During the process, only one statement reached a “Low” degree of consensus, being excluded from the document. At the final stage, a total of 27 statements were then produced and approved by the panel. The approved statements are presented in Table 3 and Fig. 1. The excluded statement is reported in Additional file 1.
Statements
Upper limb positioning
Expert statement
Keep the upper limb in abduction at an angle of less than 90°, if necessary for therapeutic purposes.
Discussion
Arm abduction greater than or equal to 90° was associated with brachial neuropathy in three observational studies, although one RCT and one nonrandomized trial reported uncertain results [11]. A systematic review of case reports highlights the occurrence of upper limb neuropathy due to positioning under general anesthesia in various surgical disciplines, especially where limbs are in forced abduction. More damage has been reported to the lateral cutaneous nerve of the forearm [12].
Expert statement
Maintain a trunk angle of between 15° and 30°
Discussion
Trunk tilt between 15° and 30° prevents ulnar neuropathy, according to a non-randomized clinical trial [11].
Lower limb positioning
Expert statement
The lower limb must not be hyperextended or spread more than 30° in supine and Trendelenburg positions.
Discussion
Hyperextension and divarication of the legs beyond 30° in the supine position promotes the onset of ischial neuropathy [11]. Hyperextension of the legs in the Trendelenburg position promotes the onset of femoral and obturator nerve neuropathy, according to an observational study [11].
Head positioning
Expert statement
Carefully assess, in each individual case, the relationship between the expected benefit and possible risks of different degrees of head tilt in patients with severe head injury.
Discussion
According to a systematic review of three cross-over studies, therapeutic head positioning in the severe head injury patient is supported by very low-quality evidence. Currently, the balance of benefits and risks remains uncertain [13].
Prone position
Rationale
Prolonged maintenance of the prone position for at least 12 h is associated with significantly reduced mortality in patients with acute respiratory distress syndrome (ARDS) [14]. Mortality is further reduced when prone positioning is combined with low current volume ventilation and when it is undertaken less than 48 h after the onset of the clinical condition [14,15,16,17,18].
The main adverse effects of prone positioning are the development of pressure injuries and endotracheal tube obstruction [15, 16]. The risk of developing pressure injuries in patients with ARDS is greater in the prone position than in the supine position [19]. Injuries can be caused by the effect of gravity on anatomical structures and the pressure created at points of contact between the body and underlying surfaces [20, 21]. The most frequent sites are the forehead, mandible, humerus, sternum, pelvic tuberosity, patella, and tibia [22].
Expert statement
Prolonged maintenance of the prone position is associated with numerous complications, including serious complications. The expected benefit must outweigh the possible risks.
Discussion
As described in a systematic review and reported in the Association of Perioperative Registered Nurses (AORN) guidelines, the prone position, used in surgical and resuscitative procedures, predisposes to increased intra-abdominal pressure, bleeding, abdominal and limb compartment syndrome, neuropathy, pressure injuries, cardiovascular decompensation, thrombosis and stroke, hepatic dysfunction, ocular damage, oropharyngeal oedema, airway maintenance dislocation, and gas embolism [23, 24].
Expert statement
The prone position is used safely in patients with severe respiratory failure undergoing extracorporeal oxygenation (ECMO).
Discussion
The safety of prone positioning in patients with severe respiratory failure treated with ECMO was investigated by a systematic review of seven observational studies that revealed limited complications [25]. The main complications were dislocation and bleeding at the level of the chest tube.
Expert statement
The prone patient must be placed in the reverse Trendelenburg position with trunk tilt between 5° and 10°.
Discussion
The risk of complications is increased when the prone patient is maintained in the Trendelenburg position [26]. Elevation of the head above the heart reduces venous congestion at the orbital and ocular levels. This reduces intraorbital and intraocular pressure. A systematic review and AORN guidelines suggest 5°–10° tilt in the prone patient in reverse Trendelenburg to reduce ocular complications [23,24,25,26].
Supine position
Rationale
Prolonged supine maintenance exposes patients to the risk of developing pressure injuries in the occipital, scapular, vertebral, sacro-coccygeal, and calcaneal decubitus areas [22].
Expert statement
In the supine position, the trunk can be tilted between 10° and 28° without an increased risk of pressure injuries. In the semi-supine position, the trunk can be tilted between 30° and 45° without increased risk of pressure injuries.
Discussion
Different trunk tilts are recommended depending on the expected benefits with respect to the clinical condition and may expose differently to increased pressure and friction at different sites of injury. There were no significant differences, in terms of incidence of pressure injuries, between trunk tilt at 28° and 10° and between 45° and 30° [19].
Expert statement
In the supine patient, keep the knees tilted between 5° and 10° and the heels elevated using a suspension device.
Discussion
AORN guidelines recommend that the supine patient have the knees tilted 5–10° and the heels elevated via a suspension device [23]. Mobility is one of the three domains that affect the occurrence of pressure injuries, along with perfusion and skin condition [27].
Multidimensional risk assessment of positioning
Expert statement
Integrate, into the patient’s care, an assessment of the risks associated with positioning that considers patient's individual risk factors, including age, body mass index (BMI), degree of mobility, perfusion status, blood glucose, and the existence of peripheral vasculopathy.
