This article appeared in the April issue of  Surgical Products.

An estimated 1.3 to 3 million adults develop a pressure ulcer each year.  Pressure ulcers are a frequent and costly problem in hospitals around the world.  They can range in severity from stage I to stage IV, with IV being the most severe. Treatment of a stage III or IV pressure ulcer is estimated to cost $70,000, and each year 60,000 people in the U.S. die from complications related to hospital-acquired pressure ulcers.

Pressure ulcers are caused by compression of soft tissue between a bony prominence and an external surface (e.g., bed or chair). When pressure from the external surface exceeds the blood pressure in the capillaries, blood flow is obstructed and the tissue breaks down.  When pressure ulcers go untreated, they can develop into deep wounds, which can lead to serious and life threatening infections.
Previous research has focused predominantly on pressure ulcers in intensive care, long-term care and rehabilitation settings, but there has been little focus on this problem in the surgical environment.

Tissue breakdown caused by a pressure ulcer can become visible within several hours after surgery or may not appear for up to three days later. As a result, a pressure ulcer developed during surgery may not be noticed until the patient’s recovery period. Prevention of pressure ulcers is widely considered to be less costly than pressure ulcer treatment, making it important for clinicians to understand and address risk factors associated with the unwanted development of pressure ulcers in surgical settings.
Immobility As A Risk Factor
Immobility is a major risk factor for pressure ulcer formation in the OR. During surgery, patients are often immobile for long periods of time.  When static pressure is applied to both the skin and underlying tissue, blood flow can be impeded, causing tissue to break down.  Outside the OR, healthcare providers typically turn immobile patients every few hours to reduce the risk of pressure ulcers.  However, during surgery this is often not possible without compromising the patient.
Following surgery, many patients need to remain in bed for a period of time to recover.  During this time, healthcare providers often change the angle of the bed or reposition patients manually. Such movements can result in pulling and stretching of underlying tissue and blood vessels. The pressure created from these movements is known as “shear force.”  When bed-ridden patients are moved, friction can cause the loss of epidermis and outer layers of the stratum corneum, increasing the risk of developing abrasion-type wounds that produce considerable amounts of exudate. The contents of exudate can contribute to the adhesion of skin to a surface and can further increase shear forces. Areas that are subject to friction are more likely to develop wounds.  Typical areas at risk of friction forces include the heels, buttocks, sacrum, elbows and trochanters.

Anesthesia As A Risk Factor
Many patients are placed under anesthesia during surgery, which can also increase the risk of developing a pressure ulcer.  Under anesthesia patients may remain stationary for extended periods with limited sensitivity to pain and pressure. The agents used in anesthesia also depress the autonomic nervous system, which can cause some degree of vasodilatation that is reflected in a lowering of blood pressure that causes a decrease in tissue perfusion.

Age As A Risk Factor
As we age our skin becomes thinner and more fragile. Skin changes in the elderly population can include the flattening of the epidermal-dermal junction, which can decrease the overall strength of the skin and increase the risk of skin tears and blistering; decreased blood flow, which can decrease skin temperature; and a decline in the reproduction of the outermost layer of the epidermis, making it difficult for the skin to absorb topical medications used to protect the skin. These changes can increase the risk of skin and wound problems, making pressure ulcer formation during surgery more likely.

Approaches To Pressure Ulcer Prevention
The use of protective emollients can help protect the skin and reduce the risk of pressure ulcers forming. These products are primarily used as a barrier to excess moisture or urinary/fecal incontinence and to keep the skin hydrated. Dry skin is often a significant independent risk factor for pressure ulcer development.
In addition to emollients, dressings are now often used as part of a protocol of care for the prevention of pressure ulcers. Clinicians can make dressing choices based on several factors. These include patient comfort, barrier properties, adhesiveness, and the ability to absorb exudate and debride sloughy/necrotic tissue.  Modern dressing technologies such as hydrofiber and foam are widely used among clinicians for the treatment of pressure ulcers. These technologies often have low-friction and waterproof barriers, which allow them to be worn for several days. This significantly reduces the need for clinicians to re-apply emollients, which can rub off on bed linen or clothing.

Hydrofiber Dressings
With the ability to be worn up to seven days, hydrofiber dressings are composed of sodium carboxymethylcellulose. What’s interesting about these dressings is that they can both absorb and contain wound fluid. This is an important feature because any exudate and bacteria it contains can be removed from the wound bed and periwound area, which can aid in the prevention of infections and maceration. The exudate is then converted into a soft gel, which creates a moist environment to support the healing process. The gel can also help remove non-viable tissue from the wound, without damaging new tissue that forms. The ability to absorb and contain fluid is also important in minimizing the release of bacteria into the air once the dressing is removed.

Foam Dressings
One of the most flexible options is foam dressings, which can be cut to fit irregular wounds. These dressings are typically made from hydrophilic polyurethane foam and are also very absorbent. Like hydrofiber dressings, they can absorb exudate and protect the surrounding periwound area from maceration.  They can also be left on patients for three or four days. Foam dressings can also sometimes be used as a secondary dressing. The most recent introduction of a wound dressing is a hybrid, combining the absorption benefits of hydrofiber dressings with the comfort and protection of foam.

Looking Forward
In an environment where healthcare costs are expected to continue to climb, the focus on strategies to address preventable health problems will continue to intensify.  With products including from protective emollients, specially engineered dressings, pressure-relieving mattresses and pressure-off-loading devices, and strategies that incorporate manual repositioning of patients and other preventative measures, we can reduce the risk of pressure ulcers. The key to success will be expanded education for HCPs to help them learn about and apply the optimal range of options to reduce the risk of pressure ulcers.