Early Detection Methods of Deep Tissue Pressure Injuries: A Systematic Review

doi:10.1007/s12204-022-2518-2

Abstract

Abstract: Deep tissue pressure injuries (DTPIs) have witnessed a growing prevalence in hospitals and other health care units especially among individuals with pathological conditions that give rise to restricted mobility, impaired sensation, and reduced tissue tolerance. The etiology of DTPIs has been a subject of controversy, to which several explanatory models have been proposed, including direct mechanical insult, ischemia-reperfusion, lymphatic occlusion, and inflammatory cytokines. In line with these pathophysiological scenarios, ultrasound, subepidermal moisture detection, and biomarker technologies have been proposed as potential early detection methods of DTPIs. This paper provides a systematic review involving these three methods. The conclusion is that combining and implementing these methods at different time periods during DTPIs development and progression respectively is likely to be the most universal, effective and promising way for DTPIs diagnosis.

Key words: deep tissue pressure injury, early detection, ultrasound, subepidermal moisture detection, biomarker technologies

摘要： 深部组织压力性损伤（DTPIs）在医院和其他医疗单位中的患病率呈上升趋势，特别是在具有活动受限、感觉受损和组织耐受性降低的病理条件下。DTPIs的病因一直存在争议，现已提出了多种解释模型，包括直接机械损伤、缺血再灌注、淋巴阻塞和炎性细胞因子。根据这些病理生理场景，超声、皮下水分检测和生物标志物技术已被认为是DTPIs潜在的早期检测方法。本文对这三种方法进行了系统的综述。结论是，在DTPIs的产生和发展过程中，在不同的时间段结合和实施以上三种方法可能是DTPIs诊断最普适、有效的方式。

关键词: 深部组织压力性损伤，早期检测，超声，皮下水分检测，生物标志物技术

CLC Number:

R 318

JIA Jingyil (贾菁怡)，LI Zhengyi1,2 (李正裔)，PENG Linjing1 (彭琳晶)，YAO Yifeil* (姚怡飞). Early Detection Methods of Deep Tissue Pressure Injuries: A Systematic Review[J]. J Shanghai Jiaotong Univ Sci, 2023, 28(4): 526-.

