Superfícies de suporte em pacientes com risco de lesão por pressão pela escala Munro

INTRODUCTION

Pressure injury is defined as tissue damage resulting from pressure on the skin or associated with shear over a bony prominence or devices.¹ These injuries are classified into stages (1, 2, 3, 4; unclassifiable; deep tissue pressure injury; related to medical devices and mucous membranes), indicating the extent of the tissue damage.² The assessment can be supported by cell phone apps, helping the professional to classify the injury.³

The prevention of pressure injuries is a concern for perioperative nursing since it is an injury that can be prevented. In Brazil, some studies describe the occurrence of pressure injuries and relate them to the risk assessment of the ELPO scale, a Brazilian scale, showing rates of 7-37.7%.^4‑5 Pressure injuries can prolong hospital stays, increase mortality rates, and treatment costs.⁶

In operating rooms, it is common to apply a combination of support surfaces during surgical positioning as a pressure injury prevention measure. In general, the available surfaces are viscoelastic, gel, pyramidal foam, area- or product-specific foams, and multilayer adhesive dressings. Support surfaces are specific structures with coatings, padding, and integrated systems that allow the body's pressure to be redistributed.⁷ This redistribution of body pressure, especially on bony prominences, is the main feature of support materials aimed at preventing pressure injuries.⁷

The effectiveness of the support surface is assessed according to its pressure redistribution properties. A randomized study with patients in prone and supine positions, using three types of support surfaces (gel, viscoelastic, standard table), recorded the patient's body pressure during the procedure. The results showed that there was no significant difference in the prone position, but in the supine position, the pressure was lower when the viscoelastic support surface was used.⁸

At the study institution, there was no risk assessment until 2022 when, after validating and translating the Munro scale into Portuguese,⁹ they began using the scale as a pressure injury risk assessment strategy. Before that, the nurse's clinical judgment was used to decide on measures to prevent perioperative injuries. With this in mind, the analysis of data after implementation makes it possible to evaluate the risk scale currently applied, as well as the effectiveness of the preventive measures used, and can contribute to the quality of nursing care. Research on injuries and surfaces is found in the literature, but studies related to the Munro scale and different surfaces are still incipient.

OBJECTIVE

To evaluate the preventive measures with support surfaces used for patients determined to be at risk of pressure injury by the Munro scale.

METHOD

This is a retrospective cohort study based on a review of electronic medical records carried out between January and December 2022. The study was conducted in a philanthropic general hospital in the city of São Paulo, with 24 operating rooms and 30 anesthesia recovery beds. This hospital performs around 1,600 procedures a month and began implementing the Munro Scale in care in January 2022, with expansion to the inpatient unit and emergency department in March 2022.

The study sample consisted of all the medical records of adult surgical patients with evidence that the Munro Scale had been filled in during the data collection period. The Munro Scale assesses risk factors present in the perioperative period. Preoperatively: mobility, fasting, loss of body weight, Body Mass Index (BMI), age, and comorbidities. Intraoperatively: classification of physical state according to the American Society of Anesthesiologists (ASA) scale, surgical position, anesthesia, humidity, surface and movement, blood pressure, and body temperature. In the postoperative period: duration of the perioperative period and volume of bleeding.¹⁰

In each perioperative phase, the items on the scale are scored from one to three and the score is calculated by phase. In the preoperative phase, scores of 5-6 are considered low risk; 7-14, moderate; and 15 or more, high. Intraoperatively, scores of 13 are considered low risk; 14-24, moderate; and 25 or more, high. Postoperatively, scores of 15 indicate low risk; 16-28, moderate; and 29 or more, high risk. Thus, the preoperative measure determines the risk for the intraoperative period, the intraoperative measure determines the risk for the immediate postoperative period, and the postoperative measure determines the risk for the immediate postoperative period.¹⁰

Medical records of adult patients who had undergone surgery during the data collection period were included. Medical records with incomplete data, duplicates, procedures with a record of interrupted surgery, and those that did not include filling in medical records were excluded. The variables were: surgical position performed, support surfaces applied in surgical positioning, and results of the Munro Scale in the pre-, intra-, and post-operative periods, as well as the occurrence of pressure injuries in patients with risk determination.

