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Table 3 Good practice summary table

From: The prevention of pressure injuries in the positioning and mobilization of patients in the ICU: a good clinical practice document by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

1.1. Upper limb positioning
 Keep the upper limb in abduction at an angle of less than 90°, if necessary for therapeutic purposes
 Evidence: B3 Uncertainty: n.a. Agreement: 4.7 Consent: Medium-Low
 Maintain a trunk angle of between 15° and 30°
 Evidence: B1 Uncertainty: n.a. Agreement: 4.7 Consent: Medium-High
1.2. Lower limb positioning
 The lower limb must not be hyperextended or spread more than 30° in supine and Trendelenburg positions
 Evidence: B2 Uncertainty: n.a. Agreement: 4.4 Consent: Medium-low
1.3. Head positioning
 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.
 Evidence: B1 Uncertainty: low Agreement: 4.8 Consent: High
1.4. Prone position
 Prolonged maintenance of the prone position is associated with numerous complications, including serious complications. The expected benefit must outweigh the possible risks.
 Evidence: B1 Uncertainty: low Agreement: 4.9 Consent: High
 The prone position is used safely in patients with severe respiratory failure undergoing extracorporeal oxygenation.
 Evidence: B2 Uncertainty: high Agreement: 4.3 Consent: Medium
 The prone patient must be placed in the reverse Trendelenburg position with trunk tilt between 5° and 10°.
 Evidence: B2 Uncertainty: low Agreement: 4.6 Consent: Medium-High
1.5. Supine position
 In the supine position, the trunk can be tilted between 10° and 28° without 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.
 Evidence: A2 Uncertainty: unclear Agreement: 4.7 Consent: High
 In the supine patient, keep the knees tilted between 5° and 10° and the heels elevated using a suspension device.
 Evidence: n.a. Uncertainty: n.a. Agreement: 4.3 Consent: Medium-High
2.1. Multidimensional risk assessment of positioning
 Integrate, into the patient’s care, an assessment of the risks associated with positioning that takes into account the patient’s individual risk factors, including age, body mass index, degree of mobility, perfusion status, blood glucose, and the existence of peripheral vasculopathy.
 Evidence: B2 Uncertainty: n.a. Agreement: 4.6 Consent: Medium-High
2.2. Pressure Injury Risk Screening Tools
 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.
 Evidence: B1-B2 Uncertainty: high - unclear Agreement: 4.4 Consent: High
 The Braden scale corrected for albuminemia, known as the Braden scale (Alb), has sufficient sensitivity and specificity for use in the ICU and may be preferred to the uncorrected Braden scale.
 Evidence: B2 Uncertainty: low Agreement: 4 Consent: Medium-Low
 The Cubbin/Jackson scale has sufficient sensitivity and specificity for use in the ICU and may be preferred to the uncorrected Braden scale.
 Evidence: B2 Uncertainty: low Agreement: 4.1 Consent: Medium
 The CALCULATE scale has shown sufficient sensitivity and specificity for the use in the ICU and may be preferred to the uncorrected Braden scale.
 Evidence: B2 Uncertainty: low Agreement: 4 Consent: Medium
3.1. Patient repositioning
 Adopt a patient repositioning protocol, customizing it based on the patient’s level of autonomy and availability of resources.
 Evidence: n.a. Uncertainty: n.a. Agreement: 4.8 Consent: High
 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.
 Evidence: A1-B1 Uncertainty: low Agreement: 4.1 Consent: Medium-High
 Adopting a patient repositioning feedback system, based on an electronic alert system or action protocol, reduces the incidence of pressure injuries.
 Evidence: A2 Uncertainty: low Agreement: 4.4 Consent: High
 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.
 Evidence: B1 Uncertainty: high Agreement: 4 Consent: Medium-High
3.2. Early mobilization
 ARDS patients on invasive mechanical ventilation for more than 24 h gain benefit from early mobilization.
 Evidence: A1 Uncertainty: high Agreement: 5 Consent: Unanimity
4.1. Positioners
 Use a viscofluid head and neck positioning device whilst maintaining the lateral decubitus position.
 Evidence: B2 Uncertainty: high Agreement: 5 Consent: Unanimity
 Use a specific heel protector associated with passive mobilization.
 Evidence: A3 Uncertainty: low Agreement: 5 Consent: Unanimity
4.2. Positioning surfaces
 Place the patient at risk of pressure injury on an air mattress.
 Evidence: A1 Uncertainty: low Agreement: 4.9 Consent: High
 Adopt two- or three-layer viscoelastic mattresses to prevent complications from immobility.
 Evidence: A2 Uncertainty: high Agreement: 5 Consent: Unanimity
 Use a visco-elastic foam mattress if it is not possible to reposition the patient at intervals of less than 4 h.
 Evidence: B1 Uncertainty: high Agreement: 4.2 Consent: Medium-High
4.3. Preventive dressings
 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.
 Evidence: A1 Uncertainty: low Agreement: 4.8 Consent: High
4.4. Multi-intervention bundles
 Adopt a multidisciplinary protocol for proper positioning and prevention of pressure injuries.
 Evidence: B1 Uncertainty: high Agreement: 4.9 Consent: High
 Involve, according to specific protocols, external operators, experts in the treatment of complex wounds, and complications of immobility
 Evidence: B2 Uncertainty: high Agreement: 4.7 Consent: High