Pressure Ulcer Management

I PRESSURE AT
NTERFACE
DIFFERENT DEGREES OF
BACKREST ELEVATION
WITH VARIOUS TYPES OF
PRESSURE-REDISTRIBUTION
SURFACES
By Juliane Lippoldt, RN, Elisabeth Pernicka, PhD, and Thomas Staudinger, MD

Background Increased elevation of the head of the bed is linked

to a higher risk for sacral pressure ulcers. A semirecumbent
position of at least 30° is recommended for the prevention of
ventilator-associated pneumonia in patients treated with
mechanical ventilation. Therefore, prevention of pressure ulcers
and prevention of pneumonia seem to demand contradictory,
possibly incompatible, positioning.
Objectives To measure pressure at the interface between sacral
skin and the supporting surface in healthy volunteers at different
degrees of upright position with different types of mattresses.
Methods An open, prospective, randomized crossover trial was
conducted with 20 healthy volunteers. Interface pressure was
measured by using a pressure mapping device with the partic-
ipant in a supine position at 0, 10°, 30°, and 45° elevation and
in the reverse Trendelenburg position at 10° and 30°. Four types
of mattresses were examined: 2 different foam mattresses and
2 air suspension beds, 1 of the latter with low-air-loss technology.
Results Peak sacral interface pressures increased significantly
only at 45° of backrest elevation (P < .001). A mattress system
with low-air-loss technology significantly reduced peak interface
pressures at all angles (P < .001).The reverse Trendelenburg
position led to lower peak pressures for all positions (P = .01).
Conclusions Backrest elevation up to 30° might be a compro-
mise between the seemingly incompatible demands of skin
integrity and the prevention of ventilator-associated pneumonia.
The reverse Trendelenburg position and a mattress system with

©2014 American Association of Critical-Care Nurses

low-air-loss technology could be additional useful tools to help

doi: http://dx.doi.org/10.4037/ajcc2014670
prevent skin breakdown at the sacrum. (American Journal of
Critical Care. 2014;23:119-126)

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 B
ody positioning is an important component in the daily care of critically ill
patients because it can affect organ function, mainly the respiratory system and
skin integrity. Development of ventilator-associated pneumonia (VAP) in patients
treated with mechanical ventilation can lead to an increased length of stay, higher
mortality, and higher costs.1,2 An upright position of 45° can decrease the risk
for VAP,3 probably by preventing aspiration of gastric contents to the lower part of the airway.4
An upright position less than 30° does not seem to be effective.5 Current recommendations6
for prevention of VAP are a backrest elevation of 45°, or at least an elevation greater than 30°.
However, placing critically ill patients in an upright position of at least 30° might result in
increased pressure forces at the sacrum and buttocks. Most pressure ulcers are localized at the
buttocks and the sacrum.7,8

