Pressure Injuries Related to the Positioning of Surgical Patients in the Operating Room and Identification of Associated Risk Factors: A Cross-Sectional Study
Funding: The authors received no specific funding for this work.
ABSTRACT
Surgery represents a significant risk factor for the development of pressure injuries. However, risk factors related to positioning-induced pressure-injuries in surgical operating rooms have not been adequately investigated. Therefore, this study aimed to determine the presence of pressure injuries and associated risk factors related to patient positioning in the operating room. This prospective, descriptive, and cross-sectional study was conducted between November 2023 and July 2024 in operating rooms of a university hospital, including surgeries from various surgical departments, with a cohort of 140 patients determined using a G*Power analysis. Data collection tools included the ‘Individual Characteristics Form’, ‘Risk Assessment Scale for Pressure Injuries Related to Surgical Positioning’ and ‘Postoperative Patient Evaluation Form’, with data collected pre, intra and postoperatively. We found that 25.7% of patients developed Stage I pressure injuries post-surgery, with the supine position being the most prevalent risk factor (p = 0.023). Patients with diabetes, higher body mass index, advanced age, longer surgeries and certain anaesthesia types had significantly increased risks (p < 0.05). Furthermore, 17.9% of patients were classified as high-risk. These findings underscore the need for nurses to monitor high-risk patients closely, adjust positioning as needed and develop tailored care plans to mitigate risk.
Summary
- Patients positioned supine during surgery and undergoing procedures lasting more than 2 h had a higher risk of developing pressure injuries.
- Patient positioning, type of anaesthesia and comorbidities were significant factors influencing the development of pressure injuries.
- The most significant risk factors identified were sex, age, body mass index and comorbidities—particularly, diabetes.
1 Introduction
Intraoperative pressure injuries (PIs) are serious complications that significantly affect patient health and hospital care. Studies have reported that the incidence of surgeries-related PIs ranges between 1.3% and 57.4%, accounting for ~45% of all hospital-acquired PIs [1, 2]. The primary causes of these injuries are prolonged immobility, insensitivity to pain due to anaesthesia, and sustained pressure on specific body parts during surgery that disrupts blood circulation, leading to tissue ischemia and necrosis. These injuries have a profound impact on patient health—leading to increased pain, infection risk, sepsis and even mortality—while also prolonging hospitalisation and complicating recovery. Left untreated, PIs can result in severe complications and even death. The economic burden of treating these injuries is substantial, with annual costs estimated at $11.6 billion in the United States and £2.1 billion in the United Kingdom and per-patient treatment costs reaching up to $40 000 [3]. This financial burden underscores the need for effective preventive strategies during surgery to improve patient outcomes and reduce healthcare costs. Globally, the prevalence of PIs in hospitalised adult patients is reported to be 12.8%, with 8.5% of these being hospital-acquired [4]. Preventing intraoperative PIs is crucial to enhancing patient outcomes and alleviating the economic burden on healthcare systems. In Turkey, the incidence of these injuries among patients in intensive care units ranges from 5.9% to 40.6% [5]. PIs often develop during acute illnesses and are particularly prevalent in patients with neurological and cardiovascular conditions [6].
PIs are defined as localised damage to the skin and subcutaneous tissues over bony prominences caused by pressure or shearing forces. These injuries are typically associated with ischaemia, cell death and tissue necrosis caused by prolonged pressure. Recent studies have also highlighted that tissue deformation, independent of ischaemia, is critical in PI development. Localised mechanical stresses can cause cellular and tissue damage within minutes, even before blood flow is compromised [7]. Therefore, understanding and mitigating both ischaemic and mechanical deformation mechanisms is essential for effective prevention strategies. Pressure on soft tissues disrupts blood flow, leading to ischaemia and subsequent tissue death. When the capillary pressure is exceeded, blood circulation is obstructed, resulting in oxygen and nutrient deprivation in the tissues [8]. Additionally, sustained pressure can disrupt both the lymphatic and blood circulation systems, causing tissue necrosis. Reactive hyperaemia caused by ischaemia is one of the first tissue responses to pressure [9].
Incorrect patient positioning, prolonged pressure, and inadequate protection during surgery can cause PIs in operating room environments. Patients undergoing cardiac, thoracic, vascular, abdominal, and orthopaedic surgeries are at high risk for PIs due to the extended duration of these procedures, the use of rigid operating tables and specialised equipment that may exert pressure on certain body parts, and the need for specific patient positioning—all of which can compromise tissue perfusion, restrict blood flow, and increase pressure on certain body areas [3, 10]. Numerous risk factors can lead to intraoperative PIs. General anaesthesia is another major contributor, as it reduces sensory perception and increases the likelihood of prolonged pressure-related injuries, particularly, in surgeries that last > 2 h [11]. The duration of surgery is a highly significant factor because longer procedures increase the likelihood of patients developing PIs [9]. A patient's position during surgery directly affects which specific pressure points may cause PIs, and must therefore be carefully managed. Blood pressure is another critical factor. Hypotension reduces blood flow to tissues, increasing the risk of PIs [12]. Moreover, vasopressor use can impair tissue perfusion, potentially leading to PIs. Hypothermia also increases this risk, making it essential to keep patients warm using heating devices during surgery [13]. Surgical instruments, such as retractors, if not used carefully, can exert pressure, thereby increasing the risk of PIs [3]. Finally, support surfaces play a key role in distributing pressure and reducing the risk of injury. Appropriate surgical table support surfaces are considered a critical preventive measure against intraoperative PIs.
In addition to surgical risk factors for PIs, patient-related risk factors—such as age, comorbidities (e.g., diabetes and cardiovascular disease), nutritional status, mobility limitations, and skin integrity—may also play crucial roles. These factors can all increase a patient's vulnerability to developing PIs during surgery [8, 14].
