Pressure ulcer prevention: can dressings protect from pressure
ulcer damage? An advertorial
Wounds International, Vol 1; Issue 1 › Practice › Pressure ulcer prevention: can dressings
protect from pressure ulcer damage? An advertorial
Using dressings such as an absorbent soft silicone self-adherent bordered foam dressing
(Mepilex Border Sacrum, Mölnlycke Health Care) to protect vulnerable areas –
particularly the sacrum, pelvic area and heels – of patients at risk of developing
pressure ulcers is a relatively economic and practical means of reducing pressure ulcer
incidence.
INTRODUCTION
Over the past 30 years clinicians have sought to find approaches to care that will solve the thorny issue
of pressure ulcer damage. Huge amounts of effort and money have been put into developing care
frameworks, educational packages and high-tech pressure-relieving equipment. These efforts should
be applauded and yet provision of care free from the fear of pressure ulcer development is still not
universally available.
The international economic downturn means that healthcare providers must look at reducing
expenditure and investing in low-cost approaches and strategies to care provision. In the UK, all the
major political parties have indicated that public service funding will be reduced following the 2010
general election and, in the US, the estimated cost of pressure ulcers to the US hospital sector is
considered unsustainable and unacceptable at $11 billion a year [1]. Therefore, in an effort to control
costs and raise quality standards, the Centers for Medicare and Medicaid Services has determined it
will no longer reimburse hospitals for treating a range of hospital-acquired conditions, including
pressure damage [2].
One approach to this problem could be to explore the possible role of relatively simple dressings to
minimise extrinsic mechanical risks associated with pressure ulcer development. This innovation could
make preventative approaches accessible to a larger number of patients and could have benefits where
high-tech approaches are not effective.
INTERVENTIONS DESIGNED TO REDUCE SHEAR AND FRICTION
Although there have been many studies focusing on the pivotal role of pressure in pressure ulcer
development, owing to technical and ethical issues, little research has been undertaken on the action of
shear and friction and how the impact of these mechanisms can be reduced [3].
Some progress has been made; certain practices, such as massage, for example, have been found to be
dangerous and have been largely abandoned [4-7]. Clinicians are advised to use care in positioning
patients to minimise shear forces [8-10], and to use low-friction turning and repositioning aids to
minimise soft tissue damage [11]. Although some authors have advocated the use of preventive
dressings and skin sealants to help reduce friction and shear, and thereby reduce the risk of skin
damage, work in this area has been at best sporadic [10-12].
The practice of using simple adhesive dressings to minimise friction is accepted by many in healthcare
as a commonsense approach, in much the same way as wound plasters are used to prevent new
footwear rubbing and producing painful blisters. However, from experience there appears to be a
reluctance amongst some practitioners to embrace this concept, stating that dressings do not prevent
pressure damage, are not scientifically validated in this indication and are not cost-effective. The
implications of this view cannot be overstated when it is considered that while the clinical community
is aware of the mechanisms of pressure-related damage and the enormous amount of money that has
been invested in pressure-redistributing surfaces, pressure ulcers remain such a common occurrence
[13].
Wounds International, Vol 1; Issue 1 › Practice › Pressure ulcer prevention: can dressings
protect from pressure ulcer damage? An advertorial
Evidence
If a significant change in approach to pressure ulcer prevention is going to be considered, it is essential
to review the potential scientific evidence to support the use of dressings in pressure ulcer prevention
(see Table 1).
Table 1 - Studies in the use of dressings in pressure ulcer prevention
One of the latest and possibly most clinically significant case study series was undertaken by Brindle et
al (2009) [14]. Use of an absorbent soft silicone self-adherent bordered foam dressing (Mepilex Border
Sacrum, Mölnlycke Health Care) (Fig 1) was evaluated for its ability to reduce the incidence of sacral
pressure ulcers in one surgical trauma intensive care unit (ICU). The baseline pressure ulcer incidence
in the ICU was stated as between 5 and 24%. Over three months, 93 patients were admitted to the ICU;
of these, 41 were identified as being at 'high risk' of developing pressure damage using a customised
tool, and were treated with the dressing. During the study there was zero incidence of sacral pressure
ulcers in patients using the dressing [14].
Fig 1: Mepilex Border Sacrum in situ
Wounds International, Vol 1; Issue 1 › Practice › Pressure ulcer prevention:
can dressings protect from pressure ulcer damage? An advertorial
The authors of the paper highlighted that the dressing had qualities that would
appear to be beneficial in the prevention of sacral pressure ulcers, including:
Excellent absorption capabilities
An atraumatic adhesion technology
An occlusive outer covering
A shape and size that was able to cover the sacrum and separate the gluteal folds [14].
