Application of Self-Adhesive Soft Silicone Common Foam Dressing in Reducing Intraoperative Pressure Ulcers in Elderly ICU Patients.

Pressure ulcer (PU), also called pressure injury, is localized damage to the skin and underlying soft tissues, usually over bony prominences, as a result of sustained mechanical loads applied to the tissues. However, in many situations, complete off-loading of sacral PUs is not possible. Minimising the exposure of wounds and their surroundings to elevated mechanical loads is crucial for healing. We for the first time reported the application of Meipicang in the prevention and treatment of intraoperative pressure ulcers in elderly ICU patients with severe illness. We found that the pressure ulcer risk score (20.15 ± 2.17) in the dressing group after intervention was higher than that (17.42 ± 3.62) in the regular group. The incidence of pressure sores in the dressing group was 3.77% lower than the 18.88% in the regular group. The psychological concern score (31.41 ± 3.15) of the dressing group was higher than that (26.92 ± 3.43) of the regular group. The trust score (29.57 ± 2.61) of the dressing group was higher than the score (24.28 ± 2.29) of the regular group. The score of physiological problems in the dressing group (34.69 ± 3.82) is higher than that in the regular group (29.88 ± 3.54). The skin complication rate of the dressing group was 5.56% lower than that of the regular group (22.64%). The comfort score (92.46 ± 4.15) of the dressing group was higher than that (80.59 ± 5.43) of the regular group. The nursing satisfaction score (94.53 ± 3.72) of the dressing group was higher than that (81.79 ± 4.61) of the regular group. To conclude, in this study, we found that the Meipicang dressing can reduce the incidence of pressure ulcers in ICU patients with severe ICU and improve the comfort and nursing satisfaction of elderly ICU patients with severe ICU, which is worthy of promotion.

1. Introduction

Pressure ulcer (PU), also called a pressure injury, is localized damage to the skin and underlying soft tissues, usually over bony prominences, as a result of sustained mechanical loads applied to the tissues. PU was caused by local tissue hand pressure for a long time, nutritional imbalance, blocked blood circulation, and persistent tissue hypoxia [1, 2]. PU is the most common complication in the daily nursing work of medical staff [3]. Patients who are stationary, such as those who are paralysed, unconscious, or under anesthesia during a surgical procedure, endure prolonged bodyweight-related compressive, tensional, and shear loads at the body-support contact areas, which, over time, may lead to the onset of PUs [4, 5].

ICU critically ill patients are those who have been bedridden for a long time. Due to edema, weight loss, skin breakage, etc., PU may occur [6]. Most of the critically ill patients in the ICU are elderly patients. Due to the decline of the body's own functions and low immunity, resistance, and other physical characteristics of the elderly, plus special factors such as the need for surgery and the possibility of tumors, it is more likely the patient will suffer from strong local compression, even in a short period of time during the operation [7, 8]. It has been compressed, which leads to ischemia in the skin and subcutaneous tissue of the patient's most compressed position. Because of the operation requirements of the operation, the patient needs to take various positions during the operation to cooperate with the smooth operation of the operation. Due to factors such as shear force, friction, pressure, and humidity, elderly patients undergoing ICU surgery have become a high-risk group for acute PU [9]. On the other hand, if the patient's PU risk assessment before surgery is a moderate to severe risk of PU, PU is more likely to occur during surgery. PU mostly occurs in the patient's bone carina, such as the heel, sacrococcygeal, buttocks, and hips; in particular, the sacrococcygeal and hip bones are prone to PU [10].

Although conventional nursing methods can reduce local pressure to a certain extent, patients still have skin redness, erythema, blisters, etc. Therefore, finding an effective intervention to reduce the incidence of PU in patients is the focus of clinical research. Mepilex is a self-adhesive soft silicone ordinary foam dressing with strong absorption, which not only can serve as a protective film on the skin surface but also directly reduces friction on the skin, reduces skin damage and bedsores, and can also use moisture [11, 12]. At present, there are few reports about the use of Mepilex for PU in ICU severely ill patients, and there are no reports about the use of Mepilex for the prevention and treatment of PU in elderly ICU severely ill patients. This study is the first report on the application of Mepilex for the prevention and treatment of PU in elderly ICU patients.