The multifactorial nature of PIs demands attention to modifiable risk factors in the surgical environment. However, there is insufficient research concerning the impact of positioning devices and patient-specific interventions during surgery. Chen et al. [1] found that PIs typically develop within 1–2 days post-surgery, with the majority classified as Stage I or II. Yücel noted that older patients have a higher risk of developing PIs [15], whereas Tuz and Mitchell [16] reported that low haemoglobin levels could increase this risk.
Tschannen et al. [17] found that every one-point increase in body mass index (BMI) increased the risk of PI by 0.97%, whereas VanGilder et al. [18] observed that PIs were more common in patients with lower BMIs. Ness et al. [19] showed that patients with morbid obesity were 3× more likely to develop PIs and that malnutrition increased this risk by 11×. Katran found that 30.5% of patients in surgical intensive care units had at least one systemic comorbid disease and that PIs occurred in 46.3% of patients with diabetes [20].
Manzano et al. [21] reported that changing patient positions did not reduce the risk of intraoperative PI, whereas Bergstrom et al. [22] demonstrated that PIs can develop on the coccyx, sacrum, and heels despite patient repositioning. Karayurt and Çelik [23] noted that PIs are most common in the supine and prone positions, with nerve injuries being more frequent in the lithotomy position. Gencer and Özkan [24] found that patients > 65 years of age are at an increased risk of developing PIs, while Saghaleini et al. [25] emphasised that malnutrition is a key risk factor.
However, these studies primarily focused on PIs that developed in intensive care or clinical settings, leaving a gap in the current understanding of PIs that occur specifically in the operating room during surgeries—particularly, those caused by patient positioning. Prolonged pressure, rigid operating tables and specific patient positions—such as supine and lateral—have been associated with an increased risk of PIs during surgery [14]. Therefore, this study aimed to investigate the risk factors associated with positioning-related PIs during surgical procedures in the operating room to address this gap in the current literature [13, 26].
2 Materials and Methods
This prospective, descriptive, cross-sectional study was conducted in the operating theatres of a university hospital between 15 November 2023, and 15 July 2024. Surgeries from the departments of ear, nose, and throat; neurosurgery; general surgery; thoracic surgery; orthopaedic surgery and urology were included. The study setting consisted of 22 surgical suites, and all surgeries conducted in the suites where the authors worked were included in the evaluation and follow-up. The author has worked as an operating room nurse for 9 years. The temperature of the operating rooms ranged between 18°C and 23°C. The patients' body temperatures were maintained between 36°C and 37°C using heated blankets throughout the procedures. There were no standardised protocols for positioning patients at the institution. The surgeon determined each patient's positioning based on the type of surgery, the surgical site and the patient's medical condition. Factors such as optimal access to the surgical site and the patient's overall health status were considered when determining the positioning strategy.
All surgical procedures were performed on Maquet Alphamaxx (Getinge Group, Germany) mobile, electrohydraulic operating tables, which allow for flexible and safe patient positioning to minimise pressure-related risks. Standard support surfaces included a surgical table foam mattress combined with viscoelastic cushions.
Additionally, Action Long Armboard Pads (Action Products, USA; Product No. 40301), made of Akton polymer, were used during procedures in which patients were placed in the lithotomy position or had their arms abducted. These pressure- and shear-reducing pads were positioned under the legs and arms to protect vulnerable areas and maintain tissue integrity throughout the surgical procedure.
2.1 Population and Sample
The required sample size for the study was calculated to be 140 patients using G*Power analysis, based on an alpha level of 0.05, a power of 0.80, and an effect size of 0.30. The standard deviation was estimated according to conventional assumptions for a medium effect size (Cohen's d = 0.30), which is commonly used in G*Power analyses for observational studies.
These values were selected based on the expected relationship between the risk factors and the development of intraoperative PIs. The patients targeted for the study were contacted after admission to the surgical ward prior to their procedures, and informed consent forms were completed by the patients in the presence of volunteers involved in the study's execution. All participants were asked to voluntarily respond to the questionnaires in a neutral environment without any pressure, interference or guidance.
The inclusion criteria for this study were: patients aged > 18 years, those undergoing elective surgeries, a surgical duration of ≥ 1 h (determined after completion of the surgery) and patients free of PIs upon arrival to the operating room. Only patients who volunteered to participate were included in the study.
The exclusion criteria were: patients undergoing emergency surgeries, those whose positions were changed during their procedures, and those who were not assessed at the 24 h mark postoperatively. Patients whose positions were changed during their procedures were excluded to maintain consistency in the study data, as the focus was on evaluating the effects of a single sustained position on the development of PIs. Analysing position changes was therefore determined to introduce additional variables beyond the scope of the study.
2.2 Data Collection Tools
A composite questionnaire compiled by the author based on a literature review was used to conduct the study. It comprised three focused questionnaires: the ‘Individual Characteristics (Patient Identification)’, the ‘Risk Assessment Scale for Surgical Position-Related Injuries (ELPO)’, and the ‘Postoperative Patient Assessment’ forms. Atrophy and edema were assessed by the researcher through visual inspection and palpation during the preoperative physical examination. Atrophy was defined as a reduction in muscle mass, thinning of the skin and loss of subcutaneous tissue. Edema was identified by observing swelling during inspection and palpation. Both variables were recorded as either present or absent without the use of a grading scale.
2.3 Individual Characteristics (Patient Identification Form)
The patient identification form included information on the patient's sex, age, height, weight, chronic illnesses, skin temperature, skin colour, skin hydration, atrophy and oedema status.