In addition, the authors argued that the dressing may reduce friction, shear and moisture by:
Preventing friction between the gluteal skin folds
Absorbing moisture collection on the intact skin
Providing a barrier between the support surface and the skin during patient re-positioning
Facilitating routine skin assessments and removal without causing trauma to the skin because of
its silicone technology
Protecting against faecal contamination of the wound from incontinence due to its occlusive
outer layer [14].
DISCUSSION
There appears to be both in vitro and in vivo evidence supporting the ability of topical dressings to
positively influence the mechanisms known to cause the development of pressure ulceration [15]. This
could have major repercussions for pressure ulcer prevention, with a shift away from the provision of
expensive pressure-relieving devices for all 'at-risk' patients and the possibility of greater preventive
interventions for the 'very high-risk' groups.
While there is still a major role for high-tech support surfaces, it has long been recognised that these
have limitations in availability, ease of use and overall costs to healthcare providers. In addition,
despite the use of these interventions, the incidence of pressure damage continues to be a problem
[14]. In a health environment where cost is an issue, clinicians are forced to explore new ways to
deliver effective, evidence-based care. If dressing products could provide an additional tier of
preventive care, this may be worth further exploration.
Pressure damage most commonly occurs to the sacrum and pelvic region [16,17]. The sacrum and natal
cleft area are particularly difficult to treat once pressure damage has occurred [18]. Dressing fixation
and retention is problematic and keeping pressure off the area is difficult while maintaining normal
activities. In addition, the close proximity of the anus means faecal contamination is likely, particularly
when incontinence is an issue. This makes secondary infection a significant risk. Anatomically, this
area of the body is prone to high levels of shear - when sitting, lying in a semi-recumbent position and
when transferring between bed and chair [19].
While the provision of pressure-relieving equipment in hospital beds is commonplace, and there is now
a range of seating products available, preventive interventions while chair-bound appear rare [20] [21].
The mobility of the buttocks, particularly when muscle tension is lost, creates intense stretching forces
that can severely compromise tissue perfusion. Prevention of such damage is therefore of the great
importance [22].
Wounds International Vol 1 | Issue 1 ©Wounds International 2009
Author
Type
Product
Numbers
Control/Comparator
Effect
Comment
Ohura et al (2005) [3]
In vitro study
Hydropolymer (Tielle)
Hydrocellular (Allevyn)
Hydrocolloid (Duoderm)
–
Standardised testing for
static friction, adhesion
and shear transmissibility
in dry and moist states
Static friction results:
hydropolymer 1.01, hydrofoam
0.72, hydrocolloid 0.48 adhesion
wet and dry: hydrofoam
and hydrocolloid identical,
hydropolymer withdrawn
due to product failure. Shear
transmission against nonstretch tape: the hydropolymer
failed, hydrofoam showed good
deformation, hydrocolloid
showed similar results to control
The hydrocolloid worked well in
dry conditions. The hydropolymer
did not perform well – it rucked
and twisted; it also had the
highest friction co-efficient and
lost adhesion when wet. The
hydrofoam had the best all-round
performance and prevented
the transmission of shear to the
underlying structures
Ohura et al (2008) [31]
In vitro study
No control product
used. Hydrocellular
foam (Allevyn Adhesive);
hydropolymer (Tielle);
Semipermeable film x
2 (Opsite, Tegaderm);
Hydrocolloid (Duoderm
CGF)
–
Pig cadaver skin tests
measuring transmission
of pressure and shear
to subcutaneous
tissue All products had a positive effect
on reducing pressure and shear
in the subcutaneous tissues.
Film and hydrocolloid products
showed best results
The study demonstrated how
shear was transmitted to the
subcutaneous tissues. The authors
concluded that reducing shear
would be clinically important
when looking to reduce pressure
ulcer formation
Ashford et al (2001) [32]
In vitro study
Hydropolymer (Tielle)
Hydrocellular (Allevyn)
Polyurethane foam
(Biatain, Lyofoam)
–
Measuring suitability
of products for foot
applications. All samples
were tested for dry and
wet state compression
tests, shearing test and
cyclical loading
Each product performed
differently. Lyofoam deformed
most during compression testing,
Allevyn and Tielle withstood the
greatest shear deflection before
failure but Biatain withstood the
greatest shear force
Overall Allevyn performed the best
Akimoto et al (2007) [33]
In vitro study
Non-proprietary foam
sheets of varying
densities and thicknesses
–
Experimental twodimensional finite
element mechanical
analysis
All the cushion pads
demonstrated a peak value less
than the control. The results
suggest that the use of a thin
cushion pad is an effective way to
prevent pressure ulcers.
