Pressure Ulcer Risk and Surgery: Practice Considerations

Pressure Ulcer Risk and Surgery: Practice Considerations Editorial Summary Poor patient and service outcomes have a long association with Pressure Ulcers (PU). Despite treatment and preventative advances the development of a PU remains a significant risk during surgery, due mainly to patients being immobile for a sustained period of time, although certain co-morbidities also elevate the risk. There is a need for clinicians to have a heightened awareness of the complex interplay of factors that can lead to the development of a PU related to having a surgical procedure. In practice, traditional risk assessment scales often do not work. This means that there is scope for the use of tools and devices that measure PU risk in real time during surgery. There should be a greater concentration of effort in this area from a research perspective.

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ressure ulcers (PU) have a long established relationship with poor patient outcomes1. Despite technological advances and preventative interventions, PU continue to emerge across different healthcare settings, raising service costs, increasing nurse time spent caring for a problem that is preventable, worsening patient outcomes and in some cases increasing mortality2. Patients undergoing surgical procedures are at high risk for developing a PU3. The reason for this is because during surgery patients are immobile, positioned on a generally hard surface area and unable to feel the discomfort caused by both the pressure and shear forces that accompany a surgical procedure4. In the past two decades, there have been a number of efforts to determine the link between surgery and PU. For example, a prospective cohort study observed that a total of 21.2% (n=44) of patients developed a total of 70 PUs within the first two days following a surgical procedure5. Similarly, in a longitudinal study a total of 12.7% (n=13) of patients developed a PU directly following a surgical procedure6. Notable about both these studies is that patients were free of any signs of a PU prior to their surgical procedure. Therefore, it is very likely that the development of a post-operative PU is linked directly to the intraoperative (surgical) period. Supporting this, in a prospective cohort study, Schoonhoven et al., (2006) found that surgery in the coming week was an independent predictor for PU development (grade 2 or higher), within an acute hospital setting consisting of both medical and surgical inpatients (OR 4.0 CI 2.5-6.5)7. This evidence points the finger at surgery placing patients at high risk of PU development.

Recognising the risk that surgery places patients at, it is important to consider the specific risk factors associated with PU development subsequent to a surgical procedure. Doing this will heighten clinician awareness about how to best prevent early stage PU in the immediate aftermath of a surgical procedure. However, the evidence indicates that PU prevention in surgical patients is not as straight forward as it may seem. For example, a retrospective study examining predisposing factors for PU development during surgery found an increased risk for patients placed in the supine position, with a longer operation duration (≥4 hours), and patients

Prof Declan Patton

Ms Hannah Wilson

Director of Nursing and Midwifery Research, School of Nursing and Midwifery; Deputy Director of the Skin Wounds and Trauma Research Centre; RCSI University of Medicine and Health Sciences

PhD Scholar, Skin Wounds and Trauma Research Centre; RCSI University of Medicine and Health Sciences

Dublin, Ireland

Dublin, Ireland

Dr Pinar Avsar

Prof Zena Moore

Lecturer, School of Nursing and Midwifery; Lead Researcher, Skin Wounds and Trauma Research Centre; RCSI University of Medicine and Health Sciences

Head of School of Nursing and Midwifery; Director of the Skin Wounds and Trauma Research Centre; RCSI University of Medicine and Health Sciences

Dublin, Ireland

Dublin, Ireland

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Pressure Ulcer Risk and Surgery: Practice Considerations

“Pain is an indicator of an early inflammatory response, and if the patient has this already going in to the operating room, they will not be able to tolerate further insults arising from pressure and shear during surgery.”

with comorbidities affecting tissue perfusion, such as patients with a history of diabetes or hypertension, also heightening the risk of PU development 8. Similarly, in a multiple logistic regression analysis, risk factors for intraoperative PU development were investigated, whereby an increase of 96% was found for surgery lasting one hour or longer (OR = 1.96, p<.001), and a 2.1 fold increase was observed for patients in the prone position versus the horizontal position (OR = 3.10, p=.01)9. This very brief snapshot of the evidence demonstrates the complex interplay of factors that can effect the development of a PU during a surgical procedure. Throughout the literature, it is apparent that not all groups of surgical patients are represented in equal measure when it comes to identifying surgery related PU development. For example, Gao et al. (2018) found that patients undergoing a cardiopulmonary bypass during surgery, had a 6.89-fold increase in PU risk, compared to those without cardiopulmonary bypass (OR =6.89, p<.01)9. However, despite presenting with a 25-30% prevalence of PU, the development of PU in cardiac surgery patients could be more adequately addressed in clinical trials10,11,12.

