#1 - Prophylactic sacral dressings
Updated: Feb 16, 2020
Effectiveness of prophylactic sacral protective dressings to prevent pressure injury: A systematic review and meta-analysis
P. Fulbrook, V. Mbuzi and S. Miles / International Journal of Nursing Studies 100 (2019) 103400
I decided to examine the article, Effectiveness of prophylactic sacral protective dressings to prevent pressure injury: A systematic review and meta-analysis, because it was published just after the National Pressure Injury Advisory Panel (NPIAP, formerly NPUAP) released the 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines. Does this meta-analysis agree with the latest NPIAP recommendations?
The aim of the meta-analysis was to investigate the strength of research evidence for the prophylactic use of sacral protective dressings to prevent pressure injury. The review was conducted using the Cochrane guidelines. It looked at randomized controlled trials that were performed between 2008 and 2019 and published in English. There were three reviewers involved in data extraction and review. The primary outcome measure was the incidence of sacral pressure injury. For this meta-analysis, intention to treat data was used, and included study data was extracted and adjusted as needed.
A total of 557 studies were retrieved with 321 duplicates being excluded. For the final review, six studies met the criteria for inclusion: four studies trialed the Mepilexâ Border Sacrum five-layer foam dressing, one study trialed the Allevyn Lifeâ Sacrum multi-layered hydrocellular foam dressing, and one study trialed the Allevyn Gentle Borderâ multi-layered hydrocellular foam dressing coated with a silicone gel adhesive.
The authors felt that the risk of bias across all the studies generated ‘some concerns’ on the scale of ‘low risk’, ‘some concerns’, and ‘high risk’. Only one study was individually felt to be at ‘high risk’ of bias due to the lack of blinding of the assessors. When per-protocol analyses were reported, the authors recalculated the incidence using intention to treat samples.
Across all the studies, a total of 1872 participants were randomized, 895 in the intervention group and 977 in the control group. The overall relative risk was 0.30, p < 0.0001, indicating that the intervention decreased the risk of sacral pressure injury by 70% with significant effect size. The absolute risk reduction was 5.6%, and the number needed to treat to prevent one pressure injury was calculated at 18.0.
A sub-group meta-analysis was performed on the intensive care studies. There were three studies with a total of 877 participants, 439 in the intervention group and 438 in the control group. The intervention group had a relative risk of 0.17, p = 0.001, decreasing the risk of sacral pressure injury by 83%. The absolute risk reduction was 4.6%, and the number needed to treat to prevent one pressure injury was 21.9.
Sub-group meta-analysis was also conducted on the four studies that implemented the Mepilexâ Border Sacrum dressing. A total of 1442 participants were randomized with 682 in the intervention group and 760 in the control group. There was relative risk of 0.32, p = 0.01, with a decrease in the development of sacral pressure injury of 68% in this sub-group. The absolute risk reduction was 3.5%, and the number needed to treat to prevent one pressure injury was 28.3.
My interpretation: Overall, this meta-analysis demonstrated a statistically significant overall reduction in pressure injury of 70% with the use of a prophylactic sacral protective dressings. Statistical analysis showed significant confidence. Furthermore, the study showed that patients in the intensive care unit, which can be assumed to be at higher risk, showed an even greater risk reduction of 83%. Original clinical practice guidelines published by the NPUAP in 2009 and 2014 under the Prevention: Emerging Therapies section stated, “Consider applying a polyurethane foam dressing to bony prominences (e.g., heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear.” The most recent version that was released in November 2019 moved the recommendation from the emerging therapy section to the preventive skincare section stating, “use a soft silicone multi layered foam dressing to protect the skin for individuals at risk of pressure injury.” Thus, we can see that the meta-analysis supports the latest NPIAP recommendation.
There are two issues which need further clarification for the implementation of these recommendations, however. First, at what level of risk for pressure injury should a patient be identified as benefiting from this intervention. The meta-analysis did show that patients in the intensive care unit, presumed to be at higher risk, demonstrated a greater reduction in pressure injury formation than the overall study population. However, further studies will need to be performed to determine at what level of risk this intervention should be implemented.
Second, this meta-analysis did not discuss the stage or depth of the injuries that were found in any of the studies. As a consequence, we cannot assume that prophylactic sacral protective dressings are effective in decreasing the risk of all pressure injuries. Based on my experience, I would expect that prophylactic sacral protective dressings of this type would be beneficial in decreasing the risk of pressure injuries due to friction and shear, meaning stage one and stage two injuries. However, it seems less likely that sacral protective dressings would be effective in decreasing the risk of deep pressure injuries such as stage three, stage four, deep tissue injury, and unstageable pressure injuries. Further studies will need to be performed to determine if these prophylactic sacral protective dressings are effective in preventing these more severe pressure injuries.