NURS 836 Week 3 Expanding the Literature Review on Prophylactic Dressings in Long Surgeries Example

Expanding the Literature Review: A Refined PICOT Question and Three Added Articles on Silicone Foam Dressings, Surgical Patients and Who Is at Highest Risk

Refining the Question

In NURS 716, my PICO question asked whether, in adults undergoing surgery of three hours or more, a prophylactic soft silicone foam dressing on the sacrum and heels, compared with standard prevention alone, reduced perioperative pressure injury. Since then, the review and conversations with our operating room staff have shown three weaknesses. The population was defined by actual surgery length, which is not known when the dressing must be applied; the intervention did not say which dressing, where or when; and the outcome had no time frame, so injuries found days later on a medical unit could not be fairly attributed to the operating room.

The refined PICOT question is: In adults aged 18 or older booked for supine, prone or lithotomy procedures whose anesthesia is expected to last at least three hours (P), does a multilayer soft silicone foam dressing placed on the sacral area and on each heel prior to final positioning and kept on for as long as 72 hours (I), compared with standard pressure injury prevention without prophylactic dressings (C), reduce the incidence of new sacral and heel pressure injuries of stage 1 or higher (O) within 72 hours after surgery (T)?

The Five Articles From NURS 716

These five established the case. Fu et al. (2025), pooling ten randomized trials, found that silicone foam lowered both sacral and heel injuries, and the network comparison by Al Jehani et al. (2026) placed silicone dressings first among six prophylactic options. In the operating room itself, Wang et al. (2026) reported intraoperative injuries in 3.0% of patients given a sacral dressing against 19.4% of controls. The two observational studies showed why the question matters in long cases: Adıgüzel Akbaba et al. (2026) found device-related injuries in 30% of adults whose surgeries lasted three hours or more, and Hooper et al. (2026) found that a widely used perioperative risk tool predicted injury less well than its developers had reported, while a higher anesthesia risk class did predict it. Their weaknesses were that most trial evidence came from mixed or intensive care settings, the surgical trial was single-center with sacral dressings only, and risk prediction was uncertain.

Three Added Articles

Article 6: A Randomized Trial After General Surgery

Yeo et al. (2023) randomized 156 ward patients, none critically ill and all scoring 18 or less on the Braden scale, who had surgery under general anesthesia at a tertiary hospital to a five-layer soft silicone foam dressing applied to the sacrum immediately after surgery or to standard prevention without a dressing. Pressure injury and blanching erythema were more frequent in the control group, and in multivariate analysis both the dressing and the admission Braden score predicted injury; time to injury also favored the dressing group. This level II trial adds surgical patients outside intensive care, closer to our population, though its dressing was applied after rather than before surgery and only to the sacrum.

Article 7: A Meta-Analysis Across Settings

Rahman-Synthia et al. (2023) pooled eleven studies of silicone dressings on the sacrum and found a risk ratio for pressure injury of 0.30 compared with usual care, with no significant difference between intensive care (0.25) and non-intensive care settings (0.38), and no significant difference between two common dressing brands. This level I synthesis addresses the concern that benefits seen in intensive care may not carry to other settings, and it suggests the choice of brand matters less than consistent use, which simplifies purchasing.

Article 8: Who Is at Highest Risk in Surgery

Johansson et al. (2026) systematically reviewed 41 observational studies of position-related injuries, 33 on pressure injuries with 26,074 patients, and found four significant risk factors for pressure injury: diabetes, higher body mass index, low preoperative albumin and intraoperative use of circulatory agents. Surprisingly, surgery duration was not significantly associated with injury in their pooled analysis, although the estimate was wide. This level V evidence on prognosis, from observational studies, helps target the dressing and raises a question about relying on duration alone to define eligibility. The newest article complicates our eligibility rule, and a review that admits this is more useful than one that only confirms it.

Synthesis

Taken together, the eight articles support the refined question. Two meta-analyses and two randomized trials show that silicone foam dressings reduce sacral and heel pressure injuries, with consistent effects across settings and dressing brands. The surgical trials, one intraoperative and one postoperative, suggest the benefit applies to our population. The observational studies show that injury is common in long surgeries and identify patient factors that add risk.

Two gaps remain. First, no trial in the set applied dressings to sacrum and heels before positioning in surgeries of three hours or more, which is our intended protocol, so our implementation will need to monitor outcomes closely rather than assume the trial effects. Second, the risk factor review suggests that eligibility based only on expected duration may miss high-risk patients in shorter cases and include low-risk patients in longer ones. For the implementation plan, I will keep the three-hour threshold for simplicity in the first phase but also include, whatever the expected duration, patients with diabetes or class III obesity, and track injuries by both criteria. Brownson et al. (2018) note that implementation decisions often have to proceed on imperfect evidence; the plan should be built to learn from its own data. In practice, that means recording for every eligible case the expected and actual anesthesia time, the patient's diabetes status, body mass index and preoperative albumin, whether the dressing was applied and the skin assessment at 24, 48 and 72 hours. With those data, the project can test after six months whether injuries cluster among the patients the risk factor review identified, and adjust eligibility if they do.

References

Adıgüzel Akbaba, M., Uslu, Y., Aytar, F., & Eren, E. (2026). Intraoperative device-related pressure injuries in patients undergoing prolonged surgery. Advances in Skin & Wound Care. Advance online publication. https://doi.org/10.1097/ASW.0000000000000510

Al Jehani, M., Al Mazrou, F., Bafail, A., Alhwsawi, H., Albalawi, I., Alanazi, G., Halawani, I., Alhije, F., & Alalola, R. (2026). Prophylactic dressing in the prevention of bedsore: A network meta-analysis. Journal of Surgical Research, 317, 235-243. https://doi.org/10.1016/j.jss.2025.09.065

Brownson, R. C., Colditz, G. A., & Proctor, E. K. (Eds.). (2018). Dissemination and implementation research in health: Translating science to practice (2nd ed.). Oxford University Press.

Fu, T., Wu, X., & Yu, B. (2025). Efficacy of silicone foam dressings in preventing pressure injuries in the sacral and heel areas of patients: A meta-analysis. Frontiers in Medicine, 12, Article 1644290. https://doi.org/10.3389/fmed.2025.1644290

Hooper, V., LaFond, C., & Perez, A. C. (2026). The performance of the Scott Triggers instrument in predicting perioperative pressure injury (PPI) development. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.06.012

Johansson, V. R., Dahl, O., Falk, A. C., Nilsson, U., Dehara, M., & von Vogelsang, A. C. (2026). Risk factors for position-related injuries in adult surgical patients: A systematic review and meta-analysis. International Journal of Nursing Studies Advances, 11, Article 100676. https://doi.org/10.1016/j.ijnsa.2026.100676

Rahman-Synthia, S. S., Kumar, S., Boparai, S., Gupta, S., Mohtashim, A., & Ali, D. (2023). Prophylactic use of silicone dressing to minimize pressure injuries: Systematic review and meta-analysis. Enfermería Clínica, 33(1), 4-13. https://doi.org/10.1016/j.enfcle.2022.05.002

Wang, C. Y., Liao, H. H., Hsieh, M. Y., & Lee, C. H. (2026). Soft silicone foam dressing for preventing intraoperative pressure injuries: A randomized controlled trial. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.08.022

Yeo, H., Hwang, J., Lee, M., No, D., & Jang, I. (2023). Effect of a prophylactic dressing for sacral pressure injuries in non-critically ill patients after general surgery: A randomized controlled trial. Worldviews on Evidence-Based Nursing, 20(3), 259-268. https://doi.org/10.1111/wvn.12651