A longitudinal study of the incidence of pressure sores and the associated risks and strategies adopted in Italian operating theatres.
Abstract: To explore the incidence of intraoperative pressure sores, the associated risk factors and the preventive strategies adopted by nurses, we adopted a longitudinal study in a 900-bed teaching hospital with multiple operating theatres, located in the North of Italy. Patients who underwent major surgery were evaluated four times: at the moment of operating theatre admission, at operating theatre discharge, and on their third and sixth postoperative day. Of the patients included (n=102) who had an average age of 62.3 years (range 20-87), 12.7% (13/102) developed a pressure ulcer in the operating theatre; 46.1% (6/13) of these ulcers were still present on the third postoperative day. Some health conditions (diabetes mellitus, cardiac diseases) and intra-operative factors (lying on the operating table for more than 6.15 hours, intraoperative hypothermia) are associated with the occurrence of pressure sores.

KEYWORDS Pressure sores / Operating room / Perioperative care / Italy
Article Type: Report
Subject: Bedsores (Risk factors)
Bedsores (Prevention)
Bedsores (Research)
Surgical nursing (Research)
Authors: Bulfone, Giampiera
Marzoli, Ilaria
Quattrin, Rosanna
Fabbro, Carmen
Palese, Alvisa
Pub Date: 02/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Feb, 2012 Source Volume: 22 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Italy Geographic Code: 4EUIT Italy
Accession Number: 283274419
Full Text: Pressure sores are a relevant health problem in many different care contexts. Pressure sores are considered a negative outcome, and are mainly associated with poor nursing care, determining high costs and the patient's discomfort. Recently, the cost of caring for patients with pressure sores has been estimated to be between $5,000 and $40,000 per annum in the USA (Feuchtinger et al 2005). Pressure sores incidence changes in relation to the patient's clinical conditions and context: for surgical patients the incidence of pressure sores ranges from 4.7% to 66% (Schoonhoven et al 2002a), and for those developed while a patient is lying on an operating table, the incidence is probably underestimated (Edlich et al 2004). While identifying surgical patients at risk of pressure sores and activating effective risk management strategies are internationally well-established priorities (Hartley 2003) involving different healthcare workers (e.g. registered nurses), working in the operating room has only recently received full consideration within the Italian context where registered nurses have this responsibility. The general aim of the study was to describe the incidence of pressure sores, risks, and nurses' strategies adopted in Italian operating theatres.

Literature review

Pressure sores

The terms 'pressure ulcers', 'decubitus ulcers', 'decubitus lesions' and 'ulcer pressure' are used to identify tissue lesions with necrotic evolution, characterised by ulceration and ischemic necrosis. Pressure sores involve skin and subcutaneous regions, and can reach muscles and bones if the condition becomes chronic. Pressure sores are the direct consequence of heavy or prolonged pressure and/or of stretching and cutting mechanisms that cause mechanical stress on tissues and vessels in those areas that are strictly bounded by protruding bones (NPUAP 2008). Pressure sores which occur in the operating theatre and those that develop during hospitalisation are different (Reddy et al 2006): the progression of intra-operative pressure sores is unusual because the ulcers start initially in the muscle and subcutaneous tissue, and only later reach the dermis and the skin. For this reason ulcers might appear immediately, within 72 hours after surgery, or up to the seventh postoperative day (Schoonhoven et al 2002b), and can be wrongly attributed to different causes (Schouchoff 2002). For Stewar and Magnano (2007), intra-operative pressure sores are very similar to those which are burn-derived; Reddy and colleagues (2006) have also documented that little pressure sores without pain can remain undiscovered if nurses do not accurately assess the skin integrity. For all these reasons, the incidence of pressure sores in the surgical patient is underestimated in the literature. Shoonhover et al (2002) have recommended evaluating the patient's skin integrity on admission to the operating theatre and on discharge, and until at least the fifth postoperative day.

Risk factors

Pressure sores appear in anatomical regions which are located near boney prominences, because of local and systemic mechanisms (Feuchtinger et al 2005). Local risk factors which are common in all bed-rested hospital patients are: tissue surfaces, length of the action of the pressure, skin dehydration or excessive wetness, patient obesity, malnutrition and comorbidities (Armstrong & Bortz 2001). The specific risk factors of intra-operative pressure sores are: duration of time spent on the operating table, positioning adopted, specific aids used (e.g. mattress), anaesthetic agents, extracorporeal circulation (Treiman et al 2001), hypothermia and hyperthermia (Schoonhoven et al 2002a,b, Aronovitch 2007), age, cerebrovascular diseases and renal failure (Schoonhoven et al 2002a,b, Schouchoff 2002).

