Table 1.
Notes (as voted by the jury) associated with recommendations and statements, results of voting process and level of strength attributed according to the GRADE method
| |
Voting Results |
|||
|---|---|---|---|---|
| No. of REC | Notes | Median (IQR) | Strong Agreement | GRADE |
| REC 1 | Skilled professionals are needed. Automatic ABPI is ineffective in evaluating peroneal artery. Patients with peroneal artery not detectable have to be referred for further evaluation. | 7 (6–8) | 37.5% | W |
| Current health care organization could not allow routine application of this recommendation. | ||||
| STAT 1 | Skilled professionals are needed. | 7 (6–8) | 50% | W |
| STAT 2 | In diabetic and not diabetic patients with calcified arteries and CKD stage III ABPI test is not reliable. | 4 (2–5) | 0% | D |
| In diabetic neuropathic patients ABPI test is not reliable. | ||||
| REC 3 | Skilled professionals are needed. | 6 (4–7) | 18.75% | U |
| REC 4 | Skilled clinicians are needed in performing this test. | 8 (7–9) | 56.25% | S |
| Sensor has to be placed proximally to the wound. | ||||
| REC 5 | Recommendation applies also in all cases when the healing potential is low, or the complete healing is not the goal. | 8 (7–9) | 75% | S |
| In these situations, a wound should be kept dry to prevent potential spreading infection along with negative outcomes such as necrotizing fasciitis, wet gangrene, or sepsis. | ||||
| REC 6 | 7 (6–9) | 37.5% | W | |
| REC 7 | LFT applied in existing HPIs is effective to reduce the friction coefficient even when applied along with the standard treatment. | 8 (8–9) | 81.25% | S |
| REC 8 | 8 (7–8) | 75% | S | |
| REC 9 | 8 (8–9) | 81.25% | S | |
| REC 10 | Skilled professionals are needed. The use of NPWT in presence of first or second stage infection could be considered. | 7 (6–8) | 43.75% | W |
| REC 11 | Recommendation applies if the patient is deemed to have a good life expectancy. | 8 (7–9) | 75% | S |
| REC 12 | The surgical intervention is considered necessary to avoid major amputation if the patient is deemed to have a life expectancy good enough. Partial/total calcanectomy or other more limited surgical interventions can be considered. | 9 (8–9) | 81.25% | S |
| REC 13 | 7 (3–8) | 31.25% | U | |
| REC 14 | 7 (5–8) | 37.5% | W | |
| REC 15 | A proper site inspection of neonatal heel is needed to detect neonatal heel injuries/complications caused by blood sampling prick. After a full cleansing, a swab sample collection is advocated for microbiological screening. | 7 (6–8) | 31.25% | W |
| A punch biopsy for detecting infection is sometimes required on clinical basis. Sharp/surgical debridement is not indicated due to the low thickness of pediatric heel tissues and to the impossibility to distinguish soft fat tissue from muscle tissue. Proper off-loading must be maintained all time. | ||||
| REC 16 | Local iodine polyvinylpyrrolidone and silver sulfadiazine are not recommended in pediatric patients because of their systemic absorption and further toxicity. | 6 (5–8) | 31.25% | W |
| Eschar removal could be necessary during follow-up when there is an eschar contraction or lifted edges. | ||||
| Proper off-loading must be maintained all time. | ||||
| REC 17 | Local iodine PVP and silver sulfadiazine are not recommended in pediatric patients because of their systemic absorption and further toxicity. | 8 (4–8) | 56.25% | U |
| Natural products (honey, hypericum perforatum, and neem oil) and nonmedicated technology such as DACC technology, also called hydrophobic binding technique, are preferable. | ||||
| REC 18 | DRT needs to be left in place for 3 weeks. | 7 (6–8) | 43.75% | W |
| DRT could be faster secured to deep tissues by the help of NPWT (continuous modality low intensity and pressure should not exceed 80 mmHg). | ||||