2. Materials and Methods

2.1. General Information

The 106 critically ill patients in the ICU admitted to our hospital from September 2018 to September 2020 were selected as the research objects. Inclusion criteria are as follows: (1) age ≥ 60 years, (2) surgical treatment is required, (3) expected hospitalization ≥ 7 days, and (4) voluntary signing of informed consent. Exclusion criteria are as follows: (1) those allergic to Mepilex, (2) those who died within 7 days of hospitalization, and (3) those who were severely unconscious and unable to cooperate with the researcher. The 106 critically ill patients in ICU were randomly divided into the dressing group (n = 53) and the regular group (n = 53). In the dressing group, there were 32 males and 21 females; the average age was 65.49 ± 4.16 years; the average hospitalization time was 14.76 ± 2.81 days. In the regular group, there were 33 males and 20 females; the average age was 65.17 ± 4.22 years; the average admission time was 14.92 ± 2.78 days.

2.2. Methods

2.2.1. Regular Group

We perform the PU risk assessment before the patient's surgery and perform preventive PU care measures for the surgical site during the operation according to the assessment results. (1) The medical bed pass device is used to move the patient to the operating bed to keep the patient's clothes and surgical towel sheets dry without wrinkles and reduce the friction of the body. (2) According to the requirements of the surgical location, the rolled up surgical towel or O-shaped cotton ring is placed in the iliac region, sacrococcygeal region, and other compression parts of the patient to reduce the local pressure. (3) During the operation, we should protect the skin of the patients, adjust the appropriate temperature in the operation room, regularly visit the patients, and measure the skin temperature and body temperature of the patients. We add a thermostat to the infusion set. When helping patients with skin disinfection, we pay attention not to wet the skin outside the disinfection area. The pad was placed under the nonsurgical limb to ensure that the auricle and eye socket were not compressed. (4) We strengthen the operation management and examination to ensure the patient is in a safe and stable operation position. We maintain the functional position of the limbs and fully expose the operation area. We ensure that the patient's limbs are not in direct contact with the metal instruments and that the tubes and electrode wires are not squeezed. (5) At the end of the operation, the patient's whole body skin tissue was evaluated, and then, the patient was transferred to the recovery room.

2.2.2. Dressing Group

Patients in the dressing group were treated with Regular group method combined with the viscous soft silicone ordinary foam dressing to prevent PU. According to the patient's PU risk assessment score and record, Mepilex (Molnlycke Health Care AB, Figure 1) is used to select the appropriate type of dressing according to the area of the patient's pressure position, and we stick it to the surgical site outside the site. After the operation is completed, the patient is transferred to the recovery room after evaluating the compression position PU of the patient. Mepilex foam dressing has been applied until the patient is awakened from anesthesia and the condition is transferred to the ward steadily. The medical staff handed over to the nurse in charge of the bed and reassessed the occurrence of PU in elderly patients.

Figure 1

Mepilex self-adhesive soft silicone ordinary foam dressing diagram.

2.3. Observation Indicators

2.3.1. PU Risk

PU risk was assessed by the nurse in charge of the ward and the nurse in the operating room 1 d before the operation and 1 w after the operation. The Braden PU risk assessment scale [13] is used for evaluation, which includes sensation, activity, humidity, movement, friction, and nutrition, with a total score of 23: extremely high risk: ≤9 points, high risk: 10-12 points, medium risk: 13-14 points, and low risk: 15-18 points; the lower the score, the higher the risk of PU.

2.3.2. PU Classification

Stage I: the surface of the skin is not damaged, but the skin part appears red, and the color will not fade when pressed with fingers. The color is obviously different from the surrounding skin tone. Stage II: the skin, dermis, and epidermis are damaged, pink wounds appear, and symptoms of congestive blisters or rupture of ulcers. Stage III: full-thickness skin tissue is missing, but tendons, muscles, and bones are not visible, but subcutaneous fat tissue is visible, there is tissue shedding and necrosis, and there may be sinus or sneaking. Stage IV: there are visible tendons, muscles, and bones, tissue crusting or shedding, sinuses, or sneaking [14]. The incidence of PU = (stage I + stage II + stage III + stage IV)/total number of cases × 100%.

