Pressure Ulcer Prevention: Using Preventive Dressings in the Operating Room Whitney Ashley, BSN, RN, CNOR

Pressure Ulcer Prevention: Using Preventive Dressings in the Operating Room Whitney Ashley, BSN, RN, CNOR - Operating Room

Patients are sicker and require more advanced health care and longer admissions which places them at risk for decubitus from decreased mobility. The operating room is one of the many places in a hospital where patients are in the same position for a long period of time, putting them at risk for skin and tissue damage. Surgeries are more complex and require longer time spent in the surgical suite. There are many interventions for positioning of patients during surgeries, such as preventive dressings for pressure points when lying supine or laterally.

This evidenced-based literature review explores the efficacy of silicone dressings to prevent the development of pressure ulcers during surgery. The use of these dressings could reduce the risk of compromised skin integrity that could lead to infection, increased length of stay or readmission, and risk for multiple surgical debridements.

Review of Literature

Standard Practice

Pressure ulcer prevention is a Joint Commission National Patient Safety Goal 1 . Most hospitals have a standard pressure ulcer prevention protocol, or policy, in place. Within the literature, the phrase “SKIN Bundle” is used in combination with preventive dressings. This phrase refers to surface, keep moving, incontinence, and nutrition 2

. Current pressure ulcer prevention measures include frequent turning or repositioning, managing moisture and incontinence, selection of an appropriate mattress, managing a proper nutritious diet, reducing friction or shear injuries, and providing education on prevention 3

. Even with these standards, pressure ulcers still develop in all areas of the hospital.

Perioperative nurses should always perform a thorough skin assessment. Intraoperatively, the focus is on positioning prior to the upcoming surgery. The nurse should always have appropriate support surfaces available to help with pressure redistribution. The intraoperative nurse should be aware of how long the surgery will be, and that a pressure ulcer could develop from extended surgical time up to 72 hours after surgery 4

. Other risk factors that should be known are the type of surgery, anticipated blood loss, chance of hypothermia, and types of anesthetic agents used during the surgery 5 .

Standard operating room tables come with a tempur-pedic type mattress, and there are also pillows made of the same material that can be used to pad the knees and legs during prone positions. Other interventions include the use of approved headrest devices made of foam, gel pads, and the PinkPad ®

positioning system that is made of a material to contour to the patient and help prevent slipping when placed in steep Trendelenburg positions which could cause shear and friction injuries 6 .

Several studies examined use of silicone border dressings to prevent pressure ulcers, in combination with standard pressure ulcer measures. In one trial, the silicone dressing was used in conjunction with either off-loading the heels or not of the subject. There was a significant difference (p=0.001) in pressure ulcer development due to elevation of the subjects’ heels; while the dressing itself did not reduce the incidence of pressure injuries, it did reduce the risk of injuries by reducing shearing forces 5

. Santamaria, et al. examined the use of a five-layer foam dressing on ED and ICU patients 7

. These patients were all placed on a low air loss mattress and given routine pressure ulcer prevention. The results showed a 10 percent lower occurrence rate for the intervention group who wore the silicone dressing 7

. Park suggest that the five-layer silicone dressing may prevent formation of stage one ulcers 8 .

Cost savings for hospitals and patients with the 5-layer silicone dressing have been demonstrated. Padula suggested that given the estimated cost it takes to care for someone who already has a stage three or four ulcer, using the dressing could save $200,000 to $600,000 per year 3

. Kalowes conducted a randomized trial of 366 patients with both groups receiving the standard SKIN bundle, but the intervention group added the 5-layer silicone dressing 2

. The effectiveness of the dressing resulted in significant cost savings.

In the operating room, a silicone preventive dressing is recommended in combination with approved positioning surfaces and devices already in use to help protect the skin from breakdown and decrease friction or shear injuries when moving the patient. The dressing may also improve the microclimate of the skin 5

. Common areas to apply the dressings for a patient in the supine position for a surgery lasting more than three hours are the sacrum and heels 4 .

