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Skin Integrity and Pressure Injuries

Equipment and Products for Pressure Management and Prevention

Support surfaces play a significant role in the prevention of pressure injuries, addressing some of the extrinsic factors of pressure, friction, shear, moisture and heat. Support surfaces used in a wheelchair are covered in the wheeled mobility chapter. The one article in this new subsection suggests that there is research supporting the use of a multi-layer foam dressing to protect high risk people against developing sacral ulcers; however the research is not specific to the SCsI population. This study explores a multi-layer foam dressing versus a gel mattress for prevention of pressure injuries in the SCI population while waiting for spinal stabilization surgery.

Author YearCountry
Research Design
Total Sample Size
Methods Outcome
Richard-Denis et al. (2017)
Population: Gel Mattress Group (n=226): Mean age=47.8yr; Gender: males=81, females=19; Level of Injury: Tetraplegic=56.2, Paraplegic=43.8; ASIA Classification: A=38.1, B=10.8, C=15.7, D=35. Multi-layer Foam Dressing Group (n=89): Mean age=50.7yr; Gender: males=73, females=27; Level of Injury: Tetraplegic=60.7, Paraplegic=39.3; ASIA Classification: A=24.7, B=11.2, C=16.9, D=47.2.
Intervention: Patients were given a preventative multi-layer foam dressing to their sacral-coccygeal area upon arrival to emergency room, compared to those who used a gel mattress pre-operatively.
Outcome Measures: Occurrence of sacral PU, Severity of PU, and comparators of age, gender, smoking status, obesity, comorbidities and injury severity score.
1. 17.7% of participants in the gel mattress group developed PU, while 19.1% of participants with the Multilayer dressing developed PU (p=0.77).
2. There were no statistically significant differences between the gel mattress group or multi-layer dressing group for severity of PU (p=0.71)
a. Grade 1: gel mattress=30% versus multi-layer dressing 29.4%
b. Grade 2: gel mattress=62.5% versus multi-layer dressing 70.6%
c. Grade 1: gel mattress=2.5% versus multi-layer dressing 0% Grade 1: gel mattress=5% versus multi-layer dressing 0%
3. Potential predictors of sacral pressure injury development during acute hospitalization: complete tetraplegia, older age, higher injury severity score.


Richard-Denis et al. (2017) study reports that research suggest the pre-operative use of multi-layer dressings can improve the protection of the skin and decrease the occurrence of pressure injuries pre-operatively in critically ill patients, Richard-Denis’ study suggests otherwise. His findings indicate that for patients sustaining acute SCI, this preventive measure is not superior to the conventional use of a gel mattress pre-operatively. The study authors suggest that if used, the multi-layer dressings should be used with caution in SCI patients, particularly with people who sustained a complete tetraplegia.


There is level 2 evidence (from one cohort study: Richard-Denis et al. 2017) that indicated, for pre-operative prevention for the SCI population, a multi-layer foam dressing is not superior in preventing sacral pressure injuries compared to viscoelastic polymer gel mattress over a foam stretcher pad.

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