2.3.3. Clinical Nursing Effect

The clinical nursing effect was evaluated with the self-made questionnaire of the ICU department. The questionnaire includes three dimensions of trust, psychological concerns, and physiological problems, a total of 25 items; the full score is 100 points; and the higher the score, the better the nursing effect.

2.3.4. Skin Condition

At 1 week after operation, the skin conditions of the two groups were observed, including whether there were erythema, redness, blisters, skin damage, and other complications. The incidence of complications = (number of complications)/total number of cases × 100%.

2.3.5. Comfort and Nursing Satisfaction

Comfort and nursing satisfaction were scored by the scale customized by our hospital. There are 10 items in the comfort scale, and the full score is 100. The higher the score, the better the comfort. There are 20 items in the nursing satisfaction scale; each item has 5 points, a total of 100 points. If the score is more than 80, it is very satisfactory; if the score is 60-80, it is satisfactory; and if the score is less than 60, it is not satisfactory.

2.4. Statistical Methods

SPSS 23.0 statistical software was used to process the data. Quantitative data were expressed as () and qualitative data as n (%). Qualitative data and quantitative data were analyzed by χ2 and t-test, respectively. P < 0.05 means the difference is statistically significant.

3. Results and Discussion

3.1. Comparison of PU Risk between the Two Groups

A comparison was made of the PU risk score of the dressing group (15.43 ± 3.19) and the regular group (15.51 ± 3.24) before the intervention (t = 0.128, P = 0.898). After the intervention, the PU risk score of the dressing group (20.15 ± 2.17) was higher than that of the regular group (17.42 ± 3.62) (t = 4.709, P < 0.001; Figure 2).

Figure 2

Comparison of PU risk scores between the two groups. ∗Indicates that compared with before intervention, P < 0.05. #Indicates that compared with regular group, P < 0.05.

3.2. Comparison of PU Occurrence in the Two Groups

In the dressing group, there were 1 case of stage I PU and 1 case of stage II. In the regular group, there were 5 cases of stage I PU, 3 cases of stage II, and 2 cases of stage III. The incidence of PU in the dressing group was 3.77% lower than 18.88% in the regular group (t = 4.605, P = 0.032; Figure 3).

Figure 3

Comparison of PU occurrence in the two groups.

3.3. Comparison of Nursing Effects between the Two Groups

The psychological concern score of the dressing group (31.41 ± 3.15) was higher than that of the regular group (26.92 ± 3.43) (t = 7.019, P < 0.001). The trust score of the dressing group (29.57 ± 2.61) was higher than the score of the regular group (24.28 ± 2.29) (t = 11.092, P < 0.001). The score of physiological problems in the dressing group (34.69 ± 3.82) was higher than that in the regular group (29.88 ± 3.54) (t = 6.724, P < 0.001; Figure 4).

Figure 4

Comparison of nursing effects between the two groups. ∗Indicates that compared with the regular group, P < 0.05.

3.4. Comparison of Skin Conditions between the Two Groups

There were 1 case of skin erythema and 2 cases of redness in the dressing group. In the regular group, there were 2 cases of erythema, 9 cases of redness, and 1 case of blisters. The incidence of skin complications in the dressing group was 5.56% lower than that in the regular group (t = 4.970, P = 0.026; Figure 5).

Figure 5

Comparison of skin conditions between the two groups.

3.5. Comparison of Comfort and Nursing Satisfaction between the Two Groups

The comfort score of the dressing group (92.46 ± 4.15) was higher than that of the regular group (80.59 ± 5.43) (t = 12.641, P < 0.001). The nursing satisfaction score of the dressing group (94.53 ± 3.72) was higher than that of the regular group (81.79 ± 4.61) (t = 15.662, P < 0.001, Figure 6).

Figure 6

Comparison of comfort and nursing satisfaction between the two groups. ∗Indicates that compared with regular group, P < 0.05.

