Decreasing Intraoperative Skin Damage in Prone Position Surgeries

  • STATUS
    Recruiting
  • participants needed
    200
  • sponsor
    University of California, Los Angeles
Updated on 25 May 2022

Summary

Preventing Pressure Injuries among patients undergoing spinal or orthopedic surgery in the prone position is challenging because of position required for surgical access and limited availability of pressure reduction surfaces for prone position operating tables. A new dressing technology (Mepilex Border Flex (MBF) provides increased conformability of the dressing to the skin with the ability of the dressing to move in all directions (e.g., 360-degree flexibility) with even slight body movements. Limited data exists on use of silicone foam dressings with all direction flexibility during prone surgical procedures.

We plan to recruit participants scheduled for surgery in the prone position at UCLA Santa Monica Medical Center and propose to examine use of the MBF dressings on the chest, iliac crest, and face (chin, cheeks, forehead) of patients undergoing this type of surgery using a prospective, non-randomized pre/post intervention clinical trial design.

Three outcome measures will be compared between patients undergoing prone surgery with standard care (no dressings, pressure reduction positioning on the operating table) and those with standard care and use of MBF dressings placed on the chest, iliac crest and face. First, we will compare incidence of erythema and pressure injuries on face, chest and iliac crest determined by visual skin assessment between the two groups. Next, we will compare incidence of moisture associated skin damage (MASD) and friction abrasions on face, chest and iliac crest determined by visual skin assessment between the two groups. Last, we will compare SEM measures indicative of pressure injury damage on face, chest, iliac crest between the two groups.

We will also complete a 6-month retrospective medical record review of patients who underwent prone surgeries from February 1, 2018 through July 31, 2018 to determine a historical pressure injury facility incident rate. The year 2018 was chosen to avoid changes associated with the COVID-19 pandemic.

Description

Preventing pressure injuries (PrIs) from developing during surgery is difficult due to insensitivity and immobility of the patient and the positioning needed for safe surgical access. Intraoperative acquired pressure injury (IAPI) rates are reported from 4% to 45% (1). IAPI rates vary due to differences in defining PrIs, surgical positions and because tissue damage that occurs in surgery may not be visible on the skin surface initially with the resulting PrI presenting several days post operatively (2,3). The sustained pressure, deformation, and shear forces on the tissues combined with changes in blood flow due to blood loss, vasopressor and anesthesia use, and temperature changes present unique risk factors for PrI development during surgery (1). Reducing PrI damage during surgery requires preventive strategies to decrease the mechanical forces of pressure and shear on the tissues loaded in the unique positions required for surgical access. In the supine position for surgery, use of silicone foam dressings on the sacrum and heels with pressure reducing devices on the operating table have decreased IAPIs (4, 5).

Preventing PrIs among patients undergoing spinal or orthopedic surgery in the prone position is especially challenging because of positioning required for surgical access and limited availability of pressure reduction surfaces for prone positioner operating tables (2,6). The face, chest, and iliac crest are all loaded in the prone position. These anatomic locations have limited soft tissue for compression and small surface areas and because of this, distribution of pressure and shear forces over a large surface area is not possible. Thus, the intensity of the pressure and shear force over these anatomic areas is high. Shear force is particularly problematic as tissues change due to variations in blood volume and flow, anesthesia, and vasopressor use during the surgical procedure all of which may increase shear forces on the tissues (2). Use of silicone foam dressings on the iliac crest and chest has been shown to reduce IAPIs in the prone position for spinal surgery (6). Most recently, use of silicone foam dressings has decreased PrIs in patients with acute respiratory distress syndrome (ARDS) from COVID-19 who are placed in prone position to manage respiratory distress (7,8). Issues with use of silicone foam dressings intraoperatively is keeping the dressing in place while positioning for surgery, protecting the skin and allowing for movement and changes in the tissues. A new dressing technology (Mepilex Border Flex (MBF)) provides increased conformability of the dressing to the skin with the ability of the dressing to move in all directions (e.g., 360-degree flexibility) with even slight body movements. Limited data exists on use of silicone foam dressings with all direction flexibility during prone surgical procedures.

