Prevalence and factors associated with pressure injury in patients undergoing open heart surgery: A systematic review and meta‐analysis

Abstract

Pressure injuries (PIs) are one of the major and costliest medical problems with severe implications for patients. Cardiovascular surgery patients are at the higher risk of developing surgery‐related PIs. So this study was conducted with the aim of investigating the prevalence and factors associated with PIs in patients undergoing open heart surgery. We identified articles through electronic databases such as Web of Science, Scopus, PubMed, ProQuest; and Persian Databases: SID, Magiran and Irandoc without restriction on language or publication period (from inception through June 2022). Finally, 17 studies that fulfilled eligibility criteria were included in final systematic review and meta‐analysis. Data analyses were conducted using STATA version 14. The pooled prevalence of PI in patients undergoing open heart surgery was 24.06% (95% CI: 17.85–30.27). High heterogeneity was observed across the included studies (I ² = 96.0, P < 0.000). The prevalence by gender was reported as 25.19% (95% CI: 13.45–36.93) in men and 33.36% (95 CI%: 19.99–46.74) in women. The result showed there was statistically significant association between PI and Female sex (Pooled Est: 1.551, 95% CI: 1.199–2.006, z = 3.345, P = 0.001), diabetes (Pooled Est: 1.985, 95% CI: 1.383–2.849, z = 3.719, P = 0.000), advanced age (SMD: 0.33 years; 95% CI: 0.09–0.57), Duration of surgery (SMD: 0.47; 95% CI: 0.19–0.75) and preoperative serum albumin level (SMD: 0.56; 95% CI: 0.14–0.98). The relatively high PIs incidence among patients undergoing open heart surgery suggests that typical PI prevention methods are insufficient for this population. Targeted prevention measures must be developed and implemented.

1. INTRODUCTION

Pressure injuries (PIs) are one of the major and costliest medical problems with severe implications for patients. The National Pressure Ulcer Advisory Panel (NPUAP) defines this wound as a disorder of localised damage to the skin and/or underlying soft tissue usually over a bony prominence or related to medical or other devices. Prolonged pressure on a localised area of tissue causes the occlusion of blood flow, preventing the supply of nutrients and oxygen to the tissue, and resulting in ischemia and reperfusion injury. This leads to cell obliteration and eventually tissue death. ¹

On April 13, 2016—The term “pressure injury”(PI) replaces “pressure ulcer” in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System according to the NPUAP. ²

PU makes a significant independent contribution to the excess patients' length of hospitalisation. ³ The patients also must pay a significant additional cost for PU treatment. ⁴ Beyond these problems, PU is associated with a higher risk of mortality. ⁵

PIs are a common side effect of many high‐acuity surgeries, and the uniqueness of the cardiac surgery population affords a higher risk of skin breakdown compared with most other surgical specialties. Literature suggests that PIs are a major comorbid event due to cardiac surgery, and that cardiac surgery itself is a risk factor for skin breakdown. ⁶ The incidence of PIs among cardiac surgery patients is variable according to the literature. One study stated that the pooled incidence of PIs among cardiac surgery patients was 18%, ⁷ whereas another study cited an incidence as high as 29.5%. ⁸

Because prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of PIs prevention protocols and although many researchers have been working to understand the risk factors which contribute to PIs development, the prevalence and risk factors of PIs in cardiac surgery patients have not been fully identified yet. So this study was conducted with the aim of investigating the prevalence and factors associated with PIs in patients undergoing open heart surgery.

2. MATERIAL AND METHODS

2.1. Search strategies

We conducted a systematic review, prospectively registered on PROSPERO (ID: CRD42022350343). This systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. ⁹ We organised the research question according to the “PICO” format which was: What are the prevalence and associated factors of pressure injury in patients undergoing open heart surgery? Our systematic review was conducted by reviewing the literature in electronic databases such as Web of Science, Scopus, PubMed, ProQuest, Science Direct; and Persian Databases: SID, Magiran, and Irandoc without restriction on language or publication period (from inception through June 2022) for cross‐sectional, cohort, and case–control studies. Medical Subject Heading (MeSH) and non‐MeSH keywords were used in the search strategy based on our research question: “Thoracic Surgery,” “Coronary Artery Bypass,” Embolectomy, “Heart Surgery,” “Cardiac Surgery,” “Cardiac Surgical Procedure,” “Heart Transplantation,” “Cardiac Valve Annuloplasty,” “Pressure Ulcer,” Bedsore, “Pressure Sore,” “Decubitus Ulcer” and “pressure injury”. Additional searches were conducted on Google Scholar and in grey literature sources such as conferences and government websites. The reference lists of full‐text articles were also examined.