Discussion
In the ICU, age, degree of mobility, perfusion status, and use of vasopressors are risk factors for the development of pressure injuries, according to a systematic review of 17 studies [28]. Obesity, diabetes, age, vasculopathy, and low BMI have been associated with increased postoperative occurrence of peripheral neuropathy in several observational studies [11].
Pressure Injury Risk Screening Tools
Expert statement
The use of a validated screening scale for the risk of pressure injuries, sufficiently specific for the ICU context, allows for the early identification of those most at risk.
Discussion
The Braden scale has been extensively validated in many care settings. According to a systematic review in 2013, it would also be the most widely tested scale in the critical care area [29]. Another systematic review noted the lack of evidence of effectiveness of the Braden scale in the ICU [30]. A subsequent meta-analysis of 11 studies and 10,044 participants concluded that the Braden scale has moderate predictive ability but is not sufficient to exclude an increased risk of pressure injuries in the ICU setting [31]. The accuracy of the Braden scale is significantly reduced in ventilated, dialyzed, inotropic, and surgical patients [32].
Expert statement
The Braden scale corrected for albuminemia, known as the Braden scale, has sufficient sensitivity and specificity for use in the ICU and may be preferred to the uncorrected Braden scale.
Discussion
The inclusion of albuminaemia in the Braden scale in the Braden version increased its specificity whilst maintaining good sensitivity [33].
Expert statement
The Cubbin/Jackson scale has sufficient sensitivity and specificity for use in the ICU and may be preferred to the uncorrected Braden scale.
Discussion
There are good alternatives to the Braden scale. The Cubbin-Jackson scale has similar predictive values to the Braden scale [29]. In a prospective observational study, the Cubbin/Jackson scale was indeed more specific than the Braden scale, whilst maintaining acceptable sensitivity [34]. However, the results may be affected by the small sample.
Expert statement
The CALCULATE scale has shown sufficient sensitivity and specificity for use in the ICU and may be preferred to the uncorrected Braden scale.
Discussion
The CALCULATE scale presented accuracy values comparable to the Braden [33]. The Norton scale reported accuracy values similar to the Braden scale, although it was affected by the small size of the samples [29]. The COMHON index and the Evaruci scale presented lower accuracy than the other aforementioned scales [35].
Patient repositioning
Background
Patient repositioning is recommended in many guidelines in different ways, depending on the resources available [36].
Expert statement
Adopt a patient repositioning protocol, customizing it based on the patient's level of autonomy and availability of resources.
Discussion
The allocation of care resources and the determination of repositioning frequency must depend on a careful assessment of the patient’s degree of autonomy and activity and their ability to reposition themselves independently [37].
Expert statement
Unconscious patient must be maintained in the lateral decubitus position. Any repositioning must be carried out by switching from one side to the other in accordance with the clinical condition.
Discussion
According to a systematic review of 24 randomized and non-randomized studies, the evidence supporting repositioning of the unconscious patient in the lateral decubitus position rather than in other decubitus positions is not of adequate quality to draw firm conclusions [38]. However, according to a meta-analysis of 16 studies, the supine decubitus position results in reduced respiratory capacity in unconscious patients, whereas the lateral decubitus position would be characterized by greater safety [39].
Expert statement
Adopting a patient repositioning feedback system, based on an electronic alert system or action protocol, reduces the incidence of pressure injuries.
Discussion
Two RCTs conducted on 1534 patients studied repositioning every 2 h of the patient using either an electronic detection and notification system or a strategic intervention protocol. In both studies, the intervention resulted in a significant reduction in the incidence of injury [19].
Expert statement
The use of a motorized patient rotation and positioning device could reduce the incidence of pressure injuries and reduce staff fatigue, compared with manual repositioning.
Discussion
A prospective study of 717 patients investigated the use of the Prevalon® Motorised Rotation and Positioning System compared with manual positioning by caregivers. The device used consisted of two 30° inclined wedges with an attachment strap, a low friction slide sheet and a full body contact interface designed for microclimate management. The wedges and slip sheet are for individual use and the first layer against the patient’s skin is a disposable pad. This device, when compared with common lifts used, reduced the incidence of pressure injuries from 1.3 to 0%, with a significant 88% reduction in perceived exertion by staff [40].
Early mobilization
Rationale
Active and passive mobilization interventions are aimed at recovering muscle tone, coordination, and range of joint movements and the performance of activities of daily living. Initial bedside interventions are followed by supine to bedside transfer exercises, from a sitting position to orthostaticism, the transition from bed to chair and walking exercises designed to improve postural stability, static and dynamic balance, and the resumption of walking with and without aids [1].
Early mobilization is even more important in ICU patients. Patients with acute lung injury present with symptoms known as Intensive Care Unit-Associated Weakness (ICUAW), which is accompanied by decline in physical function, as manifested by poor performance at the 6-min walk distance [41], up to 24 months after admission [17]. ICUAW has also been associated with increased mortality during hospitalization [42] and at 12 months after discharge [1, 43].
