PADDED LAYERS The pressure injury clock
starts ticking as soon as anesthesia kicks in.

Pressure ulcers that manifest during post-op hospitalization or after same-day discharge could have started in the OR. In years past, the OR staff might say the patient wasn't in the OR long enough for an injury to occur. Or they'd deny it happened during surgery, because a skin examination at the end of the case didn't reveal any suspicious-looking red spots. But today, wound nurses who see skin injuries and take the issue back to the OR are increasingly met with caregivers who are receptive to processing and addressing the information.

Yes, the risk of pressure ulcers developing increases the longer anesthetized patients with unprotected soft tissue remain on the OR table. And it typically takes 48 hours for the ulcer to show at the skin's surface, so it's often difficult to link it to what occurred in the OR. A combination of forensics and an understanding of how deep tissue injuries develop have led caregivers to take another look at the factors during surgery that can cause pressure ulcers and have increased awareness that injuries might not be apparent in the typical locations. For example, patients who are in the supine position during surgery can develop pressure ulcers on the buttocks, not necessarily on the sacrum or coccyx, as is often assumed.

Outpatient procedures are shorter in duration and generally performed on healthier patients who are ambulatory soon after surgery, so pressure injuries are less likely. However, the risk still exists, because an increasing number of lengthy, complex procedures are being performed on acute patients in the same-day setting. Although the likelihood of pressure ulcers occurring during outpatient procedures might be lower than during inpatient procedures, the risk of being slapped with a medical malpractice lawsuit might be higher when injuries occur in ambulatory facilities, where patients often have less tolerance for error when undergoing elective surgeries. It's good risk management practice to document the precautions you have in place.

RED FLAGS
Pressure Ulcer Risk Factors

SKIN IN THE GAME Limiting a patient's risk of injury during surgery protects your facility from litigation.

Before surgery

• operations planned for 3 hours or more
• age older than 62 years
• albumin less than 3.5 g/dl
• ASA score 3 or higher
• cardiopulmonary bypass
• operations requiring the prone position
• diabetes
• trauma, orthopedic, vascular, transplant or bariatric procedures
• body mass index below 19 or above 40

During surgery

• increased hypotensive episodes
• low core body temperature
• use of vasopressors

After surgery

• reduced mobility on post-op day 1
• use of vasopressors

SOURCE: Published in the journal Wounds International (osmag.net/rG8KwQ).

Recognize red flags
Caregivers have reexamined high-risk cases and found that pressure ulcers often occur after procedures lasting longer than 3 hours, after cases in which the patient is placed in the prone position and in frail elderly patients with fragile skin who don't have natural layers fat to help pad their bones (see "Pressure Ulcer Risk Factors").

Obesity is a risk factor in unusual ways. Heavier patients might not fit adequately on the surface of the OR table. That puts additional strain on the strap that holds them in place, which increases the risk of strap-related skin injuries. In addition, surgeons might ask to have the table's surface tilted to the side in order to increase access to a surgical site in the abdomen. That shifts a significant amount of body weight onto pelvic bones, which can cause ulcerations in areas you might not expect.

Perform a complete skin assessment on every patient, even those who aren't considered high-risk or who are undergoing relatively brief procedures. There's been some pushback against that from OR staff members, who wonder why they should examine the entire body if the operation is only occurring on the sinuses or eyes. All anesthetized patients are in fact at risk — including the small, elderly woman who's scheduled for cataract surgery. Her spine is likely quite prominent and needs to be padded, even for a relatively short procedure.

Protect problem areas
Place foam or gel dressings over areas of concern. Heels are common problem areas when patients are placed in the supine position and need to be positioned off the table's surface. During cases when the head is elevated — such as breast surgeries — skin break down can occur on the sacrum. During GYN cases, break down can occur on the lower part of the buttocks.

The pre-op nurse is best suited to pad potential problem areas, as the patient is still conscious and able to move and shift to make padding easier. She should communicate areas of specific concerns to the surgical team once the patient is moved into the OR.

When positioning patients in the OR, avoid using sand bags, rolled towels or water bottles, which actually put tremendous pressure on the areas you're trying to protect. If you use egg crates to pad boney prominences, double the layers, as the valley of a single egg crate doesn't add much protection.

Be aware of where Mayo stands and equipment cords are placed around the patient, and never lean on the drapes during surgery. Even the slightest additional pressure on the patient can increase the likelihood of a skin injury. Monitor the patient throughout the procedure, especially when the table is raised or tilted, to ensure skin surfaces remain clear of additional forces.

Gel pads specifically designed to relieve pressure on bony prominences work very well, especially if they're moldable to a patient's specific body shape. They're reusable, which is nice, but can also wear out, so be sure to check that the gel hasn't separated. The devices must be thick all the way through to offer the full protection they promise. Also be sure to follow the manufacturers' instructions when applying specific positioning aids to ensure they protect as indicated.

The age and condition of the OR mattress is a general risk factor that you can immediately assess and address. Research has shown that standard 2-inch thick foam pads covered with laminated vinyl may increase the risk of pressure ulcers developing during surgery. Pads that are 2 inches thick or less also don't offer adequate support for the heavier patient population. Consider replacing standard table pads with thicker coverings comprised of multiple layers of dense foam that's designed to disperse load pressure across the surface area. Be aware that additional layers of warming devices, pads, blankets and sheets can interfere with the surface's ability to redistribute pressure. OSM