2.2. Study selection

From the retrieved results, two researchers screened all abstracts to verify potentially relevant articles for this review. Then, the full text of the studies was independently assessed to verify articles that were qualified to be included. Any disagreement encountered was settled by discussion. In this review, the inclusion criteria were as follows: observational studies (cross‐sectional, case–control, or cohort study); and studies reporting the prevalence and associated factors of PIs in patients undergoing open heart surgeries (≥16 years of age).

The exclusion criteria were: reviews, editorials, letters, and abstracts, lack of addressing the associated factors for the incidence of pressure Injuries, being a duplicate, and low quality according to the Newcastle‐Ottawa scale.

2.3. Data extraction and synthesis

Data were extracted by two researchers using a prespecified form. These data included the first author's last name, publication year, Journal name, country, study design, sample size, participants' characteristics (eg, gender, mean age, and weight), prevalence and associate factors of PIs, etc.

2.4. Data analysis

Articles published about the prevalence and factors associated with pressure injury in patients undergoing open Heart surgery were retrieved and the variance of each study was calculated using the binomial distribution formula and the weight for each study was equal to the reciprocal of the variance. Statistical heterogeneity in the results was calculated by Q statistics (P < 0.05 considered statistically significant) and quantified using I ² statistics Inverse variance index (I ²) A value of I ² indicating 25%, 50%, or >75% heterogeneity was considered as low, moderate, or high heterogeneity, respectively. ¹⁰ If moderate or high heterogeneity was confirmed, we utilised a random effects model to pool outcomes. Conversely, if low heterogeneity was confirmed, we utilised a fixed effects model. ¹¹ Publication bias was assessed using Egger's linear regression tests. ¹² Data analysis was performed using the Stata software (version 14). For analysis, a P‐value <0.05 was considered significant.

2.5. Quality assessment of the studies included

The Newcastle‐Ottawa Scale (NOS) was used for assessing the quality of studies. ¹³ This scale has four items that examine selection categories, one that examines comparability, and three items that examine outcome (cohort studies) / Exposure (case–control studies) categories. Each item is awarded a maximum of one star within the selection and outcome/Exposure categories. A maximum of two stars can be given for comparability. Studies scoring _7 were judged to be of good quality, 5–6 as fair quality, and <5 as poor quality. Two researchers (Taghiloo, H. and Davoudian, A.) independently judged the studies for risk of bias. Any discrepancies encountered were settled by discussion.

3. RESULTS

3.1. Study selection

The PRISMA selection process is shown in Figure 1. A total of 942 studies were retrieved through database searches. After the removal of duplicates, we reviewed the title and abstract of 538 relevant studies. Of these articles, 504 were excluded, leaving 34 articles for full‐text review (2 articles full‐text were not available.). A total of 15 articles were excluded for the reasons described in Figure 1, which finally left 17 articles for the meta‐analysis.

FIGURE 1.

Screening flowchart showing the selection of qualified articles according to the PRISMA statement

3.2. Characteristics of the included studies

The characteristics of the included studies are described in Table 1. The sample size of the studies ranged from 47 to 351, with a total of 3037 patients. The mean ages of the study populations ranged from 48.2 to 67.2 years and the number of PIs cases ranged from 9 to 109, with a total of 654.

TABLE 1.

