Differences of bioelectrical impedance in the development and healing phase of pressure ulcers and erythema in mouse model.

Pressure ulcers (PUs) are economically burdensome medical conditions. Early changes in pressure ulcers are associated with erythema. In this study, bioelectrical impedance was used to measure the differences between PUs and blanchable erythema. We divided 21 ICR mice into three groups: control, 1000 mmHg-1h, and 1000 mmHg-6h. Healthy skin, blanchable erythema, and PUs were induced on the dorsal skin. The results indicated an immediate increase in impedance, resistance, and reactance values in the pressure group after release, followed by a subsequent decrease until two days after release. Compared with the control group, impedance and reactance significantly increased by 30.9% (p < 0.05) and 30.1% (p < 0.01), respectively, in the 6 h-loading group immediately after release. One and two days after release, the 1 h-loading and 6 h-loading groups exhibited significantly different degrees of decline. One day after release, impedance and resistance decreased by 30.2% (p < 0.05) and 19.8% (p < 0.05), respectively, in the 1 h-loading group; while impedance, resistance, and reactance decreased by 39.2% (p < 0.01), 26.8% (p < 0.01), and 45.7% (p < 0.05), respectively, in the 6 h-loading group. Two days after release, in the 1 h-loading group, impedance and resistance decreased by 28.3% (p < 0.05) and 21.7% (p < 0.05), respectively; while in the 6 h-loading group, impedance, resistance, and reactance decreased by 49.8% (p < 0.001), 34.2% (p < 0.001), and 59.8% (p < 0.01), respectively. One and two days after release the pressure group reductions were significantly greater than those in the control group. Additionally, we monitored changes during wound healing. Distinguishing early PUs from blanchable erythema by noninvasive bioelectrical impedance technology may have applications value in early assessment of PUs.

Prediction of tissue deformation based on mechanical and physiological factors in the prone position during surgery.

AIM: This study aimed to predict tissue deformation based on the pressure applied while lying in the prone position and physiological factors. METHODS: Healthy volunteers were instructed to lie on mattresses of four different hardness levels (50, 87.5, 175, and 262.5 N). The order in which the mattresses were used was randomized per participant. Pressure at the iliac crests was measured using a pressure mapping sensor sheet. Participants were placed in the prone position for 10 min, with pressure data used from the latter 5 min. For the tissue deformation at the iliac crests, our previous study data were used. Multiple regression analysis was used to identify predictive mechanical and physiological factors. RESULTS: The distance between the left and right greater trochanters, maximum interface pressure and age were significant predictors for compression of the skin and soft tissue. Significant predictors of internal soft tissue displacement were the distances between the left and right anterior superior iliac spines and greater trochanters. No factors predicted skin surface displacement. CONCLUSIONS: Our study provided predictive factors that may be measured easily in a clinical setting to reduce the risk of pressure ulcers during surgery in the prone position.

Are there differences between COVID-19 and non-COVID-19 inpatient pressure injuries? Experiences in Internal Medicine Units.

BACKGROUND: Pressure Injuries (PIs) are major worldwide public health threats within the different health-care settings. OBJECTIVE: To describe and compare epidemiological and clinical features of PIs in COVID-19 patients and patients admitted for other causes in Internal Medicine Units during the first wave of COVID-19 pandemic. DESIGN: A descriptive longitudinal retrospective study. SETTING: This study was conducted in Internal Medicine Units in Salamanca University Hospital Complex, a tertiary hospital in the Salamanca province, Spain. PARTICIPANTS: All inpatients ≥18-year-old admitted from March 1, 2020 to June 1, 2020 for more than 24 hours in the Internal Medicine Units with one or more episodes of PIs. RESULTS: A total of 101 inpatients and 171 episodes were studied. The prevalence of PI episodes was 6% and the cumulative incidence was 2.9% during the first-wave of COVID-19. Risk of acute wounds was four times higher in the COVID-19 patient group (p<0.001). Most common locations were sacrum and heels. Among hospital acquired pressure injuries a significant association was observed between arterial hypertension and diabetes mellitus in patients with COVID-19 diagnosis. CONCLUSION: During the first wave of COVID-19, COVID-19 patients tend to present a higher number of acute wounds, mainly of hospital origin, compared to the profile of the non-COVID group. Diabetes mellitus and arterial hypertension were identified as main associated comorbidities in patients with COVID-19 diagnosis.