Data was collected by exporting a management report from the electronic medical records system to obtain data from the records of patients who had undergone surgery and filled in the Munro Scale. Data analysis was carried out with the exported data entered into a new Excel spreadsheet, with data sanitation and unification of the surgical position descriptors, removing the derivation of the main ones for adaptation according to the Munro Scale. Descriptive statistics (frequency, mean, percentage) and the chi-square test were then performed using SPSS software (version 20.0). Significance was defined as p < 0.05 and 95% confidence intervals.

The study complied with the ethical precepts of Resolution 466/2012 of the National Health Council, under opinion number 5.344.440.

RESULTS

A total of 11,708 records were found in the medical records of patients assessed for risk using the Munro Scale. The preventive measures applied were combinations of support surfaces (viscoelastic, pyramidal foam, foam face positioner, Allen table positioner, pillow for head or lower limb flexion, and multilayer adhesive dressing). The most used preventative measure was the pillow, followed by pyramidal foam, viscoelastic, and multi-layer dressing. The surgical positions were aggregated to include the four main ones (without derivations), the most used being supine, followed by lithotomy, prone, and lateral. Data on mean age, gender, Munro Scale risk, surgical position, and support surface are shown in Table 1.

Table 1. Characteristics of patients with and without lesions. São Paulo (SP), Brazil, 2022.

Variable	All		No injury		Injured		p-value
	N	%	N	%	N	%
Age
Average	52,56	0,45	52,56	0,45	49,42	53,14	1.000
Gender
Male	5603	47,86	5560	47,87	43	46,24	0.7108
Female	6098	52,08	6046	52,06	52	55,91	0.7223
Undetermined	7	0,06	7	0,06
Pre-operative Munro scale risk
Low	5325	45,48	5292	45,57	33	35,48	0.1512
Moderate	6382	54,51	6323	54,44	59	63,44	0.2415
High	1	0,01	0		1	1,075	0.0000
Risk Munro Scale Intraoperative
Low	53	0,45	53	0,46			0.9526
Moderate	3941	33,66	3917	33,73	24	25,81	0.1538
High	3386	28,92	3350	28,84	36	38,71	0.1050
Post-operative Munro scale risk
Low	8	0,07	8	0,07			0.9789
Moderate	1432	12,23	1427	12,29	5	5,376	0.0223
High	2114	18,06	2086	17,96	28	30,11	0.0577
Surgical position
Supine/Dorsal	7839	66,95	7813	67,27	26	27,96	0.0000
Ventral/Prona	1049	8,96	1000	8,61	49	52,69	0.0000
Lateral	563	4,81	559	4,81	4	4,301	0.8227
Lithotomy	2257	19,28	2243	19,31	14	15,05	0.3516
Support surface
Viscoelastic	5255	44,88	5191	44,70	64	68,82	0.0000
Pyramidal foam	8704	74,34	8637	74,37	67	72,04	0.0000
Foam facial positioner	267	2,28	218	1,88	49	52,69	0.0000
Allen positioner	23	0,20	22	0,19	1	1,075	0.0000
Pillow	8750	74,74	8677	74,71	73	78,49	0.0000
Multi-layer adhesive dressing	1422	12,15	1347	11,60	75	80,65	0.0000

Patients at moderate risk in the preoperative assessment received the greatest number of support surfaces. In relation to preoperative risk, for all low-risk patients, pyramidal foam (46.20%, n=4021); pillow (45.93%, n=4019); viscoelastic (44.66%, n=2347); foam facial positioner (39.33%, n=105); multilayer adhesive dressing (31.58%, n=449); and the Allen table's own positioner (30.43%, n=7) were applied most frequently.

For all moderate-risk patients in the preoperative period, the most used support surface was the Allen table positioner (69.57%, n=16), followed by the multilayer adhesive dressing (68.35%, n=972); foam facial positioner (60.67%, n=162); viscoelastic (55.32%, n=2907); pillow (54.07%, n=4731); and pyramidal foam (53.79%, n=4682).

