Skin Integrity and Pressure Injuries

Factors Associated With Pressure Injury Treatment Success

There are a wide range of recognized risk factors for the development of pressure injuries; poor nutritional status, dehydration, being under- or overweight, stroke, recent bone fractures, anaemia, diabetes, vitamin deficiency, and age >70 years old (Kenneweg et al. 2015). Infected pressure injuries are difficult to treat. Underlying causes often cannot be corrected, and are associated with a high risk of clinical recurrence. Long-term surveys report an ulcer recurrence risk from 12% to 82%, with a total complication rate of 17% to 46% (Jugun et al. 2016). The table below outlines different factors that are associated with various treatment successes.

Author YearCountry
Research DesignScore
Total Sample Size		 Methods Outcome
Systematic Reviews
Baron et al., 2018
Canada
Not specified
AMSTAR=9
N=15		 Method: A systematic search was conducted using several databases to identify articles that reported on skin care self-management. A MEDLINE search strategy was designed to include search terms on SCI, self-management, and skincare. Studies were included if they were RCTs or non-randomized trials with a control group receiving the standard of care, population ≥ 50% with SCI, published in English and addressed at least one of the following outcomes: mediators of skincare behaviour, skincare behaviours, or pressure ulcer related clinical outcomes. Type of intervention utilized, and effectiveness was extracted from each study.
Databases: Embase, PsycINFO, CENTRAL, CINAHL, REHABDATA, CIRRIE, PeDro, and ERIC
Level of evidence: I, II
Questions:
1. What skincare self-management interventions are utilized in people with SCI?
2. How effective are the interventions?		 1. The most common interventions used were “instructions on how to perform behaviour” (16 interventions), “information from a credible source” (12 interventions), and “social support (unspecified)” (9 interventions).
2. Evidence to support the effectiveness of interventions improving knowledge, self-efficacy, skills relating to skincare/pressure ulcer prevention, skincare behaviours, skin status and health-care utilization for skin problems was limited, particularly for clinical outcomes.
Indivdual Studies
Lane et al. 2016
United States
Cohort
NIntial=158, NFinal=133		 Population: Intervention group: Mean age=44 yr; Gender: males=60, females=15; Level of injury: paraplegia=55, tetraplegia=20. Control group: Mean age=44 yr; Gender: males=69, females=14; Level of injury: paraplegia=53, tetraplegia=30.
Intervention: Intervention group (n=75): 6 wk period after implementation of smoking cessation guidelines (Ask, Advise, Assess, Assist, Arrange). Control group (n=83): Historical control consisting of 6 wk period prior to intervention initiation.
Outcome Measures: Smoking cessation at 6 mo; Change in wound size; Change in number of wounds.		 1. Intervention group had a significantly higher percentage of participants who stopped smoking (p=0.03).
2. No significant differences between groups in terms of percentage of participants who desired and underwent surgery.
3. In terms of percentage of participants with a decreased number of wounds, the smoker group was 33.3%, the non-smoker group was 51.6%, and the smokers who stopped group was 65.2% (p=0.03).
4. Smokers had an increase in total wound size while non-smokers and smokers who stopped had a decrease in total wound size (p=0.004).
Jugun et al. 2016
Switzerland
Case Series
N=31		 Population: Median age=60 yr; Number of pressure injuries=70.
Intervention: Patient records were reviewed for those that underwent a complete surgical debridement or excision for an infected pressure injury.
Outcome Measures: Clinical recurrence.		 1. There were 44 pressure injury recurrences and 26 remissions after a median of 1 yr post-treatment. In 86% of these recurrences, cultures yielded a different organism than the preceding episode.
2. Clinical recurrence was not significantly associated with sex, age, number of prior pressure infection episodes, immune suppression, osteomyelitis, bacteremia, serum Creactive protein level, involvement of Staphylococcus aureus, number of surgical debridements, use of vacuum-assisted closure devices, flap use, duration of antibiotic use, or duration of parenteral antibiotics.
Kenneweg et al. 2015
United States
Case Series
N=49		 Population: Mean age=45.4 yr; Gender: males=90.20%, females=9.80%; Level of injury: paraplegia=71.57%, tetraplegia=19.61%, no SCI=7.8%; Mean time since injury=214.49 mo; Number of pressure injuries=102; Pressure injury stage: II=2, III=8, IV=92.
Intervention: Patient records were reviewed for those with pressure injury reconstructions.
Outcome Measures: Differences between primary and recurrent ulcers; Pressure injury closure.		 1. Primary ulcers had significantly longer ulcer duration (p=0.02), larger surface area (p=0.009), and higher number of debridements (p=0.006) compared to recurrent ulcers.
2. Primary ulcers had significantly lower albumin levels (p=0.002), higher erythrocyte sedimentation rate (p=0.02), lower glucose (p=0.03), and higher platelet count (p=0.002) compared to recurrent ulcers.
3. Pressure injury closure was significantly correlated with lower BMI (p=0.033), smaller surface area (p=0.049), and fewer debridements (p=0.049).
4. In 83.6% of cases, closure outcome could be successfully predicted using a multivariable model consisting of prealbumin (β=0.151), hematocrit (β=0.705), hemoglobin (β=-1.419), and creatinine (β=-4.622).

Discussion

In a retrospective chart review, Lane et al. (2016) evaluated the impact of implementing evidence-based guidelines on smoking cessation in persons with spinal cord injuries and pressure injuries, as well as the impact of smoking on pressure injury healing in this population. 48% percent of the control group participants and 57% of the intervention group participants smoked cigarettes at baseline. Smoking cessation doubled with the use of the clinical practice guidelines (P=0.03). Smokers presented with a greater number of pressure injuries than nonsmokers. They experienced a mean increase rather than reduction in wound size. Nearly half (45.5%) of the intervention group participants who desired to have surgery had it performed, compared with only 34.9% of the control group participants (P=0.35).

Jugun et al. (2016) assessed interdisciplinary surgical and medical parameters associated with recurrences of infected pressure injuries. Authors found that in patients with infected pressure injuries, clinical recurrence occurs in almost two-thirds of lesions, but in only 14% with the same pathogens. The number of surgical debridements, flap use, or duration of antibiotic therapy was not associated with recurrence of pressure injury infection. Similarly, Kenneweg et al (2015) aimed to identify perioperative risk factors that may predict improved outcomes and reduced complications in primary and recurrent pressure injury reconstructions. A total of 49 patients with 102 reconstructions were reviewed. Numerous differences between primary and recurrent pressure injuries were identified, including ulcer location, patient nutritional status, wound infection, postoperative course, and recurrence. Multivariate analysis revealed a flap reconstruction prediction model using creatinine, haematocrit, haemoglobin, and prealbumin that is able to successfully predict closure outcomes in 83.6% of cases.

Conclusion

There is level 2 evidence (from one cohort study: Lane et al. 2017) that implementing evidence-based guidelines on smoking cessation in persons with spinal cord injuries can improve pressure injury healing.

There is level 4 evidence (from two series: Jugun et al. 2016, Kenneweg et al. 2015) that recurrences of pressure injury infection may be caused by reinfections from extra-hospital factors other than surgical debridements, flap use, or duration of antibiotic therapy.

The use and implementation of clinical practice guidelines may help individuals stop smoking.

Many factors play a role in the development, course, and treatment of PIs. It is vital to understand the role of patient risk factors in the development of PIs, to direct subsequent management and reconstruction, and to prevent future recurrences.

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