Incidence and risk factors of intraoperative acquired pressure injury in open heart surgical patients: a meta-analysis of prospective studies

Abstract

Purpose

This meta-analysis aimed to evaluate the incidence and risk factors of intraoperative acquired pressure injuries (IAPIs) in open heart surgical patients, focusing exclusively on prospective studies to address gaps in the existing literature.

Methods

A systematic search was conducted across PubMed, Embase, and Web of Science up to January 2025. Data on incidence and risk factors were extracted, and statistical analyses were performed using random-effects models. Heterogeneity was assessed using I² statistics; publication bias was assessed by funnel plot and Egger’s test.

Results

Ten prospective studies involving 1311 patients were included. The pooled incidence of IAPIs was 25% (95% CI 16%–35%), with high heterogeneity (I² = 94%). Sensitivity analysis confirmed stable results. Significant risk factors included prolonged surgical duration (SMD: 1.76, 95% CI 0.10–3.42, I² = 98%), advanced age (SMD: 0.30, 95% CI 0.14–0.46, I² = 0%), female sex (RR: 1.36, 95% CI 1.03–1.80, I² = 53%), and perioperative corticosteroid use (RR: 3.63, 95% CI 1.64–8.06, I² = 0%).

Conclusion

This study assessed the incidence of IAPIs in open heart surgical patients and identifies key risk factors, including prolonged surgical duration, advanced age, female sex, and perioperative corticosteroid use. However, the results should be interpreted with caution due to the high heterogeneity observed across studies. Future research should focus on larger, multicenter prospective studies to provide more robust evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-025-03097-y.

Introduction

Intraoperative acquired pressure injuries (IAPIs) are localized damages to the skin and underlying soft tissue, often occurring over bony prominences due to prolonged pressure during surgical procedures [1, 2]. These injuries are particularly prevalent among open heart surgical patients, who may be subjected to extended periods of immobility and mechanical interventions [3, 4]. A systematic review identified an incidence rate of 18% for IAPIs among patients who underwent cardiac surgery [5]. The National Pressure Ulcer Advisory Panel (NPUAP) defines pressure injuries as disorders resulting from localized ischemia, which can culminate in cell necrosis and tissue death [6]. IAPIs have significant implications for patients, leading to prolonged hospital stays, additional medical costs, and an increased risk of complications, including morbidity and mortality [7, 8]. Therefore, effective identification of associated risk factors of IAPIs is vital in the context of open heart surgeries.

The incidence of IAPIs in all surgical settings is notably variable, with reported incidence rates ranging from 4.7% to 66% [9, 10]. Such discrepancies are influenced by multiple factors, including patient demographics, comorbidities, and intraoperative conditions [9, 11]. Patient-related risk factors often include advanced age and poor nutritional status, which can compromise skin integrity [4, 12]. Intraoperative factors are also crucial, with studies indicating that surgical duration significantly affects the incidence of IAPIs [3, 12]. Understanding these risk factors is essential for developing effective prevention strategies tailored to at-risk populations [13]. Despite previous meta-analyses that have focused on pressure injuries [14, 15], a systematic exploration of prospective studies specifically addressing the incidence and risk factors of IAPIs remains lacking. Many existing studies have methodological limitations, such as small sample sizes, retrospective designs, or inconsistent definitions of pressure injuries, which can lead to variability in findings.

Therefore, the aim of this meta-analysis is to include only prospective studies to evaluate the incidence and risk factors of IAPIs in open heart surgical patients.

Material and methods

The meta-analysis was conducted in accordance with the MOOSE guidelines for reporting meta-analyses of risk factors and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [16, 17]. This meta-analysis was registered in PROSPERO (CRD420251127251).

Search strategy

A systematic and comprehensive literature search was conducted across PubMed, Embase, and Web of Science up to January 2025, to identify prospective studies examining the incidence and risk factors of IAPIs in open heart surgical patients. The search strategy combined subject headings and free-text terms, incorporating keywords such as (“Cardiothoracic Surgery”) AND (“Pressure Ulcer”) AND (“Risk Factors” OR “Prevalence”). Reference lists of relevant studies were manually reviewed to ensure inclusion of additional publications. No restrictions were applied to publication year or language to maximize comprehensiveness. The full search strategy is detailed in Supplementary Table 1. Study eligibility was assessed through title and abstract screening.