In patients with high preoperative risk, viscoelastic, pyramidal foam, and multilayer adhesive dressings were applied. Table 2 shows the surgical position and support surfaces related to preoperative risk on the Munro Scale in patients with and without injuries.

The injury rate was low (0.79%, n=93). By analyzing the areas of injury according to risk and the combination of preventive measures, a potential cause of injury was identified. In patients with low preoperative risk, 23.66% (n=22) did not receive protection in the injured area; 18.28% (n=17) were at risk and there was a failure during positioning; 2.15% (n=2) used an unprotected positioner, causing the injury; and manipulation of the surgical position caused the injury.

In patients with moderate preoperative risk, 54.84% (n=51) did not receive protection in the area of injury; 55.91% (n=52), despite being protected, were at risk and this led to injury; 11.83% (n=11) were injured due to faulty positioning; 5.38% (n=5) used the positioner without protection; and 2.15% (n=2) were injured due to intraoperative manipulation.

In the only high-risk preoperative patient who developed an injury in the iliac region, the following preventive measures were applied: dorsal and cephalic viscoelastic; pyramidal foam in the upper limbs; foam facial positioner; and multilayer adhesive dressing on the trochanter and iliac region. The injury occurred due to risk, despite the application of protection.

Table 3 shows the data on the regions of injury, risk, combination of preventive measures applied, and possible causative agent.

Table 2. Surgical positions and support surfaces based on preoperative risk. São Paulo (SP), Brazil, 2022.

Preoperative Munro Scale risk	Surgical risk and position	Viscoelastic		Pyramidal foam		Facial foam positioner		Allen positioner		Pillow		Multi-layer adhesive dressing
		no injury	with injury	no injury	with injury	no injury	with injury	no injury	with injury	no injury	with injury	no injury	with injury
	Low	2325	25	3989	27	104	16	7		3985	28	443	21
	Supine/Dorsal	1675	10	2913	10	12	2			2886	12	210	2
	Ventral/ Prone	215	9	326	12	88	13	7		332	12	113	14
	Lateral	123	2	133	2	1	0			151	1	42	2
	Lithotomy	312	4	617	3	3	1			616	3	78	3
	Moderate	2882	38	4643	39	162	32	16	1	4692	45	960	33
	Supine/Dorsal	1914	6	3137	9	13	2			3154	11	452
	Ventral/ Prone	274	26	415	24	142	26	15	1	454	27	205	26
	Lateral	240	1	270	1	3	1			289	0	142	1
	Lithotomy	454	5	821	5	4	3	1		795	7	161	6
	High	1	1	1	1		1					1	1
	Lateral	1	1	1	1		1					1	1
	Total	5208	64	8633	67	266	49	23	1	8677	73	1404	55

Table 3. Areas of injury related to low and moderate preoperative risk, preventive measures and causative agent. São Paulo (SP), Brazil, 2022.