| Skilled plastic surgeons are needed. | ||||
| Disposable NPWT devices are suggested because they do not interfere with social activities. | ||||
| REC 19 | Any stage. | 8 (8–9) | 93.75% | S |
| The device has to be effective to keep the leg in a neutral position. | ||||
| The usage of cushion is not advisable in an already existing HPI. | ||||
| An off-loading device such as a boot is considered a better and suitable option to off load the heels. | ||||
| REC 20 | Panel cannot recommend a specific off-loading device. | 8 (8–9) | 87.5% | S |
| However, following characteristics may be considered to inform the choice: | ||||
| - easily cleanable, lightweight, easy wearable, easy to remove, cost/effective, durability | ||||
| - other elements to be considered are materials, technology, shape. | ||||
| REC 21 | Panel cannot recommend a specific off-loading device. | 8 (6–9) | 68.75% | S |
| However following characteristics may be considered to inform the choice: | ||||
| - Easily cleanable, lightweight, easy wearable, easy to remove, cost/effective, durability | ||||
| - Other elements to be considered are materials, technology, shape. | ||||
| Patients with stages I and II and stable stage III lesions can walk while wearing an off-loading device. | ||||
| REC 22 | Panel cannot recommend a specific off-loading device. | 8 (7–9) | 62.5% | S |
| However, following characteristics may be considered to inform the choice: - easily cleanable, lightweight, easy wearable, easy to remove, cost/effective, durability | ||||
| - other elements to be considered are materials, technology, shape | ||||
| REC 23 | A range of pressures from 50 to 200 mmHg can be used with these devices. | 7 (6–8) | 43.75% | W |
| Panel cannot recommend a specific amount of negative pressure to use on HPI. | ||||
| Skilled professionals are needed. | ||||
| REC 24 | A range of pressures from 50 to 200 mmHg can be used with these devices. | 7 (6–7) | 18.75% | W |
| Panel cannot recommend a specific amount of negative pressure to use on HPI. | ||||
| Skilled professionals are needed. | ||||
| REC 25 | A range of pressures from 50 to 200 mmHg can be used with these devices. | 7 (6–8) | 31.25% | W |
| Panel cannot recommend a specific amount of negative pressure to use on HPI. | ||||
| Skilled professionals are needed. | ||||
| REC 26 | 8 (8–9) | 87.5% | S | |
| REC 27 | 8 (7–9) | 68.75% | S | |
| REC 28 | 8 (7–9) | 68.75% | S | |
| REC 29 | Skilled clinicians are needed | 9 (8–9) | 87.5% | S |
| REC 30 | 8 (8–9) | 81.25% | S | |
| REC 31 | An interdisciplinary team for HPI could include other specialists (e.g., orthopedist, diabetologist) with expertise in managing pressure injuries. | 9 (8–9) | 81.25% | S |
| REC 32 | 9 (8–9) | 87.5% | S | |
| REC 33 | CT scans and undue X-ray should be avoided. 3D scan allows to discriminate cases who need to be subjected to scintigraphy. | 8 (7–8) | 68.75% | S |
| Pediatrics probes are needed. | ||||
| A peculiar training and skilled professionals are required. | ||||
| REC 34 | A diabetic foot center is defined as follows: “any setting characterized by a multidisciplinary team with specific experience.” | 9 (8–9) | 87.5% | S |
| Time for referral should not exceed 48 h for third and fourth stages. | ||||
For the text of recommendations and statements and details about voting interpretation, see Results and Methods sections, respectively.
3D, three-dimensional; ABPI, ankle–brachial pressure index; CKD, chronic kidney disease; CT, computed tomography; DACC, dialkylcarbamoyl chloride; DRT, dermal regeneration template; HPIs, heel pressure injuries; IQR, interquartile range; LFT, low friction technology; NPWT, negative pressure wound therapy; PVP, polyvinylpyrrolidone; S, strongly recommended; U, uncertain; W, weakly recommended