Characteristics of reviewed studies

R.N.	Study	country	Study design	Sample size, N		Patient without PIs		Patient with PIs		Prevalence (95% CI)
				Total	Mean Age ± SD	Total	Mean Age ± SD	Total	Mean Age ± SD	P%	UL	LL
16	Cai et al (2021)	China	Prospective Cohort Study	149		112	48.2 ± 18.3	37	54.7 ± 15.0	24.83	31.77	17.89
17	Shih et al (2020)	Taiwan	Prospective study	47	57.3 ± 11.4	37	58.1 ± 12.1	10	54.4 ± 8.1	21.28	32.98	9.58
18	Chen et al (2020)	China	Retrospective Cohort Study	214	51.2 ± 12.0	171	51.3 ± 12.2	43	50.8 ± 11.4	20.09	25.46	14.72
24	Senmar et al (2017)	Iran	Cross‐Sectional	82	60.93 ± 10.52	51		31		37.80	48.30	27.31
21	Lu et al (2017)	China	Prospective Cohort Study	149		112	48.2 ± 18.3	37		24.83	31.77	17.89
22	Azimian et al (2017)	Cross‐Sectional	Cross‐Sectional	82	60.93 ± 10.52	55	57.70 ± 10.46	27	67.51 ± 7.10	32.93	43.10	22.76
19	Shokati et al (2016)	Iran	Prospective study	70	63.4	38	65.7 ± 12.4	32	66.9 ± 11.4	45.71	57.38	34.04
20	Ramezanpour et al (2016)	Iran	Prospective Cohort Study	249	62.36 ± 10.38	169		80		32.13	37.93	26.33
25	Shen et al (2015)	China	Retrospective study	239		194		45		16.14	20.41	11.87
26	Alizade et al (2012)	Iran	Cross Sectional	333	57 ± 13	263		70		21.02	25.40	16.64
27	An exploratory	Brazil	Exploratory, descriptive cohort study	182	63	146		36		80.22	25.57	13.99
15	Schuurman et al (2008)	Netherlands	Prospective Cohort Study	204	68.1 ± 9.6	95	67.2 ± 9.3	109	70.4 ± 9.9	53.43	60.28	46.59
28	Sewchuk et al (2006)	Use	Retrospective study	50	66.98	41		9	72 ± 11.34	18.00	28.65	7.35
14	Pokorny et al (2003)	USA	Interrupted time series	351		327		24		6.84	9.48	4.20
29	Thomas et al (1999)	USA	Prospective Cohort Study	163		152		11		20.37	10.60	2.90
30	Lewicki et al (1997)	USA	Retrospective study	337	62	321		16		4.75	7.02	2.48
23	Papantonio et al (1994)	USA	Prospective study	136	61.9	99	59.7 ± 14.0	37	67.9 ± 9.6	27.21	34.69	19.73

Abbreviations: R.N., reference number; PIs, pressure injuries; SD, standard deviation; P, prevalence; UL, upper limit; LL, lower limit; CI, confidence interval.

3.3. General prevalence of pressure injury

The prevalence of pressure injury was from 4.75% to 53.4% among all studies. The pooled prevalence of Pressure Injury was 24.06% (95% CI: 17.85–30.27). High heterogeneity was observed across the included studies (I ² = 96.0, P < 0.000) (Figure 2).

FIGURE 2.

Forest plot of the pooled prevalence of pressure injury in patients undergoing open heart surgery

3.3.1. Prevalence of pressure injury by gender

The minimum prevalence of PIs was reported as 4.5% in men in the study by Pokorny et al conducted on a sample of 222 men, ¹⁴ and its maximum was reported as 45.74% in the study by Schuurman et al, which was conducted on a sample of 129 men. ¹⁵ In the present study, the review of the eight articles that examined a total of 819 men showed the prevalence of PIs is 25.19% (95% CI: 13.45–36.93) in men. ^{14 , 15 , 16 , 17 , 18 , 19 , 20 , 21} The minimum prevalence of PIs was reported as 10.85% in women in a study by Pokorny et al conducted on a sample of 129 women, ¹⁴ and its maximum was reported as 66.67% in a study by Schuurman et al conducted on a sample of 75 women. ¹⁵ In the present study, the review of the eight articles that examined a total of 995 women showed the prevalence of ulcers to be 33.36% (95% CI: 19.99–46.74) in women. ^{14 , 15 , 16 , 17 , 18 , 19 , 20 , 21}

3.4. PIs risk factors

A summative list of risk factors was compiled based on the findings from each of included studies (Table 2). Five unique risk factors were identified. Advanced age (P = 0.007), female sex (P = 0.005), diabetes mellitus (P = 0.002), duration of surgery (P = 0.018), and intraoperative serum albumin (P = 0.050) were significantly associated with PIs.

TABLE 2.