Surgical position x Region of injury	Preoperative Munro Scale		Total	Preventive measures applied	Possible causative agent
	Low	Moderate
Supine position	13	13	26
Heels	4	2	6	viscoelastic dorsal, cephalic; pyramidal foam in upper limbs, lower limbs, heels; cephalic pillow, lower limbs, sacral, scapular multilayer adhesive dressing	failure to position, lack of protection
Elbow	1		1	viscoelastic dorsal, cephalic; pyramidal foam in upper limbs and heels; foam facial positioner; lower limb pillow; multilayer adhesive dressing Sacral , Scapular	failure to position
Hand	2	1	3	dorsal viscoelastic, cephalic; lower limb pyramidal foam, calcaneal; foam facial positioner; lower limb pillow, cephalic, sacral, scapular multilayer adhesive dressing	failure to position
Scapula		1	1	viscoelastic dorsal, cephalic; pyramidal foam in heels; lower limb pillow	lack of protection
Face	2	2	4	cephalic pillow; pyramidal foam in upper limbs, heels; lower limb pillow	Intraop movement
Forehead, nose, ear	1	5	6	viscoelastic calcaneus; pyramidal foam in upper limbs and calcaneus; pillow lower limbs, without description of protection	positioner without protection
Occipital	3	1	4	dorsal viscoelastic; cephalic viscoelastic; pyramidal foam in upper limbs, shoulder and heels; lower limb pillow, cephalic	failure to position
Sacral region	1	1	2	no description of protection; pyramidal foam in upper limbs and heels; lower limb and cephalic pillow	lack of protection
Ventral decubitus	14	35	49
Face	5	7	12	viscoelastic chest, supra pubic; pyramidal foam in upper limbs, knees; foam facial positioner; pillow lower limbs; multilayer adhesive dressing Iliac, Facial, Chin, Chest, Knees, without description of protection	lack of protection, risk
Forehead	2	11	13	viscoelastic thorax, supra pubic; pyramidal foam in upper limbs and knees; foam facial positioner; lower limb pillow; multilayer adhesive dressing Iliac, Facial, Thorax; no description of protection	lack of protection, risk
Iliac region		6	6	viscoelastic chest, supra pubic; pyramidal foam knees; foam face positioner; lower limb pillow; multilayer adhesive dressing face, chest, iliac; no description of protection; allen table protectors (face, iliac)	risk
Knee	1	3	4	viscoelastic chest, supra pubic; pyramidal foam in upper limbs, knees and heels; foam facial positioner; lower limb pillow; multilayer adhesive dressing facial, iliac, chest	lack of protection
Chin	2	6	8	no description of protection; viscoelastic chest, supra pubic; pyramidal foam knees; foam facial positioner; lower limb pillow; multilayer adhesive dressing chest, iliac, facial	lack of protection
Ocular region		1	1	viscoelastic thorax, supra pubic; pyramidal foam in upper limbs and knees; foam facial positioner; lower limb pillow; multilayer adhesive dressing iliac, facial, thorax	risk
Penis	1		1	pyramidal foam knees; foam facial positioner; lower limb pillow; multilayer adhesive dressing iliac, facial, chest	failure to position
Chest	3	11	14	viscoelastic chest, supra pubic; pyramidal foam in upper limbs, knees; foam face positioner; lower limb pillow; multilayer adhesive dressing Chest, iliac, chin, zygomatic, forehead, knees; no description of protection; Allen table protectors (face, iliac);	lack of protection, risk
Zygomatic region	5	7	13	viscoelastic chest, supra pubic, knees; pyramidal foam on upper limbs and knees; foam facial positioner; lower limb pillow; multilayer adhesive dressing on face, chin, chest, iliac, knees	positioning failure, risk
Lithotomy	2	2	4
Heels	1		1	viscoelastic dorsal, cephalic; pyramidal foam in upper limbs; cephalic pillow; sacral multilayer adhesive dressing	lack of protection
Shoulder	1		1	dorsal viscoelastic; pyramidal foam in upper limbs; sacral multilayer adhesive dressing	positioner without protection
Ocular edema		1	1	foam facial positioner; sacral multilayer adhesive dressing	risk
Sacral region		1	1	viscoelastic dorsal, cephalic; pyramidal foam in knees	lack of protection
Lateral	4	9	13
Gluteus		1	1	no description of protection	lack of protection
Iliac region	2	2	4	viscoelastic lateral, axillary, upper and lower limbs; pyramidal foam in upper limbs and heels; lower limb and cephalic pillow; multi-layer adhesive dressing trochanter, iliacus	lack of protection, risk
Not described		1	1	dorsal viscoelastic; pyramidal foam in heels; lower limb and cephalic pillow; multi-layer adhesive dressing Sacral, Iliac	risk
Ear	1		1	dorsal viscoelastic; pyramidal foam in upper and lower limbs; cephalic pillow; axillary and trochanter multilayer adhesive dressing	failure to position
Supra pubic region		1	1	lateral viscoelastic; pyramidal foam in upper limbs; foam facial positioner; cephalic pillow; multilayer adhesive dressing sacral, iliac	risk
Chest		3	4	axillary viscoelastic; pyramidal foam in upper limbs; cephalic pillow; multilayer adhesive dressing axillary, sacral, trochanter	lack of protection, risk
Sacral region		1	1	lower limb pillow; sacral multilayer adhesive dressing	lack of protection, risk
Trochanter	1	1	2	no description of axillary viscoelastic protection ; foam facial positioner; cephalic pillow; sacral and supra pubic multilayer adhesive dressing	lack of protection
Total	33	59	92