References

[1] EDSBERG L E, BLACK J M, GOLDBERG M, et al.Revised national pressure ulcer advisory panel pressureinjury staging system [J]. Journal of Wound, Ostomy& Continence Nursing, 2016, 43(6): 585-597.
[2] BLACK J, BAHARESTANI M M, CUDDIGAN J, etal. National Pressure Ulcer Advisory Panel’s updatedpressure ulcer staging system [J]. Advances in Skin &Wound Care, 2007, 20(5): 269-274.
[3] PRESTON A, RAO A, STRAUSS R, et al. Deep tissue pressure injury: A clinical review [J]. The American Journal of Nursing, 2017, 117(5): 50-57.
[4] BOUTEN C V, KNIGHT M M, LEE D A, et al. Compressive deformation and damage of muscle cell subpopulations in a model system [J]. Annals of Biomedical Engineering, 2001, 29(2): 153-163.
[5] CEELEN K K, STEKELENBURG A, LOERAKKERS, et al. Compression-induced damage and internal tissue strains are related [J]. Journal of Biomechanics,2008, 41(16): 3399-3404.
[6] MAK A F T, ZHANG M, TAM E W C. Biomechanics of pressure ulcer in body tissues interacting with external forces during locomotion [J]. Annual Review of Biomedical Engineering, 2010, 12: 29-53.
[7] BADER D L, BARNHILL R L, RYAN T J. Effect of externally applied skin surface forces on tissue vasculature [J]. Archives of Physical Medicine and Rehabilitation, 1986, 67(11): 807-811.
[8] JAN Y K, BRIENZA D M, BONINGER M L, et al.Comparison of skin perfusion response with alternating and constant pressures in people with spinal cord injury [J]. Spinal Cord, 2011, 49(1): 136-141.
[9] MANORAMA A, MEYER R, WISEMAN R, et al.Quantifying the effects of external shear loads on arterial and venous blood flow: Implications for pressureulcer development [J]. Clinical Biomechanics, 2013,28(5): 574-578.
[10] TAYLOR R, JAMES T. The role of oxidative stress in the development and persistence of pressure ulcers [M]//Pressure ulcer research. Berlin, Heidelberg:Springer, 2005: 205-232.
[11] MILLER G E, SEALE J L. The recovery of terminallymph flow following occlusion [J]. Journal of Biomechanical Engineering, 1987, 109(1): 48-54.
[12] SCHUBERT V, FAGRELL B. Evaluation of the dynamic cutaneous post-ischaemic hyperaemia and thermal response in elderly subjects and in an area at riskfor pressure sores [J]. Clinical Physiology, 1991, 11(2):169-182.
[13] JAUL E, BARRON J, ROSENZWEIG J P, et al.An overview of co-morbidities and the development of pressure ulcers among older adults [J]. BMC Geriatrics, 2018, 18(1): 305.
[14] SULLIVAN R. A two-year retrospective review of suspected deep tissue injury evolution in adult acute care patients? [J]. Ostomy/Wound Management, 2013,59(9): 30-39.
[15] FLETCHER J, BADER D, DOWNIE F, et al. Recognising, managing and preventing deep tissue injury(DTI) [M]//London: Wounds UK, 2017.
[16] BLACK J M, CUDDIGAN J E, WALKO M A, et al.Medical device related pressure ulcers in hospitalized patients [J]. International Wound Journal, 2010, 7(5):358-365.
[17] VANGILDER C, MACFARLANE G D, HARRISONP, et al. The demographics of suspected deep tissue injury in the United States: An analysis of the International Pressure Ulcer Prevalence Survey 2006-2009[J]. Advances in Skin & Wound Care, 2010, 23(6): 254-261.
[18] COX J, EDSBERG L E, KOLOMS K, et al. Pressure injuries in critical care patients in US hospitals:Results of the international pressure ulcer prevalence survey [J]. Journal of Wound, Ostomy, and Continence Nursing, 2022, 49(1): 21-28.
[19] MAO C L, RIVET A J, SIDORA T, et al. Update on pressure ulcer management and deep tissue injury[J]. The Annals of Pharmacotherapy, 2010, 44(2): 325-332.
[20] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific PressureInjury Alliance. Prevention and treatment of pressure ulcers: Quick reference guide [M]//2nd ed. Perth:Cambridge Media, 2014: 1-75.
[21] KUMAR S. Seats, seating, and seat selection: Implications for pressure ulcers [M]//Ergonomics for rehabilitation professionals. Boca Raton: CRC Press,2009: 232-259.
[22] HENSON A, KENNEDY-MALONE L. A quality improvement project comparing two treatments for deep tissue pressure injuries to feet and lower legs of longterm care residents [J]. Advances in Skin & WoundCare, 2020, 33(11): 594-598.
[23] HONAKER J, BROCKOPP D, MOE K. Suspected deep tissue injury profile: A pilot study [J]. Advancesin Skin & Wound Care, 2014, 27(3): 133-140.
[24] SUN W N, LIU Y Q, SHENG L S, et al. Clinical nursing practice of three cases of deep tissue injury [J].Chinese Journal of Injury Repair and Wound Healing (Electronic Edition), 2020, 15(2): 156-158 (inChinese).
[25] MATSUMOTO M, NAKAGAMI G, KITAMURA A,et al. Ultrasound assessment of deep tissue on thewound bed and periwound skin: A classification system using ultrasound images [J]. Journal of Tissue Viability, 2021, 30(1): 28-35.