Inclusion and exclusion criteria

Studies were included based on the PECOS framework: (1) population: open heart surgical patients; (2) exposure: IAPIs; (3) comparator: patients not exposed to specific risk factors (where applicable); (4) outcome: incidence and risk factors for IAPIs; and (5) study design: prospective cohort studies. Additionally, studies were required to use the NPUAP staging criteria or equivalent for IAPIs diagnosis.

Exclusion criteria were as follows: (1) cross-sectional, retrospective, case reports, or review studies; (2) studies published as abstracts only or with inaccessible full texts. Studies with incomplete data for effect size calculation were excluded. For example, if a study provided the sample size for the IAPIs group and non-IAPIs group, but not the mean and standard deviation, it would be excluded.

Quality assessment

For the prospective cohort studies in our research, two independent reviewers assessed study quality using the Newcastle–Ottawa Scale (NOS) specifically designed for cohort studies [18], which evaluates seven criteria: representativeness of exposed cases, selection of non-exposed cases, ascertainment of exposure, absence of the outcome at study start, comparability of cohorts, assessment of outcome, and adequacy of follow-up. Each domain was meticulously examined to ensure a comprehensive and objective evaluation. Discrepancies between reviewers were resolved through deliberation or consultation with a third reviewer to achieve consensus.

Data extraction

Two reviewers independently extracted data from all included studies. The extracted data encompassed author details, publication year, type of cardiac surgery, study characteristics (country, design, outcome measures), and patient demographics, including age and sample size in IAPIs patients and non-IAPIs patients. Discrepancies between reviewers were resolved through discussion to achieve consensus, ensuring the accuracy and reliability of the extracted information.

Outcome measures

The primary outcome measure was the incidence of IAPIs in open-heart surgical patients. Secondary outcomes focused on identifying risk factors associated with IAPIs. Risk factors were categorized into patient-related and intraoperative variables. Patient-related factors included age, female, perioperative corticosteroid use, weight, perioperative albumin levels, and diabetes. Intraoperative factors encompassed surgical duration. Data were extracted from prospective studies to ensure robust analysis.

Statistical analysis

For the meta-analysis of IAPIs incidence in open heart surgical patients, a generalized linear mixed model (GLMM) [19], specifically a random-intercept logistic regression model, was conducted. Study weights were assigned based on the inverse variance of proportions and between-study heterogeneity (τ²), ensuring larger studies were given greater weight than smaller ones. For continuous outcomes related to risk factors, pooled effect estimates were calculated using the standardized mean difference (SMD), which expresses the size of the effect in standard deviation units and reflects the differences between the IAIPs and non-IAIPs groups [20], accompanied by a 95% confidence interval (CI). For dichotomous variables, we employed relative risk (RR), defined as the ratio of the probability of the event occurring in the IAIPs group compared to the non-IAIPs group, along with the corresponding confidence intervals. Statistical heterogeneity was assessed using Q statistics and quantified with the I² statistic, where values of 25%, 50%, and > 75% indicated low, moderate, and high heterogeneity [21]. Due to the anticipated potential heterogeneity among different types of open heart surgery, a random-effects model was adopted for the analysis by default. Additionally, we conducted a leave-one-out sensitivity analysis on the outcomes with more than two studies to identify the sources of heterogeneity and assess the robustness of the results. In addition, we performed subgroup analysis and meta-regression analysis based on sample size, publication year, and region of origin to find out the potential sources of incidence of IAIPs. Publication bias was assessed using Egger’s linear regression test for outcomes over three studies [22]. All analyses were performed using R software (version 4.3.1), with P < 0.05 considered statistically significant.

Results

Literature search and study selection

A systematic literature search was conducted across three databases, yielding 496 studies, with an additional 2 studies identified from other sources. After removing 113 duplicates, 362 records were excluded during initial screening based on titles and abstracts due to non-eligible publication types (e.g., case reports, letters, reviews, animal experiments, meta-analyses) or clearly irrelevant content. Full-text review of the remaining 23 articles excluded studies not involving open heart surgical patients (n = 6), cross-sectional studies (n = 2), and retrospective studies (n = 5). Ultimately, ten prospective studies were selected for meta-analysis [3, 4, 12, 23–29]. The selection process is detailed in the PRISMA flowchart (Fig. 1).

Fig. 1.

