Abstract
The aim of this study was to investigate the relationship between perioperative corticosteroids administration and the incidence of pressure ulcers (PUs) in cardiovascular surgical patients. A retrospective analysis was performed on data from consecutive patients who had cardiac surgery in 2012. Univariate and multivariate logistic regression analyses were performed to evaluate the relationship between perioperative corticosteroid administration and the incidence of surgery‐related PU (SRPU). A total of 286 cardiac surgery patients were included in this study; of these, 47 patients developed 57 SRPUs, an incidence of 16·4% [95% confidence interval (CI): 12·3–21·2%). The SRPU incidence was significantly higher in corticosteroid‐administered group compared with groups not receiving corticosteroids (43·8% versus 14·8%, Pearson's χ 2 = 9·209, P = 0·002). The crude odds ratio (OR) was 4·472 (95% CI: 1·576–12·694). After performing multivariate logistic regression analysis, the adjusted OR was 2·808 (95% CI: 1·062–11·769). This result showed that perioperative corticosteroid administration was an independent risk factor for PUs in cardiovascular surgical patients. Therefore, it is recommended that in order to prevent PU perioperative corticosteroids should be administered with caution to cardiovascular surgical patients.
Keywords: Cardiovascular surgery, Corticosteroids, Risk factor, Surgery‐related pressure ulcer
Introduction
Pressure ulcers (PUs) that develop in surgical patients with prolonged surgery are called surgery‐related PU (SRPU). The most common types of SRPU were PUs related to cardiac procedures 1. Our previous systematic review pooled 17 studies with 5451 patients, and found that the incidence of SRPU in cardiac surgical patients of the last 5 years was 0·18 [95% confidence interval (CI): 0·14–0·22] 2. Therefore, it is very important to prevent the occurrence of SRPU. However, the most widely used Braden scale has found low predictive validity for SRPU, and cannot be used alone for assessing PU risk in surgical patients 3, 4; hence, there must be another risk factor for SRPUs.
Corticosteroids are widely used in cardiovascular surgical patients. Pharmacological effects include reducing systemic inflammatory response 5, decreasing the incidence of atrial fibrillation 6, decreasing possible neuronal damage 7 and improving postoperative outcomes 8. However, some studies found that perioperative corticosteroid administration increased the incidence of SRPU. Stordeur et al. enrolled 163 patients undergoing cardiovascular surgery, and found 48 (29·5%) patients developed 75 pressure sores. Logistic regression analysis showed that postoperative steroid therapy (P = 0·020) was the predictor of PUs 9. In another study, Lewicki et al. found that 16 cardiac surgery patients (4·7%) developed 22 PUs, and the risk factors included haemoglobin, haematocrit and albumin, presence of intra‐aortic balloon pump postoperative, preoperative Braden risk score, diabetes mellitus, comorbidity and rapid return to preoperative body temperature, but not postoperative corticosteroid medication 10. Following this, few studies have assessed the relationship between perioperative corticosteroids administration and the incidence of SRPU. It is still controversial whether perioperative corticosteroid administration is related to SRPU.
The purpose of this study was to investigate the relationship between perioperative corticosteroid administration and the incidence of PUs in cardiovascular surgical patients.
Methods
Design
A retrospective analysis was performed among consecutive cardiac surgery patients to identify the risk factors. This study was approved by the medical ethics committee of our hospital.
Setting
This study was conducted in a 1000‐bed teaching hospital. About 250–350 cardiac surgeries are carried out each year.
Patient population
The consecutive patients undergoing cardiac surgery between January 2012 and December 2012 were selected for the study. Inclusion criteria were paediatric and adult patients of any age undergoing cardiac surgery and aortic surgery. Exclusion criteria were cardiac surgery patients not moved to cardiac surgery intensive care unit postoperatively (such as transpleural and extrapleural ligation of patent ductus arteriosus) and cardiac intervention.
Data collection
A retrospective review of the medical records was done to obtain data. Based on discharge records from cardiac surgery intensive care unit, related medical records were identified. All notes for each patient were reviewed, which included daily notes of surgeons and nurses, surgery and anaesthesia records and medical tests. The data collected were entered into a data entry template designed with EpiData (version 3.1; Epidata Association, Odense, Denmark). The template included four parts: (i) demographic characteristics, which included patients' age, gender, weight and disease category; (ii) SRPU information, which included SRPU occurrence (yes or no), the severity of ulcers [based on the classification by the National Pressure Ulcer Advisory Panel (NPUAP) 11], the number of the ulcers, the anatomical location and outcomes (healing or non‐healing); (iii) corticosteroid information, which included administration (yes or no), type of drug, dosage and frequency of administration; and (iv) other SRPU possible risk factors according to previous review 12, which included haemoglobin level, albumin level, length of surgery, length of cardiopulmonary bypass vasoactive drugs, hypotensive periods and other risk factors.