2.4 ELPO
This scale was developed by Lopes et al. [27] in 2016 to assess the risk of PIs associated with surgical positioning. However, despite its development, there has been limited research in the literature on its application and validation in diverse surgical settings—particularly regarding assessing how different surgical positions contribute to PIs. This study aimed to address this gap by applying the scale in various surgical contexts and providing new insights into positioning-related risk factors that have not yet been fully explored. Şengul et al. conducted a validity and reliability study of the Turkish version of the ELPO scale in 2022 [28]. An item analysis revealed that the item–total score correlations ranged from 0.044 to 0.664, indicating internal consistency. The scale comprises seven areas: type of surgical positioning, duration of surgery, type of anaesthesia used, use of support surfaces, positioning of extremities, comorbidities and patient age. Each of these seven areas was scored between one (1), indicating the lowest risk and five (5) for the highest. The total possible score on the scale ranged from 7 to 35, with scores of ≤ 19 indicating a low PI risk and scores of ≥ 20 indicating a high risk.
2.5 Postoperative Patient Assessment Form
In the postoperative patient assessment form, questions regarding PI staging were included alongside patient identification information. PI staging was performed using the National Pressure Ulcer Advisory Panel (NPUAP) staging system [29].
- Stage I: Intact skin with non-blanchable redness, most often over areas of bony prominence. The area may be painful, firm, soft, warmer or cooler than the surrounding tissue.
- Stage II: Partial-thickness loss of the dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough. These PIs may also present as intact or ruptured serum-filled blisters.
- Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible; however, the bones, tendons, or muscles are not exposed. Sloughing may be present but does not obscure the depth of tissue loss. These PIs may include undermining and tunnelling.
- Stage IV: Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may also be present. These PIs often include undermining and tunnelling.
2.6 New Definitions
Medical device-related PI: These injuries are caused by devices designed for diagnostic and therapeutic purposes. The PI generally conforms to the pattern or shape of the device and should be staged using the standard NPUAP system.
Mucosal membrane PI: These injuries occur on mucosal membranes where medical devices have been used. They cannot be staged, owing to the nature of the affected tissue [30].
2.7 Data Collection Procedures
Following admission to the surgical ward prior to their procedures, the author informed the patients about the study, and consent was obtained. Before surgery, individual patient characteristics and the presence of any preoperative PIs were assessed through face-to-face interviews and direct observations. During surgery, the author assessed the patients using the ELPO scale, focusing on areas exposed to prolonged pressure. Postoperatively, the surgical team performed final skin checks before each patient was transferred from the operating room to assess the formation of new PIs. The ELPO scale recommends evaluating patients according to the highest risk factors for PI, such as changes in anaesthesia and positioning. For instance, if a patient was moved from the lithotomy to the supine position during surgery, the assessment is based on the highest-risk position (in this case, lithotomy, which is associated with significant pressure on the sacrum and heels). Similarly, sedation presents a higher risk than local anaesthesia because it reduces the patient's ability to respond to discomfort and shift positions, thereby increasing the likelihood of tissue damage. Thus, the highest PI risk category was noted when multiple factors were present.
After each surgery, the author visited the postoperative recovery unit to assess the patient's skin for the development of PIs and recorded the assessments using the NPUAP staging system. The patients were re-evaluated for PIs in the ward at the 24 h postoperative mark, and the findings were recorded in the postoperative patient assessment form.
2.8 Statistical Analysis
The data obtained were analysed using SPSS 27.0 (IBM Corp., Armonk, NY, USA). The study variables included patient age, sex, marital status, educational background, occupation, height, weight, type of surgery, comorbidities and ELPO score. The data form consisted of two sections. The first collected information on age, sex, marital status, educational level, occupation, height, weight and comorbidities, while the second assessed the ELPO score. Demographic information and the frequency of participants' responses to the questions were calculated and presented in tabular form. Because approximately 60% of the surgeries were conducted in the supine position, the data did not follow a normal distribution. To compare the survey data, the Mann–Whitney U and Kruskal–Wallis tests were used to analyse the nonparametric data, whereas the chi-squared test was used to analyse the categorical data. To identify the risk factors associated with PIs, logistic regression analysis was performed to assess the relationship between potential risk factors (e.g., anaesthesia type, surgical position and duration) and the development of PIs. Statistical significance was set at p < 0.05.
3 Results
As shown in Table 1, the study population was evenly distributed by sex, with most participants being married and middle-aged (40–59 years). Primary school was the most common educational level, and the majority reported having an income equal to their expenses. Hypertension and diabetes were the most frequent chronic illnesses. Most patients had an ASA score of 2, with normal peripheral skin temperature, colour, and hydration. Notably, 35.7% of patients were overweight, and 25% were obese–factors associated with increased PI risk.