"A-PePSI LIGhT" Assessment Score to Predict Pressure Sore Impaired Healing Late Recurrence, Immobility, Greater Surface, Inhibited Thrombocytes.

BACKGROUND: Complication rates of up to 46 percent are reported following pressure sore surgery. Pressure sore patients often exhibit ineffective postoperative wound healing despite tension-free flap coverage, necessitating surgical revision and prolonged hospitalization. Rather than pressure sore recurrence, such impaired healing reflects a failed progress through the physiologic stages of the normal wound-healing cascade. The principal objective of the study reported here was to elucidate potentially modifiable inherent variables that predict predisposition to impaired healing and to provide a tool for identifying cases at risk for complicated early postoperative recovery following pressure sore reconstruction. METHODS: A retrospective chart review of late-stage (stage 3 or higher) sacral and ischial pressure sore patients who underwent flap reconstruction from 2014 to 2019 was performed. A multivariable logistic regression model was used to identify key patient and operative factors predictive of impaired healing. Furthermore, the Assessment Score to Predict Pressure Sore Impaired Healing (A-PePSI) was established based on the identified risk factors. RESULTS: In a cohort of 121 patients, 36 percent exhibited impaired healing. Of these, 34 patients suffered from dehiscences, necessitating surgical revision. Statistically significant risk factors comprising late recurrence (OR, 3.8), immobility (OR, 12.4), greater surface (>5 cm diameter; OR, 7.3), and inhibited thrombocytes (aspirin monotherapy; OR, 5.7) were combined to formulate a prognostic scoring system (A-PePSI LIGhT). CONCLUSIONS: The A-PePSI LIGhT score serves as a prognostic instrument for assessing individual risk for impaired healing in pressure sore patients. Preoperative risk stratification supports rational decision-making regarding operative candidacy, allows evidence-based patient counseling, and supports the implementation of individualized treatment protocols. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Exploring the Role of Pain as an Early Indicator for Individuals at Risk of Pressure Ulcer Development: A Systematic Review.

BACKGROUND: Pressure ulcer (PU) development begins with an inflammatory response, arising due to pressure and shear forces causing changes to the cytoskeletal structure of cells. Thus, pain, synonymous with inflammation, may be an indicator of PU development. AIM: To explore the role of pain as an indicator of PU development and to determine how this pain was measured. METHOD: We searched PUBMED, CINAHL, SCOPUS, Cochrane, and EMBASE databases. A total of 879 records were returned, with eight satisfying the inclusion criteria. Narrative data synthesis was undertaken. The quality of studies was assessed using the evidence-based librarianship (EBL) checklist. RESULTS: The studies were conducted between 2000 and 2019, and 75% (n = 6) employed a cross-sectional design. The mean sample size was 760 participants (SD = 703). Of the included studies, 87.5% (n = 7) identified that pain was associated with PU development. The most frequent pain assessment tool was the numeric rating scale (37.5%; n = 3). Using the EBL checklist, 62.5% (n = 5) of the studies scored ≥75%, reflecting validity. LINKING EVIDENCE TO ACTION: Pain is associated with PU development; however, further research is required to validate these findings and assess the characteristics associated with pain as a symptom preceding PU development.

Development of a nomogram for predicting nasogastric tube-associated pressure injuries in intensive care unit patients.

Here, we aimed to build a nomogram model to estimate the probability of nasogastric tube-associated pressure injuries (NTAPIs) in intensive care unit(ICU)patients. This prospective cohort study included 219ICU patients with nasogastric tube between September 2019 and January 2020.Univariate and multivariate logistic regression analyses were used to develop the nomogram model. The resulting nomogram was tested for calibration, discrimination, and clinical usefulness. Of the included patients, 58 developed NTAPIs, representing an incidence rate of 26.5%. Binary logistic regression analysis revealed that the prediction nomogram included C-reactive protein, vasopressor use, albumin level, nasogastric tube duration, and Sequential Organ Failure Assessment score. The value of these predictors was again confirmed using theLasso regression analysis. Internal validation presented a good discrimination of the nomogram, with an area under the curve value of 0.850, and good calibration (Hosmer-Lemeshow test, P = 0.177). The decision curve analysis also demonstrated preferable net benefit along with the threshold probability in the prediction nomogram. The nomogram model can accurately predict the risk factors for NTAPIs, to formulate intervention strategies as early as possible to reduce NTAPI incidence.