Because shearing and pressure forces are assumed
to be the main causes of skin breakdown,9 the semi-
recumbent position with a person lying supine with
the head and back upright at 30° to 45° might
contribute to the development of pressure ulcers.
Increased pressure is thought to lead to closing of
capillaries, thus impairing tissue perfusion. Capil-
laries are assumed to close at a pres-
Most pressure sure greater than 32 mm Hg,10 and
the risk for pressure ulcers
ulcers are increases.11,12 Similar to VAP, pressure
localized at the ulcers have been linked to increased
length of stay,13 high costs,14,15 and
buttocks and pain.16 Support surfaces are often
the sacrum. used to prevent skin breakdown,
including low-tech foam mattresses
and high-tech alternating pressure mattresses or
low-air-loss beds.17 In addition to distributing a
patient’s weight, low-air-loss supports tend to control
the microclimate of the patient’s skin.18
We measured pressure at the interface of the skin
and the support surface at the sacral and buttocks
region of healthy volunteers at different degrees of
upright position and with different types of mat-
tresses. We hypothesized that increases in sacral
About the Authors
Juliane Lippoldt is a registered nurse, Department of
Medicine I, Intensive Care Unit, General Hospital of
Vienna, Elisabeth Pernicka is a statistician, Department
of Medical Statistics, Medical University of Vienna, and
Thomas Staudinger is head physician, Department of
Medicine I, Intensive Care Unit, Medical University of
Vienna/General Hospital of Vienna, Vienna, Austria.
Corresponding author: Thomas Staudinger, Department
of Medicine I, Intensive Care Unit, Medical University of
Vienna/General Hospital of Vienna, Waehringer Guertel
18-20, 1090 Vienna, Austria (e-mail: thomas.staudinger@
meduniwien.ac.at).
interface pressure occur with higher degrees of back-
rest elevation and that use of a high-tech mattress
leads to comparatively lower sacral interface pressures.
Methods
Study Design
The study was designed as an open, prospective,
randomized crossover trial. The approval of the
local ethical review board was obtained, and all
participants gave written informed consent.
Instruments
The Xsensor pressure-mapping system (Xsensor
Technology Corp) was used to measure pressure at
the interface of sacral skin and the support surface
at different degrees of upright position. The thin
and flexible pressure-sensing system is a 60.9 ¥
60.9-cm (24 ¥ 24-in) pad that consists of 2304 (48
¥ 48) 1.27-cm (0.5-in) independent pressure sen-
sors. The data are sent to a computer for visualiza-
tion and recording (Figure 1). The X3 Standard
Sensor Pad Calibration Device (Xsensor Technology
Corp) was calibrated to measure a range of pres-
sures between 0 and 200 mm Hg.
Mattress Replacement Systems
Four types of mattresses (Kinetic Concepts, Inc;
KCI) representing the whole spectrum of KCI mat-
tresses used in an intensive care unit at the General
Hospital of Vienna, Vienna, Austria, were evaluated.
The TheraRest VE Mattress Replacement System
is a mattress made of viscoelastic foam. It is recom-
mended for early intervention for patients at low
risk for pressure ulcers and for patients seeking
improved comfort. The AtmosAir 4000 Mattress
Replacement System is also a foam mattress. It con-
sists of 4 air cylinders that function as dynamic air
chambers. Cut-off valves automatically adjust the

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 mm Hg Distribution

50 0
internal air pressure. According to the manufacturer,
the indications for this pressure redistributing sys- 44 2
tem are prevention and treatment of pressure ulcers. 38 30
The ProfiCare Mattress Replacement System con- 33 75
sists of 17 independent air chambers. A core made 27 95
of foam underneath the air chambers can provide 22 70
alternating pressure on demand via an air pump.
16 148
Hence, the system offers both alternating and static
11 208
pressure management. An integrated pressure-sens-
ing pad regulates the internal air pressure according 5 30
to the patient’s weight. The TheraPulse ATP Therapy 0 1646
System is a stand-alone unit in which a mattress is 658 cells > 5 mm Hg
integrated into a bed frame. It combines pulsating
Figure 1 Example of an interface pressure profile measured
air suspension therapy with low-air-loss technology. with the Xsensor pressure-mapping system shows the inter-
The air pressure of the cushions is regulated by face-pressure distribution at the sacral and buttocks area of
entering the weight and height of the patient via the one of the participants on mattress 1 in flat-lying position. Col-
control panel of the framed therapy system. Accord- ors indicate different thresholds of pressure measured by each
sensor cell.
ing to the manufacturer, the main indications for
use of the ProfiCare and TheraPulse systems are pre-
vention of skin breakdown for patients at moderate
or high risk for pressure ulcers and the treatment of
a b
pressure ulcers.