| Variable | Category | N | % |
|---|---|---|---|
| Sex | Female | 71 | 50.7 |
| Male | 69 | 49.3 | |
| Marital status | Married | 122 | 87.1 |
| Single | 18 | 12.9 | |
| Age | 18–39 years | 27 | 19.3 |
| 40–59 years | 44 | 31.4 | |
| 60–69 years | 34 | 24.3 | |
| 70–79 years | 22 | 15.7 | |
| ≥ 80 years | 13 | 9.3 | |
| Educational level | Illiterate | 9 | 6.4 |
| Primary school | 53 | 37.9 | |
| Middle school | 34 | 24.3 | |
| High school | 31 | 22.1 | |
| University | 13 | 9.3 | |
| Income status | Less than expenses | 18 | 12.9 |
| Equal to expenses | 117 | 83.6 | |
| More than expenses | 5 | 3.6 | |
| Chronic illnesses | None | 75 | 53.6 |
| Diabetes | 25 | 17.9 | |
| Hypotension | 12 | 8.6 | |
| Peripheral neuropathy | 3 | 2.1 | |
| Hypertension | 35 | 25.0 | |
| Peripheral artery disease | 9 | 6.4 | |
| Deep vein thrombosis | 2 | 1.4 | |
| ASA score | 1 | 13 | 9.3 |
| 2 | 124 | 88.6 | |
| 3 | 2 | 1.4 | |
| 4 | 1 | 0.7 | |
| Peripheral skin temperature | Normal | 132 | 94.3 |
| Cold | 8 | 5.7 | |
| Peripheral skin colour | Normal | 134 | 95.7 |
| Red | 1 | 0.7 | |
| Pale | 5 | 3.6 | |
| Peripheral skin hydration | Normal | 134 | 95.7 |
| Dry | 6 | 4.3 | |
| Atrophy | Yes | 29 | 20.7 |
| No | 111 | 79.3 | |
| Edema | Yes | 25 | 17.9 |
| No | 115 | 82.1 | |
| BMI | < 18.5 (Underweight) | 4 | 2.9 |
| 18.5 ≤ 24.9 (Normal) | 51 | 36.4 | |
| 25.0 ≤ 29.9 (Overweight) | 50 | 35.7 | |
| ≥ 30.0 (Obese) | 35 | 25.0 |
- Abbreviations: ASA score, anaesthesia risk according to the American Society of Anesthesiologists; BMI, body mass index.
As shown in Table 2, most patients were positioned supine (54.3%) and underwent surgeries lasting 1–2 h (52.1%). General anaesthesia was predominantly used (89.3%), and surgical table foam mattresses with viscoelastic cushions were employed for nearly all patients. Anatomical extremity positioning was maintained in 78.6% of cases. The majority of patients had no comorbidities (56.4%), but vascular disease (33.6%) and diabetes (10.0%) were also present. Patients aged 40–59 years formed the largest age group (31.4%).
| Variable | Category | N | % |
|---|---|---|---|
| Surgical position | Supine | 76 | 54.3 |
| Lateral | 18 | 12.9 | |
| Prone | 16 | 11.4 | |
| Lithotomy | 30 | 21.4 | |
| Surgery duration | ~1 h | 11 | 7.9 |
| 1–2 h | 73 | 52.1 | |
| 2–4 h | 56 | 40.0 | |
| Anaesthesia | Local | 2 | 1.4 |
| Regional | 13 | 9.3 | |
| General | 125 | 89.3 | |
| Support surface | Viscous elastic surgical table mattress/viscous elastic cushion | 1 | 0.7 |
| Surgical table foam mattress/viscous elastic cushion | 139 | 99.3 | |
| Extremity position | Anatomical position | 110 | 78.6 |
| Knees elevated > 90° or lower extremity abduction > 90° | 30 | 21.4 | |
| Comorbidities | No comorbidities | 79 | 56.4 |
| Vascular disease | 47 | 33.6 | |
| Diabetes | 14 | 10.0 | |
| Age | 18–39 years | 26 | 18.6 |
| 40–59 years | 44 | 31.4 | |
| 60–69 years | 34 | 24.3 | |
| 70–79 years | 22 | 15.7 | |
| ≥ 80 years | 14 | 10.0 |
According to Table 3, postoperatively, peripheral skin temperature was normal in 131 patients (93.6%) and cold in 9 patients (6.4%). Skin colour was normal in 134 patients (95.7%), while erythema was detected in 1 patient (0.7%). Erythema was absent in 108 patients (77.1%), with the highest incidence observed in the back region (7.9%). Skin hydration was normal in 134 patients (95.7%). Atrophy was absent in 80.7% of the patients, and 85% reported no position-related pain. PIs were not observed in 102 patients (72.9%), whereas 36 patients (25.7%) had stage I PIs immediately postoperatively, and 2 (1.4%) had stage I PIs when assessed 24 h postoperatively. Postoperative skin assessments showed that PIs were most frequently located on the back, including the sacral and thoracic regions (11 patients, 7.9%), followed by the popliteal region (6 patients, 4.3%), heels (4 patients, 2.9%), breasts (4 patients, 2.9%), greater trochanter (3 patients, 2.1%), nose (3 patients, 2.1%), forehead (2 patients, 1.4%), knees (2 patients, 1.4%) and iliac crest (1 patient, 0.7%).
| Variable | Finding | N | % |
|---|---|---|---|
| Peripheral skin temperature | Normal | 131 | 93.6 |
| Cold | 9 | 6.4 | |
| Peripheral skin colour | Normal | 134 | 95.7 |
| Red | 1 | 0.7 | |
| Pale | 5 | 3.6 | |
| Erythema | None | 108 | 77.1 |
| Back | 11 | 7.9 | |
| Greater trochanter | 3 | 2.1 | |
| Nose | 3 | 2.1 | |
| Thoracic vertebra | 4 | 2.9 | |
| Iliac crest | 1 | 0.7 | |
| Female breasts | 4 | 2.9 | |
| Heels | 4 | 2.9 | |
| Forehead | 2 | 1.4 | |
| Knees | 2 | 1.4 | |
| Popliteal area | 6 | 4.3 | |
| Peripheral skin hydration | Normal | 134 | 95.7 |
| Dry | 6 | 4.3 | |
| Peripheral skin atrophy | Yes | 27 | 19.3 |
| No | 113 | 80.7 | |
| Edema | Yes | 25 | 17.9 |
| No | 115 | 82.1 | |
| Position-related pressure pain score | No pain | 119 | 85.0 |
| Mild | 14 | 10.0 | |
| Moderate | 6 | 4.3 | |
| Severe | 1 | 0.7 | |
| Pressure injury staging | None | 102 | 72.9 |
| Stage I | Immediately postoperatively | 36 | 25.7 |
| 24 h postoperatively | 2 | 1.4 |
As shown in Table 4, patients positioned supine had a significantly higher risk of developing PIs immediately after surgery compared to those positioned laterally, prone, or in the lithotomy position (χ2 = 14.673, p = 0.023). Although surgeries lasting 2–4 h tended to show a higher incidence of PIs, this difference was not statistically significant (χ2 = 6.851, p = 0.144). Similarly, patients receiving general anaesthesia exhibited more PIs than those under local or regional anaesthesia, but the difference was not statistically significant (χ2 = 6.851, p = 0.144). No significant associations were found between the support surface or extremity position type and PI development (p > 0.05). However, the presence of diabetes was significantly associated with an increased risk of PIs (χ2 = 12.088, p = 0.017). No significant differences were detected among the age groups in relation to PI development (χ2 = 7.095, p = 0.526).