Positioning on the operating table

Lying for a long time on the operating table is considered a major pressure sores risk (Schoonhoven et al 2002). Five standard postures are mostly used during surgery: supine, lateral, prone, lithotomy and sitting posture (Masatsugu et al 2005) as shown in Figure 1. Defloor and De Schuijimer (2000) have examined which positions are significantly associated with pressure sores. Considering the different postures, the study pointed out that: a) 0[degrees], 30[degrees] and 60[degrees] supine posture showed no significant difference in pressure sores occurrence; b) sitting posture (90[degrees] supine) caused a high risk of pressure sores occurrence because it loads the entire body weight on a very small surface (the sacral region); c) the semi-Fowler and prone postures are the positions with the lowest probability of pressure sores.

[FIGURE 1 OMITTED]

Patients can develop pressure sores on specific susceptible regions in relation to the surgical posture adopted: for example as a result of being placed supine, patients can develop pressure sores on their shoulder blades, occipital, sacrum, elbows, shoulders and heels. For this reason it is important to identify the risk and to protect each region with appropriate preventive supports. It is fundamental to emphasise that, during general anaesthesia, patients are not able to feel pain and activate physiological protective mechanisms. When nurses arrange the patient's position, particular attention needs to be paid to the upper limbs; pressure on the ulnar nerve must be reduced to the minimum possible level. When possible, the inferior limbs should be slightly raised to reduce venous stasis and pressure on the heels. Prone patients could develop pressure sores on the nose, forehead, chin, thorax, breasts, genitals, iliac crest, toes, kneecaps and sides of the feet (Masatsugu et al 2005). During the lateral position, major pressure is developed on the ear, shoulder, trochanter, side of the medial knee, malleolus, side of the foot, and the elbow (Aronovitch 2007).

One leg should be kept in extension over the other one, which needs to be kept in flexion, and a pillow must always be placed between them to contain the adduction mechanism and to reduce contact between the legs (NPUAP 2008). During the sitting position, the patient's back is kept high in a vertical position. Pressure sores can develop on the shoulder blades, shoulders, occipital, sacrum, side of the lateral knee, elbows and hips (Treiman et al 2001). During surgery these postures might be modified on the basis of the surgeon's need and the patient's needs and risks (Baker & Leaper 2003).

Time spent on the operating table

The length of stay on operating table is a risk factor for pressure sores. Defloor and De Schuijimer (2000) have reported a low risk for pressure sores after 1.5 hours; the risk was doubled if the exposure lasted from 2.5 to 4 hours, and was tripled in the case of more than 4 hours. In order to reduce the risk, in some cases, there was the possibility to reposition the patient during surgery. Although it is impossible to reduce the time spent by the patient on the operating table, there are many strategies to prevent pressure sores in the intraoperative period with dry, viscoelastic and polymer overlays for patients with undergoing surgical procedures lasting [greater than or equal to] 90 min (Pham et al 2011).

Risk management strategies

Anti-decubitus surfaces are preventive aids or supports suited to distributing and relieving, pressures loaded by the body on the bed (Thomas & James 2002). Static surfaces (e.g. air with sensors, air release, fluidised air, foams, gels, hollow fibres) should be preferred in the operating theatre because they ensure stability during surgery (Baker & Leaper 2003). Ranawat and colleagues (2004) identified the ideal characteristics for intra-operative anti-decubitus surfaces; they should guarantee: stability, steadiness, pressure reduction and redistribution. In particular, gel mattresses and foam rubber mattresses showed limited efficacy in pressure sores prevention (Shelton & Lott 2003, Edlich et al 2006, Feuchtinger et al 2007), while polyester and polyurethane rubber viscous-elastic mattresses assured the best effectiveness. In comparison with standard mattresses (12cm of thick foam), polyester/polyurethane mattresses decrease the tissue pressure from 20% to 30% (Mathias 2003). The use of air or water alternate circulation mattresses is not recommended because they increase the patient's instability (Edlich et al 2006).

Krause et al (2001) have suggested the use of preventive protection for heels and elbows, which encourage the patient's skin to slip over the operating table, and reduce adherence to the mattress and bed linen when the patient needs to be moved. Reducing the patient's exposure to humidity is also recommended. Humidity causes skin maceration and weakens the natural epidermis barriers. The use of skin padding appropriately to decrease friction, shear forces and transpiration might decrease the risk of pressure sores development (Shultz 2005).

