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FIRST
CLINICAL DATA WITH A HIGH TECH LOW AIR LOSS MATTRESS
Dr
Maarten J. Lubbers
Pressure Ulcers (bedsores,
decubitus) are a common, but in most cases preventable, problem among
hospitalised patients. An extensive prevalence survey conducted in 43
Dutch acute-care hospitals revealed a mean prevalence of 21.6%.1 Patients
admitted to intensive care units (ICU’s) are at particularly high
risk of developing pressure ulcers. These patients are generally not able
to signal increased tissue pressure and react accordingly, because they
have received analgesics, sedation or muscle relaxants.2,3 The surgery
itself, anaesthesia, inotropics and positive pressure ventilation may
adversely affect the pump action of the heart, leading to reduced blood
circulation in the skin and underlying tissues.1 Incidence and prevalence
studies involving ICU’s are scarce and they report rates ranging
from 1% to 66%.1,2,4,5 The prevalence of pressure ulcers in Dutch ICU’s
is high: in the national prevalence survey it was 28.7%. Patients who
had undergone surgery showed significantly higher prevalence of pressure
ulcers than patients who had not (34.8% ÷ 25.1%). However, this
study was a prevalence survey and cannot conclude from the data whether
the ulcers occurred before or after surgery. Tutuarima et al showed in
their study on pressure ulcers in three ICU’s that 31% suffered
from hospital acquired P.U. Sacrum, ears and heels were most involved:
15%, 12% and 12%, respectively. Buttocks, mouth and back were affected
in 5%, 4% and 4%. Cross tabulation on PU showed no association with gender,
age, post surgery and Apache II. All patients were positioned on active
pressure relief mattresses.
Noise level. Decreasing the noise at 10db, the noise
level will be reduced to 50%.
Extra
protection measures were practised for 80% of the patients. Protection
of the heels and ears were each supplied to 60%, multiple positional turning
and protection of the skin to 43%, and 38%.6 The EPUAP summary report
on the prevalence of pressure ulcers stated that decubitus ulcers afflict
one in five hospital patients. Surprisingly few patients apparently received
fully appropriate interventions. The highest percentage allocated appropriate
preventive care was found in the U.K. However, even in the U.K. fewer
than 10% received fully appropriate preventive care. There is much scope
for the improvement of pressure ulcer care.7
A variety of support surfaces are available for prevention and treatment
of patients with or without pressure ulcers. The supports range from a
plain slab of foam to complex beds. The challenge to the clinician is
to choose the one that best meets the patient’s needs. Support surfaces
are classified according to the Cullum systematic review (Table 1).8,9
Reger reviewed the physiology of soft tissue, shear and pressure-related
injuries and the biomechanical principles of support surface function
to aid the clinician in choosing the most appropriate support. In pressure
ulcers the primary factors are pressure and shear. The secondary factors
include temperature, moisture, applied load duration atrophy and posture.
The quality of any support surface is a function of interface stresses
and the microclimate at the patient-support contact. The clinician has
two excellent technologies for controlling the skin-support surface interface:
Air-Loss and Air-Fluidised.10 The critically ill ICU patient who is at
risk for pressure ulcer development and does not tolerate turning because
of haemodynamic instability or poor oxygenation may benefit from an oscillating
low air loss therapy bed.4 There is enough evidence to advise that patients
who do not get enough turning, lifting and mobilisation must be placed
on pressure redistribution (= reducing/relieving) equipment.11 In these
groups of high-risk patients, high tech devices (e.g., LAL and AF) are
high priorities of research.4,7,8,9 There is very little published evidence
available.9 Disadvantages of these high tech (LAL/AF) devices are the
size, weight, noise and basic user interface.
We report the first clinical data with an improved LAL mattress, which
is lighter, smaller, more user-friendly, and has reduced noise level (Table
2). Two SICU patients were treated (Table 3). Our conclusions (Table 4)
were very positive: this new mattress seems a real improvement, especially
the touch screen and the reduced noise level. We recommend a proper clinical
RCT.
References
1. Bours GJJW, De Laat E, Halfens RJG, Lubbers MJ, Prevalence, risk factors
and prevention of pressure ulcers in Dutch intensive care units. Intensive
Care Med 2001, 27: 1599–1605.
2. Herman LE, Rothman KF, Prevention, care and treatment of pressure (decubitus)
ulcer in intensive care unit patients. J Intensive Care Med 1989, 4: 117–123.
3. Goodrich C, March K, Form ED to ICU: a focus on prevention of skin
breakdown. Crit Care Nurs 1992, Q15:1–13.
4. Peerless JR, Davies A, Klein D, Yu D, Skin complications in the ICU.
Clinics in Chest Med 1999, 20: 453–467.
5. Weststrate JTM, Hop WCJ, Aalberts AGJ, Vreeding AWJ, Bruining HA, The
clinical relevance of the Waterlow pressure sore risk scale in the ICU.
Intensive Care Med 1998, 24: 815–20.
6. Tutuarima JA, Lubbers MJ, Vostermans J, Pressure ulcers: location and
protection measures on three ICU’s of the AMC-Amsterdam, 7th EPUAP
Congress 2003.
7. Clark M, Bours G De Floor T, Summary report on the prevalence of pressure
ulcers, EPUAP Review 2002, 4: 49–57.
8. Cullum N, Nelson EA, Shellon T, Systematic reviews of wound care management.
Health Technology Assessment 2001; 5(9).
9. McInnes E, The use of pressure-relieving devices for the prevention
of pressure ulcers in primary and secondary care. A clinical practise
guideline. J Tissue Viab 2004, 14: 4–23.
10. Reger SI, Validation test for climate control on air-loss support.
Arch Phys Med Rehabil. 2001, 82: 597–603.
11. CBO report, Richtlijn decubitus, 2002, www.cbo.nl
Low-tech devices
• Standard foam mattress.
• Alternative foam mattresses or overlays (for example, high-specification
foam, convoluted foam, viscoelastic, cubed foam). These are comfortable
and aim to redistribute pressure over a larger contact area.
• Gel-fitted mattresses or overlays.
• Fibre-fitted mattresses or overlays.
• Fluid-filled mattresses or overlays.
• Air-filled mattresses or overlays.
High-tech
devices
• Alternating-pressure devices: the patient lies on air-filled sacs,
which sequentially inflate and deflate and relieve pressure at different
anatomical sites for short periods. These devices may incorporate a pressure
sensor.
• Air-fluidised devices: warmed air is circulated through fine ceramic
beads covered by a permeable sheet. These allow support over a larger
contact area.
• Low-air-loss devices: patients are supported on air-filled sacs
inflated at a constant pressure, through which air is able to pass.
• Turning beds or frames (kinetic of profiling beds): beds that
either aid manual repositioning of the patient or reposition the patient
by motor-driven turning and tilting.
2 SICU patients:
• Female, 68 year, 70 kg, 1.65 m
4 x A, Apache II 29,3 days, dead
decubitus grade IV heel
• Female, 41 year, 72 kg, 1.70 m
Guillain-Barré, lung embolus, heparin, G-I bleeding
Apache II 18, 14 days, survived
decubitus grade III, sacrum
Conclusions:
better same worse
Touch screen : 88% 12% 0
Blower unit : 34% 66% 0
Noise : 66% 34% 0
Overall user friendly: 56% 44% 0
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