Discussion
ulcers, skin damage, pain
ADVERSE EVENTS, EVENTS, MINOR, ULCERS
The PENFUP study evaluated the impact of preventive use of HCD compared to the administration of petrolatum in patients admitted to two tertiary hospitals for surgical or medical treatment, at high risk of PU but with intact skin. The results showed no differences in the incidence rate or the efficacy estimates between both interventions in preventing PU. However, they did present an incremental cost with the use of HCD.Regarding the incidence of ulcers acquired in hospitalization (global of 8.7) and the prevalence of the location of the events (sacral region), our results are consistent with those reported in other studies worldwideWe may explain the results based on two statements. First, the capacity or ability to protect the skin by the two products under study is limited and is lower than the level of risk or potential skin damage that the patients have at the time of admission, and that may be related to multiple determinants of health. Second, the patients in both study groups received other preventive interventions in accordance with the clinical practice guidelines (CPG) established in both hospitals (RNAO) in the prevention of UP: repositioning time by schedule and use of pressure reducers (pillows). These interventions promote the mobilization and relief of body weight in some at-risk body areas.About the first aspect, skin protective dressings have been implemented in prevention, and clinical results may vary depending on the manufacturing and properties of their materials. Bioengineering studies have described HCD (frequently used in prevention) components with little biomechanical protective efficacy. It is explained because its modulus of elasticity has a modulus ten times greater than that of the skin (in units of Pascal, kPa), which means that it exerts a more significant internal pressure, tension, and resistance, very different from the thermal characteristics of healthy skin. These items may increase the risk of injury. Bioengineering studies report that the dressings with a more excellent to lesser resemblance to the characteristics of the skin are those based on hydrogel, gels, silicones, gauze foams, and, finally, less protection is observed in hydrocolloid dressingsConcerning the use of petrolatum, the existing evidence in the evaluation of results shows some improvement in the protection of the skin as a barrier in adults hospitalized in Nursing homes in the reduction of skin tears (associated with friction and friction)Related to the second aspect, The studies included in this meta-analysis reported very little evidence about the use of other overlapped additional strategies for prevention during clinical trials superimposed (i.e., repositioning, use of specialized mattresses, or the use of pressure-reducing pillows) that cannot be ignored or avoided (based on no minor ethical issues), just as in our study they were administered to both groups following the usual clinical practice guidelines, probably competing in effectivenessIn addition to the above, patients included in our study were evaluated with high and very high risk with the Braden scale, indicating a high prognosis for developing a PUThe evidence about the impact of the use of dressings in a hospitalized population at risk confirms the existence of uncertainty about the benefit of topical agents and dressings in preventing the incidence of PU. A meta-analysis of data from clinical trials involving more than 3000 patients, in which the effectiveness of the use of dressings, the effectiveness of the use of topical agents, and the use of combining the two types of interventions were explored, did not report evidence of the benefit of the use of HCD or topical agents in the appearance of pressure ulcersThe use of HCD was also evaluated in this study compared to polyurethane dressings in which no differences were observed (1 trial, n = 160, RR 0.58; 95% CI 0.24 to 1.14). The results of benefit in favor of silicone dressings compared to no dressing use were evidenced in a clinical trial in this same study (n = 1247, RR0.25, 95% CI 0.16 to 0.41), especially preventing grade I and grade II PU, but not grade III, indeterminate or deeper.The adverse events that may occur are essential in using these two interventionsIn another way, studies evaluating the cost of PU showed a range of care for each PU between $20,000 and $151,700 USIf nurses or other health providers plan to use an HCD or petrolatum-based skin cream, our results suggest no proven benefit in favor of either intervention. If its use is required, it should place patients at risk in multiple possible areas and not discontinue the rest of the group interventions that can help in prevention. Decision-making about hospital implementation should allow for that HCDs show low effectiveness and high cost. Also, HCD may affect the quality of life of patients when they are removed or changed, producing pain and damage to the skin (with risk of injury). Patients could be consulted before deciding which protection strategy to use. The low level of certainty of the evidence means that additional and better-quality research is needed to advance the evidence for interventions to prevent PU.