Using Air Cushion in the Prevention of Occipital Pressure Ulcer in Children Undergoing Heart Surgery

Background & Aims:The prevalence of congenital heart (CHD) defects is about 6-8 per 1000 live births, more than half of which will require surgery during the first year of life. In Iran, the rate of diagnosis of cardiovascular diseases is increasing, so that the mortality caused by them in the intervals of 1989 to 2006 has increased from 27 to 30%. CHD accounts for almost one-third of all congenital anomalies. Today, CHD has become one of the health-threatening problems and one of the physical debilitating factors for children in Iran and is considered as one of the main causes of death in the first year of life. Surgical procedures, like any other treatment, have side effects. One of the significant complications following surgery is pressure ulcers. This complication is caused by the patient being in a relatively stable position, which health care providers perform to access the surgical site, control the patient's respiratory status, access the peripheral vein, and monitor devices. Static and dynamic mattresses have been used in medical centers to reduce pressure in the prevention of pressure ulcers. In this study, an attempt was made to use a dynamic mattress designed to fit the size and weight of infants and children undergoing open heart surgery. Materials & Methods: This study was a randomized clinical trial in which the participants of this study were 135 children undergoing open heart surgery with aged of 0 to 12 years referred to two heart centers in Tabriz and Tehran cities. They were included in the study by continuous sampling during one year (September 2016- September 2017). The participants were randomly assigned to two groups of experimental and control. The group of intervention used air cushions that has an air inlet and outlet pump and is filled and emptied by a pump alternately and creates 3 to 4 cm waves. This air cushion with dimensions of 40 by 30 cm waterproof and anti-allergy air cushion covered with a cotton cover that has a patent with international classification in Iran (A61G 7/00; A47C 27/08). In the control group, based on the routine care of each hospital, a protective gel was used under the head. Assessment for each sample included the following steps: (1) before the operation (2) after the operation (inside the operating room), (3) the first day after the operation (4) the second day after the operation (stages 3 and 4 the child's head was assessed in the intensive care unit).  In the present study, data collection tools include: 1. Checklist of the National Pressure Ulcer Advisory Panel (NPUAP), in order to assess the condition of the skin on the occurrence of pressure ulcer and the completed the checklist, wound was assessed and recorded in 4 steps. 2. The Braden Q Scale was modified and developed on the basis of the Braden Scale by Curley et al. for predicting pediatric pressure ulcer especially in PICUs. This scale has been used in the population of children under 6 years of age in PICUs. This scale reflects the needs of the child's patient and it has 7 subsets, included sensory perception, moisture, activity, mobility, nutrition, friction and oxygenation. Oxygenation has been added to the Braden Scale for infants . The score range of this questionnaire is between 7 and 28 and low scores indicate high risk and high scores indicate low risk that scores 22-28 indicate low risk, 17-21 indicates moderate risk and 16 and less, the risk is high. In the present study, the reliability of the Braden Q scales was confirmed using internal consistency. Cronbach's alpha coefficient was 0.78 for Braden Q scale. Also, the correlation coefficient in 20 samples in simultaneous observation between researcher and two different nurses were more than r = 0.70. Face validity and content validity of the Braden Q were assessed by 10 faculty member nurses and surgeons. The data were analyzed using SPSS software (version 20.0; SPSS), descriptive statistics (mean and standard deviation) and inferential statistics (Chi-square, independent and paired t-test, Fisher's exact test, Mann-Whitney, analysis of covariance). Results: A total of 135 children were included in the study, including 69 children in the intervention group and 66 children in the control group. In the control group 4 children were excluded from the study. Findings of this study showed that more than half of the children participating in this study were girls in the intervention and control groups. More than 85% of mothers and more than 65% of fathers had a diploma in the two groups of intervention and control groups. Most of fathers had jobs and mothers were housewives. In the intervention group, the most common disease was Transposition of the Great Arteries (22%), and in the control group, Tetralogy of Fallot (33.9 %). Result of present study showed that the control and intervention groups were homogeneous in terms of demographic and clinical characteristic.  The incidence of postoperative pressure ulcers in the control group was 38.7%, the first day after surgery 71% and the second day after the surgery, it reached 67.7%. The results of Cochran's test showed that the incidence of pressure ulcers did not differ significantly over time in the control group. While in the intervention group, none of the participants in all postoperative periods, on the first day, on the second day after surgery, did not observe occipital pressure ulcer. Numerical index of predictive dimensions of pressure ulcer in the control and intervention groups, showed a significant difference in sensory perception before surgery between the two groups (P = 0.004). By controlling the confounding effect, the results of analysis of covariance ( ANCOVA) showed that there was a significant difference between the two groups in the periods after the surgery until the second day of surgery (P <0.05). Sensory perception in the times after the surgery and the first day of surgery in the intervention group was significantly lower than the control group, while on the second day of surgery the opposite was observed. There was a significant difference between the two groups in terms of activity after surgery and the second day of surgery (P <0.05). Activity on the day after surgery in the intervention group was significantly lower than the control group and on the second day of surgery was the opposite. There was a significant difference in mobility before surgery between the two groups (P = 0.001). However, the results of ANCOVA showed that there was a significant difference in mobility between the two groups only after the intervention (P = 0.02) so that the mobility in the intervention group was significantly lower than the control group. There was a significant difference in moisture before surgery between the two groups (P = 0.022).The results of ANCOVA showed that there was a significant difference between moisture between the two groups only after the intervention (P = 0.001). The moisture score in the intervention group was significantly higher than the control group. In terms of friction, there was no significant difference between the intervention and control groups in any of the studied times (P <0.05). There was a significant difference between the two groups in terms of nutrition before surgery (P = 0.003). The results of ANCOVA showed that there was a significant difference between the two groups only during the first day of surgery (P = 0.02). Nutrition in the intervention group was significantly lower than the control group. Also, there was no significant difference between oxygenation before surgery and after the surgery. The results showed that the difference between the two groups in all three times was significant in terms of oxygenation (P <0.05). In all three times, oxygenation was significantly higher in the intervention group than the control group. Furthermore, the results of independent t-test showed that there was no significant difference between the scores of pressure ulcers in the preoperative times between the intervention and control groups (P <0.05), but after the surgery and the second day of surgery, the scores of pressure ulcers in the intervention group were significantly more than the control group (P = 0.002). This means that the pressure ulcer scores in the intervention group were better than the control group at the desired times. Conclusion: The results showed that the use of air cushion appropriate to the size and weight of infants and children is a suitable equipment to prevent occipital pressure ulcer in children undergoing open heart surgery compared to routine methods for placing the head during long-term surgery in two hospitals. Therefore, it is recommended that air cushions appropriate to the age and size of children be used to prevent pressure ulcers in the back of the head and the consequences of this complication in children undergoing long operations, including open heart surgery.