Study design

To explore the intra-operative pressure sores incidence, the associated risk factors and the preventive strategies adopted by nurses, we adopted a longitudinal study in a 900-bed teaching hospital located in the North of Italy.

Sample and sampling

Patients who underwent major surgery (general, cardiac, vascular, plastic and neurosurgery) were eligible. A consecutive sample of patients who underwent major surgery was asked to participate in the study and, after having obtained their informed consent, they were included. The inclusion criteria were:

* patients lying for more than two hours on the operating table, according with Defloor and De Schuijimer (2000)

* patients who were observable for at least six days after surgery.

Patients lying on the operating table for less than two hours or who transferred to intensive care units or other hospitals after surgery were excluded.

Setting

In Italy operation room nurses might assume three main different roles: the scrub nurse, the anesthetist nurse and the perioperative nurse. Both the perioperative nurse and the anaesthetist nurse have the responsibility to assess the patient's condition at his/her admission in the operating room. The perioperative nurse has the responsibility of positioning the patient on the operating table, and the assessment of his/her conditions (included skin integrity and risk of pressure sores) before discharge from the operating room. In some operating rooms, there are also nurses' aides who support nurses in their role.

Instruments and data collection procedures and methods

Data collection was carried out over 60 days, from 1st September to 31st October 2009, and involved nurses and chief nurses working in the operating theatres and surgical wards. Patients were evaluated four times: at the moment of the operating theatre admission, at the operating theatre discharge, and on their third and sixth postoperative day. A data grid based on the factors which emerged from the literature review was adopted. The grid was composed of four sections:

1) Demographic data (e.g. age, gender), specific patient clinical conditions and risk factors such as comorbidities, body mass index (BMI), haematocrit, albuminemia and haemoglobin preoperative levels

2) Intra-operative risk factors that occurred (e.g. posture adopted, repositioning or not, duration of the surgery, episodes of hypothermia, general anaesthesia, extracorporeal circulation)

3) Pressure sores risk management strategies adopted by nurses (e.g. aids used, protectors, pillows, other supports),

4) Pressure sores developed on leaving the operating theatre and after three and six days. Pressure sores that appeared in the postoperative days have been included only if they developed in the regions exposed to high pressure according to the patient's posture maintained on the operating table. The pressure sores staging was done using the National Pressure Ulcer Advisory Panel's standard (NPUAP 2008):

a) Stage I: Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area.

b) Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. c) Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling.

d) Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling.

The grid was initially tested with ten surgical patients not included in the study. In addition, researchers had been trained to collect data by attending a four hour long course. To ensure validity of the measurements, preliminary concordance was assessed between two researchers who independently evaluated the patient and then compared the grid completed (concordance > 95%). The data was collected by the researchers staying in the operating theatre during the surgery procedure of each patient. The follow-up was also done by researchers in the surgical ward where patients were admitted after surgery.

Ethical issues

In accordance with Italian law, the Internal Review Board of the hospital had given its consent to the research project. Patient records were treated with confidentiality. Each patient was asked for, and gave informed consent. The operating theatre nurses, ward nurses and chief nurse gave informed consent for their daily practice to be observed.

Data analysis

The collected data was elaborated using the EpiInfo system, version 3.3.2 (2007). Average, median, standard deviation ([+ or -]), ranges, frequencies and percentages were calculated according to the nature of the variables. Each pressure sores risk assessed according to the available literature was associated with the pressure sores occurrence, calculating the relative risk (IC95%). The statistical significance was fixed at P = 0.05.

Results

We included 102 patients consecutively, all of those eligible. The demographic data, patients' risk of pressure sores, and the risk management strategies adopted by operating theatre nurses are reported in Table 1.

Intra-operative postures adopted

83% (85/102) of the patients adopted the supine posture, 7.8% per cent (8/102) the prone posture, 5.9% (6/102) the lateral posture, 2% (2/102) the kneeling posture, and 1% (1/102) the lithotomy posture. Of the patients adopting the supine posture, 96.4% (82/85) had their inferior limbs abducted, 81.1% (69/85) had their inferior limbs flexed, 95.2% (81/85) had their right superior limb abducted, and 77.6% (66/85) also had the left one abducted. 100% (85/85) of the patients kept the head in line with the axis of the body, without any inflection. The majority of the patients adopting the prone posture had both superior limbs bent forward, with both elbows bent (87.5%, 7/8); the remaining 12.5% (1/8) had their limbs lying along the body. The head was kept in line with the axis of the body for 75% (6/8) of the patients, while for the remaining 25% (2/8), the head was bent.