Degrees of Backrest Elevation 0°-20°

Sacral interface pressure was measured in the
following 6 positions: with the entire bed in a neu-
tral flat position and upright positions of 0° (supine),
10°, 30°, and 45° (Figure 2a) and with the entire
bed in the reverse Trendelenburg position (ie, the
entire bed is tilted, with the head and body placed
higher than the lower extremities) and upright posi-
tions of 10° (maximal reverse Trendelenburg posi-
tion), and 30° (maximal reverse Trendelenburg
position plus 20° backrest elevation) (Figure 2b).
Data Collection
Each volunteer’s weight and height were meas-
ured by using a conventional scale and tape measure.
The pressure-sensing pad was placed on the mattress
in such a way that the volunteer had direct contact
with it. All participants were asked to dress in scrubs
and lie supine on 1 of the 4 mattresses. For each
participant, interface pressure was measured at dif-
ferent degrees of backrest elevation on each type of
mattress, resulting in a total of 24 interface pressure
profiles for each participant. One interface pressure
profile consisted of 10 repeated measurements within
10 seconds. Measurements started 2 minutes after
the participant rested calmly and comfortably with
the sacrum centered on the pressure-sensing pad.
For measurements for the upright positions, the tilt
of the hip was brought in line with the tilt of the bed.
The TheraPulse system required the input of weight
and height of the volunteer in addition to a manual
0°-45°
10°
Figure 2 a, Angles of head-of-bed elevation with bed in neu-
tral position. b, Angles of head-of-bed elevation with the entire
bed in the reverse Trendelenburg position.
adjustment of the air pressure of the cushions. All
mattresses were placed on the same bed frame indi-
cating the degree of backrest elevation. The accuracy
of the different angles of upright position was cross-
checked by using a protractor. In order to minimize
the potential for experimental
error, interface pressure was meas- Sacral skin-
ured with the mattress in static pres-
sure mode with the ProfiCare support surface
system and without air pulsation interface pressure
therapy with the TheraCare system.
At each measurement, 3 param- was measured at
eters were recorded: (1) contact different degrees
area, the overall number of inde-
pendent pressure sensors exceeding of upright position.
the threshold of 5 mm Hg; (2) peak
pressure, the highest pressure detected by a single
sensor cell at the sacral or buttocks area; and (3) risk
area, the number of independent pressure readings
greater than 32 mm Hg.

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 Table 1
Demographics of participants
Body mass An analysis of variance with the target variable
Participant Sex Age, y Weight, kg Height, m indexa contact area was performed. Tested independent
variables were the 4 different types of mattresses;
1 Male 30 76 1.76 25
the 4 different angles, with 0° and the supine posi-
2 Male 33 89 1.89 25 tion as the reference category; and the bed position,
A or B, with type A as the reference. Additionally,
3 Female 25 69 1.72 23 interactions between the independent variables and
participant-related parameters (age, sex, weight,
4 Female 43 51 1.54 22
height, and body mass index) were tested. Similar
5 Male 62 88 1.71 30 analyses were performed with the target variables
peak pressure and risk area. The Spearman correla-
6 Female 24 58 1.77 19 tion coefficient was computed to determine if the
target variables (contact area, peak pressure, risk
7 Male 38 78 1.82 24
area) were correlated. Differences were considered
8 Female 31 66 1.76 21 significant at P < .05.

9 Male 32 85 1.90 24 Results

Of the 20 participants in the study, 50% were
10 Male 33 91 1.76 29
women. Median age was 31 years (range, 24-62;
11 Female 31 61 1.67 22 mean, 33; SD, 9), median body height was 1.76 m
(range, 1.54-1.89, mean, 1.73, SD, 0.1), median
12 Female 28 58 1.65 21 weight was 77.5 kg (range, 51-94; mean, 76; SD, 13),
and median body mass index (calculated as weight
13 Female 29 58 1.67 21
in kilograms divided by height in meters squared)
14 Male 31 71 1.77 23 was 24 (range, 19-37; mean, 25; SD, 4). Demograph-
ics are given in the Table.
15 Male 46 91 1.78 29
Contact Area
16 Female 39 78 1.59 31
For all mattress types, contact area significantly
17 Male 26 77 1.78 24 increased with increasing angle of backrest elevation
(P < .001) and with increasing body weight (P < .001).
18 Female 29 81 1.66 29 Compared with the TheraRest VE Mattress Replace-
ment System (foam), the TheraPulse ATP Therapy
19 Male 36 94 1.83 28
System had a significantly higher overall number
20 Female 26 91 1.57 37 of sensor cells with readings greater than 5 mm Hg
(P < .001). Differences between the TheraRest VE,
Mean (SD) 33 (9) 76 (13) 1.73 (0.1) 25 (4) the AtmosAir 4000, and the ProfiCare mattress replace-
aCalculated
ment systems were not significant. At 45° of back-
as weight in kilograms divided by height in meters squared.
rest elevation, a significantly higher number of sensor
cells reading more than 5 mm Hg were recorded for
Statistical Methods and Data Analysis the TheraPulse ATP Therapy System (P = .03) and
For a difference in peak pressures between 2 the AtmosAir 4000 mattress (P < .001) than for the
measurements of 4 mm Hg and a standard deviation TheraRest VE mattress. Values for part A and part B
of 6 mm Hg, the power was 80% (2-sided, a = 0.05) did not differ significantly (Figure 3a).
with 20 participants.
The sequence of the type of mattress and the Peak Pressure
degree of backrest elevation was chosen according to Peak pressures significantly increased with
a randomization protocol. The random sequence of increasing weight (P < .001) and decreased with age
measurements was calculated by using a Latin square (P < .001). In comparison with values for the 0°
design. For each participant, an individual sequence supine position, peak pressures were significantly
of measurements was determined according to random- higher at 45° for all mattresses (P < .001). Peak
ization, and each volunteer passed through his or her pressures for the TheraPulse ATP Therapy System
sequence consecutively. SAS, version 9.1, software were significantly lower than those for the TheraRest
(SAS Institute Inc) was used for statistical analysis. VE mattress (P < .001). Overall, peak pressures were