Statistical analysis
Univariate differences in continuous variables were tested for statistical significance by the Student's t‐test or Mann–Whitney U‐test; differences in categorical variables were tested using the χ 2 test or Fischer's exact test. Multivariate analysis was used to evaluate the impact of potential confounding variables on those variables identified as primary risk factors by logistic regression methods. The odds ratio (OR) with 95% CIs was used as a measure of clinical relevance. Statistical analyses were performed using IBM SPSS software (version 19.0; IBM, Armonk, NY).
Results
Patient characteristics
A total of 286 cardiac surgery patients were included in this study. Their ages ranged from 2 to 84 years, and the mean was 46·9 ± 22·1 years. Almost 55·9% patients were men and 44·1% patients were women. Among all five disease categories, 30·1% was congenital heart disease, 36·0% was valvular disease, 9·4% was coronary heart disease, 15·0% was macrovascular disease and 9·4% was others.
Surgery‐related PU incidence
Among all 286 patients, 47 patients developed SRPU. The SRPU incidence was 16·4%, with a 95% CI of 12·3–21·2%; of these 46 PU patients (97·9%) were rated as stage I and only one patient (2·1%) was rated as stage II. Among 47 SRPU patients, 57 PUs developed, and 7 (14·9%) developed more than one PU. The most common locations for the PUs were the sacrum and coccyx (50·9%), heels (22·8%), ischial tuberosities (10·5%) and other sites (15·8%); however, all PUs eventually healed.
Among patients without SRPU and those with SRPU, it was found that differences in patients' gender, weight, vasoactive agents intraoperatively and vasoactive agents postoperatively were not statistically significant between two groups (P > 0·05). But the differences in patients' age, disease category and length of surgery were statistically significant between the two groups (P < 0·05). The baseline characteristics of the two groups are shown in Table 1.
Table 1.
Baseline characteristics in groups without SRPU and with SRPU
| Variables | n | Without SRPU group | n | With SRPU group | P |
|---|---|---|---|---|---|
| Age (years) | 239 | 45·5 ± 22·8, 53·0 [2–84] | 47 | 53·9 ± 16·3, 55·0 [5–81] | 0·017a |
| Gender (M/F) | 239 | 135/104 | 46 | 24/22 | 0·590 |
| Disease category | 239 | 80/78/24/37/20 | 47 | 6/25/3/6/7 | 0·013a |
| Weight (kg) | 191 | 55·3 ± 20·8, 60·0 [9–101] | 46 | 59·4 ± 16·8, 59·5 [14–102] | 0·212 |
| Length of surgery (minutes) | 230 | 182·6 ± 98·8, 182·5 [30–615] | 45 | 259·7 ± 108·9, 240 [80–675] | 0·000a |
| Length of CPB (minutes) | 135 | 49·3 ± 36·4, 36·0 [13–215] | 39 | 49·3 ± 22·7, 44·0 [16–107] | 0·991 |
| Vasoactive agents intraoperatively (Y/N) | 239 | 190/49 | 47 | 35/12 | 0·442 |
| Vasoactive agents postoperatively (Y/N) | 239 | 106/133 | 47 | 18/29 | 0·444 |
SRPU, surgery‐related pressure ulcer; CPB, cardiopulmonary bypass; Disease category: congenital heart disease/valvular disease/coronary heart disease/macrovascular disease/others.
P < 0·05.
Corticosteroids administration and SRPU incidence
A total of 16 patients were administered corticosteroids perioperatively (5·6%, 16 of 286). All patients were intravenously administered with dexamethasone 10 mg. Three patients received more than once. In 16 patients who received corticosteroids, 7 developed SRPU. The incidence and 95% CI were 0·438 and 0·198–0·701, respectively. In another 270 patients who did not receive corticosteroids, 40 developed SRPU. The incidence and 95% CI were 0·148 and 0·108–0·196, respectively. Univariate χ 2 test showed that the SRPU incidence was significantly higher in corticosteroid‐administered group compared with group not receiving corticosteroids (Pearson's χ 2 = 9·209, P = 0·002). The OR with 95% CI was 4·472 (1·576–12·694).