| Variable | None (n) | Immediately Post-op Stage I (n) | 24 h Post-op Stage I (n) | Total (n) | χ 2 | p |
|---|---|---|---|---|---|---|
| Surgical position | 14.673 | 0.023 | ||||
| Supine | 62 | 13 | 1 | 76 | ||
| Lateral | 8 | 9 | 1 | 18 | ||
| Prone | 9 | 7 | 0 | 16 | ||
| Lithotomy | 23 | 7 | 0 | 30 | ||
| Surgery duration | 6.851 | 0.144. | ||||
| ~1 h | 9 | 2 | 0 | 11 | ||
| 1–2 h | 58 | 15 | 0 | 73 | ||
| 2–4 h | 35 | 19 | 2 | 56 | ||
| Anaesthesia type | 6.851 | 0.144 | ||||
| Local | 2 | 0 | 0 | 2 | ||
| Regional | 11 | 1 | 1 | 13 | ||
| General | 89 | 35 | 1 | 125 | ||
| Support surface | 0.375 | 0.829 | ||||
| Viscous elastic | 1 | 0 | 0 | 1 | ||
| Foam mattress + cushion | 101 | 36 | 2 | 139 | ||
| Extremity position | 0.560 | 0.756 | ||||
| Anatomical | 80 | 28 | 2 | 110 | ||
| Elevated/abducted | 22 | 8 | 0 | 30 | ||
| Comorbidities | 12.088 | 0.017 | ||||
| No comorbidities | 65 | 13 | 1 | 79 | ||
| Vascular disease | 31 | 15 | 1 | 47 | ||
| Diabetes | 6 | 8 | 0 | 14 | ||
| Age group | 7.095 | 0.526 | ||||
| 18–39 years | 21 | 5 | 0 | 26 | ||
| 40–59 years | 35 | 8 | 1 | 44 | ||
| 60–69 years | 24 | 10 | 0 | 34 | ||
| 70–79 years | 13 | 8 | 1 | 22 | ||
| ≥ 80 years | 9 | 5 | 0 | 14 | ||
- Note: Chi-squared analysis. Bold indicates statistically significant value (p < 0.05).
The regression analysis results presented in Table 5 demonstrate the effects of various demographic and clinical variables on the risk of PIs. Both simple linear and logistic regression analyses conducted in this study yielded significant findings regarding risk factors for PI development. Regarding surgical positioning, sex (p = 0.014) and educational level (p = 0.014) were identified as significant risk factors. For surgery duration, significant associations were observed with BMI (p = 0.000) and income status (p = 0.048). Regarding the type of anaesthesia, sex (p = 0.035), age (p = 0.000), and the presence of atrophic skin (p = 0.001) were determined to be significant factors. In terms of support surface use, the presence of comorbidities (p = 0.000) was identified as a significant risk factor. For extremity positioning, sex (p = 0.000) and income status (p = 0.023) were significantly associated with an increased risk of PIs.
| Variable | Significant factor | p |
|---|---|---|
| Sex | Surgical position type | 0.014 |
| Type of anaesthesia | 0.035 | |
| Extremity position | 0.000 | |
| Educational level | Surgical position type | 0.014 |
| Comorbidities | 0.000 | |
| Age | 0.000 | |
| BMI | Surgery duration | 0.000 |
| Income status | Surgery duration | 0.048 |
| Extremity position | 0.023 | |
| Diabetes | Comorbidities | 0.000 |
| Age | 0.000 | |
| ASA classification | Comorbidities | 0.003 |
| Age | 0.000 | |
| Skin atrophy | Type of anaesthesia | 0.001 |
| Comorbidities | 0.045 | |
| Age | 0.000 | |
| Skin temperature | Age | 0.000 |
| Skin colour | Age | 0.000 |
| Skin hydration | Age | 0.000 |
- Note: Only variables with statistically significant associations (p < 0.05) are presented in the table. Logistic regression analysis was performed.
As shown in Table 6, logistic regression analysis identified several significant risk factors for the development of PIs based on ELPO scores. Female sex (p = 0.039), being married (p = 0.034), being in the70–79-years age group (p = 0.000), having a primary school education (p = 0.001) and the presence of diabetes (p = 0.036) were all significantly associated with a higher risk of developing PIs. These findings emphasise the importance of considering demographic and comorbidity factors when evaluating patient risk for positioning-related PIs.
| Variable | Low risk (n) | High risk (n) | p |
|---|---|---|---|
| Sex (female) | 63 | 8 | 0.039 |
| Marital status (married) | 97 | 25 | 0.034 |
| Age (70–79 years) | 11 | 11 | 0.000 |
| Educational level (primary school) | 36 | 17 | 0.001 |
| Diabetes (yes) | 18 | 7 | 0.036 |
- Note: Statistically significant results are shown in bold. Logistic regression analysis was performed.