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 a 1200

Number of sensor cells reading > 5 mm Hg

1000

800

600

400 Mattress 1
Mattress 2
200
Mattress 3
Mattress 4
0 Baseline 10° 30° 45° 10° 30°

Part A Part B

b 100

80
Peak pressure, mm Hg

60

40

Mattress 1

20 Mattress 2
Mattress 3
Mattress 4
0 Baseline 10° 30° 45° 10° 30°

Part A Part B

c 400
Number of sensor cells reading > 32 mm Hg

300

200

Mattress 1
100 Mattress 2
Mattress 3
Mattress 4
0 Baseline 10° 30° 45° 10° 30°

Part A Part B

Figure 3 Clustered bar charts show mean (SD) number of sensor cells reading more than 5 mm Hg (a), peak pressure
values (b), and number of sensor cells reading more than 32 mm Hg (c) at the different degrees of backrest elevation
on the 4 types of mattresses. Mattresses: 1, TheraRest VE Mattress Replacement System; 2, AtmosAir 4000 Mattress
Replacement System; 3, ProfiCare Mattress Replacement System; 4, TheraPulse ATP Therapy System.

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 significantly lower for part B than for part A (P = .01).
At an upright position of 30°, peak pressures tended
to be lower during part B than during part A, but
the differences were not significant (Figure 3b).
Risk Area
Risk area significantly increased with higher
weight and decreased with age (P < .001). Compared
with numbers at the 0° supine position, numbers
of sensor cells reading more than
32 mm Hg at 45° were significantly
Peak pressures higher for all mattresses (P < .001).
increase when The number of sensor cells with read-
ings greater than 32 mm Hg was sig-
increasing the nificantly lower for the AtmosAir 4000
angle of upright and the TheraPulse ATP mattresses
than for the TheraRest VE mattress
position to 45°. (P < .001). Overall, significantly fewer
risk areas were found during part B
than during part A (P = .01). At an upright position
of 30°, differences between part A and part B were
not significant with any mattress (Figure 3c).
Correlation Between the 3 Target Variables
The highest correlation was found between the
variables peak pressure and risk area (r = 0.84; P < .001).
Correlation coefficients were lower between the vari-
ables contact area and risk area (r = 0.27; P < .001)
and between contact area and peak pressure (r = 0.18;
P < .001).
Discussion
We found a significant increase in peak pressures
when the angle of upright position was increased to
45°. This result differs from that of a recent investi-
gation19 in which peak pressures dif-
Elevation up to fered significantly between supine
and 30° semirecumbent positions.
30° did not result Peterson et al19 examined the effects
in a higher number of 7 different angles of backrest ele-
vation on sacral interface pressures in
of sensor cells healthy volunteers on a single bed
used in an intensive care unit. Sacral
reading more peak pressures in the supine position
than 32 mm Hg. were comparable to our findings, but
peak pressures in the semirecumbent
positions of 30° and 45° were higher. This difference
could be due to the different types of mattresses used.
In our study, compared with the supine position,
backrest elevation up to 30° was not associated with
a higher number of sensor cells reading more than
32 mm Hg (risk area) at the sacral region. This find-
ing, however, is consistent with the results of Peter-
124 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2014, Volume 23, No. 2
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son et al,19 who also observed a significantly higher
number of sensor cells reading 32 mm Hg or greater
at the 45° semirecumbent position and higher angles.
We and Peterson et al both used the Xsensor
pressure-mapping system to measure interface pres-
sure, so comparability of the results of the 2 studies
is given. The same system was not used in other
studies,20-22 however.
Placing participants in a semirecumbent position
with the help of the reverse Trendelenburg position
resulted in significantly lower peak pressures and