We propose to examine use of MBF dressings on the chest, iliac crest, and face (chin, cheeks, forehead) of patients undergoing surgery in a prone position using a prospective, non-randomized pre/post-intervention clinical trial. The specific aims are to:

  1. Compare IAPI, erythema, and skin damage (e.g., friction abrasions, moisture associated skin damage (MASD)) incidence at chest, iliac crest, and face of patients undergoing surgery in a prone position with use of standard care (no dressings, pressure reduction positioning on the operating table) to use of MBF dressings placed on chest, iliac crest, and face with standard care.
  2. Compare subepidermal moisture (SEM) values (a biophysical measure of inflammatory tissue changes), at chest, iliac crest, and face of patients undergoing surgery in a prone position with use of standard care (no dressings, pressure reduction positioning on the operating table) to use of MBF dressings placed on chest, iliac crest, and face along with standard care.
  3. Explore cost estimates for use of MBF dressings placed on chest, iliac crest, and face for surgery in a prone position.

Patients undergoing surgery are at high risk for pressure injuries (PrIs) (1,2). In addition to increasing risk of death, infection, and hospital length of stay, PrIs among surgical patients increases hospital costs by 44% per hospital stay (1,3). Preventing PrIs from developing during surgery is difficult due to insensitivity to pain and immobility of the patient and the specialized positioning needed for safe surgical access. Intraoperative Acquired Pressure Injury (IAPI) rates are reported ranging from 4% to 45% (1, 4-8). IAPI rates vary due to surgical positions and because tissue damage that occurs in surgery may not be visible initially on the skin surface with the resulting PrI presenting several days post operatively (9). The sustained pressure, deformation, and shear forces on the tissues combined with changes in blood flow due to blood loss, vasopressor and anesthesia use, and temperature changes present unique challenges for PrI development during surgery (1,2). Reducing PrI damage during surgery requires preventive strategies to decrease the mechanical forces of pressure and shear on the tissues loaded in the unique positions required for surgical access. In the supine position for surgery, use of silicone foam dressings on the sacrum and heels along with pressure reducing devices on the operating table have decreased IAPIs (10-13).

The prone position for surgery has been shown to be a risk factor for IAPIs in multiple studies (1,2,4,14). Yet, there is limited data on IAPIs for surgeries in the prone position with Luo and colleagues reporting incidence at 4.7% and Yoshimura et al showing an 11% incidence (4,15). Preventing PrIs among patients undergoing spinal or orthopedic surgery in the prone position is especially challenging because of positioning required for surgical access and limited availability of pressure reduction surfaces for prone positioner operating tables (2,15). The face, chest, and iliac crest are all loaded on small operating table surfaces in the prone position. These anatomic locations have limited soft tissue for compression and small surface areas and because of this, distribution of pressure and shear forces over a large surface area is not possible. Thus, the intensity of the pressure and shear force over these anatomic areas is high. Shear force is particularly problematic as tissues change due to variations in blood volume and flow, anesthesia and vasopressor use, and initiation of the inflammatory response during the surgical procedure all of which may increase shear forces on the tissues (1,2,16). Use of silicone foam dressings on the iliac crest and chest has been shown to reduce IAPIs in the prone position for spinal surgery (15). Most recently, use of silicone foam dressings has been suggested for use to decrease PrIs in patients with acute respiratory distress syndrome (ARDS) from COVID-19 who are placed in prone position to manage respiratory distress (17,18). Issues with use of silicone foam dressings intraoperatively is keeping the dressing in place while positioning for surgery preoperatively, protecting the skin and allowing for movement and changes in the tissues intraoperatively, and safe nontraumatic removal immediately postoperatively. A new dressing technology (Mepilex Border Flex (MBF)) provides increased conformability of the dressing to the skin with the ability of the dressing to move in all directions (e.g., 360-degree flexibility) with even slight body movements while using a silicone-based adhesive allowing for atraumatic removal.

