DO NOT DUPLICATE. Pressure ulcers are a common problem for patients, causing significant

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1 Original research WOUNDS 2012;24(9): From 1 Nursing School of Nantong University, Nantong Ci, Jiangsu Province, China; 2 Affiliated Hospital of Nantong University, Nantong Ci, Jiangsu Province, China Address correspondence to: Juan Wu Affiliated Hospital of Nantong University Department of Intensive Care Unit Xi Si Road 20# Nantong CI, Jiangsu Province China pphss@126.com 234 WOUNDS The Incidence of Pressure Ulcers in Surgical Patients of the Last 5 Years: A Systematic Review Hong-Lin Chen; 1 Xiao-Yan Chen; 2 Juan Wu 2 Abstract: This systematic review looks at the incidence of pressure ulcers in surgical patients of the last 5 years. Methods. The authors searched Pubmed and Web of Science for studies published after Screening and data abstraction were performed independently by 2 reviewers. Results. Seventeen studies (5,451 patients) met the inclusion criteria. The incidence of surgery-related pressure ulcers ranged from to The pooled incidence was 0.15 (95% CI , I 2 = 98.2%). For cardiac surgery, hip fracture surgery, and patients on the surgical intensive care unit, the pooled incidence was 0.18 (95% CI , I 2 = 62.8%), 0.22 (95% CI , I 2 = 98.4%), and 0.11 (95% CI , I 2 = 98.5%), respectively. Conclusion. The data on the incidence of surgery-related pressure ulcers indicates that appropriate monitoring and treatment need to be performed. Pressure ulcers are a common problem for patients, causing significant pain and additional costs. Many studies have investigated the incidence and the prevalence of pressure ulcers. The incidence of pressure ulcers is 0.4% to 38%; within long-term care, 2.2% to 23.9%; and in home care, 0% to 17%. 1-2 Patients undergoing an operation are prone to develop pressure ulcers during the procedure. 3 It has been accepted that pressure ulcers are caused by 3 different tissue forces: pressure, shear force, and friction, all of which have an important role in the occurrence of surgery-related pressure ulcers. Contributing factors to the incidence of surgery-related pressure ulcers include the fact that during surgery, patients are immobile, and not able to feel pain caused by prolonged pressure on the operating table; the use of anesthetic agents can cause a loss of muscle tone that increases pressure over bony prominences; and prolonged pressure causes decreased perfusion, leading to ischemia and tissue necrosis. In addition, shearing and friction injury can occur as patients are repositioned on tables then transported. Shear force can cause the pinching off of blood vessels, which may aggravate ischemia and tissue necrosis, and friction may cause excess shedding of layers of epidermis. Some cardiac surgery patients have to use intra-aortic balloon pumps postoperatively; movement is not allowed when these are in use. This

2 combination of factors may cause surgery-related pressure ulcers, which exhibit some different epidemiological characteristics compared with general pressure ulcers. In 1999, a national survey on 104 usable facilities with a total of 1,128 surgical patients showed the overall incidence based on a beta binomial was 8.5% (95% confidence interval: 6.1% to 10.9%). 4 But after that, there wasn t a large-scale survey to show the incidence of surgery-related pressure ulcers. Over the past decade, pressure ulcer prevention and treatment strategies have changed as many new methods are emerging. The objective of this systematic review was to describe the incidence of surgery-related pressure ulcers reported in prospective longitudinal studies of the last 5 years. Keypoints Over the past decade, pressure ulcer prevention and treatment strategies have changed as many new methods are emerging. The objective of this systematic review was to describe the incidence of surgery-related pressure ulcers reported in prospective longitudinal studies of the last 5 years. Methods Data sources and search strategy. The authors searched Pubmed and Web of Science databases. A search strategy of ( pressure ulcer [MeSH Terms] AND surgical procedures, operative [MeSH Terms] AND ( incidence [TW] OR prevalence [TW]) AND humans [MeSH Terms]) was used in Pubmed advanced search. A search strategy of (TS = (Pressure SAME Ulcer*) or TS = (Pressure SAME Sore*) or TS = (Bed SAME Sore*) or TS = (Decubitus SAME Ulcer*) AND TS = (Surg* or Operat*) AND TS = (incidence or prevalence) was used in Web of Science advanced search. The time span was set from 2005 to 2011 in the 2 databases. The searches were performed on August 3, Study selection criteria. To identify relevant studies, a list of inclusion and exclusion