PRISMA flow diagram illustrating the study selection process

Study description and quality assessment

Following the selection process, ten prospective cohort studies comprising a total of 1311 patients were assessed. The sample sizes ranged from 24 to 249 patients. These studies were conducted primarily in cardiovascular surgery departments of various hospitals. Table 1 and Table 2 provide a summary of the patient and technical characteristics of these studies.

Table 1.

Study and patient characteristics of the included studies

Author, year	Country	Study design	Definition of IAPIs	Outcome measure (prevalence and risk factors)	Sample size, N		Patient without IAPIs		Patient with IAPIs
					Total	Age (mean ± SD)	Total	Age (mean ± SD)	Total	Age (mean ± SD)
Cai et al. [3]	China	Pro	Localized damage to the skin and underlying soft tissue related to surgery-related pressure	(1)(2)(3)(4)(5)(8)	149	NA	112	48.2 ± 18.3	37	54.7 ± 15
Shih et al. [4]	China	Pro	Damage to the skin and underlying tissues caused by prolonged pressure, shear, and friction	(1)(2)(3)(5)(8)	47	57.3 ± 11.4	37	58.1 ± 12.1	10	54.4 ± 8.1
Lu et al. [12]	China	Pro	Surgery-related pressure ulcers refers to pressure ulcers that occur in cardiovascular surgical patients, typically resulting from prolonged surgery	(1)(2)(3)(4)(5)(6)(7)(8)	149	49.8 ± 17.7	112	48.2 ± 18.3	37	54.7 ± 15
Shokati et al. [28]	Iran	Pro	Pressure ulcers defined by the National Pressure Ulcer Advisory Panel (NPUAP) as a localized injury to the skin and/or underlying tissue, usually occurring over a bony prominence	(1)(2)(3)(7)(8)	70	63.4	38	65.7 ± 12.4	32	66.9 ± 11.4
Ramezanpour et al. [25]	Iran	Pro	Pressure ulcers are injuries to the skin and/or underlying tissue caused by prolonged pressure	(1)(3)(7)	249	62.36 ± 10.38	169	NA	80	NA
Schuurman et al. [26]	Netherlands	Pro	Defined through the classification system of the European Pressure Ulcer Advisory Panel (EPUAP)	(1)(2)(3)(8)	204	68.1 ± 9.6	95	67.2 ± 9.3	109	70.4 ± 9.9
Thomas et al. [29]	USA	Pro	Defined as localized injuries to the skin and/or underlying tissue that occur over a bony prominence due to pressure or pressure in combination with shear force	(1)	163	NA	152	NA	11	NA
Papantonio et al. [24]	USA	Pro	Stage I: non-blanchable erythema of intact skin, typically resolving within 30 min of pressure relief Stage II: partial thickness tissue loss with involvement of the dermis, presenting as a shallow open wound Stage III: full thickness tissue loss involving subcutaneous tissue, potentially exposing muscle, tendon, or bone	(1)(2)(7)(8)	136	61.9	99	59.7 ± 14	37	67.9 ± 9.6
Huang et al. [23]	China	Pro	defined according to the classification system recommended by the European Pressure Ulcer Advisory Panel (EPUAP)	(1)	120	56	110	NA	10	NA
Shaw et al. [27]	China	Pro	Defined as localized damage to the skin and underlying soft tissue, ranging from mild reddening of the skin to more severe tissue damage and even infection	(1)	24	NA	21	NA	3	NA

(1) Prevalence of intraoperative acquired pressure injury; (2) age; (3) female; (4) perioperative corticosteroid use; (5) weight; (6) perioperative albumin levels; (7) diabetes; (8) surgical duration; Pro prospective; NA not available

Table 2.

Surgery characteristics of the included studies

Author, year	Type of cardiac surgery	Cardiopulmonary bypass	Cardiopulmonary bypass duration		Vasoactive agents
			Patient without IAPIs	Patient with IAPIs	Patient without IAPIs	Patient with IAPIs
Cai et al. [3]	VDH, CHD	On-pump	48.9 ± 23.1	48.9 ± 23.1	30/82	9/28
Shih et al. [4]	Elective cardiac surgery	NA	NA	NA	NA	NA
Lu et al. [12]	CHD, VDH, CAD, TAA	On-pump	48.9 ± 36.0	48.9 ± 23.1	30/82	9/28
Shokati et al. [28]	Elective cardiac surgery	NA	NA	NA	NA	NA
Ramezanpour et al. [25]	CABG, VDH, combined coronary and valve procedures	NA	NA	NA	NA	NA
Schuurman et al. [26]	Elective cardiac surgery	NA	NA	NA	NA	NA
Thomas et al. [29]	CABG	On-pump	114 ± 43	129 ± 40	NA	NA
Papantonio et al. [24]	Elective cardiac surgery	On-pump	103.7 ± 35.3	114.5 ± 32.8	NA	NA
Huang et al. [23]	MVR, AVR, DVR, CABG, Bentall procedure	On-pump	NA	NA	NA	NA
Shaw et al. [27]	Elective cardiac surgery	NA	NA	NA	NA	NA