Subsequent Pressure Injury Development in Mechanically Ventilated Critical Care Patients with Hospital-Acquired Pressure Injury: A Retrospective Cohort Study.

OBJECTIVE: To identify factors associated with subsequent hospital-acquired pressure injury (HAPrI) formation among patients in surgical and cardiovascular surgical ICUs with an initial HAPrI. METHODS: Patients admitted to a level 1 trauma center and academic medical center in the Western US between 2014 and 2018 were eligible for this retrospective cohort study. Inclusion criteria were development of an HAPrI stage 2 or above, age older than 18 years, the use of mechanical ventilation for at least 24 hours, and documentation of a risk-based HAPrI-prevention plan including repositioning at least every 2 hours. The primary outcome measure was development of a second, subsequent HAPrI stage 2 or higher. Potential predictor variables included demographic factors, shock, Charleston comorbidity score, blood gas and laboratory values, surgical factors, vasopressor infusions, levels of sedation or agitation, Braden Scale scores, and nursing skin assessment data. RESULTS: The final sample consisted of 226 patients. Among those, 77 (34%) developed a second HAPrI. Independent risk factors for subsequent HAPrI formation were decreased hemoglobin (odds ratio, 0.71; 95% confidence interval [CI], 0.53-0.92; P < .000), vasopressin infusion (odds ratio, 2.20; 95% CI, 1.17-4.26; P = .02), and longer length of stay in the ICU (odds ratio, 1.01; 95% CI, 1.00-1.02; P = .009). CONCLUSIONS: Patients with an HAPrI are at high risk of subsequent HAPrI development. Anemia, vasopressin infusion, and longer ICU stays are independent risk factors for repeat HAPrI formation.

Backrest elevation in the semi-lateral position: Case of a sacral pressure ulcer with undermining formation.

Backrest elevation for a patient with a sacral-coccygeal pressure ulcer is necessary in certain situations, particularly to enable the patient to take meals. Deep pressure ulcers with undermining formations affect patients and create challenges for caregivers. The procedure of backrest elevation potentially worsens the pre-existing sacral-coccygeal pressure ulcers with undermining formations. Here, we report a Case of the clinical care of a patient using a simple approach for backrest elevation that minimizes additional injury to the existing sacral pressure ulcer covered with granulation tissue. In this case, we performed the backrest elevation in the semi-lateral position. After the backrest elevation, the patient was repositioned to the supine position to take a meal. The supine position was allowed at any time except during backrest elevation. The pressure ulcer of the patient improved rapidly using the combined treatment of our positioning approach and appropriate topical ointments. This practical approach may be effective for some patients as it potentially decreases the effect of shear force. The rationale for this approach can be explained by the mechanism of the undermining formation outlined in our experimental study using a pressure ulcer model mounted to a phantom. Although we used this position for patients with sacral-coccygeal pressure ulcers, this simple approach may also be considered for other patients based on our proposed pathogenesis of undermining formations.

Comparison of interface pressures on three operating table support surfaces during surgery.

AIM OF THE STUDY: To investigate the effect of support surface usage and positions on interface pressure during surgery. MATERIALS AND METHODS: This randomized controlled experimental study was conducted between October 2018 and June 2019. The study included patients who had planned surgery in supine and prone positions. The sample size was 72 patients. Patients were assigned to three groups (gel support surface, viscoelastic support surface and standard operating table) according to the determined randomization table. During the surgery, the pressure in the patients' body was recorded. The statistics program IBM SPSS Statistics 25.0 packaged software was used in the analyses of data. RESULTS: There was no statistically significant difference between the total body average interface pressure (mmHg) values between the supporting surfaces in the prone position. There was a statistically significant difference between the total body average interface pressure (mmHg) values between the support surfaces in the supine position, and the average interface pressure measured on the viscoelastic foam support surface was significantly lower than the gel support surface and the standard operating table. CONCLUSION: In the study, the use of viscoelastic foam support surface was found to be more effective than the use of a standard operating table and gel support surface. Viscoelastic foam support surface is recommended for patients at risk for pressure injury in the operating room.