Associated risk factors of PIs, mentioned in included studies

R. N.	Study	Associated factors	Insignificant factors
16	Cai et al (2021)	Duration of surgery, patient weight, cardiopulmonary bypass duration, perioperative corticosteroid administration, patient age, disease category	Gender, use of intraoperative vasoactive agents, and use of postoperative vasoactive agents
17	Shih et al (2020)	An extreme body mass index (BMI) and Operation time	—
18	Chen et al (2020)	The presence of diabetes (P = 0.000) and hypertension (P = 0.041), CPB duration (P = 0.041), and the use of vasoactive drugs (P = 0.007)	Age (P = 0.818), weight (P = 0.471), sex (P = 0.705), preoperative haemoglobin level (P = 0.147), disease category (P = 0.737), operative time (P = 0.229), blood loss (P = 0.565)
24	Senmar et al (2017)	Average diastolic blood pressure on the first day (P = 0.04), the mean central venous blood pressure on the second day (P = 0.01), mean heart rate on the second day (P = 0.04), age (P = 0.000), duration of hospitalisation in a special section (P = 0.002), presence of diabetes (P = 0.04), cardiac surgery (P = 0.01), smoking (P = 0.000) and the pump during surgery (P = 0.03)	Age and the hospitalisation time in the section
21	Lu et al (2017)	The patient's age, disease category, surgery duration, and perioperative corticosteroids (P < 0.10)	Patients' gender, weight, smoke status, diabetes, perioperative albumin levels, cardiopulmonary bypass duration, postoperative mechanical ventilation duration, vasoactive agents intraoperatively and postoperatively (P > 0.10)
22	Azimian et al (2017)	The mean of CO2 of arterial blood pressure in the fourth day (P = 0.04), smoking (P = 0.000), age (P = 0.000) and length of ICU stay (P = 0.002)	Mean oxygen saturation, mean arterial oxygen pressure, the average oxygen content of the blood, the average fraction of inspired oxygen, and the body temperature.
19	Shokati et al (2016)	Lower Braden Scale score (P = 0.001), diabetes (P = 0.01), hypertension (P = 0.001), NPO time after surgery (P = 0.006), mean time of surgery (P = 0.007), mean time of need to mechanical ventilation after surgery (P = 0.003), low ejection fraction (P = 0.006) and lower level of haemoglobin after surgery (P = 0.012)	—
20	Ramezanpour et al (2016)	Age (more than 70 years) (P = 0.002), history of renal disease (P = 0.007), acidosis during surgery (P = 0.053), wetness and moisture of the skin during surgery (P = 0.020), use of inotropic after surgery (P = 0.000), and acidosis after surgery (P = 0.003).	Gender (P = 0.097), history of diabetes (P = 0.114), history of hypertension (P = 0.285), history of high cholesterol (P = 0.143), diastolic pressure less than 60 mmHg during surgery (P = 0.171) and inotrope use during surgery (P = 0.153)
25	Shen et al (2015)	Length of surgery (P = 0.003). the patient's age, disease category, and corticosteroids (P < 0.05).	The length of cardiopulmonary bypass (P = 0.830). The patients' gender, weight, intraoperative and postoperative vasoactive agents (P > 0.05).
26	Alizade et al (2012)	Duration of surgery, surgical positions, pressure over a bony prominence	—
27	Carneiro et al (2011)	—	—
15	Schuurman et al (2008)	—	Duration of surgery
28	Sewchuk et al (2006)	Age greater than 60, more than three comorbidities, time on OR bed	—
14	Pokorny et al (2003)	Age, sex (female), and heart failure (P = <0.001, 0.02, and 0.02, respectively), Braden score day 2 to 5 after surgery, and time from admission to surgery and from admission to hospital discharge	—
29	Thomas et al (1999)	Older age (68 years versus 62 years, P = 0.007), female sex (57% versus 28%, P = 0.001), diabetes (57% versus 33%, P = 0.005), and longer pump time (129 min versus 114 min, P = 0.009)	—
30	Lewicki et al (1997)	Greater comorbidity; lower haemoglobin, haematocrit, and serum albumin levels; and the presence of diabetes mellitus, the time required to return to preoperative body temperature, being turned only once a day, presence of an Intraaortic balloon (eg, IABP)	—
23	Papantonio et al (1994)	Age, preexisting respiratory disease, diabetes mellitus, reduced haematocrit, albumin less than 3/6 g/dL, ecchymosis, OR time	—

3.4.1. Association between PIs and the patients' age

Eight studies were selected for meta‐analysis to observe the association between PIs and the age of the patients. ^{15 , 16 , 17 , 18 , 19 , 21 , 22 , 23} We used a random effects model for these studies because of the heterogeneity between them (I ² = 64.0%, P = 0.007). The results showed that advanced age was a risk factor for PIs in patients undergoing open heart surgery (SMD: 0.33 years; 95% CI: 0.09–0.57) (Figure 3).