MVR mitral valve replacements; AVR aortic valve replacements; DVR double valve replacements; CABG coronary artery bypass grafting; TAA thoracic aortic aneurysms; CHD congenital heart disease, VDH valvular disease of the heart; CAD coronary artery disease; Pro prospective; NA not available

The assessment of the ten prospective studies using the NOS scale reveals that most studies demonstrate acceptable methodological quality, which is shown in Supplementary Table 2. The total scores ranged from eight to nine, with the majority scoring nine, reflecting robust methodological quality in assessing IAPIs in open heart surgical patients.

Incidence of IAPIs in open heart surgical patients

For IAPIs incidence, ten studies were analyzed using random effect models due to the high heterogeneity (I² = 94% and P < 0.01). A total of 1311 open heart surgical patients showed the incidence of IAPIs was 25% (95% CI 16–35%) (Fig. 2). A leave-one-out sensitivity analysis revealed no potential source of heterogeneity was found (Fig. 3). However, the incidence following sensitivity analysis remained stable, and only minor variations in the results ranged from 24 to 27%. Subgroup analysis and meta-regression did not find any potential source of heterogeneity based on sample size, publication year, and region of origin (Table 3 and Supplementary Figs. 1–3).

Fig. 2.

Forest plot of the incidence of intraoperative acquired pressure injuries in open heart surgical patients

Fig. 3.

Leave-one-out sensitivity analysis for intraoperative acquired pressure injuries in open heart surgical patients

Table 3.

Subgroup analysis and meta-regression analysis

Covariate	Studies, n	Incidence of IAPIs (95% CI)	Meta-regression P-value
Publication year
Before 2015	6	23% (6%–46%)	0.89
After 2015	4	25% (16%–36%)
Sample size
< 100	3	27% (10%–47%)	0.80
≥ 100	7	24% (13%–37%)
Region of origin
Asia	7	24% (15%–35%)	0.79
Non-Asia	3	27% (5%–57%)

IAPIs intraoperative acquired pressure injuries

Quantitative analysis of risk factors for intraoperative acquired pressure injuries

We included six studies [3, 4, 12, 24, 26, 28] that investigated the relationship between IAPIs and surgical duration, with a SMD of 1.76 (95% CI 0.10–3.42, I² = 98%), indicating a significant association. Longer surgical duration was associated with a higher incidence of IAPIs (Fig. 4a). Additionally, six studies [3, 4, 12, 24, 26, 28] examined the correlation between IAPIs and age, revealing a significant association with an SMD of 0.30 (95% CI 0.14–0.46, I² = 0%) (Fig. 4b). Analysis of gender across six studies [3, 4, 12, 25, 26, 28] revealed that female patients faced a significantly higher risk of IAPIs, with a RR of 1.36 (95% CI 1.03–1.80, I² = 53%) (Fig. 4c). Furthermore, two studies [3, 12] assessed the impact of perioperative corticosteroid use, which demonstrated a significant association with IAPIs (RR: 3.63, 95% CI 1.64–8.06, I² = 0%) (Fig. 4d).

Fig. 4.

Forest plots of statistically significant risk factors for intraoperative acquired pressure injuries. a Surgical duration; b age; c female; d perioperative corticosteroid use

Three studies [3, 4, 12] investigated the relationship between IAPIs and weight, yielding a SMD of −0.05 (95% CI −0.29–0.20, I² = 0%), indicating no significant association (Fig. 5a). Similarly, two studies [12, 24] examined the correlation between IAPIs and perioperative albumin levels, with an SMD of −0.32 (95% CI −0.65–0.01, I² = 0%), also showing no significant association (Fig. 5b). Additionally, four studies [12, 24, 25, 28] assessed the impact of diabetes on IAPIs, revealing a RR of 1.08 (95% CI 0.88–1.33, I² = 45.2%), which was not statistically significant (Fig. 5d).