We propose to examine use of MBF dressings on the chest, iliac crest, and face (chin, cheeks, forehead) of patients undergoing surgery in a prone position using a prospective, non-randomized pre/post-intervention clinical trial design. Three outcome measures will be compared between patients undergoing prone surgery with standard care (no dressings, pressure reduction positioning on the operating table) and those with standard care and use of MBF dressings placed on chest, iliac crest, and face. First, we will compare incidence of erythema and PrIs on face, chest, and iliac crest determined by visual skin assessment between the two groups. Next, we will compare incidence of moisture associated skin damage (MASD) and friction abrasions on face, chest, and iliac crest determined by visual skin assessment between the two groups. Last, we will compare SEM measures indicative of PrI damage on face, chest, iliac crest between the two groups.

We will also complete a 6-month retrospective medical record review of patients who underwent prone surgeries from February 1, 2018 through July 31, 2018 to determine a historical PrI facility incidence rate. The year 2018 was chosen to avoid changes associated with the COVID-19 pandemic.

Setting and Subjects After approval by The University of California, Los Angeles, Office of the Human Research Protection Program and the UCLA Medical Center Nursing Research Council we will obtain written informed consent to participate in the study directly from patients who are able to provide informed consent.

Two surgical groups, the neurological and the orthopedic surgery groups, will be used to recruit participants scheduled for surgery in the prone position to be conducted at UCLA Santa Monica Medical Center. UCLA Santa Monica Medical Center performs about 15 prone surgeries per week. Participant inclusion criteria are patients scheduled to undergo orthopedic or neuro surgery in prone position, over 18 years of age, able to understand English, and able to provide informed self-consent. Exclusions to participation include less than 18 years old, inability to provide informed consent, and scheduled for surgery in a position other than prone position. We will also conduct a 6-month retrospective medical record review of patients who underwent prone surgery between February 1, 2018 through July 31, 2018 to determine the historical PrI incidence for UCLA Santa Monica Medical Center.

Protocol The study data collection period is anticipated to be 6 months, 3 months of pre-intervention baseline assessments followed by 3 months of intervention assessments. COVID-19 precautions will be in place throughout all study related activities and will follow UCLA Health Center guidelines: all parties will wear cloth face mask and a plastic face shield, 2-minute hand hygiene using soap and water and

hand sanitizer for use, gloves and gowns prior to any contact, and maintain social distance (>6') between all activities as possible.

Pre-intervention Baseline. During pre-intervention baseline (3 months) participants will undergo visual skin assessment and SEM Scanner readings at face (chin, cheeks, forehead), chest and iliac crest, conducted by the research staff, preoperatively, immediately following surgery in the Post Anesthesia Recovery (PAR) Unit, on transfer to the floor unit, post-operative day 3 and post-operative day 5 or discharge from hospital (whichever occurs first).

Intervention. During intervention (3 months) participants will undergo visual skin assessment and SEM Scanner readings at face (chin, cheeks, forehead), chest and iliac crest, conducted by the research staff and then placement of MBF dressings to the face (chin, cheeks, forehead), chest and iliac crest, conducted by the research staff immediately following surgery with the MBF dressings removed in the PAR unit, on transfer to the floor unit, post-operative day 3 and post-operative day 5 or discharge from hospital (whichever occurs first).

Data Collection Research staff will collect all data after training in all protocols by the PI. Data collection includes medical record abstraction, visual skin assessments, and SEM Scanner measures. Each is described below.

Medical record abstraction. The electronic medical record (EPIC) will be abstracted for demographic data (gender, age, race/ethnicity) and medical data (height, weight, body mass index, comorbidities such as diabetes, hypertension, peripheral vascular disease and, smoking status, medical diagnoses, Braden Scale for predicting Pressure Sores (Braden) score, use of any PrI preventive strategies such as support surface use, repositioning schedules), surgery type, surgery length, use of vibration machines or other instruments in surgery, length of time in PAR unit, anesthesia used, use of vasopressors during surgery, estimated blood loss, volume of fluids provided during surgery, blood pressure during surgery, American Society of Anesthesiologists physical status score and documentation of any skin damage including PrIs, MASD, and friction abrasions.