criteria was generated. The authors included studies: (1) that investigated the incidence of surgery-related pressure ulcers of all stages, not including suspected deep tissue injury, in the last 5 years; (2) were conducted for purposes other than determining the prevalence and incidence of surgery-related pressure ulcers, but from which the authors could extract the data of the surgery-related pressure ulcers incidence; (3) were cross-sectional, cohort, case control studies, and randomized clinical trials. The authors excluded studies that: (1) only investigated the prevalence of surgery-related pressure ulcers, but did not include incidence data; (2) investigated the incidence of pressure ulcers, not only for surgery-related pressure ulcers, such as data from medical and surgery centers, and data from comprehensive ICUs; (3) investigated the incidence of pressure ulcers complicated by a kind of disease which included patients not treated with surgery, such as spinal cord injury or hip fracture; and (4) investigated the incidence of pressure ulcers, not including stage I. Study data extraction. Each abstract of the identified articles in 2 databases were reviewed. From each article meeting the selection criteria, a uniform data extraction tool to collect the following data was used: first author, published year, number of events, sample size, type of surgery, and patient characteristics. When this data could not be extracted from the abstract, a full-text analysis of the study was carried out. Two reviewers independently extracted data. Disagreements were resolved by consensus and discussion with a third reviewer. Statistical analysis. For each of the selected studies, the incidence with 95% confidence intervals (CI) was computed. For the meta-analysis, the overall pooled incidence with 95% CI was estimated by Der Simonian and Laird s random-effects model. 5 The heterogeneity was analyzed by Cochran s Q test and I 2 statistic. A P < 0.05 by Cochran s Q test indicated significant heterogeneity; an I 2 > 50% indicated substantial heterogeneity. Analyses were all performed using Meta DiSc 1.4 (version 0.6). 6 Results Eligible studies. The authors initially retrieved 84 potentially relevant articles from Pubmed, and 222 articles from Web of Science. A total of 67 repeated articles were excluded. Of these 239 articles, 191 were inappropriate and excluded. An additional 31 articles did not meet the eligibility criteria and were excluded. Thus, 17 articles 7-23 with 5,451 patients were included for analysis (Figure 1). Table 1 summarizes the major characteristics of the included studies. Study sample sizes ranged from 60 to 896. Included studies represented a great diversity across many countries: 5 studies from the United 9,14,17-19, 3 studies from the Netherlands 12,16,22, 2 studies from Brazil 7,11, and the remaining 7 studies were from the Czech Republic 8, Canada 10, Korea 13, United Kingdom 20, Turkey 21, Sweden 23, or Pan-European countries. 15 Patients included are divided into 4 categories: patients who underwent cardiac surgery; patients who underwent surgery for hip fracture; patients on the surgical ICU; and those Vol. 24, No. 9 September

3 Figure 1. Flow diagram showing selection of studies. who underwent other procedures, including orthopedic, neuro-, cardiothoracic, general, vascular, ob-gyn, or shoulder surgeries). Pooled incidence of surgery-related pressure ulcers. The incidence of surgery-related pressure ulcers of the included studies ranged from to The pooled incidence of surgery-related pressure ulcers of the 17 included studies was 0.15 (95% CI , 2 I = 98.2%). (Figure 2A) Keypoints The authors initially retrieved 84 potentially relevant articles from Pubmed, and 222 articles from Web of Science. A total of 67 repeated articles were excluded. Of these 239 articles, 191 were inappropriate and excluded. An additional 31 articles did not meet the eligibility criteria and were excluded. Thus, 17 articles 7-23 with 5,451 patients were included for analysis (Figure 1). The incidence of surgery-related pressure ulcers of the included studies ranged from to The pooled incidence of surgery-related pressure ulcers of the 17 included studies was 0.15 (95% CI , Ι 2 = 98.2%) (Figure 2A). 236 WOUNDS Two studies 7,22 assessed the pressure ulcer incidence for cardiac surgery. The incidence of the 2 studies was 0.21 (95% CI ) and 0.14 (95% CI ), respectively. The pooled incidence was 0.18 (95% CI , I 2 = 62.8%). (Figure 2B) Three studies 8,15-16 assessed the pressure ulcer incidence for hip fracture surgery. The incidence of the 3 studies was 0.34 (95% CI ), 0.08 (95% CI ), and 0.30 (95% CI ), respectively. The pooled incidence was 0.22 (95% CI , I 2 = 98.4%). (Figure 2C) Three studies 9,13,17 assessed the pressure ulcer incidence for the surgical ICU. The incidence of the 3 studies was 0.24 (95% CI ), 0.18 (95% CI ), and 0.03 (95% CI ), respectively. The pooled incidence was 0.11 (95% CI , I 2 = 98.5%). (Figure 2D) The other 8 studies 10-12,14,18,20-21,23 assessed the pressure ulcer incidence for orthopedic, neuro-, cardiothoracic, general, vascular, or ob-gyn surgeries. The surgery-related pressure ulcers incidence ranged from to One study 19 assessed 896 patients having ar-