Fig. 5.

Forest plots of non-statistically significant risk factors for intraoperative acquired pressure injuries. a Weight; b perioperative albumin levels; c diabetes

Leave-one-out sensitivity analysis of risk factors for intraoperative acquired pressure injuries

Leave-one-out sensitivity analyses were performed for age, female, weight, diabetes, and surgical duration. The results for age, female, weight, and diabetes were stable; no matter which study was excluded, the conclusions remained unchanged (Supplementary Figs. 4–6). However, for the female outcome, excluding Shokati et al. (2016) [28] resulted in no statistical difference (Supplementary Fig. 7). For the surgical duration, excluding any one of the studies by Cai et al. (2021) [3], Lu et al. (2017) [12], or Shokati et al. (2016) [28] resulted in no statistical difference, indicating that the interpretation of results for this outcome should be approached with caution (Supplementary Fig. 8).

Publication bias

For incidence of IAPIs, funnel plot analysis and Egger’s test showed no significant publication bias (P = 0.55) (Fig. 6). In addition, funnel plots for age, female, diabetes, and surgical duration also showed no significant publication bias (P = 0.18, 0.73, 0.71, 0.17) (Supplementary Figs. 9–12).

Fig. 6.

Funnel plot and Egger’s test for publication bias analysis for incidence of intraoperative acquired pressure injuries

Discussion

In this meta-analysis, we aimed to evaluate the incidence and risk factors of IAPIs specifically in open heart surgical patients, particularly by focusing on prospective studies to fill existing gaps in the literature. Our results revealed a pooled incidence of IAPIs at 25%. Key risk factors identified included prolonged surgical duration, advanced age, female sex, and perioperative corticosteroid use.

The analysis conducted by the Cleveland Clinic Foundation [30] included 337 patients undergoing various cardiac surgical procedures, specifically highlighting the postoperative risk factors for pressure injuries. They pointed out considerable variability in pressure injury incidence among surgical patients, reporting rates that ranged from as low as 12–17%, and as high as 66%. Among all patient groups, those undergoing cardiac surgery were noted to have the highest incidence of pressure injuries, highlighting the importance of an in-depth exploration of risk factors in this population. Our meta-analysis found that the incidence of IAPIs was 25% (95% CI 16%–35%), which aligns closely with findings from prior studies [12, 14]. However, it is worth noting that variations in diagnostic criteria, assessment tools, and staging systems for pressure injuries can lead to inconsistencies in data collection and interpretation [31]. This highlights the necessity for future research to establish standardized definitions and assessment protocols for IAPIs.

Our meta-analysis identified several key risk factors—age, female gender, and perioperative corticosteroid use, and surgical duration—as statistically significant risk factors associated with IAPIs in patients undergoing open heart surgery. Advanced age is associated with reduced skin elasticity, impaired tissue perfusion, and slower wound healing, all of which increase susceptibility to pressure-induced tissue damage [24, 26]. Female patients may be at higher risk due to anatomical differences, such as thinner skin and reduced subcutaneous tissue, which provide less protection against prolonged pressure and shear forces [25, 26]. Furthermore, perioperative corticosteroid use can significantly impair tissue repair and regeneration [3, 32]. Prolonged exposure to these medications may lead to thinning of the skin and compromise blood vessel integrity, substantially increasing the risk of tissue damage [12].

Additionally, our meta-analysis identified prolonged surgical duration as another significant risk factor for IAPIs in open heart surgical patients. The extended immobility associated with lengthy surgeries increases the duration of sustained pressure on vulnerable tissues, particularly in weight-bearing areas, leading to ischemia, tissue hypoxia, and subsequent damage [3, 12]. Prolonged surgeries also heighten the risk of IAPIs due to the cumulative effects of mechanical stress, such as shear forces and friction [28, 33]. Furthermore, extended operative times may result in hemodynamic instability, reduced tissue perfusion, and impaired thermoregulation, further compromising tissue integrity [28]. While the association between surgical duration and IAPIs is well-supported, it is essential to recognize that other intraoperative factors, such as anesthesia management and patient-specific vulnerabilities, may also contribute to this relationship [34]. However, due to data limitations, our meta-analysis was unable to explore and synthesize these aspects. Future research should focus on developing strategies to minimize surgical duration where feasible and implementing targeted interventions, such as advanced pressure-relieving devices and frequent repositioning protocols, to mitigate the risks associated with prolonged surgeries.