We will also conduct a 6-month retrospective medical record review of patients who underwent prone surgery between February 1, 2018 through July 31, 2018 to determine the historical PrI incidence for UCLA Santa Monica Medical Center. The retrospective medical record review will include data as noted above. The time period for the retrospective medical record review was chosen to align temporally with the prospective data to be collected.

Visual Skin Assessment. Visual skin assessment training of research staff will emphasize stage 1 PrIs and deep tissue injury (DTI), a PrI that begins at the muscle tissue interface and presents as deeply discolored skin, because these conditions may be difficult to detect. Research staff will assess skin health through direct visual assessments preoperatively or within 1 week of scheduled surgery, immediately after surgery in PAR unit, on transfer to the floor unit, post-operative days 3 and 5 or discharge whichever occurs first. Participants are positioned in bed in a supine position for visual assessments. Eight anatomic locations will be assessed: right and left chest at nipple line, iliac crest, and cheeks, mid forehead and chin. Skin is assessed for discoloration (redness), erythema, PrI, MASD, and friction abrasion. Areas of visual skin discoloration are palpated for blanchability using finger palpation (press tissues with finger firmly for 5 seconds, release, and look for return of normal skin color) and defined as blanchable versus non-blanchable. Erythema is graded as minimal, moderate, or severe discoloration, where minimal was defined as pink or slight redness to the skin, moderate as bright redness in lightly pigmented skin and purple in darkly pigmented skin, and severe as dark red to purple in lightly pigmented skin and black to blue-grey colors in darkly pigmented skin. Erythema is defined as moderate skin discoloration (bright redness in light skin tones and purple in dark skin tones), with blanching (blanching not considered for dark skin tones). DTI is defined as

severe skin discoloration (purple or maroon in light skin tones and black to blue-grey in dark skin tones) with or without blanching. Stage 1 PrIs are defined as moderate skin discoloration (all skin tones), with non-blanching (non dark skin tones). PrIs more severe than stage 1 will be classified using the EPUAP/NPIAP/PPPIA's 2019 staging system (1) and assessed using the Bates-Jensen Wound Assessment Tool (BWAT) (32). For skin that demonstrates none of the above visual characteristics, the assessment is considered normal skin.

Subepidermal Moisture Measure. The SEM readings will be obtained on clean dry skin directly over each anatomic location using the SEM Scanner (Bruin Biometrics, Los Angeles, CA), a handheld dermal phase meter that requires light skin touch and provides SEM readings in 3 seconds (range 0-7 picoFarads (pF)) concurrently with the visual skin assessments. The SEM Scanner uses dielectric parameters, high-frequency low power electromagnetic waves of 32 kHz are transmitted via an electrode that is manually placed on the skin surface. In the skin, the induced electrical field interacts mainly with water molecules closest to the electrode with depth of interaction depending on the diameter of the circular electrode (in this study at a depth of 4mm) (19-21). The portion of the electromagnetic energy that is not absorbed by tissue water is reflected and measured by the device and displayed in the measuring unit. SEM values are displayed in picoFarads. Reliability of the device has been previously reported (33).

Descriptive statistics will be used to describe the sample. Chi square (categorical data), t-tests (continuous data) and Analysis of Variance (ANOVA) will be used as appropriate to compare demographic and medical data between the two groups (standard care versus MBF dressings) and to compare the total sample to the retrospective historical sample. Chi square (categorical data), t-tests (continuous data) and Analysis of Variance (ANOVA) will be used as appropriate to compare incidence and severity of PrI, erythema, MASD, friction abrasions, and SEM values between groups (standard care versus MSB dressings) and to compare the total sample incidence of PrIs and skin damage to documented PrIs and skin damage determined from the retrospective historical sample.

Costs of the dressings will be described.

Details
Condition Pressure Injuries, Prone, Surgery
Treatment Mepilex Border Flex® (MBF) dressing
Clinical Study IdentifierNCT04884737
SponsorUniversity of California, Los Angeles
Last Modified on25 May 2022

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