As shown in Table 7, our examination of the PI staging values based on demographic information using ELPO scores revealed statistically significant differences between BMI values and PI staging. Specifically, patients with obesity were more likely to develop stage I PIs immediately following their procedures (p = 0.000). The frequency of developing stage I PIs immediately postoperatively was higher among males, married patients, those aged 60–69 years, primary school graduates; those whose incomes equalled their expenses, those with diabetes, those with an ASA score of 2, and those with normal skin temperature, skin colour and skin hydration; as well as those without atrophy or edema. However, statistically significant differences were only observed for BMI. No statistically significant differences were found in terms of PI risk (p > 0.05) for any of the other demographic variables (i.e., sex, marital status, age group, educational level, income status, presence of diabetes, ASA score, skin temperature, skin colour, skin hydration, atrophy and edema).
| Variable | Pressure injury staging | n | p | |||
|---|---|---|---|---|---|---|
| No pressure injury (n) | Stage I, immediately postoperatively (n) | Stage I, 24 h postoperatively (n) | ||||
| Total | 102 | 36 | 2 | 140 | — | |
| Sex | Female | 56 | 15 | 0 | 71 | 0.139 |
| Male | 46 | 21 | 2 | 69 | ||
| Marital status | Married | 88 | 32 | 2 | 122 | 0.794 |
| Single | 14 | 4 | 0 | 18 | ||
| Age | 18–39 years | 22 | 5 | 0 | 27 |
0.470 |
| 40–59 years | 35 | 8 | 1 | 44 | ||
| 60–69 years | 24 | 10 | 0 | 34 | ||
| 70–79 years | 13 | 8 | 1 | 22 | ||
| ≥ 80 years | 8 | 5 | 0 | 13 | ||
| Educational level | Illiterate | 6 | 3 | 0 | 9 |
0.106 |
| Primary school | 32 | 20 | 1 | 53 | ||
| Middle school | 30 | 4 | 0 | 34 | ||
| High school | 26 | 4 | 1 | 31 | ||
| University | 8 | 5 | 0 | 13 | ||
| BMI | Underweight | 4 | 0 | 0 | 4 |
0.000 |
| Normal Weight | 39 | 11 | 1 | 51 | ||
| Overweight | 38 | 11 | 1 | 50 | ||
| Obese | 21 | 14 | 0 | 35 | ||
| Income status | Equal to expenses | 85 | 30 | 2 | 117 | 0.612 |
| Diabetes | No | 62 | 12 | 1 | 75 | 0.103 |
| Yes | 8 | 17 | 0 | 25 | ||
| ASA score | 1 | 9 | 4 | 0 | 13 |
0.960 |
| 2 | 90 | 32 | 2 | 124 | ||
| 3 | 2 | 0 | 0 | 2 | ||
| 4 | 1 | 0 | 0 | 1 | ||
| Peripheral skin temperature | Normal | 96 | 34 | 2 | 132 | 0.938 |
| Cold | 6 | 2 | 0 | 8 | ||
| Peripheral skin colour | Normal | 96 | 36 | 2 | 134 |
0.674 |
| Red | 1 | 0 | 0 | 1 | ||
| Pale | 5 | 0 | 0 | 5 | ||
| Peripheral skin hydration | Normal | 96 | 36 | 2 | 134 |
0.311 |
| Dry | 6 | 0 | 0 | 6 | ||
| Atrophy | Yes | 22 | 6 | 1 | 29 | 0.485 |
| No | 80 | 30 | 1 | 111 | ||
| Edema | Yes | 15 | 10 | 0 | 25 | 0.170 |
| No | 87 | 26 | 2 | 115 | ||
- Note: Chi-squared analysis was performed.
4 Discussion
This study examined demographic and clinical patient characteristics to assess the risk of PIs related to surgical positioning. Linear and logistic regression analyses revealed significant differences regarding patient age, diabetes history, ASA classification, peripheral skin temperature, skin colour, hydration and skin atrophy. Our assessment of ELPO scores revealed that the risk increased with age—particularly in male patients, those with diabetes, and those with lower educational levels. Statistically significant differences in PI stages were observed both immediately and 24 h postoperatively. A higher BMI was also associated with more severe injuries. However, surgical duration, type of anaesthesia used, support surface, extremity positioning and comorbidities did not significantly influence the development of PIs.
Tura et al. [30] identified intraoperative factors such as support surfaces, skin conditions, and prolonged surgical duration as significant risk factors for PIs. Similarly, in this study, skin condition and surgical duration were found to significantly influence the occurrence of PIs, based on the patients' ELPO risk scores.
This study found that patients aged ≥ 60 years—particularly those in the 70–79 age range—have the highest risk of developing intraoperative PIs, highlighting age as a critical factor. Decreased skin elasticity, impaired tissue perfusion and circulatory problems in older patients are likely contributors to this increased risk. Age-related changes such as reduced collagen synthesis and diminished skin turgor weaken the dermis–epidermis connection, making the skin more susceptible to injury [15, 31, 32].
In patients with diabetes, impaired nutritional control was found to contribute to PIs, which is consistent with the findings of Saghaleini et al. [25]. Uncontrolled blood sugar levels impair tissue perfusion and delay wound healing, thereby increasing the risk of PIs. These results underscore the importance of addressing nutritional deficiencies as a key factor for preventing PIs.