All of the patients (6/6) adopting the lateral posture had their right inferior limb bent, they had their superior limbs bent forward with the right elbow bent, and they kept the head in line with the axis of the body. The two kneeling patients kept both superior limbs bent forward and both inferior limbs bent level with the knees. Both of them had their heads lying sideways. Finally, the patient who adopted the lithotomic posture had the inferior limbs bent: the right superior limb was bent at elbow level, while the left one lay along the body. The head was in line with the axis of the body.

Repositioning

Only 2.9% (3/102) of patients were repositioned during the intra-operative period. Of these, two changed their prone posture while one changed the lithotomic posture. All patients were repositioned in the supine posture at the end of the surgery.

Outcomes: intra-operative and postoperative pressure sores

Overall 12.7% (13/102) of the patients developed pressure sores during the intra-operative period: two patients in the cheekbone area, two in the sacrum area, two on the elbows, and the remaining seven on the left and right forearm, buttocks, knees, heels, breasts, and ears. All of the pressure sores were at the first stage according to the NPUAP standard. 38.4% (5/13) developed during cardiac surgery, 30.8% (4/13) during general surgery, 15.3% (2/13) during neurosurgery, and the remaining 15.3% (2/13) during vascular surgery.

Of the pressure sores that developed during the intra-operative period, 46.1% (6/13) were still present on the third postoperative day. The body regions involved were the sacrum (two), forearm (one), buttocks (one), heel (one) and knee (one). 83.3% (5/6) of the pressure sores remained at the first NPUAP stage, while 16.6% (1/6) progressed to the second stage (on the buttocks). All the pressure sores developed (6) were also present on the sixth postoperative day and they were all at the first NPUAP stage. Diabetes mellitus emerged statistically as being associated with the occurrence of pressure sores (RR [relative risk] 2.2, IC95% 1.1-3.7), as did cardiac diseases (RR 1.1, IC95% 1.9-4.7), and vascular disease (RR 2.8, IC95% 1.7-2.6) in patients who had a haematocrit values less than 35% (RR 5.6, IC95% 1.9-18.7). In particular, patients lying on the operating table for more than 6.15 hours have shown more probability of developing pressure sores (RR 2.4, IC95% 1.6-3.8) than the control group; those suffering from at least one intra-operative hypothermia episode (RR 3.1, IC95% 1.6-2.9) have more probability of developing pressure sores than patients without any episodes. Patients on gel mattresses (not gel overlays and pad) have also shown more probability of developing pressure sores (RR 4.2, IC95% 1.3-13.6) than those on other surfaces. Other risks were not associated with the occurrence of pressure sores.

Discussion

To our knowledge, this is the first Italian study involving multiple operating theatres. The issue of pressure sores developed during hospitalisation has received great emphasis during recent years. In the Italian context however, intra-operative pressure sores have only been considered since 2003 when the Minister of Health instituted a specific commission on 'Clinical Risk' (2003). Pressure sores are considered mainly a negative nursing outcome (Feuchtinger et al 2006). Pressure sores prevention and management is well established in the surgical units and is mainly the responsibility of the nurses in our context. However, in the operating theatre, the factors determining pressure sores are not related only to the quality of nursing care received. In our operating theatres several factors play an important role in the pressure sores risk prevention: the surgeon's decision (such as posture, time for repositioning), the anaesthetist's decision (such as general anaesthesia), and also the available resources (having or not the appropriate mattress) are some examples.

Overall, 12.7% of the patients included in our study of a similar age and with similar general characteristics to those documented by previous studies (Schoonhoven et al 2002b, Hartley 2003, Feuchtinger et al 2007, NPUAP 2008) developed pressure sores, and this result is consistent with data reported in the literature. On the third postoperative day 46.1% of the patients with intra-operatively developed pressure sores still showed the same ulcers. 83.3% (5/6) of the pressure sores remained at the first stage, while 16.6% (1/6) progressed to the second stage.

Many studies have reported positive associations between pressure sores and out-of-range values of haemoglobin, haematocrit, and serum albumin (Schouchoff 2002b, Feuchtinger et al 2005). However, our study has highlighted a positive association only between haematocrit less than 35% and pressure sores (RR 5.6, IC95% 1.9-18.7) which needs to be carefully considered in the preoperative patient evaluation.