4 Table 1. Characteristics of the included studies. First Author Carneiro, GA Published Year Country Number of Events Sample Size Incidence Type of Patient Gender 2011 Brazil % Cardiac surgery Not mentioned Not mentioned Kopp, L 2011 Czech Republic Slowikowski, GC Campbell, KE 2010 United % Surgery for hip fracture 50 male (13.6%) and 219 female (81.4%) % Surgical ICU 208 male (56.4%) and 161 female (43.6%) 2010 Canada % Orthopedic surgery Diccini,S 2009 Brazil % Neurosurgical surgery % Cardiothoracic surgery 29 male (40.0%) and 43 women (60%) 26 male (43.4%) and 34 female (56.6%) 129 male (63.2%) and 75 female (36.8%) Kim, EK 2009 Korea % Surgical ICU 145 male (66.2%) and 74 female (33.8%) Grisell, M 2008 United Lindholm, C 2008 Schuurman, 2009 Netherlands JP Pan- European Rademakers, 2007 Netherlands LMF Frankel, H 2007 United % Thoracic and/or lumbar surgery % Surgery for hip fracture % Surgery for hip fracture Age 81 (70-99) 58.3 ± ± (19-78) 68.1 ± ± 1.2 (16-98) Not mentioned male (25.0%) and 476 female (75.0%) 171 male (23.7%) and 551 female (76.3%) 80 (37-99) 82.2 ( ) Aronovitch, SA 2007 United % Surgical ICU Not mentioned Not mentioned % Cardiac, general, orthopedic, and vascular surgeries Not mentioned Not mentioned Vol. 24, No. 9 September

5 Table 1. Characteristics of the included studies. First Author Keyurapan, E Published Year Country 2007 United Nixon, J 2007 United Kingdom Number of Events throscopic or combined arthroscopic and open shoulder procedures. Each patient had an axillary roll during surgery. Three pressure ulcers occurred. The incidence was (95% CI ). 238 WOUNDS Sample Size Incidence Discussion Some available evidence showed that, due to more effective strategies and better prevention, the pressure ulcer prevalence and incidence in long-term care facilities and other health care facilities decreased in the last 10 years. 24,25 Surgery-related pressure ulcers are the most common hospital-acquired ulcers. The principle finding from this systematic review is that the pooled incidence of the included studies was 0.15 (95% CI ). The data from a national survey 4 of surgery-related pressure ulcers in 1999 indicated that among the 1,128 included patients, of the 544 (48%) patients that had no comorbidities, 7% developed ulcers; of the 584 (52%) with at least one comorbidity, 9.1% developed ulcers; and the overall incidence was 8.5% (95% CI 60.1% %). Compared with this survey 10 years ago, the current study s results show the incidence of surgeryrelated pressure ulcers has not decreased, but increased. Studies confirmed that an age > 60 years, complications with diabetes or renal insufficiency, low American Society of Anesthesiologists (ASA) or New York Heart Association (NYHA) Functional Classification scores, and length of surgery, were the independent risk factors for surgery-related pressure ulcers. 17,23,26 Due to the development of surgical techniques, the number of elderly surgical patients, surgical patients with complex complications, and patients needing surgery of a longer Keypoints Type of Patient Gender % Shoulder surgery Not mentioned Not mentioned % General, vascular, and orthopaedic Karadag,M 2006 Turkey % Ob-Gyn, neurosurgery, general surgery; thoracic/ cardiovascular surgery; orthopedic 32 male (39.2%) and 52 female (61.9%) Feuchtinger, J 2006 Netherlands % Cardiac surgery 125 male (71.4%) and 50 female (28.6%) Lindgren, M 2005 Sweden % Orthopaedic 157 male (121), abdominal (54.9%) and (80), or cardiovascular surgery 129 female (45.1%) (60), and the remainder (25) Age Not mentioned > 55 years 48 ± 13.3 (20-74) ± 13.1 Compared with a survey 10 years ago, the current study s results show the incidence of surgery-related pressure ulcers has not decreased, but increased. Studies confirmed that an age > 60 years, complications with diabetes or renal insufficiency, low American Society of Anesthesiologists (ASA) or New York Heart Association (NYHA) Functional Classification scores, and length of surgery, were the independent risk factors for surgery-related pressure ulcers. 17,23,26