Although not a dressing study this
has significant results for the use of
foam as a ‘padding’ material over
the sacral/heel regions
Callaghan and Trapp
(1998) [34]
In vivo study of nasal
bridge pressure ulcer
occurrence while using
non-invasive positive
pressure ventilation
Hydrocolloid (Granuflex), n=30 (10
Gel pads (Spenco Dermal) in each
group)
and control group
Randomised controlled
trial
90% of control group showed skin The hydrocolloid group showed
deterioration, 70% deteriorated
significant reduction in pressure
with gel pads, 30% deteriorated
ulcer incidence
with the hydrocolloid
Nakagami et al (2006)
[35]
In vivo study of heel
ulcer development in
an elderly population
Film dressing, pressure
ulcer prevention dressing
n=30
Quasi-experimental
randomised comparator
study
The pressure-relieving dressing
significantly reduced shear force
from 11.7 +/- 5.8 to 2.2 +/- 1.4
Newtons (p<0.001, Wilcoxon
signed-rank test)
The results suggest that the
dressings did not significantly
reduce interface pressure
Nakagami et al (2007)
[36]
In vivo study of
trochanteric pressure
ulcer development in
older at-risk patients
Semi-occlusive dressing
containing ceramide 2
(Remois pad) v standard
care
n=37
Experimental bilateral
comparison study
No patients developed pressure
ulceration in either the control
or intervention arm of the study.
There was a significantly lower
rate of persistent erythema within
the interventionarm (p=0.007, RR
0.18 [95% CI: 0.05-0.73] and NNT
4.11 [2.50-11.63])
The authors concluded that the
dressing was effective in patients
with highly prominent bones and
dry skin to prevent pressure ulcers
Bots and Apotheker
(1998) [37]
In vivo study in heel
ulcer reduction among
very high-risk ICU
patients
Hydropolymer (Tielle)
n=10
Cohort study
Ten patients with grade 1 ulcers
were selected to enter the study.
All patients were assessed every
four days, and followed-up for
four weeks. After seven days
all indications of erythema had
disappeared
The product was subsequently
adopted as ‘standard care’ in the
ICU. Over the next two years there
was a 72% reduction in pressure
ulcer prevalence within ICU
Bots and Apotheker
(2004) [38]
In vivo study in heel
ulcer reduction in
surgical patients
compared to historical
data
Hydropolymer (Tielle) v
standard
n=140
Comparative cohort
study
The study resulted in a reduction
in pressure ulcer prevalence from
36.5% to 8.5% (a reduction total
of 76.7%)
The authors found some technical
problems with using the product
(distortion and detachment) which
necessitated the use of secondary
cotton tubing
Sansom and Flynn (2007)
[39]
In vivo study following
the progress of
‘moderate to high risk’
patients following
admission through
A&E
Hydrocellular heel
dressing (Allevyn) v
standard care
n=100
(n=20
follow-up)
Comparative cohort
study
Although uncontrolled, this study
A randomly selected subindicated the dressing’s potential
group (n=20) were followed up
following hospital admission; 44% in pressure ulcer prevention
of the control group exhibited
pressure damage while 3.3% of
patients in the intervention arm
exhibited pressure damage
Torra i Bou et al (2002)
[40]
In vivo study
comparing a heel
protective bandage
and hydrocellular
dressing in pressure
ulcer reduction
Hydrocellular heel
dressing (Allevyn) v
standard care
n=130
(65+65)
Multi-centred, open,
labeled and controlled
study
111 patients completed the
study; 44% of the control group
exhibited pressure damage,
while 3.3% had damage in the
intervention group.
The results were considered highly
significant (p<0.001) and was
said to indicate the product was
effective in reducing the incidence
of pressure ulcers when compared
to standard care
Hall (1983) [41]
In vivo study of older
orthopaedic patients
Semipermeable film
(Opsite) versus standard
care
n=34
(18+16)
Comparative
18 patients had film dressings
applied to all pressure points,
16 had standard of care. The test
group exhibited a 5.5% incidence
in pressure ulcers. The control
arm patients exhibited a 43.7%
incidence
Closer examination of the study
indicated discrepancies in
treatment regimes and quality of
care between the two groups that
may have introduced significant
bias
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