3.6. Discussion

Clinical surveys identify the sacral area as the most common site for PUs associated with prolonged supine position (bedrest). Compressive loads applied by the heavy pelvis and shear loads caused by static or dynamic frictional forces (such as when a patient slides downwards in the bed because of gravity or during repositioning) subject the soft tissues around the sacrum to sustained deformations, which may lead to a PU [2, 3, 7, 9]. PU is a problem that has always plagued critically ill patients in the bedridden elderly ICU, and it is also a problem that medical staff pay close attention to. Studies have shown that the incidence of PU in elderly patients who are bedridden for a long time is closely related to age. The older the patient, the more likely they are to develop PU, which is as high as 70% in patients over 70 years of age [15]. Once PU is formed, it is difficult to heal, which not only increases the patient's pain but also greatly hinders the patient's recovery from the disease. Traditional nursing methods can play a certain role in the prevention and treatment of PU, but there are still many drawbacks, and the workload of nursing staff is also relatively large [16]. Therefore, this study explored whether Mepilex dressing is better than traditional nursing methods in preventing and treating PU in elderly ICU patients who have been bedridden for a long time.

The results of this study showed that the PU risk score of the dressing group (20.15 ± 2.17) after intervention was higher than that of the regular group (17.42 ± 3.62). The incidence of pressure sores in the dressing group was 3.77% lower than the 18.88% in the regular group. The psychological concern score of the dressing group (31.41 ± 3.15) was higher than that of the regular group (26.92 ± 3.43). The trust score of the dressing group (29.57 ± 2.61) was higher than the score of the regular group (24.28 ± 2.29). The score of physiological problems in the dressing group (34.69 ± 3.82) is higher than that in the regular group (29.88 ± 3.54). The skin complication rate of the dressing group was 5.56% lower than that of the regular group (22.64%). The comfort score of the dressing group (92.46 ± 4.15) was higher than that of the regular group (80.59 ± 5.43). The nursing satisfaction score of the dressing group (94.53 ± 3.72) was higher than that of the regular group (81.79 ± 4.61). It indicates that Meipicang dressing can reduce the incidence of pressure ulcers in ICU patients with severe ICU and improve the comfort and nursing satisfaction of elderly ICU patients with severe ICU.

Elderly ICU patients have poor skin elasticity, and most of them are in a loose and dry state. As the age increases, the patient's subcutaneous capillaries decrease and the skin becomes thinner. The patient's skin is not sensitive to the external environment, etc. These are the objective reasons that elderly ICU patients are more likely to have PU, so it is extremely important to prevent and treat PU in elderly ICU patients clinically [17].

The use of Mepilex reduces the friction between the skin and the bed sheet in the ulcer-prone parts, avoids skin abrasion, improves the local blood supply and oxygen supply, and reduces the shearing force of the skin [16, 18]. On the other hand, Mepilex dressing can absorb the secretions of the skin, keep the skin dry, and maintain a proper temperature, which helps prevent the occurrence and development of PU [19, 20]. Mepilex is a new type of soft silicone foam dressing. Self-adhesive soft silicone is a kind of high molecular organic compound. It can prevent the evaporation of water vapor on the wound surface and play a function similar to the skin stratum corneum. It provides protection for the moist healing environment of skin wounds. The main function of the special foam layer of Mepilex dressing is to absorb wound exudate [21, 22]. Mepilex has an antibacterial and waterproof semipermeable polyurethane film that can gently adhere to the skin near the wound and will not adhere to the surface of the wound. Therefore, Mepilex can reduce damage to new granulation tissue; avoid bleeding, pain, and reinjury to the surrounding skin; reduce edema; and improve the speed of wound healing [23, 24].

In addition, the healing of ordinary wounds takes a long time to reach the crusting process. Mepilex dressings use the moisturizing principle to speed up the healing process [25, 26]. The humid environment is closer to the physiological environment. When the dressing is in contact with the wound surface, Mepilex can provide a slightly acidic environment and appropriate local temperature on the wound surface, thereby promoting the division, proliferation and proliferation of wound endothelial cells, fibroblasts, keratinocytes, and Vascular proliferation [27, 28]. Studies have shown that the healing speed of PU in a humid environment is approximately twice the healing speed of PU in a natural perception environment [29, 30]. Future research may focus on further adjusting the stiffness preference in sacral dressings, which can be potentially different between purely prophylactic dressings vs. treatment dressings.

4. Conclusion

This study for the first time reported the application of Mepilex for the prevention and treatment of PU in elderly ICU patients. We found that Mepilex dressing can reduce the incidence of PU in critically ill patients in ICU, improve nursing comfort and satisfaction, and is worthy of promotion.