布浸湿外敷于创面上,外用无菌纱布覆盖固定;对照组创面用康复新液湿敷。观察两组患者创面愈合情况。结果观察组疗效明显优于对照组,差异有统计学意义（P＜0.05）。结论康复新液联合胰岛素治疗糖尿病压疮能更有效地控制创面感染,促进创面愈合,提高压疮治愈率,且操作简便易行,经济安全,值得在临床和家庭中推广使用。     

去腐生肌膏联合居家护理在压疮延续护理中应用的效果评价

目的 观察去腐生肌膏联合居家护理在压疮延续护理中的应用效果.方法 选择3年内住院的压疮患者71例,随机分为观察组和对照组,观察组33例,压疮共计58处,采用去腐生肌膏联合居家护理;对照组38例,压疮共计66处,采用凡士林纱布和常规护理方法.对比2组患者离院1,3个月KPS评分、ADL评分、SWLS评分,以及患者压疮的愈合情况.结果 2组患者离院3个月KPS评分和ADL评分比较差异有统计学意义,生活满意度评分比较差异有统计学意义.2组患者1个月后压疮治愈率、显效率和总有效率比较差异均有统计学意义.结论 在居家护理中,通过制订全面的护理方案,提高家属的护理技能,能够有效提高患者的生活满意度和生活状态,并且通过无张力手法改变患者体位,减少患者皮肤间的摩擦,加之去腐生肌膏的无菌擦拭,能够提高压疮的治疗有效率,缩短压疮的愈合时间.     

伤口床准备原则在Ⅲ、Ⅳ期压疮患者中的应用效果观察

目的9例Ⅲ、Ⅳ期压疮患者创面处理效果。针对患者压疮创研大,感染严重,机体营养状况差,创面难愈合的特点,运用伤口床准备原则,为压疮创面进一步愈合提供良好创基。方法根据伤口床准备原则对压疮伤口进行处理,局部清创后用银离子藻酸盐填充溃疡创口,隔日换药,分泌物多时每日换药。伤口被污染时随时换药,并做记录。结果18周后肉芽组织覆盖整个创面,伤口愈合快。结论运用伤口准备原则处理Ⅲ、Ⅳ期压疮效果显著。     

腹腔镜手术患者发生压疮的手术室相关原因以及护理对策分析

目的：探讨腹腔镜手术患者发生压疮的手术室相关原因并提出护理对策。方法回顾性分析186例腹腔镜手术患者的手术资料,探讨发生压疮的手术室相关原因,并针对性地提出护理对策。结果186例腹腔镜手术患者中,术中及术后3 d内共发生Ⅰ～Ⅱ期压疮17例,压疮发生率为9.14％;腹腔镜手术患者发生压疮的手术室相关原因包括手术体位、手术时间过长、皮肤潮湿、术中低血压状态持续时间、低氧血症等。结论腹腔镜手术患者术后发生压疮是多种因素作用的结果,针对压疮发生的相关原因,术中加强预防性措施,有助于降低术后压疮发生率。     

氦氖激光照射联合硼酸湿敷治疗老年患者压疮的效果

目的探讨氦氖激光照射联合硼酸湿敷治疗老年患者压疮的效果。方法将52例住院带有压疮的老年患者随机分成对照组和治疗组,对照组常规清洁疮面后用硼酸纱布湿敷;治疗组同样清创后给予氦氖激光照射压疮表面20min,再用硼酸纱布湿敷,每天1次。两组患者治疗期间均采用压疮综合治疗护理措施。观察30d压疮愈合情况。结果治疗组有效率为96．2％,对照组有效率为69．2％。两组比较差异有统计学意义（X2=4．837,P〈0.05）;治疗组显效时间也明显较对照组缩短[（12．19±6．40）d比（19．36±9．30）d],差异有统计学意义（t=-2.425,P〈0．05）。结论氦氖激光照射联合硼酸湿敷治疗老年患者压疮,能够促进伤口愈合,缩短病程。     

Examining the validity of pressure ulcer risk assessment scales: a replication study

Risk assessment scales (RASs) intended to identify patients most at risk of developing pressure ulcers have been widely used for many years. Numerous studies have evaluated their predictive validity but potential bias has been inherent in the design of all. To overcome these problems a simulation study was conducted in which clinical nurses were asked to identify the degree of risk experienced by four patients employing the three RASs discussed most frequently in the literature (Norton, Braden and Waterlow Scores). These findings were compared with nurses' clinical judgment rated on a visual analogue scale. The simulations consisted of high-resolution photographs accompanied by case studies of the patients. The nurses' scores were compared to estimates of risk generated by an expert panel. Nurses' clinical judgment agreed much more closely with expert opinion than any of the RASs. A replication study was undertaken to confirm these findings. One hundred and fifteen nurses participated in replication. Again the nurses' clinical judgment matched expert opinion much more closely than the results of the RASs. Replication also drew attention to a number of methodological issues which deserve consideration when using simulation to test the effectiveness of clinical tools and the need to establish adequate measures of external validity whenever use of this method is contemplated.