6 Figure 2. Incidence of surgery-related pressure ulcers. Squares indicate the incidence of individual study. Diamonds indicate the pooled incidence of included studies. An I 2 > 50% indicated heterogeneity. A: Pooled incidence was 0.15 (95% CI ) in the 17 included studies; B: Pooled incidence was 0.18 (95% CI ) in the 2 cardiac surgery studies; C: Pooled incidence was 0.22 (95% CI ) in the 3 hip fracture surgery studies; D: Pooled incidence was 0.11 (95% CI ) in the 3 surgical ICU studies. duration, increased. The result may be the increased incidence of surgery-related pressure ulcers of the last 5 years. The results show appropriate monitoring and treatment for surgery-related pressure ulcers needs to be performed in order to lower surgery-related pressure ulcer incidence. The national survey 4 in 1999 also showed the most common surgical procedures related to pressure ulcers were cardiac (29.3%), general/thoracic (27.7%), orthopedic (20.6%), and vascular (9.8%). The author s systematic review included patients who underwent cardiac surgery; patients who underwent surgery for hip fracture; patients on the surgical ICU; and those who underwent orthopedic, neuro-, cardiothoracic, general, vascular, ob-gyn, or shoulder surgery. This systematic review showed the pooled incidence for cardiac surgery-related pressure ulcers was 0.18 (95% CI , I 2 = 62.8%). A literature review indicated that except for pressure, shear force, and friction, additional risk factors for pressure ulcers included the tissue tolerance for oxygen as temperature manipulation; vasoactive drugs; hypotensive periods; reduced hemoglobin and hematocrit levels; time on the operating room table; frequency of repositioning; immobility time; age; low albumin level; and corticosteroid use. 27 Prevention measures for cardiac surgery-related pressure ulcers should be aimed at supporting tissue tolerance for pressure and oxygen, and relieving devices on the operating room table or postoperatively in bed. 27 In this systematic review, the pooled incidence for hip fracture surgery-related pressure ulcers was 0.22 (95% CI , I 2 =98.4%). Hip surgery complicated with pressure ulcers resulted in delayed patient mobilization. Some intrinsic patient characteristics (eg, nutritional status and continence status) and the extrinsic exposures (eg, longer interval between admission and surgery, longer duration of surgical anesthesia, comprehensive measures of comorbidity, and disease severity) are the risk factors for hip fracture surgeryrelated pressure ulcers. 28 Hip fracture surgical patients are still associated with a high risk of pressure ulcers. For preventing and treating hip fracture surgery-relat- Vol. 24, No. 9 September

7 ed pressure ulcers, Lindholm recommended performing risk assessment and skin observation with special attention to patients > 71 years 15, or with significant Braden risk factors; observing and correcting dehydration; and observing patients with diabetes mellitus and cardiovascular and pulmonary diseases. In this systematic review, the pooled incidence of pressure ulcers in the surgical ICU was 0.11 (95% CI , I 2 = 98.5%). Studies showed the risk factors for pressure ulcers were the same as other procedures: elder age, diabetes, and low Braden Scale score. 9,17 In addition to these 3 types of surgery, orthopedic, neuro-, cardiothoracic, general, vascular, and ob-gyn surgery were included to review the incidence of surgeryrelated pressure ulcers. The incidence of surgery-related pressure ulcers with these procedures ranged from to Because only 1 study of each type of surgery was included, the authors cannot conduct the meta-analysis. However, the authors found the surgery that most frequently becomes complicated with pressure ulcers is vascular surgery. A study that assessed the incidence of pressure ulcers after arthroscopic or combined arthroscopic and open shoulder procedures was included. The incidence was (95% CI ). Pressure ulcers occurred because of axillary roll position for the duration of a long operation. While the incidence of pressure ulcers was low, this surgery can easily be complicated with pressure ulcers. Keypoints Because only 1 study of each type of surgery was included, the authors cannot conduct the metaanalysis. However, the authors found the surgery that most frequently becomes complicated with pressure ulcers is vascular surgery. A study that assessed the incidence of pressure ulcers after arthroscopic or combined arthroscopic and open shoulder procedures was included. The incidence was (95% CI ). Pressure ulcers occurred because of axillary roll position for the duration of a long operation. While the incidence of pressure ulcers was low, this surgery can easily be complicated with pressure ulcers. 