Characterisation of an ischemia reperfusion model for the formation of a stage I pressure ulcer in mouse skin.

Pairs of magnets were applied to the loose skin on the backs of mice in order to cause ischemia for periods of 1.5, 2, 2.5 and 3 h followed by reperfusion. We found 1.5 h of ischemia resulted in the most reliable outcome of blanched skin but no redness or skin breakdown. Histological analysis at 4 h of reperfusion showed, in the centre of the insult, condensed nuclei in the epidermis and sebaceous glands with a build up of neutrophils in the blood vessels, and a reduction in the number of fibroblasts. At 24 h, spongiosis was seen in the epidermis and pockets of neutrophils began to accumulate under it, as well as being scatted through the dermis. In the centre of the insult there was a loss of sebaceous gland nuclei and fibroblasts. Four days after the insult, spongiosis was reduced in the epidermis at the edge of the insult but enhanced in the centre and in hair follicles. Leukocytes were seen throughout the central dermis. At 8 days, spongiosis and epidermal thickness had reduced and fibroblasts were reappearing. However, blood vessels still had leukocytes lining the lumen. The gap junction protein connexin 43 was significantly elevated in the epidermis at 4 h and 24 h reperfusion. Ischemia of 1.5 h generates a sterile inflammatory reaction causing the loss of some cell types but leaving the epidermis intact reminiscent of a stage I pressure ulcer.

Retrospective Cohort Noninferiority Analysis of Barrier Cream in Preventing Pressure Injuries.

OBJECTIVE: To assess the effectiveness of a dimethicone- and zinc-based barrier cream compared with hyperoxygenated fatty acids in preventing pressure injuries (PIs) in patients at high or very high risk. METHODS: Researchers conducted a retrospective noninferiority study in an inpatient acute care hospital in Spain that included hospitalized patients in nonsurgical departments with impaired mobility. RESULTS: The study authors reviewed 522 patients in a control group (hyperoxygenated fatty acids) and an experimental group (barrier cream) over a period of 7 days. The incidence of PI was 31% in the control group and 31.1% in the experimental group. The hazard ratio for developing PI was 0.84 (confidence interval, 0.61-1.17; P = .32) in the experimental group compared with the control group, meeting the criteria for noninferiority. The Kaplan-Meier estimator indicated no statistically significant difference between groups (log-rank = 0.654). CONCLUSIONS: Dimethicone- and zinc-based barrier cream was not inferior to hyperoxygenated fatty acids in preventing PIs in hospitalized patients at high or very high risk of developing them during their hospital stay.

"Doctor, how long will it take?" Results from an historical cohort on surgical pressure ulcer healing delay and related factors in persons with spinal cord injury.

BACKGROUND: Flap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors. METHODS: This observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Hérault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure. RESULTS: 85 patients were included. Median healing time was 48 days (R: 20-406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02). CONCLUSION: After primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.

Risk Factors of Endotracheal Intubation-Related Pressure Injury among Patients Admitted to the ICU.

OBJECTIVE: To investigate the characteristics and risk factors of endotracheal intubation-related pressure injury (EIRPI) in patients admitted to the ICU and provide a basis for EIRPI prevention and treatment. METHODS: A total of 156 patients with endotracheal intubation who were admitted to ICU at a first-class hospital from January to December 2018 were enrolled in this study. Investigators collected and analyzed data and outcomes such as patient characteristics (demographic and clinical), endotracheal catheter-related factors, and the assessment and features of pressure injuries. RESULTS: The incidence of EIRPI was 23.7%. The most commonly affected site was the lip (76.7%). The incidence was affected by endotracheal intubation types, endotracheal catheter indwelling time, subglottic suction, catheter fixation, and fixator types (P < .05). In addition, the moisture, mobility, and friction/shear Braden subscale scores were also correlated with the incidence of pressure injury (P < .05). Long endotracheal catheter indwelling time, the use of catheters with subglottic suction, high Braden moisture subscale score, low Braden mobility subscale score, and low Braden friction and shear subscale scores were predictive factors for EIRPI (P < .05). CONCLUSIONS: Patients in the ICU are at higher risk of developing EIRPI. Early identification of risk factors and timely intervention are the keys to preventing EIRPI.

Angiosomal Vascular Occlusions, Deep-Tissue Pressure Injuries, and Competing Theories: A Case Report.