Three covariate values were found statistically different between the two groups. Therefore, multivariate logistic regression analysis was performed and the results are shown in Table 2. Corticosteroid administration, disease category (especially for congenital heart disease) and length of surgery were three independent risk factors for SRPU in cardiovascular surgical patients, with ORs of 2·808 (95% CI: 1·062–11·769), 0·110 (95% CI: 0·018–0·673, protective factor for congenital heart disease) and 1·005 (95% CI: 1·000–1·011), respectively.
Table 2.
Logistic regression analysis of perioperative corticosteroid administration and SRPU incidence in cardiovascular surgical patients
| Variables | B | SE | Wald | Sig. | OR | 95% CI for OR | |
|---|---|---|---|---|---|---|---|
| Lower | Upper | ||||||
| Corticosteroids (1) | 1·570 | 0·771 | 4·152 | 0·042 | 2·808 | 1·062 | 9·769 |
| Age | 0·010 | 0·018 | 0·352 | 0·553 | 1·011 | 0·976 | 1·046 |
| Gender (1) | 0·018 | 0·482 | 0·001 | 0·969 | 1·019 | 0·396 | 2·620 |
| Disease category | 5·710 | 0·222 | |||||
| Disease category (1) | −2·211 | 0·926 | 5·698 | 0·017 | 0·110 | 0·018 | 0·673 |
| Disease category (2) | −0·635 | 0·597 | 1·131 | 0·288 | 0·530 | 0·164 | 1·709 |
| Disease category (3) | −21·735 | 24990·461 | 0·000 | 0·999 | 0·000 | 0·000 | . |
| Disease category (4) | −0·717 | 1·023 | 0·491 | 0·484 | 0·488 | 0·066 | 3·628 |
| Weight | −0·029 | 0·019 | 2·382 | 0·123 | 0·972 | 0·936 | 1·008 |
| Length of surgery | 0·005 | 0·003 | 4·405 | 0·036 | 1·005 | 1·000 | 1·011 |
| Length of CPB | −0·002 | 0·008 | 0·083 | 0·774 | 0·998 | 0·982 | 1·013 |
| Vasoactive agents intraoperatively (1) | 0·501 | 0·551 | 0·827 | 0·363 | 1·650 | 0·560 | 4·859 |
| Vasoactive agents postoperatively (1) | 0·422 | 0·492 | 0·735 | 0·391 | 1·525 | 0·581 | 4·004 |
| Constant | −0·956 | 1·550 | 0·380 | 0·537 | 0·385 | ||
SRPU, surgery‐related pressure ulcer; OR, odds ratio; CI, confidence interval.
The relationship between perioperative corticosteroid administration and SRPU incidence in cardiovascular surgical patients is shown in Table 3 and Figure 1.
Table 3.
The relationship between perioperative corticosteroid administration and SRPU incidence in cardiovascular surgical patients
| Corticosteroids | SRPU | Incidence (95% CI) | Crude OR (95% CI) | Adjusted OR (95% CI) | ||
|---|---|---|---|---|---|---|
| No | Yes | Total | ||||
| No | 230 | 40 | 270 | 0·148 (0·108−0·196) | 4·472 (1·576–12·694) | 2·808 (1·062–11·769) |
| Yes | 9 | 7 | 16 | 0·438 (0·198−0·701) | ||
| Total | 239 | 47 | 286 | 0·164 (0·123–0·212) | ||
SRPU, surgery‐related pressure ulcer.
Figure 1.
The relationship between perioperative corticosteroid administration and surgery‐related pressure ulcer (SRPU) incidence in cardiovascular surgical patients.
Discussion
In this study, all patients used similar prevention strategies, which included transfusion and albumin infusion preoperatively for anaemia and hypoproteinaemia; pressure redistribution intraoperatively and postoperatively; and repositioning every 2 hours after stability of haemodynamics postoperatively. Pressure damage was assessed when patients returned to the cardiac surgery intensive care unit, and every 2 hours simultaneously with repositioning. Stage I SRPUs was recognised as intact skin with non‐blanchable redness of a localised area usually over a bony prominence. Stage I may be difficult to detect in individuals with dark skin tones, but it is easy to identify in the Han Chinese people with yellow skin. Stage II SRPUs was recognised as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough 11. In our study, we found that the SRPU incidence was 16·4% (95% CI: 12·3–21·2%). The result was the same as the incidence in mixed surgical samples reported in previous studies 1, 2. Our study also showed that 97·9% SRPUs were rated as stage I. It was also similar to the previous study where the majority of SRPUs were stage I 1. The SRPUs always developed within 24–72 hours postoperatively.