Other Preventative Dressings and Measures

Hydrocellular foam dressings, hydrocolloid dressings that contain a ceramide-2, fatty acids oil, and polyurethane film dressings were studied. In a three-group trial, Aloweni et al. administered the standard of care to each group, which consisted of repositioning of patients every three hours, use of positioning devices, the use of an alternating air mattress, use of slide sheets, frequent elimination rounds, and standard skin care which involves application of a barrier cream 9

. The other two intervention groups added a fatty acid oil spray and a foam silicone dressing to the standard of care protocol. Aloweni et al. demonstrated that the foam dressing outperformed (p=0.04) the oil spray, and the standard of care group 9

. Another trial examined a Smith & Nephew hydrocellular dressing for patients who were in surgery for more than four hours, experienced cardiac arrest, experienced shock or sepsis, or were on vasopressors for more than 48 hours. Pressure ulcers for the three study units ranged from 6.98 to 13.00 per 1000 patient days pre-intervention and decreased to 3.4 to 7.6 per 1,000 days with the hydrocellular dressing 1 . Another trial compared 64 subjects receiving polyurethane film (control) to 66 subjects receiving a ceramide-2 containing hydrocolloid dressing (intervention). Five subjects in the intervention group developed pressure injuries (7.6 %) compared to 13 subjects in the control group (20.3%) 10

. Two out of these three trials were conducted outside of the United States, and these dressings may not be approved for use in the United States of America.

Most trials in the literature review used traditional pressure ulcer prevention measures or a SKIN Bundle as a control. For the operating room, traditional measures include mattresses that are designed for pressure redistribution, foam paddings, gel pads, and pillows 4

. Perioperative nurses should be mindful of length of surgery, friction and shearing when moving patients, proper use of positioning devices, types of anesthetics used, type of surgery, patient body temperature, and vasopressors 4 .

The ten articles included in this review demonstrated a need for more studies involving the use of preventive dressings. The most commonly used dressing in the United States is a soft silicone border dressing for the sacrum and the heels. The reviewed studies showed decreased ulcers in high-risk patients and decreased ulcer formation when used over bony prominences with surgical patients. These studies supported the use of dressings in conjunction with other standard of care pressure ulcer prevention strategies. Hydrocellular dressings are promising alternatives to a polyurethane film or fatty acid oil spray.

Based on this review, research at Carilion is warranted to trial preventive dressings in the operating room to reduce pressure ulcers in high risk patients, with specific focus on silicone border dressing in conjunction with traditional pressure ulcer prevention standards. An important component of this work will be the evaluation of financial impact to the organization and to patients.

References

1. Byrne, J. (2016) Prophylactic Sacral Dressing For Pressure Ulcer Prevention In High-Risk Patients. American Journal of Critical Care, 25(3), 228-234. doi:10.4037/ajcc2016979 2. Kalowes, P. (2016). Five-Layered Soft Silicone Foam Dressing To Prevent Pressure Ulcers In the Intensive Care Unit. American Journal Of Critical Care, 25(6), E108-E119. doi:10.4037/ ajcc2016875 3. Padula, W.V. (2017). Effectiveness and Value of Prophylactic 5-Layer Foam Sacral Dressings to Prevent Hospital-Acquired Pressure Injuries in Acute Care Hospitals: An Observational Cohort Study. Journal of Wound, Ostomy & Continence Nursing, 44(5), 413-419. doi:10.1097/ WON.0000000000000358 4. Spruce, L. (2017). Back to Basics: Preventing Perioperative Pressure Injuries. AORN Journal,105(1), 92-99. doi:10.1016/j.aorn.2016.10.018 5. Al-Majid, S., Vuncanon, B., Carlson, N. and Rakovski, C. (2017), The Effect of Offloading Heels on Sacral Pressure. AORN Journal, 106, 194-200. doi:10.1016/j.aorn.2017.07.002 6. Steck-Bayat, K.P., Henderson, S., Aguirre, A.G. et al. Prospective randomized controlled trial comparing cephalad migration in robotic gynecologic surgery using egg-crate foam versus the Pink Pad ® . J Robotic Surg (2019). https://doi.org/10.1007/s11701-019-00990-10.1111/ iwj.121017 7. Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., De Vincentis, S., Ng, A. W., Manias, E., Liu, W. and Knott, J. (2015), 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. Int Wound J, 12, 302-308. 8. Park Hee, K. (2014) The Effect of a Silicone Border Foam Dressing for Prevention of Pressure Ulcers and Incontinence-Associated Dermatitis in Intensive Care Unit Patients. Journal of Wound, Ostomy & Continence Nursing, 41(5), 424-429. doi:10.1097/

WON.0000000000000046 9. Aloweni F., Lim, M.L., Chua, T.L., Tan, S.B., Lian, S.B., & Ang, S.Y. (2017). A randomized controlled trial to evaluate the incremental effectiveness of a prophylactic dressing and fatty acids oil in the prevention of pressure injuries. Wound Practice & Research, 25(1), 24-34. 10.Kohta, M., Sakamoto, K., Kawachi, Y., & Oh-i, T. (2015). A single-center, prospective, randomized, open- label, clinical trial of ceramide 2-containing hydrocolloid dressings versus polyurethane film dressings for pressure ulcer prevention in high-risk surgical patients. Chronic Wound Care Management and Research, 2015, (1), 171-179.