ABSTRACT: Compression of the soft tissue between a support surface and a bony prominence has long been the accepted primary mechanism of pressure injury (PrI) formation, with the belief that said compression leads to capillary occlusion, ischemia, and tissue necrosis. This explanation presupposes an "outside-in" pathophysiologic process of tissue damage originating at the local capillary level. Despite advances in prevention protocols, there remains a stubbornly consistent incidence of severe PrIs including deep-tissue injuries, the latter usually evolving into stage 4 PrIs with exposed bone or tendon. This article presents just such a perioperative case with the aim of providing further evidence that these more severe PrIs may result from ischemic insults of a named vessel within specific vascular territories (labeled as angiosomes). Pressure is indeed a factor in the formation of severe PrIs, but these authors postulate that the occlusion occurred at the level of a named artery proximal to the lesion. This vascular event was likely attributable to low mean arterial pressure. The authors suggest that the terminology proposed three decades ago to call both deep-tissue injuries and stage 4 PrIs "vascular occlusion pressure injuries" should be the topic of further research and expert consensus.

Dressings for preventing pressure ulcers: how do they work?

Pressure ulcers (PUs) negatively affect quality of life (QoL) and cause problems for patients, such as pain, distress and often specific difficulties with treatments used to manage the wound. Thus, it is important to implement appropriate prevention strategies in order to achieve high-quality care, thereby reducing the burden of PUs on patients, the healthcare system and society as a whole. PU development arises due to the adverse effects of pressure, shear, friction and moisture at the skin/surface interface. Preventive interventions typically include risk assessment, reducing pressure and minimising shear and friction. More recently, certain wound dressings, as a potential additional protective strategy for preventing PUs, have been introduced. This review explores the mechanisms of action of dressings for preventing PUs. Findings from the review indicate that decreasing frictional forces transmitted to the patient's skin is achieved by use of a dressing with an outer surface made from a low friction material. Furthermore, the ability of dressings to absorb and redistribute shear forces through good adhesion to the skin, high loft and lateral movement of the dressing layers is important in reducing shear forces. This is achieved when the dressing reduces pressure transmitted to the patient's tissues by the propriety of high loft/thickness and padding that allows a degree of cushioning of bony prominences. Further, dressings may reduce humidity at the skin/dressing interface, i.e., the dressing is absorbent and/or permits moisture to evaporate quickly. As part of an established PU prevention protocol, dressings may help decrease PU incidence.

Characteristics of Critically Ill Adults With Sacrococcygeal Unavoidable Hospital-Acquired Pressure Injuries: A Retrospective, Matched, Case-Control Study.

PURPOSE: To identify characteristics of critically ill adults with sacrococcygeal, unavoidable hospital-acquired pressure injuries (uHAPIs). DESIGN: Retrospective, matched, case-control design. SUBJECTS/SETTING: Patients admitted to adult intensive care units (ICUs) at an urban academic medical center from January 2014 through July 2016. METHODS: Thirty-four patients without uHAPI were matched to 34 patients with sacrococcygeal uHAPI. Time points of interest included admission to the ICU, the week preceding the definitive assessment date, and hospital discharge status. Variables of interest included length of stay, any diagnosis of sepsis, severity of illness, degree of organ dysfunction/failure, supportive therapies in use (eg, mechanical ventilation), and pressure injury risk (Braden Scale score). RESULTS: All 34 sacrococcygeal pressure injuries were classified as uHAPI using the pressure injury prevention inventory instrument. No statistically significant differences were noted between patients for severity of illness, degree of organ dysfunction/failure, or pressure injury risk at ICU admission. At 1 day prior to the definitive assessment date and at discharge, patients with uHAPI had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores (greater organ dysfunction/failure) and lower mean Braden Scale scores (greater pressure injury risk) than patients without uHAPI. Patients with uHAPI had significantly longer lengths of stay, more supportive therapies in use, were more often diagnosed with sepsis, and were more likely to die during hospitalization. CONCLUSION: Sacrococcygeal uHAPI development was associated with progressive multiorgan dysfunction/failure, greater use of supportive therapies, sepsis diagnosis, and mortality. Additional research investigating the role of multiorgan dysfunction/failure and sepsis on uHAPI development is warranted.