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Catherine Milne and colleagues present the findings of their review, ccna2@juno.com

Deep tissue pressure injury (DTPI) is a serious form of pressure injuries. The condition remains invisible for up to 48 hours and then progresses rapidly to full-thickness skin and soft tissue loss. Many other conditions that lead to purple skin can be misidentified as DTPI, making the diagnosis difficult at times. A thorough history exploring exposure to pressure is imperative.

An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning-related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.

Deep tissue injury (DTI) can be difficult to diagnose because many other skin and wound problems can appear as purple skin or rapidly appearing eschar. The diagnosis of DTI begins with a thorough history to account for times of exposure to pressure, such as ‘time down’ at the scene or time during which the patient was flat and could not respond. Patients with light skin tones present with classic skin discolouration of purple or maroon tissue, a defined border around the area of injury, and often surrounding erythema is evident. Persistent erythema and hyperpigmentation, rather than blanching, should be used to determine pressure injury in dark skin tone patients. Differential diagnosis includes stage 2 pressure ulcers, incontinence‐associated dermatitis, skin tears, bruising, haematoma, venous engorgement, arterial insufficiency, necrotising fasciitis and terminal skin ulcers. Many skin problems can also have a purple hue or rapidly developing eschar, and a working knowledge of dermatology is needed.

Pressure ulcers occur with some frequency in the elderly, debilitated population in long-term–care facilities. Pressure ulcers cause morbidity and mortality and, by virtue of breaking the integumentary barrier, predispose to skin and soft-tissue infections. The latter often are deep and require lengthy medical and surgical therapy. Prevention depends on avoidance of pressure, as well as providing adequate nutrition and meticulous skin care.

Although pressure ulcer (PrU) development is now generally considered an indicator for quality of care, questions and concerns about situations in which they are unavoidable remain. Considering the importance of this issue and the lack of available research data, in 2010 the National Pressure Ulcer Advisory Panel (NPUAP) hosted a multidisciplinary conference to establish consensus on whether there are individuals in whom pressure ulcer development may be unavoidable and whether a difference exists between end-of-life skin changes and pressure ulcers. Thirty-four stakeholder organizations from various disciplines were identified and invited to send a voting representative. Of those, 24 accepted the invitation. Before the conference, existing literature was identified and shared via a webinar. A NPUAP task force developed standardized consensus questions for items with none or limited evidence and an interactive protocol was used to develop consensus among conference delegates and attendees. Consensus was established to be 80% agreement among conference delegates. Unanimous consensus was achieved for the following statements: most PrUs are avoidable; not all PrUs are avoidable; there are situations that render PrU development unavoidable, including hemodynamic instability that is worsened with physical movement and inability to maintain nutrition and hydration status and the presence of an advanced directive prohibiting artificial nutrition/hydration; pressure redistribution surfaces cannot replace turning and repositioning; and if enough pressure was removed from the external body the skin cannot always survive. Consensus was not obtained on the practicality or standard of turning patients every 2 hours nor on concerns surrounding the use of medical devices vis-à-vis their potential to cause skin damage. Research is needed to examine these issues, refine preventive practices in challenging situations, and identify the limits of prevention.