FIGURE 3.

Forest plot of the association between pressure injury patients' age

3.4.2. Association between PIs and patient's gender

To show the association between PIs and the sex of patients, eight studies were selected for meta‐analysis. ^{14 , 15 , 16 , 17 , 18 , 19 , 20 , 21} The result showed there was a statistically significant association between PIs and Female sex (Pooled Est: 1.551, 95% CI: 1.199–2.006, z = 3.345, P = 0.001) (Figure 4). The Egger's test showed no statistically significant publication bias (P = 0.096) at 5% significant level.

FIGURE 4.

Forest plot of the association between PIs and female sex

3.4.3. Association between PIs and diabetes mellitus

Five studies assessed the association between PIs and diabetes. ^{18 , 19 , 20 , 21 , 30} The result showed there was a statistically significant association between PIs and diabetes (Pooled Est: 1.985, 95% CI: 1.383–2.849, z = 3.719, P = 0.000), (Figure 5).

FIGURE 5.

Forest plot of the association between PI and diabetes mellitus

3.4.4. Association between PIs and duration of surgery (minutes)

Six studies assessed the association between pressure injury and duration of surgery. ^{15 , 16 , 17 , 19 , 21 , 23} We used a random effects model for these studies because there was heterogeneity between them (I2 = 63.5%, P = 0.018). The results showed the duration of surgery was a risk factor for PIs in patients undergoing heart surgery (SMD: 0.47; 95% CI: 0.19–0.75) (Figure 6).

FIGURE 6.

Forest plot of the association between PIs and surgery duration (min)

3.4.5. Association between PIs and the preoperative serum albumin (mg/dL)

To show the association between PIs and serum albumin, three studies were selected for meta‐analysis. ^{21 , 23 , 30} We used a random effects model for these studies because there was heterogeneity between them (I ² = 66.6%, P = 0.050). We found that perioperative albumin level is an independent risk factor for PIs in cardiac surgical patients (SMD: 0.56; 95% CI: 0.14–0.98) (Figure 7).

FIGURE 7.

Forest plot of the association between PIs and Preoperative serum albumin level (mg/dL)

3.5. PIs location (parts of the body)

A summative list of body sites which is at higher risk of PIs development, mentioned in included studies, showed in Table 3. Most of the studies' results showed that the common body sites of PIs are the sacrum, coccyx, buttocks, and heels.

TABLE 3.

PIs location (parts of the body)

R.N.	Study	PIs location (body site)
18	Chen et al (2020)	Sacrum and coccyx (50.8%), heels (23.0%), elbow (16.4%), and other (9.8%).
19	Shokati et al (2016)	Buttocks (59%)
25	Shen et al (2015)	Sacrum and coccyx (50.9%), heels (22.8%), ischial tuberosities (10.5%), and other sites (15.8%)
26	Alizade et al (2012)	Buttocks (97%), ear (1.5%), sacrum (1.5%)
27	Carneiro et al (2011)	Sacrum and coccyx (11%), buttocks (3.3%), hand (2.2%), left leg (1.6%), left chest (1.1%) Right scapula, Left malleolus, Right arm (0.5%)
28	Sewchuk et al (2006)	Coccyx (82%), Heel (18%)
29	Thomas et al (1999)	Heel (36.4%), the proximal leg (45.4%), or both the heel and the leg (18.2%)
30	Lewicki et al (1997)	Heels, gluteal folds, buttocks, sacrums, scapulas, toes, and ankles

4. DISCUSSION

Our findings demonstrate that the pooled prevalence of PIs in patients undergoing open heart surgery is 24.06% and these patients are at a higher risk of PIs development. Similar to our finding, the results of the study of Schoonhoven et al showed that 21.2% of patients after the surgery developed some degree of PUs. ³¹ In a study in 2007 in Germany, Feuchtinger et al reported that nearly 50% of patients after cardiac surgery developed PUs. ³² In another study in 2004 the incidence of PUs was reported to be about 37% percent by salsali et al. ³³

According to our review, the prevalence of PIs was higher in women (33.36%) than in men (25.19%), which is consistent with the results of the shafipour et al study ³⁴ and inconsistent with the results of Primiano et al and Shaw et al studies, ^{35 , 36 , 37} which reported the prevalence to be higher in men.