Expert statement
ARDS patients on invasive mechanical ventilation for more than 24 h gain benefit from early mobilization.
Discussion
An early mobilization protocol for ARDS patients undergoing invasive mechanical ventilation for more than 24 h resulted in a reduction in total mechanical ventilation time, with reduced frequency of adverse events. There was no significant improvement in mortality or functional status of the patient at discharge [14, 44, 45]. In contrast, it appears that early mobilization does not significantly affect the quality of life of critically ill patients with severe brain damage [46].
Immobility causes pressure to be unloaded onto the areas of the body in contact with the positioning surface, which thus become sensitive areas for the onset of complications, first and foremost pressure injuries. Complications can be prevented by improving the quality of the interface between the body and the surface. This can be achieved by using suitable positioning surfaces and specific devices.
A device with physical characteristics such as to ensure an effect of wrapping and immersion of the part of the body concerned, thanks to the use of special materials capable of preserving the memory of the shape of the body part resting on them, increases the area on which the force given by the weight of the body is discharged, reducing tissue tension. At the same time, a material with viscoelastic properties tends not to change under the weight of the body, maintaining the correct alignment, thus reducing the tension that would result in increased pressure on the tissues [47, 48].
Positioners
Expert statement
Use a viscofluid head and neck positioning device whilst maintaining the lateral decubitus position.
Discussion
A positioner made of a viscofluid material provided better maintenance of head and neck position and the lateral decubitus position [49]. In another comparison study with a historical cohort, head positioning of 127 patients on ECMO with the Z-Flo device significantly reduced the incidence of occipital injury [50]. In the study, the device was reshaped every 2 h by the operators, although this practice is not within the manufacturer’s guidance.
Expert statement
Use a specific heel protector associated with passive mobilization.
Discussion
The Prevalon® Heel Protector device combined with passive limb mobilization at each shift significantly reduced the incidence of heel injury in an RCT of 54 patients compared with the use of common cushions. In addition, a significant improvement in limb mobilization angle was found in prevention of contracture in plantar flexion [51].
Positioning surfaces
Expert statement
Place the patient at risk of pressure injury on an air mattress.
Discussion
A meta-analysis of 65 studies concluded that there is a slight preventive effect of air mattresses against pressure injuries compared with conventional mattresses [52]. Based on the literature reviewed, best practices for the use of different anti-decubitus surface technologies cannot be outlined. It also remains for future research to understand whether it is appropriate to abandon the sheet when using technologically developed contact surfaces that minimize shear and pressure forces.
Expert statement
Adopt two- or three-layer viscoelastic mattresses to prevent complications from immobility.
Discussion
According to a recent systematic review, the evidence in favor of the use of anti-decubitus materials in intensive care is characterized by a high risk of bias, whilst the highest quality studies found no significant differences with common mattresses [53]. In some subsequent studies, the use of a viscoelastic pressure redistributing mattress has been shown to significantly reduce the incidence of pressure injuries [54]. No differences were observed between the use of two- or three-layer viscoelastic mattresses [19]. The use of alternating active pressure mattresses is of uncertain effectiveness [19].
Expert statement
Use a visco-elastic foam mattress if it is not possible to reposition the patient at intervals of less than 4 h.
Discussion
The use of a viscoelastic foam mattress with patient repositioning every 4 h had similar injury incidence compared with an air mattress with repositioning every 2 h [55].
Preventive dressings
Expert statement
Apply a multi-layered polyurethane foam preventive dressing with silicone to areas at risk of developing injuries, bony prominences, and areas subjected to pressure, rubbing, and shear forces.
Discussion
The 2017 AORN guidelines recommend the use of preventative dressings on bony prominences or other areas subject to pressure, friction, and shear force [23]. Said preventive dressings significantly reduce the occurrence of pressure injuries [19, 56]. Although, until a few years ago, there was insufficient evidence to recommend a specific device [57], new studies have demonstrated the effectiveness of multi-layered polyurethane foam preventative dressings with silicone, which are also recommended by the NPIAP-EPUAP-PPPIA 20196 guidelines. The products tested in the literature are Mepilex® Border Sacrum, Mepilex® Border Heel, ALLEVYN® Gentle Border, and ALLEVYN® Life Sacrum [56]. The most studied sites are the heel and the sacrum [56, 58].
Multi-intervention bundles
Expert statement
Adopt a multidisciplinary protocol for proper positioning and prevention of pressure injuries. Involve, according to specific protocols, external operators, experts in the treatment of complex wounds, and complications of immobility
Discussion
Implementation of a standardized pressure injury prevention and repositioning protocol could increase practitioner adherence to preventive practices [59]. An example in the literature is the Universal Pressure Ulcer Prevention (UPUP) Bundle. It suggests a process consisting of the application of emollients, complete skin assessment, distancing of the heels from the bed surface, early use of pressure redistribution surfaces, and repositioning of the patient. According to this protocol, the periodic presence in the intensive care unit of a nurse specializing in the treatment of complex wounds is also guaranteed [60]. Comparing the clinical activity before and after insertion of the UPUP Bundle, improved performance was observed, especially in patient repositioning and heel lift [60].