The relevance of the BMI reported by several studies (Schoonhoven et al 2002, Feuchtinger et al 2005, NPUAP 2008), which highlighted the association between pressure sores and BMI ranging from 25.76kg/m2 to 28.6kg/m2 was not confirmed in our study. A similar insignificant association has emerged between pressure sores and extra-corporeal circulation (ECC) as documented also by previous authors (Defloor & De Schuijimer 2000). The inclusion criteria adopted in our study, and the limited number of patients suffering from these conditions, has probably influenced the statistical associations.

General anaesthesia, for its effects on body thermoregulation, was also considered as a pressure sores risk factor because reducing peripheral perfusion and generating cellular hypoxia, in cases of high pressure, increases the risk of pressure sores in the involved tissues (Masatsugu et al 2005). The majority of our patients (96.1%) underwent general anaesthesia. Within this group of patients, having at least one episode of hypothermia during the intra-operative period increased the probability of pressure sores by three times (RR 3.1) compared with patients who did not experience hypothermia.

Many diseases were identified by the literature as pressure sores risk factors, e.g. diabetes mellitus, cardiac disease, vascular disease, respiratory diseases, renal failure and cancer (Sewchuk et al 2006). Our study did not give exactly the same results, probably because of the limited size of the analysed sample and the relative under-representation of patients with comorbidities. Moreover, diabetes mellitus, cardiac diseases and vascular failure were statistically significantly associated with pressure sores occurrence.

The length of stay on the operating table is also considered a critical risk factor. For Houwing and colleagues (2004), 40% of patients who underwent surgery and spent more than three hours on the operating table developed pressure sores. Our study has confirmed this result, emphasising that patients who stayed on the operating table for more than 6.15 hours showed a higher probability of developing pressure sores than patients on an operating table for less time (RR 2.4; IC95% 1.6-3.8). According to Shelton and Lott (2003), the main pressure sores occurrence emerged in patients positioned in the supine posture (83.3%), with less in the prone posture (7.8%). For those positioned in the lateral posture, pressure sores occurred in 5.9%, in contrast to data reported by Aronovich and colleagues (2007). No patient positioned in the lithotomic position developed pressure sores, in contrast to results reported by Defloor and De Schuijimer (2000). The materials used by different operating theatre nurses in the risk management were extremely variable. The literature reports that gel mattresses have limited efficacy in intra-operative pressure sores prevention (Ranawat et al 2004). In our study, this mattress was used for 28.4% of the patients and showed a significant association with pressure sores (RR 4.2). This result, as already reported in some studies, needs to be considered with care: gel mattresses cause an over-warming of the patient's skin, generating wetness and inducing skin maceration. The optimal preventive support must possess specific characteristics, such as the ability to decrease pressure on body parts at high risk, to realise a good micro-climate for skin, and to be easy for nurses to use. However, there is no clear evidence about whether gel mattresses encompass these abilities (NPUAP 2008). The high variability in the prevention strategies adopted suggests the need to develop hospital intra-operative pressure sores recommendations from international guidelines (NPUAP 2008, EPUAP 2008), which highlight the evidence available and the specific risk management strategies needed for specific risks.

Limits of the study

Our study has several limits: firstly, the size of the sample. Many operating theatres were included, and this might be considered both a strength and a weakness. The extreme clinical variability of the patients, while it gives a global picture of the risk and the pressure sores occurrence in an Italian teaching hospital, has limited the analysis of the specific risk of the patients involved.

Conclusions

Our study confirms the results previously reported in the literature. Of the patients included, 12.7% developed a pressure ulcer in the operating theatre. These ulcers remained for several days after surgery, and ranged from first to second stage ulcers. The risk factors associated with pressure ulcers that emerged in our study: the duration of the stay on the operating table, the haematocrit value (less than 35%), and hypothermia, are some of those previously reported in the literature. Having data on the occurrence of pressure sores is extremely important for both operating theatre nurses and ward nurses to understand and compare outcomes, and for monitoring the effectiveness of the prevention strategies adopted. In our study these were very variable.