In our study, we found that the SRPU incidence was significantly higher in the corticosteroid‐administered group compared with those who did not receive corticosteroids (43·8% versus 14·8%, P = 0·002). The crude OR was 4·472 (95% CI: 1·576–12·694). Because other factors could affect SRPU incidence, other possible risk factors according to previous review were also collected 11. The possible risk factors included haemoglobin level, albumin level, length of surgery, length of cardiopulmonary bypass vasoactive drugs and hypotensive periods. We did not collect on bypass or off bypass as a covariate. Most of off‐bypass patients were excluded, such as those with transpleural and extrapleural ligation of patent ductus arteriosus. The length of surgery for off bypass was short, and the SRPU risk for these patients was low. After adjusted by these possible risk factors, the adjusted OR was 2·808 (95% CI: 1·062–11·769). These results showed that perioperative corticosteroid administration was an independent risk factor for PUs in cardiovascular surgical patients. We also found that the patient (2·1%) who developed stage II PU had used dexamethasone 10 mg twice.
Some evidence supported that perioperative corticosteroid administration was a risk factor for SRPU. Wicke et al. reported that methylprednisolone treatment significantly decreased transforming growth factor‐beta (TGF‐beta) and insulin‐like growth factor‐I (IGF‐I) levels in the wound fluid and hydroxyproline content in the tissue (P < 0·05) 13. While decrease in growth factors was an important factor for PU development 14, Campagnolo et al. reported that corticosteroid could also lower the rate of collagen deposition in acute vocal fold wound healing 15. Mastropietro et al. found that greater cumulative duration of corticosteroid exposure is independently associated with postoperative infection in complex cardiac surgery 16. Prone to cause infection may be another reason for PU development and difficult to heal.
However, in a recent well‐known randomised controlled clinical trial, Dieleman et al. enrolled 4494 patients aged 18 years or above undergoing cardiac surgery with cardiopulmonary bypass. Patients were randomly assigned to receive a single intraoperative dose of 1 mg/kg dexamethasone (n = 2239) or placebo (n = 2255). The result showed that intraoperative dexamethasone did not reduce the 30‐day incidence of major adverse events, which included death, myocardial infarction, stroke, renal failure or respiratory failure, compared with placebo 17. Another randomised controlled clinical trial reported that combined preoperative and intraoperative use of glucocorticoids in neonatal cardiac surgery does not favourably affect early clinical outcomes and may exacerbate perioperative renal dysfunction 18. On the basis of these randomised controlled clinical trials, it is recommended that perioperative corticosteroids should not be used for cardiovascular surgical patients.
Limitation
This was a retrospective study. Based on the data from Oxford Centre for Evidence‐Based Medicine (March 2009) 19, the levels of evidence ranked 3b. The results should be confirmed by prospective studies with large samples.
Conclusion
Our results showed that perioperative corticosteroid administration was an independent risk factor for PUs in cardiovascular surgical patients. Therefore, in order to prevent PUs, it is recommended that perioperative corticosteroids should be administered cautiously to cardiovascular surgical patients.
Author contribution
H‐LC was involved in study design, acquisition of data, analysis and interpretation of data. W‐QS was involved in acquisition of data and drafted the submitted article. Y‐HX was involved in acquisition of data, analysis and interpretation of data. QZ was involved in acquisition of data, analysis and interpretation of data. JW was involved in study design, analysis and interpretation of data.
Acknowledgements
We thank Dean of the Affiliated Hospital of Nantong University, Professor Jian‐Hua ZHU and director of department of hospital medical records, Mr Lin DAI for their assistance in retrieving the cases. We are grateful to Yan Si, Hu‐Ting Zhang, Hui‐Yu Ji, Qiong Wu, Jian‐Chun Que and Jing‐Wen Bao from School of Nursing, Nantong University, who participated in retrieving the cases. We also thank Ms Xin Zhao from School of Nursing, Nantong University, who effectively managed data collection and collation process. This work was supported by Nantong Municipal Science and Technology Bureau (grant number: BK2013014). The authors had no conflicts of interest to declare in relation to this article.
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