This study determined that surgical positioning, according to the ELPO risk score, significantly affects the development of PIs both immediately and at 24 h postoperatively. The most commonly used position was supine (54.3%), followed by the lithotomy, lateral and prone positions. Although the supine position is generally considered low risk, its associated PI risk increases with prolonged surgical duration [33]. The lithotomy position also poses a higher risk, due to the increased pressure it places on the perineal area [29, 33]. A significant association was found between the supine position and PIs (p = 0.014), with extremity positioning also showing a notable effect (p = 0.001). Similar findings were reported by Karayurt and Çelik [23], with higher risks observed in the supine and prone positions. This study also identified that comorbidities—particularly, vascular disease and diabetes—play important roles in the development of PIs. Chronic conditions, particularly diabetes and hypertension, were found to be major factors that increased the risk of PIs.
Delayed wound healing in patients with diabetes is caused by impaired blood flow, reduced oxygen delivery and the adverse effects of hyperglycemia on collagen synthesis and tissue repair. Hypertension worsens this risk by causing vascular stiffness and narrowing, further impairing circulation and delaying nutrient and oxygen delivery to wounds [34, 35]). A meta-analysis by Cao et al. [36] found that diabetes increased the risk of PIs by 1.77×. In this study, diabetes significantly increased the risk of PIs (p = 0.036). This is consistent with the findings of Menšíková et al. [37], who identified impaired circulation and delayed tissue repair as key factors underlying this association. These results confirm that diabetes is a major risk factor for PIs [35, 37].
In this study, 81.6% of the patients who underwent surgery in the supine position did not develop PIs. However, positioning remained a significant risk factor, with 38 PIs occurring across all positions—confirming that surgical positioning is a major contributor to PI risk [23, 38]. Although surgical duration was not found to be a statistically significant risk factor (p > 0.05), more patients developed PIs as the surgical duration increased. For example, 43.18% of the patients who underwent surgeries lasting 2–4 h developed PIs, indicating a potential trend. This aligns with the findings of Kim et al. [39], who suggested that prolonged surgery is a risk factor for PIs. Research has also shown that pressures exceeding 32 mmHg during surgery can compromise capillary circulation, leading to ischemia and necrosis, with the duration of pressure playing a critical role [8].
In this study, 17.9% of the patients were classified as high-risk according to the ELPO assessment scale. Among these patients, most PIs developed immediately postoperatively, with stage I injuries identified in only two at 24 h postoperatively. This suggests that patients with high ELPO scores are more likely to develop PIs. Preventing these injuries requires careful management of surgical positioning, anaesthesia, support surfaces, and extremity alignment. The ELPO score is a valuable tool for surgical teams in terms of identifying high-risk patients who require additional precautions [40]. Lima et al. [41] demonstrated a significantly higher risk of PIs in high-risk ELPO patient groups, which aligns with our current findings. Proper positioning, as emphasised by Spruce in the Association of Perioperative Registered Nurses guidelines, is essential for preventing PIs.
In this study, 72.9% of the patients did not develop PIs. However, 25.7% experienced Stage I PIs immediately postoperatively and 1.4% had Stage I PIs when assessed 24 h postoperatively, underscoring the importance of care both during and after surgery.
Although Stage I injuries are considered superficial, their high incidence indicates early tissue compromise and emphasises the need for vigilant intraoperative skin assessments. Immediate identification and intervention in Stage I injuries through repositioning, use of appropriate support surfaces, and enhanced intraoperative nursing protocols are critical to preventing progression to more severe injuries. These findings suggest that incorporating routine intraoperative skin checks and staff education on early PI signs could strengthen surgical patient care protocols. These findings are consistent with the current literature on Stage I PIs [14, 26, 42]. For instance, Chen et al. [1] reported PIs in 159 patients, 139 of whom had Stage I injuries (vs. 20 with Stage II injuries). Studies have highlighted the need for careful surgical positioning to prevent PIs [1, 33]. In this study, the type of anaesthesia used was not generally significant in terms of PI development, but patients who received general anaesthesia had a higher risk than those who received local or regional anaesthesia. This increased risk is likely due to patient immobility and impaired sensory perception under general anaesthesia, facilitating PI development. Similarly, Chen et al. [43] found that reduced mobility and sensory loss under general anaesthesia increased the risk. The high proportion of patients who received general anaesthesia may have influenced this finding in our study. Significant relationships were identified between anaesthesia type and sex (p = 0.035), age (p = 0.001) and peripheral atrophic skin condition (p = 0.001)—with older and male patients at higher risk, possibly due to skin atrophy.
This study found that surgeries that lasted > 1 h carried a significantly higher risk of PIs (1–2 h, 52.1%; 2–4 h, 40%). This finding is consistent with the literature, highlighting that longer surgical duration is a key factor affecting the development of PIs [44]. A meta-analysis by Shafipour et al. [45] also confirmed that surgical duration is a major risk factor for positioning-related PIs. Frequent repositioning during extended surgeries and the use of appropriate support surfaces are recommended to prevent these injuries.
Although viscoelastic cushions on surgical tables are known to reduce the risk of PIs [46, 47], we did not find statistically significant differences in PI occurrence based on the type of support surface. Although statistical significance was not achieved, this finding has important clinical implications. The consistent use of similar support surfaces across the patient population may have minimised observable differences. Nonetheless, maintaining high-quality, pressure-redistributing surfaces remains a crucial preventive strategy, as emphasised by the NPIAP and EPUAP guidelines, which recommend routine use of appropriate support surfaces as part of a multifaceted approach to prevent PIs [29]. According to these guidelines, support surfaces should be selected based on patient-specific risk factors and used alongside regular repositioning and skin assessments. Future studies employing a greater variety of support surfaces may provide more definitive evidence regarding their comparative effectiveness.
