Prevent Spine Surgery Pressure Injuries

Neurosurgery-Spine

By: Joyce Black

Published: 8/10/2020

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Tables, padding, pressure sensors and skin assessments protect prone patients during lengthy procedures.


Spine surgery patients placed in the prone position can develop pressure injuries on areas of their bodies without much natural protection. Fortunately, there are plenty of products and practices that can help keep their skin intact during complex cases that typically last longer than two hours.

Efforts to prevent pressure injuries begin with pre-op assessments of the patient's skin integrity. Everyone's body habitus is different, however, so examine patients for potential trouble spots in pre-op. Also make sure they don't have some kind of chest deformity, a prominent set of ribs or have had a mastectomy traits that can increase the risk of pressure injures. Pad these areas as appropriate. In general, focus on protecting a patient's face, chest, chin and ribs.

When assessing patients in pre-op, use the Scott or Munro trigger scales, which help to predict pressure injuries in surgical patients. In addition to these results, the biggest risk factor for pressure injury is the duration of the surgery. Any procedure lasting longer than 2.5 hours increases the likelihood of skin breakdown. Of course, patients with ASA scores of 3s and 4s have a higher risk than those with 1s or 2s — and there's a huge jump in risk between scores of 2 and 3. Operations are often longer for patients with higher ASA scores due to the need for additional time to manage their underlying diseases. In addition, patients who have more comorbid disease often have surgical conditions in later stages requiring more complex and lengthy procedures. However, don't be fooled into thinking that a young healthy person having a multilevel spinal fusion that will take several hours is not at risk — let the estimated time of surgery be your guide.

Patients should be reexamined for pressure injuries in the PACU, even though most don't appear for about 48 hours after a procedure. During the post-op follow-up, you should always ask patients if any deep-tissue pressure injuries have formed. They appear as bruising or manifest as pain in areas of the body exposed to pressure during surgery, so be sure to ask about discomfort in the face, shoulders, ribs and lower legs.

Added protection

TROUBLE SPOTS Protecting the chin, shoulders, elbows and ribs in pre-op or padding the parts of the table where they'll be resting can minimize the risk of pressure injuries.   |  Joyce Black, PhD, RN, CWCN, FAAN

Adhesive dressings and egg crate foam adequately protect sensitive areas such as elbows and shoulders. Also consider fluidized positioning pillows that mold to the part of the body you want to protect. The pillows hold their shape throughout the procedure and are a better option than regular pillows, which gradually compress during the case from the weight of the patient's body.

The first and best thing to do to prevent pressure injuries is to properly pad the surface of the surgical table. Make sure the padding on whatever frame you use is still functional. There should be at least four inches of foam that still has its memory and hasn't worn out. Test the condition of foam padding by pushing your hand into it. If the foam is functional, your handprint will quickly disappear. If the foam is old or worn, the handprint will remain for several minutes.

There are a couple of different types of OR tables that work well for patients in the prone position. Any well-padded table that holds the patient in the jumping jack position allows surgeons to get as close as possible to the patient's spine as they work. Others are designed with an opening to free up space around the abdomen. These tables are needed — especially for individuals with high BMIs — to reduce pressure on the abdomen, blood vessels and liver, thereby making breathing easier for patients and reducing the risk of increased bleeding in the surgical space. The edges of the area in which the abdomen drops into create the potential for pressure injuries, so padding the patient's body where it meets these edges is crucial.

You can also invest in gel pads to place atop your OR tables, mattresses that inflate and deflate during surgery to help relieve pressure from patients' abdominal area, as well as waffle mattresses that have small air pockets and vents in them that prevent moisture from forming on patients' skin to further reduce the risk of pressure injury.

Pressure sensors, some the size of the entire OR table and some as small as four-by-four inches, are available to help you determine where patients are most susceptible for pressure injuries. When patients lay on top of the large device, or when a small one is slipped under them, interface pressure between the body and the surface is mapped on a computer. Hot spots appear as different colors on a monitor. Areas on the patient that appear red or orange are under too much pressure. If they appear yellow or green, there's little to no risk of a pressure injury. When you locate red and orange spots, you can pad the patient in those areas, or place better padding on those parts of the bed.

If a high percentage of your patients return to surgeons' offices with deep tissue injuries a couple of days after their surgeries or report deep tissue issues during post-op calls with nurses, you know improvements must be made to how you protect sensitive areas. In that instance, you can map individual patients before procedures begin to locate and protect their specific hot spots.

Raising awareness

ON THE SURFACE Specialty designed spine tables improve access to the surgical site and can help to protect patients from pressure-related harm.   |  Joyce Black, PhD, RN, CWCN, FAAN

Your clinical educator should make sure staff understand the general risk factors that contribute to pressure injures and provide constant reminders about injuries that can occur while patients are in the prone position. Education only takes you so far, however. If you become aware of a prevalence of pressure injuries and educate staff about them, preventative measures should be operationalized in your facility's documentation system.

Photographs of bodies in all the major surgical positions can be embedded in your facility's electronic medical record, along with the pressure-injury hot spots for each position. Nurses can plug the procedure that's about to take place into the medical record and have the appropriate image pop up, along with the probable pressure ulcer locations for that position. If the patient's skin condition in those areas is poor, extra padding can be applied for additional protection.

Hospitals that track pressure injuries show that 40% originate in the OR. That information often gets lost because injuries often don't appear until well after surgery. While that percentage might not be as high in the outpatient arena, your staff can't assume there's no risk of pressure injuries occurring when patients are placed in the prone position. Assumptions like that make you ripe for lawsuits. Not padding a patient's face is not a good defense in a case filed by a patient who decided to have an elective back surgery and walked out with a visible wound on their chin. OSM

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