Analysis of PIs prevalence rates at the Cleveland Clinic Foundation showed that for two consecutive years, cardiac surgery patients had the highest occurrence rates of all patients ³⁰ When present, the following variables were identified as increasing the risk of PUs development in patients undergoing cardiac surgery: several comorbidities; lower haemoglobin, haematocrit, and serum albumin levels; lower preoperative Braden Risk Assessment Scale scores; the presence of diabetes mellitus; more rapid return to preoperative body temperature; being turned only once daily; and the use of an intra‐aortic balloon pump (IABP). In our review, there was a statically significant association between age, female sex, diabetes mellitus, duration of surgery, and preoperative serum albumin with PIs. In this regard, Tschannen et al reported that patients in whom a pressure ulcer developed were more likely to have diabetes (P < 0.001) and their study showed the association between age and time in the operation room with PIs (P < .001). ³⁶ Frankle et al study also showed similar findings which showed that diabetes (odds ratio [OR] 2.7, 95% CI 1.1–6.4) and age > 60 years (OR 2.9, 95% CI 1.2–7.1), as independent predictors of PUs. ³⁸

Our meta‐analysis indicated that PIs risk increased almost along with the surgery duration in cardiovascular surgical patients that consistent with the study of Rao et al ³⁹ which mentioned cardiac surgery patients are exposed to compressive and shearing forces during their procedures and in particular, when patients remain on the operating room table for extended periods of time during long surgeries, they have prolonged exposure to pressure. In addition, Chen et al ⁴⁰ reported the length of surgery as an important risk factor for PIs in cardiovascular surgical patients. But it is not consistent with the result of the Jeserum et al study which reported the length of time on the OR table not to be associated with PIs development. ⁴¹

In the present study, we identified preoperative serum albumin as a risk factor for PIs development after open heart surgeries. In this regard, Kim et al study reported that preoperative low albumin levels (OR: 0.21, 95% CI 0.05–0.82; P < 0.05) and is independently associated with PUs development after surgery. ⁴² Mozumder et al study reported that preoperative serum albumin level was found to be the most valuable predictor of postoperative outcome after valve replacement surgery (B = −2.251, OR 0.105, 95% CI 0.011–0.986, P < 0.05). ⁴³

Our review showed that the presence of PIs in the sacrum, buttocks, coccyx, and heels is higher than in other body parts. Similar to our finding Stordeur et al reported sacrum and heels as common sites of sores. ⁴⁴ Schoonhoven et al study reported that more than half (52.9%) of the lesions were developed on the heels. ³¹ In addition, Chen et al reported that the majority of PIs are located on the sacrum and coccyx. It may be because of Patients undergoing cardiovascular surgery are placed in the supine position and bear weight on the sacrum and coccyx area and heels, which has little subcutaneous tissue protection.

According to the results obtained, women are more prone to developing PIs than men, with older patients and those with underlying diseases such as diabetes and lower serum albumin level. There was no sufficient data to identify the association between PIs with haemoglobin, haematocrit, preoperative Braden Risk Assessment Scale scores; body temperature, and the use of an intra‐aortic balloon pump (IABP). Further studies are needed in this regard.

5. LIMITATION

There are some limitations in this meta‐analysis. First, some of the included studies were retrospective case–control studies, which were more prone to bias. Second, there was high heterogeneity between the included studies. These two limitations need to be considered when evaluating the conclusion.

6. CONCLUSION

A high prevalence of PIs in patients undergoing open heart surgeries was detected in this review, so special protocols are needed to decrease the prevalence of PIs. Some PIs prevention strategies should be carried out for the prolonged surgery for cardiovascular patients. On the other hand, PI is preventable through identifying risk factors and applying guidelines and simple interventions in patients who are at higher risk of PIs development before surgery. Additional protection of the skin and other targeted measures to reduce and redistribute pressure are necessary to prevent PIs during surgery.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Taghiloo H, Ebadi A, Saeid Y, Jalali Farahni A, Davoudian A. Prevalence and factors associated with pressure injury in patients undergoing open heart surgery: A systematic review and meta‐analysis. Int Wound J. 2023;20(6):2321‐2333. doi: 10.1111/iwj.14040

DATA AVAILABILITY STATEMENT

Data available on request from the authors.