[26] QUINTAVALLE P R, LYDER C H, MERTZ P J, et al.Use of high-resolution, high-frequency diagnostic ultrasound to investigate the pathogenesis of pressure ulcer development [J]. Advances in Skin & Wound Care,2006, 19(9): 498-505.
[27] TANG L L, SHEN X, GONG S J, et al. Application ofultrasound in early diagnosis of deep tissue injury andprediction of prognosis of pressure ulcers [J]. Nursingand Rehabilitation Journal, 2017, 16(11): 1193-1196(in Chinese).
[28] LIU Q F, LI L J, JI L H, et al. Feasibility study onpressure ulcer management using high-frequency ultrasound by ward medical staff [J]. Chinese NursingResearch, 2019, 33(1): 166-169 (in Chinese).
[29] KANNO N, NAKAMURA T, YAMANAKA M, etal. Low-echoic lesions underneath the skin in subjectswith spinal-cord injury [J]. Spinal Cord, 2009, 47(3):225-229.
[30] HELVIG E I, NICHOLS L W. Use of high-frequencyultrasound to detect heel pressure injury in elders [J].Journal of Wound, Ostomy, and Continence Nursing,2012, 39(5): 500-508.
[31] PORTER-ARMSTRONG A P, ADAMS C,MOORHEAD A S, et al. Do high frequency ultrasound images support clinical skin assessment? [J].ISRN Nursing, 2013, 2013: 314248.
[32] SCAFIDE K N, NARAYAN M C, ARUNDEL L. Bedside technologies to enhance the early detection ofpressure injuries: A systematic review [J]. Journalof Wound, Ostomy, and Continence Nursing, 2020,47(2): 128-136.
[33] AOI N, YOSHIMURA K, KADONO T, et al. Ultrasound assessment of deep tissue injury in pressure ulcers: Possible prediction of pressure ulcer progression[J]. Plastic and Reconstructive Surgery, 2009, 124(2):540-550.
[34] DEPREZ J F, BRUSSEAU E, FROMAGEAU J, et al.On the potential of ultrasound elastography for pressure ulcer early detection [J]. Medical Physics, 2011,38(4): 1943-1950.
[35] HAMALUIK K, MOUSSA W, FERGUSON-PELL M.Numerical characterization of quasi-static ultrasoundelastography for the detection of deep tissue injuries[J]. IEEE Transactions on Medical Imaging, 2014,33(7): 1410-1421.
[36] SCH?FER G, DOBOS G, LüNNEMANN L, et al.Using ultrasound elastography to monitor human softtissue behaviour during prolonged loading: A clinicalexplorative study [J]. Journal of Tissue Viability, 2015,24(4): 165-172.
[37] MANSUR R, PEKO L, SHABSHIN N, et al. Ultrasound elastography reveals the relation between bodyposture and soft-tissue stiffness which is relevant to theetiology of sitting-acquired pressure ulcers [J]. Physiological Measurement, 2021, 41(12): 124002.
[38] YABUNAKA K, IIZAKA S, NAKAGAMI G, et al.Three-dimensional ultrasound imaging of the pressureulcer. A case report [J]. Medical Ultrasonography, 2015,17(3): 404-406.CHEN J L, GUO R Q, ZHOU Q, et al. Teaching practice and exploration of standardized training for resident doctors of ultrasound department [J]. Journal ofClinical Ultrasound in Medicine, 2018, 20(5): 355-356(in Chinese).
[40] MOORE Z, PATTON D, RHODES S L, et al. Subepidermal moisture (SEM) and bioimpedance: A literature review of a novel method for early detection ofpressure-induced tissue damage (pressure ulcers) [J].International Wound Journal, 2017, 14(2): 331-337.
[41] CHING C T S, CHOU M Y, JIANG S J, et al. Tissue electrical properties monitoring for the preventionof pressure sore [J]. Prosthetics and Orthotics International, 2011, 35(4): 386-394.
[42] CARMO-ARA′UJO E M, DAL-PAI-SILVA M, DALPAI V, et al. Ischaemia and reperfusion effects on skeletal muscle tissue: Morphological and histochemicalstudies [J]. International Journal of ExperimentalPathology, 2007, 88(3): 147-154.
[43] ZHANG G Z, YU J, ZHU H B. Research progresson relationship between subepidermal moisture andpressure injury [J]. Chinese Nursing Research, 2021,35(22): 4043-4045 (in Chinese).
[44] PARK S, KIM C G, KO J W. The use of sub-epidermalmoisture measurement in predicting blanching erythema in jaundice patients [J]. Journal of Wound Care,2018, 27(5): 342-349.
[45] OLIVEIRA A L, MOORE Z, CONNOR T O, et al.Accuracy of ultrasound, thermography and subepidermal moisture in predicting pressure ulcers: A systematic review [J]. Journal of Wound Care, 2017, 26(5):199-215.
[46] BATES-JENSEN B M, MCCREATH H E,NAKAGAMI G, et al. Subepidermal moisturedetection of heel pressure injury: The pressure ulcerdetection study outcomes [J]. International WoundJournal, 2018, 15(2): 297-309.
[47] BATES-JENSEN B M, MCCREATH H E,PONGQUAN V. Subepidermal moisture is associated with early pressure ulcer damage in nursinghome residents with dark skin tones: Pilot findings [J].Journal of Wound, Ostomy, and Continence Nursing,2009, 36(3): 277-284.
[48] GEFEN A, GERSHON S. An observational, prospective cohort pilot study to compare the use of subepidermal moisture measurements versus ultrasound and visual skin assessments for early detection of pressureinjury [J]. Ostomy/Wound Management, 2018, 64(9):12-27.