Additionally, a systematic review highlighted that both cardiac and hip surgery patients represent cohorts that are at an increased risk of PU development, which could possibly be due to the age profile of patients undergoing these specific surgeries, combined with the increased duration of time required for these procedures13.

This brief glance at the literature shows clearly that cardiac and hip surgery patients require a closer consideration in terms of clinicians thinking about PU prevention.

Some more specific patient factors require clinical attention when patients are to undergo surgery and one of these is pain. A prospective cross-sectional exploratory study by Nilsson (2013) investigated risk factors for postoperative pain and PU associated with supine positioning, in patients undergoing general anaesthesia. A total of 5% (n=4) of patients had reported pain

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in their heels, 50% (n=2) of which had developed bilateral grade 1 PU14. Reported pain before the surgical procedure was found to be a significant risk factor for postoperative pain (p=.017 OR 13.1 95% CI 1.4-23.9). This single study places an emphasis on the need for clinicians to assess pain in patients who are undergoing surgery, as this pain may be directly linked to subsequent PU development. This is because pain is an indicator of an early inflammatory response, and if the patient has this already going in to the operating room, they will not be able to tolerate further insults arising from pressure and shear during surgery15.

Although the duration of the procedure is a dominant feature linked to PU development related to surgery, it is clear that there are many other factors involved in the development of surgical related PU. Thus, it is imperative that clinicians implement preventive interventions to manage and minimise these risks. Identifying those who need prevention strategies is a critical first step, and this is achieved through risk assessment16. Visual skin assessment and risk assessment scales are the most widely used methods to determine PU risk for those undergoing surgery3,17,18. However, a greater challenge is capturing PU development and managing PU risk during the intraoperative period. Recently, Martins de Oliveira et al., (2022) have examined the predictive ability of subepidermal moisture (SEM) measurement versus traditional risk assessment and visual skin assessment for PU detection among adults undergoing surgery. This non-experimental, comparative, descriptive cohort study showed that the variables which emerged as statistically significant relating to abnormal SEM measurement deltas among these participants were: surgery duration (p=0.038); having orthopaedic surgery (p=0.020); supine surgical position (p=0.003); spinal anaesthetic type (p=0.0001); and Waterlow and Braden mobility subscale day one postoperatively (p=0.0001)17.

Crucially, Martins de Oliveira et al., (2022) draw

Pressure Ulcer Risk and Surgery: Practice Considerations

“Recent trends, based on technological methods of predicting risk, such as the measurement of SEM, offer some light in the search for a clinically viable and more reliable method of predicting PU risk, particularily in surgical patients.”

attention to the risk assessment of patients using the Braden and Waterlow scales. They point out that the use of the Braden and Waterlow risk assessment scales for surgical patients should be reassessed by placing greater consideration on mobility as a risk factor for surgical patients and focusing on cellular responses to pressure and shear identified through SEM measurements17. In a nutshell, although the use of a risk assessment tool is recommended by international PU prevention guidelines, existing tools are limited in their scope and ability to 100% accurately predict the occurance of a PU in all cases19. However, recent trends, based on technological methods of predicting risk, such as the measurement of SEM, offer some light in the search for a clinically viable and more reliable method of predicting PU risk, particularily in surgical patients.

References 1. Khor HM, Tan J, Saedon NI, Kamaruzzaman SB, Chin AV, Poi PJ, Tan MP. Determinants of mortality among older adults with pressure ulcers. Arch Gerontol Geriatr. 2014 NovDec;59(3):536-41. doi: 10.1016/j.archger.2014.07.011. Epub 2014 Jul 21. PMID: 25091603.

2. Walker RM, Gillespie BM, McInnes E, Moore Z, Eskes AM, Patton D, Harbeck EL, White C, Scott IA, Chaboyer W. Prevention and treatment of pressure injuries: A meta-synthesis of Cochrane Reviews. J Tissue Viability. 2020 Nov;29(4):227-243. doi: 10.1016/j.jtv.2020.05.004.

Epub 2020 Jun 28. PMID: 32624289.

