Risk of pressure ulcer development in surgical patients: A review of the literature

Advances in Wound Care,  Apr 1999  by Stotts, Nancy A

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Abstract

OBJECTIVE: The purpose of this paper is to review the scientific knowledge about risk factors for pressure ulcer development in the surgical population.

DATA SOURCE: A literature review was conducted from 1960 to present using MEDLINE and the key words pressure ulcer, decubitus ulcer, surgery, surgical patient, research, clinical research, and human. All sources were English.

STUDY SELECTION: Included were articles that specifically addressed the risk of pressure ulcers in the surgical population and had ulcer formation as an outcome measure.

DATA EXTRACTION: All data were reviewed and extracted by the author.

DATA SYNTHESIS: The development of pressure ulcers has been explored in only a small proportion of surgical patients. Few groups of surgical patients have been addressed. Major surgical populations potentially at risk because of their immobility, debility, and therapy have not been studied. A portion of the literature is quite old and one issue is whether the older studies are relevant, considering the rate of change in treatment. Pressure relief, seen as the single most important factor in pressure ulcer prevention, is underrepresented in the analysis of factors leading to pressure ulcer development.

CONCLUSION: There is limited information about pressure ulcer risk in the preoperative, intraoperative, and postoperative periods. Because the surgical period is defined temporally, and more so than pressure ulcers in the chronically ill, this paradigm must be examined using a time-based evaluation. The Agency for Health Care Policy and Research guideline for pressure ulcer prevention needs to be tested in surgical patients. ADV WOUND CARE 1999;12:127-36

SOME 17 MILLION SURGERIES ARE PERformed in the United States annually.1 A considerable portion of patients are on bed- or chair-rest and therefore are considered at risk for pressure ulcer development.2 The incidence of pressure ulcers in surgical patients varies from 19% to 66%,34 yet little data are available about the risk of surgical patients for pressure ulcers or the factors that contribute to pressure ulcer development in this population.

To appreciate the scientific knowledge of risk factors for pressure ulcer development in surgical patients, a literature review from 1960 to present was conducted.

The year 1960 was selected because it reflects the time when Kosiak5 reported his famous time-intensity study and Norton, McLaren, and Exton-Smith6 performed their classic work on pressure ulcer risk assessment. Several clusters of research were identified and categorized into general surgery (Table 1), hip fracture and hip surgery (Table 2), and cardiovascular surgery patients (Table 3), as well as surgical intensive care (Table 4) and intraoperative patients (Table 5). Those studies which did not report a separate analysis on surgical patients were not reviewed, including those by Norton, McLaren, Exton-Smith;6 Allman, Laprade, Noel, et al;78 Bergstrom, Demuth, Braden;9 Bergstrom, Braden, Kemp et al;io and others. In addition, case studies are not addressed (eg, a report by Vermillion l l on operating room[OR] acquired pressure ulcers). It should be noted that there are no articles addressing pressure ulcer development in sameday surgery, outpatient surgery, or 23hour-stay surgery. Selected for inclusion were those articles that specifically addressed the risk of pressure ulcers in the surgical population and had ulcer formation as an outcome measure. The studies are presented chronologically.

Overview of Research Studies

Hicks(1971)

Hicksl2 provides one of the first reports of pressure ulcer risk among surgical patients. She reviewed the charts of 100 randomly selected patients who had surgery lasting more than 2 hours. The age range was 10 days to 81 years, with a mean age of 39.1 years. Thirteen percent developed pressure ulcers, 69% in patients under the age of 60. The Norton Scale did predict ulcers in adults but not in children under age 6. Hicksl2 concluded that a surgical procedure of 6 to 8 hours was critical in ulcer formation and that ulcers occurred in an area of the body in contact with the OR table. She also noted that there was no discernable pattern between pressure ulcer development and age or diagnosis. All data were presented descriptively; no inferential statistics were reported. Roberts and Goldstone (1979) Four British studies also are reported, examining pressure ulcer development in elderly orthopedic patients. The first is by Roberts and Goldstone,13 who studied pressure ulcer risk in elderly orthopedic patients. Of the 64 patients admitted to the study, 13 developed pressure ulcers more serious than erythema ( 12 were defined as being at risk with the Norton Scale); 5 were admitted with a pressure ulcer; and 46 did not develop a pressure ulcer despite being at risk according to the Norton Scale. Roberts and Goldstone]3 found that the combination of less time on the OR table (P

Goldstone and Goldstone (1982) Goldstone and Goldstone14 followed every other patient admitted to the orthopedics ward in a 15-month period (n = 40) and found 18 patients who developed pressure ulcers and 22 who did not. The groups were quite similar in age, gender, principal diagnosis, time preoperatively on the wards, and length of surgery. Their Norton Scale scores on admission were significantly different (P