240 WOUNDS Limitations First, the included studies were not all special surveys for the incidence of surgery-related pressure ulcers, but clinical studies which reflected the incidence of surgery-related pressure ulcers. This may have resulted in the imprecision of the pooled data. Second, it was found that the I 2 of each meta-analysis was > 50%, which indicated substantial heterogeneity. This may have resulted in some degree of measurement bias. Conclusion The findings suggest pressure ulcers are still one of the more common complications of these surgical procedures. Appropriate monitoring and treatment for surgery-related pressure ulcers needs to be performed in order to lower surgery-related pressure ulcer incidence. This pooled incidence data may provide a benchmark to evaluate surgery-related pressure ulcers. References 1. Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289(2): Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8): Schoonhoven L, Defloor T, Grypdonck MH. Incidence of pressure ulcers due to surgery. J Clin Nurs. 2002;11(4): Aronovitch SA. Intraoperatively acquired pressure ulcer prevalence: a national study. J Wound Ostomy Continence Nurs 1999;26(3): DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3): Zamora J, Abraira V, Muriel A, Khan K, Coomarasamy A. Meta-DiSc: a software for meta-analysis of test accuracy data. BMC Med Res Methodol. 2006;6: Carneiro GA, Leite Rde C. Skin lesions in the intraoperative period of cardiac surgery: incidence and characterization. Rev Esc Enferm USP. 2011;45(3): Kopp L, Obruba P, Edelmann K, et al. Pressure ulcer and mortality risk after surgical treatment of proximal femoral fractures in the elderly. Acta Chir Orthop Traumatol Cech. 2011;78(2): Slowikowski GC, Funk M. Factors associated with pressure ulcers in patients in a surgical intensive care unit. J Wound Ostomy Continence Nurs. 2010;37(6): Campbell KE, Woodbury MG, Houghton PE. Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population. Int Wound J. 2010;7(1): Diccini S, Camaduro C, Senyer ILI. The incidence of pressure ulcer in neurosurgical patients from a university hospital. Acta Paul Nurse. 2009;22(2): Schuurman JP, Schoonhoven L, Keller BP, van Ramshorst

8 B. Do pressure ulcers influence length of hospital stay in surgical cardiothoracic patients? A prospective evaluation. J Clin Nurs. 2009;18(17): Kim EK, Lee SM, Lee E, Eom MR. Comparison of the predictive validity among pressure ulcer risk assessment scales for surgical ICU patients. Australian Journal of Advanced Nursing 2009;26(4): Grisell M, Place HM. Face tissue pressure in prone positioning: a comparison of three face pillows while in the prone position for spinal surgery. Spine. 2008;33(26): Lindholm C, Sterner E, Romanelli M, et al. Hip fracture and pressure ulcers - the Pan-European pressure ulcer study - intrinsic and extrinsic risk factors. Int Wound J ;5(2): Rademakers LMF, Vainas T, van Zutphen S, et al. Pressure ulcers and prolonged hospital stay in hip fracture patients affected by time-to-surgery. Eur J Trauma Emerg Surg. 2007;33(3): Frankel H, Sperry J, Kaplan L. Risk factors for pressure ulcer development in a best practice surgical intensive care unit. Am Surg. 2007;73(12): Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common risk factors? OWM. 2007;53(2): Keyurapan E, Hu SJ, Redett R, McCarthy EE, McFarland EG. Pressure ulcers of the thorax after shoulder surgery. Knee Surg Sports Traumatol Arthrosc. 2007;15(12): Nixon J, Cranny G, Bond S. Skin alterations of intact skin and risk factors associated with pressure ulcer development in surgical patients: a cohort study. Int J Nurs Stud. 2007;44(5): Karadag M, Gumuskaya N. The incidence of pressure ulcers in surgical patients: a sample hospital in Turkey. J Clin Nurs. 2006;15(4): Feuchtinger J, de Bie R, Dassen T, Halfens R. A 4-cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery. J Clin Nurs. 2006;15(2): Lindgren M, Unosson M, Krantz AM, Ek AC. Pressure ulcer risk factors in patients undergoing surgery. J Adv Nurs. 2005;50(6): Lahmann NA, Dassen T, Poehler A, Kottner J. Pressure ulcer prevalence rates from 2002 to 2008 in German long-term care facilities. Aging Clin Exp Res. 2010;22(2): VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United : an analysis of the International Pressure Ulcer Prevalence Survey Adv Skin Wound Care. 2010;23(6): Schoonhoven L, Defloor T, van der Tweel I, Buskens E, Grypondck. Risk indicators for pressure ulcers during surgery. Appl Nus Res. 2002;15(3): Feuchtinger J, Halfens RJ, Dassen T. Pressure ulcer risk factors in cardiac surgery: A review of the research literature. Heart & Lung 2005; 34(6): Baumgarten M, Margolis D, Berlin JA, et al. Risk factors for pressure ulcers among elderly hip fracture patients. Wound Repair Regen. 2003;11(2): Vol. 24, No. 9 September