3. Peixoto CA, Ferreira MBG, Felix MMDS, Pires PDS, Barichello E, Barbosa MH. Risk assessment for perioperative pressure injuries. Rev Lat Am Enfermagem. 2019 Jan 17;27:e3117. doi: 10.1590/1518-8345.2677-3117. PMID: 30698218; PMCID: PMC6336361.

4. EPUAP, N., PPPIA 2019. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline.

5. SCHOONHOVEN, L., DEFLOOR, T. & GRYPDONCK 2002. Incidence of pressure ulcers due to surgery. Journal of Clinical Nursing, 11, 479-487.

6. BULFONE, G., MARZOLI, I., QUATTRIN, R., FABBRO, C. & PALESE, A. 2012. A longitudinal study of the incidence of pressure sores and the associated risks and strategies adopted in Italian operating theatres. J Perioper Pract, 22, 50-6.

7. SCHOONHOVEN, L., GROBBEE, D. E., DONDERS, A. R., ALGRA, A., GRYPDONCK, M. H., BOUSEMA, M. T., SCHRIJVERS, A. J., BUSKENS, E. & PRE, P. S. G. 2006. Prediction of pressure ulcer development in hospitalized patients: a tool for risk assessment. Qual Saf Health Care, 15, 65-70.

8. LUMBLEY, J. L., ALI, S. A. & TCHOKOUANI, L. S. 2014. Retrospective review of predisposing factors for intraoperative pressure ulcer development. J Clin Anesth, 26, 368-74.

9. GAO, L., YANG, L., LI, X., CHEN, J., DU, J., BAI, X. & YANG, X. 2018. The use of a logistic regression model to develop a risk assessment of intraoperatively acquired pressure ulcer. Journal of Clinical Nursing, 27, 2984-2992.

10. CHELLO, C., LUSINI, M., SCHILIRO, D., GRECO, S. M., BARBATO, R. & NENNA, A. 2019. Pressure ulcers in cardiac surgery: Few clinical studies, difficult risk assessment, and profound clinical implications. Int Wound J, 16, 9-12.

11. RAO, A. D., PRESTON, A. M., STRAUSS, R., STAMM, R. & ZALMAN, D. C. 2016.

Risk Factors Associated With Pressure Ulcer Formation in Critically Ill Cardiac Surgery Patients: A Systematic Review. J Wound Ostomy Continence Nurs, 43, 242-7.

12. FEUCHTINGER, J., HALFENS, R. J. G. & DASSEN, T. 2005. Pressure ulcer risk factors in cardiac surgery: a review of the research literature. Heart & Lung, 34, 375-385.

13. CHEN, H. L., CHEN, X. Y. & WU, J. 2012. The incidence of pressure ulcers in surgical patients of the last 5 years: a systematic review. Wounds, 24, 234-41.

14. Nilsson UG. Intraoperative positioning of patients under general anesthesia and the risk of postoperative pain and pressure ulcers. J Perianesth Nurs. 2013 Jun;28(3):137-43. doi: 10.1016/j.jopan.2012.09.006. PMID: 23711309.

15. Wilson H, Moore Z, Avsar P, Moda Vitoriano Budri A, O’Connor T, Nugent L, Patton D. Exploring the Role of Pain as an Early Indicator for Individuals at Risk of Pressure Ulcer Development: A Systematic Review. Worldviews Evid Based Nurs. 2021 Aug;18(4):299-307. doi: 10.1111/wvn.12528. Epub 2021 Jul 24. PMID: 34302432.

16. H. & MOORE, Z. 2022. Sub-epidermal moisture versus traditional and visual skin assessments to assess pressure ulcer risk in surgery patients. J Wound Care, 31, 254-264.

17. MARTINS DE OLIVEIRA, A. L., O’CONNOR, T., PATTON, D., STRAPP, O’CONNOR, T. 2017. Subepidermal moisture (SEM) 18. WHITEING, N. L. 2009. Skin assessment of patients at risk of pressure ulcers. Nurs Stand, 24, 40-4.

19. Moore ZE, Patton D. Risk assessment tools for the prevention of pressure ulcers.

Cochrane Database Syst Rev. 2019 Jan 31;1(1):CD006471. doi: 10.1002/14651858.CD006471. pub4. PMID: 30702158; PMCID: PMC6354222.

20. HETTRICK, H., HILL, C. & HARDIGAN, P. 2017. Early Detection of Pressure Injury Using a Forensic Alternate Light Source. Wounds, 29, 222-228.

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