Pressure Ulcers: Surgery's Sore Subject

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Your OR team can prevent pressure injuries by following these 5 guidelines


The elderly woman left your facility with a tiny incision in her back and a gaping wound on her chin — one the expected scar of spine surgery, the other the unwelcomed scab of a pressure ulcer. Your OR team could have avoided this gruesome outcome had they followed the 5 guidelines in “The Standardized Pressure Injury Prevention Protocol” (osmag.net/upWE4W) I co-authored:

1. Pad the patient. The No. 1 way to prevent pressure injuries is to apply foam dressings or gel cushions and pads to where patients come into contact with the bed, especially to areas of risk such as the sacrum and the heels.

Next, take a look at the mattresses on your OR tables. Gel pads that are ½ to ¾ of an inch thick work well. There are also thinner pads, about 3⁄8 of an inch, that have parallel columns of air that inflate and deflate during the case to change the pressures against the patient’s skin. Inflatable waffle mattresses have little pockets of air with venting holes in between that let air flow and moisture vent to keep patients dry. Patients having surgery while in a prone, face-down position need dressings applied to their face, chest and chin. The front of the body doesn’t have a lot of padding and ulcerates very rapidly.

2. Assess your patients. The ASA score, which anesthesia providers use to assess a patient’s fitness before surgery, is the best measure of a patient’s risk of pressure injuries. The higher the ASA score, the less tolerant tissue will be to pressure. It’s easy to see someone in their 70s getting a knee replacement who looks reasonably healthy and assume she’s not likely to get a pressure ulcer when in fact she could be a high-risk candidate. It doesn’t take much time or friction to trigger some kind of pressure wound. It’s also important to know how long the patient’s surgery is going to be. Once you get to 3 hours of surgery, the risk of pressure injuries goes up 40% every 30 minutes.

3. Skip the Braden Scale. The Braden Scale doesn’t help predict the risk of surgery-related pressure injury or ulcer. The measurement was designed for hospital settings, and patients in outpatient facilities are awake, alert and ambulating after surgery. They don’t have the risk factors of a hospitalized patient who is heavily sedated and can’t move in bed. If you’d like your nurses to have a paper-and-pencil fixed risk assessment measurement, I would have them do it with the Scott Triggers Tool (osmag.net/Qou5QQ) instead.

NEEDS HEALING Procedures that immobilize the leg as well as post-op exercises can cause friction blisters and other injuries to the heels.   |  University of Nebraska Medical Center

4. Assess the skin at admission. If a patient presents with a pressure ulcer already on his heel or her backside, for example, that body area would need additional padding to make sure as little pressure as possible is put on to that body part during the operation. When possible, the heels of a patient should be lifted off the operating table. The simplest way to do that is to use egg crate foam. It comes in a big brick. People tend to break it in half, but you’re better off leaving it as one piece and using it as a cushion under the calf of the patient so that their heels float off the end of it.

Post-surgical heel injuries are very common because if you’re operating on the leg, it’s not moving, so the heel is just dug right into the table. If the patient is draped across the legs, you don’t see the heels. You could dress the heel, especially for patients with significant arthritis or who are having knee surgery, but in most cases foam achieves the same result — getting the heels off the bed — and is a whole lot cheaper.

Repositioning patients is straightforward: Make sure they get off the position they were laying in while in the operating room. If they were on their face all day, they simply lie on their back afterward. If they were on their back all day, however, tell patients they need to give their back a rest and that you need to get them on their side. That usually convinces them to turn, even though it might hurt because we’re moving a body part that just had a surgery.

5. Watch for PACU injuries. I’ve seen a lot of heel injuries take place in post-op knee surgery patients when a physical therapist or another professional tells the patient to bend her knee up, push her heel into the bed and then slide her leg down into the bed. This makes the heel literally run up and down the mattress and leads to blistering. This is a standard exercise and a common occurrence in post-op outpatient settings, so your nurses need to make sure the patients have a dressing on that heel or a sock on their foot to prevent a big friction blister.

Keep your guard up

Because there’s a lag from the time the pressure is applied until the time the skin breaks down, nobody thinks about that the pressure injury is from the surgery. It’s often hard to link the injury in your mind to something that happens hours before seeing it. Don’t fall into the trap of thinking that your surgeries aren’t long enough to use these kinds of safeguards. In the right set of circumstances, a pressure injury can happen in a couple of hours, and you can go a long way toward preventing them. OSM

TECHNOLOGY TO THE FORE
High-Tech Pressure Ulcer Detection
UNDER THE SKIN Hand-held devices can detect pressure injuries by identifying blood flow, perfusion and metabolic activity that aren't visible to the naked eye.   |  University of Nebraska Medical Center

Your nurses no longer have to rely on their subjective clinical judgments to assess a patient’s risk of pressure injury thanks to a few emerging detection technologies:

  • Subdermal detection systems. Subepidermal moisture (SEM) scanners and heat thermography scanners (pictured) can detect pre-visual pressure injuries by measuring moisture content and high temperatures under the skin. The SEM scanners are about the size of a smartphone, while the heat topographers resemble a mini-megaphone or police radar gun.

There’s also a financial benefit to detecting pressure wounds that existed before patients arrive for surgery: You can prove to insurers that the wounds were present on admission and avoid reimbursement penalties.

  • Rotating tables. Continuous lateral rotation tables use compartmentalized hydraulics to move different body parts at different times so patients aren’t in the same position for very long. “Patients can start developing early symptoms of a deep tissue injury during a surgery like a hip replacement that takes a few hours,” says William V. Padula, PhD, MS, assistant professor of pharmaceutical and health economics in the School of Pharmacy at the University of Southern California. “Pressure ulcers can start forming earlier than that in patients who are under a lot of stress and malnourished.”

Dr. Padula, a health economist, cost-justifies the $50,000 beds by noting that the average pressure injury can cost around $100,000 to treat and around $250,000 to litigate.

  • Pressure maps. A pressure grid placed under a patient’s body is hooked up to a monitor, so a nurse can explore areas that the patient has been laying on for a long period of time. The sensors in the grid document how the patient is positioned during their recovery. If patients have been stationary for a couple of hours, the map will let the nurse know so she can reposition them.

— Adam Taylor

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