Our meta-analysis builds upon previous research by providing novel insights into the incidence and risk factors of IAPIs specifically in open heart surgical patients. In 2022, Song et al. [15] conducted a meta-analysis evaluating risk factors for IAPIs across various surgical populations, identifying advanced age, BMI < 23 kg/m², low preoperative Braden scale scores, and prolonged surgical duration as significant risk factors, particularly in female patients. However, their study included only a small proportion of cardiac surgical patients and did not focus on this high-risk subgroup, nor did it address the incidence of IAPIs. In contrast, our study specifically targets open heart surgical patients, offering a more granular analysis of risk factors and providing the comprehensive estimate of IAPI incidence in this population.

Similarly, Taghiloo et al. (2022) [14] conducted a meta-analysis investigating the risk factors for IAPI in cardiac surgical patients, including a total of 17 studies. Their results indicated a statistically significant association between the occurrence of IAPI and several factors: female sex (pooled estimate: 1.55, 95% CI 1.19–2.00), diabetes (pooled estimate: 1.98, 95% CI 1.38–2.84), 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). However, diabetes and preoperative serum albumin levels did not show statistical differences in our study. Their analysis predominantly included retrospective and cross-sectional studies, which are prone to bias and limit the strength of the conclusions. In contrast, our meta-analysis exclusively incorporated high-quality prospective cohort studies, thereby providing higher-level evidence and more reliable results. It is worth noting that this high standard contributed to the limited number of studies regarding diabetes and preoperative serum albumin levels, with only four and two studies available, respectively. Future research is needed to further validate the impact of these factors.

Some limitations of the current meta-analysis should be considered when interpreting the results. Firstly, the high heterogeneity observed across studies, particularly for the incidence of IAPIs (I² = 94%), poses a significant challenge. This heterogeneity stems not only from statistical variations, but also from methodological and clinical differences in patient populations, which are inherent biases in meta-analytic synthesis. Despite employing leave-one-out sensitivity analysis and meta-regression analysis to investigate potential sources of heterogeneity, no single study or variable was identified as a significant contributor to the observed heterogeneity. Nevertheless, the results remained relatively stable, and no publication bias was detected, supporting the robustness of the findings. Secondly, the sample size for some risk factors (such as preoperative serum albumin levels and perioperative corticosteroid use) is limited. This is primarily due to our stringent inclusion criteria of only prospective studies, which restricted the number of eligible patients. Future studies with larger sample sizes are needed to provide more robust conclusions for these risk factors.

Conclusions

This meta-analysis specifically addresses the gap in understanding the incidence and risk factors of intraoperative acquired pressure injuries (IAPIs) in open heart surgical patients by exclusively analyzing prospective studies. Our findings reveal that the pooled incidence of IAPIs is 25%, with substantial heterogeneity (I² = 94%), indicating the variability in study results. Key risk factors identified include prolonged surgical duration, advanced age, female sex, and perioperative corticosteroid use, which significantly increase the risk of IAPIs. These findings provide valuable insights for clinical practice, suggesting that targeted strategies to mitigate these risks could improve patient outcomes. However, the high heterogeneity underscores the need for caution when interpreting these results. To address this limitation and strengthen the evidence, future research should focus on large-scale, multicenter prospective studies with standardized methodologies. Such studies are essential to confirm these findings and develop effective prevention strategies for IAPIs in this patient population.

Author contributions

Zhihao Fang, Tian Chen: Data curation, formal analysis, methodology, software, writing – original draft. Weixi Zheng: Data curation, software, writing – original draft. Qiuyu Chen: Formal analysis, methodology, writing – original draft. Pinying Chen, Qing Zhuo: Conceptualization, supervision, validation, visualization, writing – review & editing. All authors contributed to the manuscript and approved the final version for submission.

Funding

This study was supported by the Startup Fund for scientific research, Fujian Medical University (Grant number: 2022QH1222), Fujian Provincial Children’s Hospital Science and Technology Innovation Launch Fund (Hsinchu Youth Nursing Talents Training Program, Grant number: Children YCXH202203).

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

This is a systematic review and meta-analysis, ethics approval and consent to participate are not applicable.

Consent for publication

Not applicable. The manuscript does not include the participant’s identification image or other personal or clinical details.

Competing interests

The authors declare no competing interests.