smaller areas of skin exposed to pressures greater than
32 mm Hg. When backrest elevation was combined
with the reverse Trendelenburg position, interface
pressures at 30° upright position were significantly
lower (Figure 2b) than pressures in the semirecum-
bent position. Some of the participants, however, slid
down in the inclined bed. As a consequence, shear-
ing forces could occur or be intensified, and the tilt
of the hip might not be anatomically correct.
We also found a significant reduction of inter-
face pressures with the TheraPulse ATP Therapy
System, a bed with low-air-loss technology. Because
the contact area was highest with this support surface
and increasing contact area correlated with lower
interface pressures, our data support the assumption
that better pressure distribution leads to minimized
peak pressures. Higher weight led to higher pressures
and larger contact areas with all mattresses. With the
low-air-loss system, the effect of higher body weight
on pressure can be alleviated by better weight distri-
bution. The role of low-air-loss systems in preventing
pressure ulcers, however, remains to be elucidated.23
The results of the few studies on the benefits of low-
air-loss systems are mixed17 and of low quality.24
Theaker et al25 found no differences in the incidence
of pressure ulcers between critically ill patients placed
on a low-air-loss bed and those placed on an alter-
nating-pressure mattress. In contrast, in another
study26 in critically ill patients, the incidence of
pressure ulcers with a low-air-loss bed was less than
the incidence with a standard bed in the intensive
care unit. Similarly, Black et al27 found that the
incidence of pressure ulcers was lower with a low-
air-loss mattress than with a powered air-pressure
redistribution mattress. Their conclusion that “it may
be possible to maintain elevation of the head of the
bed while minimizing sacral pressure ulcer risk”
supports our findings.
Our study has several limitations. Because it was
conducted in healthy volunteers, the findings can-
not necessarily be extrapolated to critically ill patients.
The clinical relevance of the surrogate parameter
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peak pressure can be questioned. In an evaluation of
different pressure indices in healthy volunteers, Bain
et al28 found that peak pressure was the most reliable
parameter, yet was limited by its sensitivity to experi-
mental errors. In contrast, Sprigle et al29 recommend
using the peak pressure index, which they defined as
the highest recorded pressure values within a 10-cm2
area, as a more reliable measure. We chose to meas-
ure peak pressure by using the same method used by
other investigators such as Peterson et al,19 who did a
study comparable to our study. Peak pressure could
be misleading because it relies on the reading of a
single sensor cell. Because our results for risk area,
which represented larger areas of higher pressure,
highly correlated with our results for peak pressure,
peak pressure most likely is a reliable surrogate
parameter for pressure at the interface of skin and
the support surface.
Moreover, using 32 mm Hg as the pressure
threshold for capillary closing is still controversial.
This commonly used threshold was derived from
experiments on capillary closing performed in the
1930s,10 but no evidence exists that it is related to
interface pressure or development of skin damage.
We arbitrarily chose this threshold for defining areas
of higher pressure, but no direct relationship
between the recorded absolute values and develop-
ment of ulcers can be assumed.
Interface pressure mapping is being questioned;
many mapping methods and devices exist, making
comparability of measurements difficult. Recently,
an attempt was made to address this issue and stan-
dardize these kinds of measurements.30 We tried to
adhere to the recommendations of that consensus
document.30 However, we did not obtain physiologi-
cal measurements of skin perfusion as recommended,