DISCUSSION

The results showed a low rate of pressure injuries. This may have been due to the risk assessment associated with the application of preventive measures since, with the risk of injury previously identified, support surfaces can be implemented. In this study, the occurrence of injury was statistically significant in patients at moderate and high risk, and in the comparison of support surfaces between the groups with and without injury.

A set of pressure injury prevention measures, recommended by the Association of Perioperative Registered Nurses (AORN),¹² The Joint Commission¹³ and European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance,¹ determines skin assessment, risk assessment, and care planning, considering a systematic risk assessment at defined intervals, with repetition as often as necessary.

In an American study, the implementation of these measures reduced the number of injuries to zero.¹⁴ In another institution, the prospective use of risk assessment and prevention measures in 350 surgical patients resulted in a 60% reduction in pressure injuries.¹⁵

The results of this study showed that the pressure injuries developed by the few patients were potentially caused by the absence of protection in the injured area, a failure during surgical positioning, or the application of an unprotected positioner. Sometimes the nursing team took preventative measures but left pressure points related to that surgical position unprotected.

There is evidence that the majority of perioperative nurses are unaware of institutional protocols, such as risk assessment, skin assessment, and pressure injury prevention information,¹⁶ resulting in the need for staff training. Another study states that personal competence to prevent pressure injuries has a strong correlation with risk identification and injury prevention. There are strong associations between being responsible for the development of pressure injuries and knowledge about risk identification and injury prevention.¹⁷

However, knowledge may not be translated into practice due to barriers such as lack of time, personnel, and adequate equipment.¹⁸ Therefore, actions to overcome these barriers are fundamental to reducing pressure injuries.

Support surfaces have been applied to patients at low, moderate, and high risk. The use of viscoelastics and foams is discussed and implemented in other centers¹⁹ to prevent pressure injuries, although more studies with better comparative evidence are needed. Pillows were used solely for the comfort positioning of the head and lower limbs, rather than to maintain the surgical position like other surfaces.

The use of pillows, rolled towels, sheets, and blankets as positioners is still a clinical practice, but it is considered unsafe, not only because the sheets are made of flammable materials, but also because they were not designed to fit the contours of the body and maintain their shape afterward, tending to flatten under the forces of body weight.²⁰

Multilayer adhesive dressings were more frequently applied to patients at moderate risk, as recommended by the institution's protocol. In a randomized clinical trial on preventing calcaneal injuries in elective surgeries, it was concluded that multilayer silicone dressings are more effective than transparent film in preventing injuries caused by positioning.²¹ Another study, focusing on the forehead and chin, found that these dressings remarkably relieve facial soft tissue loads by more than 50%, providing solid biomechanical evidence to support nursing practice in the application of multilayer silicone dressings.²²

The limitations of this study include the collection of data from a single center. Despite the sample size, the results may not be generalizable to other centers. Additionally, the data comes from medical records, which may have gaps not incorporated into this study.

For clinical practice, this study highlights the importance of perioperative nurses' knowledge and attitudes towards applying preventive measures for positioning injuries. Effective risk assessment and care planning, along with the use of support surfaces, are crucial for reducing the occurrence of pressure injuries.

CONCLUSION

Six support surfaces were identified as effective pressure injury prevention measures, showing significant results when applied according to the level of risk. The study concludes that identifying risk using the Munro scale at different stages of the perioperative period, along with the application of support surfaces for low, moderate, and high-risk patients, was essential in achieving a low occurrence of pressure injuries.

CONFLICT OF INTEREST

Nothing to declare.

REFERENCES

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Correspondence

Cristina Silva Sousa

Email: cssousa@icloud.com

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