[49] BATES-JENSEN B M, REILLY S, HILLIARD C, et al. Subepidermal moisture and pressure injury in a pediatric population: A prospective observational study[J]. Journal of Wound, Ostomy, and Continence Nursing, 2020, 47(4): 329-335.
[50] KIM C G, PARK S, KO J W, et al. The relationshipof subepidermal moisture and early stage pressure injury by visual skin assessment [J]. Journal of Tissue Viability, 2018, 27(3): 130-134.
[51] BATES-JENSEN B M, MCCREATH H E, KONO A,et al. Subepidermal moisture predicts erythema andstage 1 pressure ulcers in nursing home residents: A pilot study [J]. Journal of the American Geriatrics Society, 2007, 55(8): 1199-1205.
[52] O’BRIEN G, MOORE Z, PATTON D, et al. The relationship between nurses assessment of early pressureulcer damage and sub epidermal moisture measurement: A prospective explorative study [J]. Journal ofTissue Viability, 2018, 27(4): 232-237.
[53] OKONKWO H, BRYANT R, MILNE J, et al. Ablinded clinical study using a subepidermal moisturebiocapacitance measurement device for early detectionof pressure injuries [J]. Wound Repair and Regeneration, 2020, 28(3): 364-374.
[54] GERSHON S. Using subepidermal moisture level as anindicator of early pressure damage to local skin and tissue [J]. Advances in Skin & Wound Care, 2020, 33(9):469-475.
[55] UETA M, SUGAMA J, KONYA C, et al. Use of ultrasound in assessment of necrotic tissue in pressure ulcers with adjacent undermining [J]. Journal of Wound Care, 2011, 20(11): 503-504.
[56] GEFEN A. The SEM Scanner for early pressure ulcerdetection: A 360-degree review of the technology [J].Wounds International, 2020, 11(4): 22-30.
[57] BRYANT R A, MOORE Z E, IYER V. Clinical pro-file of the SEM Scanner- Modernizing pressure injurycare pathways using sub-epidermal moisture (SEM)scanning [J]. Expert Review of Medical Devices, 2021,18(9): 833-847.
[58] LI A L, SONG J. Biomarkers classification and theirapplication in clinical medicine [J]. Chinese Journal ofPharmacology and Toxicology, 2015, 29(1): 7-13.
[59] SUN M, YANG G, ZHAO Y, et al. Screening of aptamer for breast cancer biomarker calreticulin and itsapplication to detection of serum and recognition ofbreast cancer cell [J]. Chinese Journal of Analytical Chemistry, 2020, 48(5): 642-649 (in Chinese).
[60] BADER D, OOMENS C. The potential of biomarkersin the early detection of pressure ulcers [M]//Scienceand practice of pressure ulcer management. London:Springer, 2018: 1-15.
[61] EDSBERG L E, WYFFELS J T, OGRIN R, et al. Apilot study evaluating protein abundance in pressureulcer fluid from people with and without spinal cordinjury [J]. The Journal of Spinal Cord Medicine, 2015,38(4): 456-467.
[62] SARI Y, NAKAGAMI G, KINOSHITA A, et al.Changes in serum and exudate creatine phosphokinaseconcentrations as an indicator of deep tissue injury:A pilot study [J]. International Wound Journal, 2008,5(5): 674-680.
[63] MINEMATSU T, NAKAGAMI G, SARI Y, et al. Candidate biomarkers for deep tissue damage from molecular biological and biochemical aspects [J]. Journal of Tissue Viability, 2010, 19(2): 77-83.
[64] MAKHSOUS M, PANDYA A, MODI M, et al. Serumand urine biomarker elevation indicating the onset of deep tissue injury as examined on a rat model[C]//ASME 2010 Summer Bioengineering Conference.Naples: ASME, 2010: 807-808.
[65] MAKHSOUS M, LIN F, PANDYA A, et al. Elevationin the serum and urine concentration of injury-relatedmolecules after the formation of deep tissue injury in arat spinal cord injury pressure ulcer model [J]. PM &R,2010, 2(11): 1063-1065.
[66] LOERAKKER S, HUISMAN E S, SEELEN H A M, etal. Plasma variations of biomarkers for muscle damagein male nondisabled and spinal cord injured subjects[J]. Journal of Rehabilitation Research and Development, 2012, 49(3): 361-372.
[67] TRAA W A, STRIJKERS G J, BADER D L, et al.Myoglobin and troponin concentrations are increasedin early stage deep tissue injury [J]. Journal of theMechanical Behavior of Biomedical Materials, 2019,92: 50-57.
[68] SCHWARTZ K, HENZEL M K, ANN RICHMONDM, et al. Biomarkers for recurrent pressure injury riskin persons with spinal cord injury [J]. The Journal ofSpinal Cord Medicine, 2020, 43(5): 696-703.
[69] WYFFELS J T, FRIES K M, RANDALL J S, etal. Analysis of pressure ulcer wound fluid using twodimensional electrophoresis [J]. International WoundJournal, 2010, 7(4): 236-248.
[70] PADULA W V, MALAVIYA S, HU E, et al. Thecost-effectiveness of sub-epidermal moisture scanningto assess pressure injury risk in US health systems [J].Journal of Patient Safety and Risk Management, 2020,25(4): 147-155.