thus limiting the validity of the recorded interface
pressures with respect to any biological importance.
Furthermore, interface pressures were not recorded
for angles greater than 45° because elevation of the
head of the bed more than 45° is rarely used in cur-
rent practice.31-33
For the ProfiCare and TheraPulse ATP mattresses,
alternating regional pressure changes and pulsation
therapy, respectively, are offered as additional features
and may have additional beneficial effects on tissue per-
fusion. Both features may temporarily and regionally
influence interface pressure. We did not use either
feature because data obtained with use of the features
would not be comparable with data obtained with
the other mattresses. However, by not using these
features, we might have underestimated the poten-
tially beneficial effects of these mattresses.
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Conclusions
Sacral interface pressures increased significantly
only with a 45° upright position; only a minimal
or no increase was observed between pressures
obtained with participants supine and in a 30°
upright position. A 30° head-of-bed elevation
could therefore reconcile the supposedly incompati-
ble demands of skin integrity and prevention of
VAP. Pressure-redistributing support surfaces with
low-air-loss technology and the combination of the
reverse Trendelenburg position (always keeping the
danger of shear forces due to slipping down the
bed in mind) and elevation of the head of the bed
seem useful to minimize sacral interface pressures
and therefore could be indicated for patients at
high risk for pressure ulcers or when an upright
position of more than 30° is desired.
ACKNOWLEDGMENTS
Mattresses were provided by KCI Austria.
FINANCIAL DISCLOSURES
Dr Staudinger has received speaker’s fees from KCI.
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REFERENCES
1. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and
economic consequences of ventilator-associated pneumonia:
a systematic review. Crit Care Med. 2005;33(10):2184-2193.
2. Kollef MH, Hamilton CW, Ernst FR. Economic impact of
ventilator-associated pneumonia in a large matched
cohort. Infect Control Hosp Epidemiol. 2012;33(3):250-256.
3. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S,
Ferrer M. Supine body position as a risk factor for nosoco-
mial pneumonia in mechanically ventilated patients: a ran-
domised trial. Lancet. 1999;354(9193):1851-1858.
4. Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbent posi-
tion protects from pulmonary aspiration but not completely
from gastroesophageal reflux in mechanically ventilated
patients. Am J Respir Crit Care Med. 1995;(4, pt 1):1387-1390.
5. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel
FH, et al. Feasibility and effects of the semirecumbent posi-
tion to prevent ventilator-associated pneumonia: a random-
ized study. Crit Care Med. 2006;34(2):396-402.
6. Lorente L, Blot S, Rello J. Evidence on measures for the
prevention of ventilator-associated pneumonia. Eur Respir
J. 2007;30(6):1193-1207.
7. Hoppe C, Pöhler A, Kottner J, Dassen T. Pressure ulcers:
new data about risk, prevalence and places of develop-
ment: results of a study in German nursing homes and
hospitals [in German]. Pflege Z. 2008;61(2):90-93.
8. Cox J. Predictors of pressure ulcers in adult critical care
patients. Am J Crit Care. 2011;20(5):364-375.
9. Defloor T. The risk of pressure sores: a conceptual scheme.
J Clin Nurs. 1999;8(2):206-216.
10. Landis EM. Micro-injection studies of capillary blood pres-
sure in human skin. Heart. 1930;15:209-228.
11. Suriadi, Sanada H, Sugama J, et al. A new instrument for
predicting pressure ulcer risk in an intensive care unit. J
Tissue Viability. 2006;16(3):21-26.
12. Sugama J, Sanada H, Takahashi M. Reliability and validity
125
 of a multi-pad pressure evaluator for pressure ulcer man-
agement. J Tissue Viability. 2002;12(4):148-153.
13. Graves N, Birrell F, Whitby M. Effect of pressure ulcers on
length of hospital stay. Infect Control Hosp Epidemiol. 2005;