Nurses play a crucial role in the prevention of intra-operative pressure sores, which represents a healthcare outcome. The variability in the risk management prevention strategies adopted might constitute an opportunity to adopt evidence-based nursing recommendations based on the needs of each operating theatre in relation to the specific patients cared for. Each body region exposed to pressure must be carefully protected with optimal preventive and evidence-based aids. Operating theatre nurses have to be consulted by those having the responsibility to decide on the resources (e.g. mattress, pillows, other supports) giving voice to expert nurses who have experience and knowledge of the materials' effectiveness. Each patient must always be accurately evaluated to highlight the specific risk during admission to the operating theatre and also before leaving it, especially in the body regions exposed to higher pressures. While several instruments assessing patients' risk of pressure sores are available for ward nurses (Norton, Braden or Waterloo scale - Bergstrom et al 1992), there is an urgent need to develop a specific tool for operating theatre nurses in order to standardise their evaluations, compare pressure sores occurrence between patients with similar risks, and evaluate the effectiveness of the preventive strategies adopted within homogeneous groups of patients at risk of pressure sores. Continuing educational strategies might also be developed both for operating theatre and ward nurses, while nursing documentation needs to highlight this risk and the outcomes achieved for all surgical patients.

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Acknowledgement

We thank Paola De Lucia (Supervisory Nurse, University Hospital of Udine, Italy), Arianna Cecchetto, Quinto Sbrizzai, Marina Cleva, Michela Puntel, Caterina Todino, Roberta Tomada for their valuable help in the study. We also thank the reviewers of the Journal of Perioperative Practice for their constructive recommendations during the manuscript revision.

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication November 2011.

Correspondence address: Alvisa Palese, Viale Ungheria 20, Udine Universitay, 33100 Udine, Italy. Email: alvisa.palese@uniud.it

About the authors

Giampiera Bulfone MNS, BNS

Nurse Educator, School of Nursing, University of Udine, Italy

Ilaria Marzoli BNS

Operating Room Nurse, Teaching Hospital of Udine, Italy

Rosanna Quattrin MD Chair of Hygiene, University of Udine, Italy

Carmen Fabbro MNC, BNS

Supervisory Nurse, Operating Room, Teaching Hospital of Udine, Italy

Alvisa Palese MNS, BNS

Associate Professor Nursing Science, University of Udine, Italy

No competing interests declared
Patients                                    Freq no = 102 (%)

Gender        Female                                 39 (38.2)
              Male                                   63 (61.8)

Average age                                         62.3 years
                                                ([+ or -]14.3,
                                                  range 20-87)

Operating
rooms
              Neurosurgery/spinal cord               30 (29.4)
              injury
              Cardio surgery                         39 (38.2)
              Plastic and vascular surgery             6 (5.9)
              General surgery                        27 (26.5)

Risk factors
              Plasma albumin 2g/dl                       2 (2)
              Haematocrit 35%                        14 (13.7)
              Haemoglobin 12 g/dl                    17 (16.7)
              BMI                           26.7 ([+ or -]5.4,
                                                  range 18-44)
              Lying on operating table             6.34 ([+ or
              (average time in hours)            -]0.17, range
                                                   3.45-15.00)
              Extracorporeal circulation             33 (32.4)
              General anaesthesia                    98 (96.1)
              Episodes of intra-operative            45 (44.1)
              hypothermia
              Diabetes mellitus                      14 (13.7)
              Cardiological diseases                 42 (41.2)
              Vascular diseases                      25 (24.5)
              Respiratory diseases                     7 (6.9)
              Renal diseases                           3 (2.9)
              Cancer                                 48 (47.1)

Prevention
strategies

Mattresses    Polyurethane foam mattress             102 (100)
              Water mattress                           34 (33)
              Gel mattress                           29 (28.4)
              Foam rubber mattress                   23 (22.5)

Other         Gel headrest                           60 (58.8)
protectors
              Lint-made headrest                     13 (12.7)
              Rubber foam headrest                     5 (4.9)
              Elbow protectors                       76 (74.5)
              Heel protectors                        19 (18.6)
              Hydrocolloid dressing                  31 (32.3)
              Footboards                             30 (29.4)

Supports      Arms                                   39 (38.2)
              Sternum                                  5 (4.9)
              Shoulder blades                            1 (1)
              Legs                                       1 (1)
              Sponge                                    49(48)
              Buttocks                                 6 (5.9)

Pillows       Polyurethane foam                      17 (16.7)
              Gel pillows                            35 (34.3)
              Rubber foam                            43 (42.2)

BMI = Body mass index
Table 1 Patients, settings, risk factors and prevention strategies
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