In this study, sex was found to be an important factor in the risk of PIs, with more male patients being categorised into the higher-risk ELPO score group. Compared to men, women with ischemic heart disease tend to be older, which may be due to the protective effects of oestrogen on the cardiovascular system. One reason for the higher risk associated with male sex may stem from the more frequent occurrence of circulatory system disorders in men, indicated by the ASA scores of our patients.
Most of our patients had normal peripheral skin temperatures and colours, although a smaller proportion exhibited cold skin temperatures and pale colours. Saindon et al. [48] emphasised the importance of normal skin temperature in terms of supporting circulation and oxygenation to prevent PIs. Although 77.1% of our patients did not show signs of erythema, it was observed in areas subjected to prolonged pressure, with erythema most frequently seen in the back (7.9%). This contrasts with other studies, which have reported that the sacral area and heels are more commonly affected [1, 4, 49, 50]. This is likely due to the predominant use of the supine position in our study.
Extremity positioning and comorbidities such as vascular disease and diabetes are significant factors in PI development. Deviation from anatomical positioning increases the risk, particularly when the knees or lower extremities are elevated or abducted beyond 90°. Chronic diseases further increase the likelihood of PIs, which is consistent with existing literature on the importance of managing surgical duration, anaesthesia, support surfaces, and extremity positioning [48].
Our findings suggest that incorporating risk stratification tools, such as the ELPO score, into preoperative evaluations can help identify patients at higher risk for PIs. This enables the surgical team to tailor positioning strategies, optimise support surfaces, and enhance intraoperative skin surveillance to prevent injury better.
4.1 Limitations
This study had several key limitations worth noting. First, it was limited to patients in operating rooms where the author had a fixed assignment, which may have affected the generalisability of the findings. Additionally, although the ethics committee form indicated that PIs should be assessed at 48 and 72 h postoperatively, 80% of the patients were discharged after 24 h, limiting these assessments to the 24 h mark. Although the original study protocol, as approved by the ethics committee, planned for postoperative PI assessments at 48 and 72 h, approximately 80% of patients were discharged within 24 h of surgery, limiting the assessment period. However, according to the literature, surgical positioning-related PIs can occur intraoperatively, within the first hour, 24 h, 72 h, or even up to 6 days postoperatively (8). Therefore, the assessment within the first 24 h remains consistent with existing definitions of positioning-related PIs. Nevertheless, it is acknowledged that PIs developing after the 24 h may have been missed, and this limitation has been clearly stated in the revised manuscript.
Furthermore, although a second observer was initially planned to participate in the study, all assessments were ultimately conducted solely by the author because the second observer was reassigned. The absence of a second observer may have introduced observer bias, potentially influencing the consistency and objectivity of the assessments.
Although the sample size was calculated using G*Power analysis to detect medium effect sizes with sufficient power, the relatively small number of participants may limit the generalisability of the findings, especially considering the number of variables included in the regression models. Future studies with larger sample sizes are recommended to validate and strengthen these findings.
5 Conclusion
This study identified key risk factors for position-related PIs in surgical patients—including surgical position, type of anaesthesia, support surface, extremity positioning, comorbidities, and age. The ELPO risk score emerged as a valuable tool for assessing and mitigating these risks. Our findings highlight the importance of considering patient-specific factors, such as BMI and diabetes, particularly, in surgeries involving prolonged durations or those performed in the supine position. However, although a trend was observed suggesting that longer surgical durations may increase PI risk, this relationship was not statistically significant in our study.
The novelty of this study lies in its focus on position-related PIs during surgeries—an area that has been underexplored compared to other clinical settings. By integrating the ELPO score into routine surgical practice, healthcare teams can better predict and reduce the risk of PIs, ultimately improving patient outcomes.
Future studies in this field should explore preventive strategies tailored to specific surgical positions and investigate the long-term outcomes of PIs.
5.1 Recommendations
Patient positioning should be carefully evaluated to prevent PIs during surgical procedures. Appropriate support surfaces are essential to protect areas vulnerable to pressure. Regular skin assessments should be conducted throughout surgeries to maintain skin integrity, and periodic checks should be performed to prevent the development of PIs. Patients in high-risk groups, including those with chronic conditions and specific demographic risk factors (e.g., age and BMI), should undergo comprehensive preoperative evaluations, and personalised care plans should be developed for them. Additionally, patients who undergo surgery under general anaesthesia should be closely monitored during both the intra- and postoperative periods to detect early signs of PIs. Given the high incidence of Stage I injuries observed in this study, intraoperative preventive strategies, such as frequent skin inspections, minimising shear and friction forces, using pressure-relieving devices, and considering intraoperative repositioning when feasible, should be emphasised. Enhancing nurse education on PI prevention and regularly updating best practices are critical for improving patient outcomes.
Future research should focus on developing new strategies to prevent PIs and applying these findings across diverse patient populations to increase the generalisability and effectiveness of the results.
Acknowledgements
We would like to thank all the healthcare personnel working in the surgical units at Pamukkale University Hospitals and Prof. Dr. Arzu Tuna for their contributions to our study.
Ethics Statement
Written permission was obtained from Sengul et al. [28], who conducted the first validity and reliability study of the ELPO scale in Turkey, for use of the ELPO questionnaire. This study was approved by the ethics committee of a university hospital and by the individual surgical departments that participated (i.e., general, thoracic, neurosurgery, otolaryngology, urology, and orthopaedics). Written informed consent forms were signed by all patients who participated.
Conflicts of Interest
The authors declare no conflicts of interest.
Open Research
Data Availability Statement
The data supporting the findings of this study are stored in SPSS software within the author's personal archive. The data are not publicly available in a data repository; however, access to the data may be granted upon reasonable request by contacting the corresponding author.