26(3):293-297.
14. Dealey C, Posnett J, Walker A. The cost of pressure ulcers in
the United Kingdom. J Wound Care. 2012;21(6):261-266.
15. Severens JL, Habraken JM, Duivenvoorden S, Frederiks CM.
The cost of illness of pressure ulcers in the Netherlands.
Adv Skin Wound Care. 2002;15(2):72-77.
16. Gorecki C, Closs SJ, Nixon J, Briggs M. Patient-reported
pressure ulcer pain: a mixed-methods systematic review.
J Pain Symptom Manage. 2011;42(3):443-459.
17. McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC,
Cullum N. Support surfaces for pressure ulcer prevention.
Cochrane Database Syst Rev. 2011;(4):CD001735.
18. Figliola RS. A proposed method for quantifying low-air-loss
mattress performance by moisture transport. Ostomy
Wound Manage. 2003;49(1):32-42.
19. Peterson M, Schwab W, McCutcheon K, van Oostrom JH,
Gravenstein N, Caruso L. Effects of elevating the head of
bed on interface pressure in volunteers. Crit Care Med. 2008;
36(11):3038-3042.
20. Harada C, Shigematsu T, Hagisawa S. The effect of 10-degree
leg elevation and 30-degree head elevation on body displace-
ment and sacral interface pressures over a 2-hour period. J
Wound Ostomy Continence Nurs. 2002;29(3):143-148.
21. Rondorf-Klym LM, Langemo D. Relationship between body
weight, body position, support surface, and tissue interface
pressure at the sacrum. Decubitus. 1993;6(1):22-30.
22. Whittemore R, Bautista C, Smith C, Bruttomesso K. Interface
pressure measurements of support surfaces with subjects in
the supine and 45-degree Fowler positions. J ET Nurs.
1993;20(3):111-115.
23. Lachenbruch C. Skin cooling surfaces: estimating the impor-
tance of limiting skin temperature. Ostomy Wound Manage.
2005;51(2):70-79.
24. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a
systematic review. JAMA. 2006;296(8):974-984.
126 AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2014, Volume 23, No. 2
Downloaded from ajcc.aacnjournals.org by guest on November 16, 2015
25. Theaker C, Kuper M, Soni N. Pressure ulcer prevention in
intensive care—a randomised control trial of two pressure-
relieving devices. Anaesthesia. 2005;60(4):395-399.
26. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical util-
ity and cost-effectiveness of an air suspension bed in the
prevention of pressure ulcers. JAMA. 1993;269(9):1139-1143.
27. Black J, Berke C, Urzendowski G. Pressure ulcer incidence
and progression in critically ill subjects: influence of low air
loss mattress versus a powered air pressure redistribution
mattress. J Wound Ostomy Continence Nurs. 2012;39(3):
267-273.
28. Bain D, Ferguson-Pell M, McLeod A. Evaluation of mattresses
using interface pressure mapping. J Wound Care. 2003;12(6):
231-235.
29. Sprigle S, Dunlop W, Press L. Reliability of bench tests of
interface pressure. Assist Technol. 2003;15(1):49-57.
30. Tissue Viability Society. Laboratory measurement of the inter-
face pressures applied by active therapy support surfaces:
a consensus document. J Tissue Viability. 2010;19(1):2-6.
31. Grap MJ, Munro CL, Hummel RS III, Elswick RK Jr, McKin-
ney JL, Sessler CN. Effect of backrest elevation on the
development of ventilator-associated pneumonia. Am J
Crit Care. 2005;14(4):325-333.
32. Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA,
Kollef MH. Tracheobronchial aspiration of gastric contents
in critically ill tube-fed patients: frequency, outcomes, and
risk factors. Crit Care Med. 2006;34(4):1007-1015.
33. Lyerla F, LeRouge C, Cooke DA, Turpin D, Wilson L. A nurs-
ing clinical decision support system and potential predictors
of head-of-bed position for patients receiving mechanical
ventilation. Am J Crit Care. 2010;19(1):39-47.
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Interface Pressure at Different Degrees of Backrest Elevation With Various
Types of Pressure-Redistribution Surfaces
Juliane Lippoldt, Elisabeth Pernicka and Thomas Staudinger
Am J Crit Care 2014;23:119-126 doi: 10.4037/ajcc2014670
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