Investigation of Operating Theatre Pressure Injury Risk and Influencing Factors in Patients Undergoing Open Heart Surgery: A Single-Center Cross-Sectional Study

Investigation of Operating Theatre Pressure Injury Risk and Influencing Factors in Patients Undergoing Open Heart Surgery: A Single-Center Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Investigation of Operating Theatre Pressure Injury Risk and Influencing Factors in Patients Undergoing Open Heart Surgery: A Single-Center Cross-Sectional Study İzzettin Ekinci, Aynur Koyuncu, Ayla Yava This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6507141/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aim: This study was conducted to determine the risk of operating theatre pressure injury and the factors influencing this risk in patients undergoing open heart surgery. Method: Ethical approval was obtained before starting the study (Approval No: 2022/110). The study was conducted as a cross-sectional study between January 15, 2023 and April 1, 2023 . The sample of the study consisted of 147 patients who underwent open heart surgery at a university hospital in Şanlıurfa . The research data were collected using the Patient Identification Form and the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale. Data were collected one day prior to and on the day of the surgery. SPSS 23.0 (IBM) was used for data analysis, and p<0.05 was considered the threshold to be statistically significant. This study utilized the STROBE checklist for reporting purposes. Results: The average age of the patients was 61.51 ± 11.66, with 63.1% being male and 40.6% having completed secondary education. Significant factors found to affect the risk of intraoperative pressure injury included a high body mass index (p = 0.005), prolonged surgery duration (p = 0.001), and moderate hypothermia (p = 0.030). Although the overall risk of pressure injury was found to be moderate, undergoing surgery for 6 hours or more (p = 0.001) and having a high BMI (p= 0.005) were determined to significantly increase this risk. Conclusion: This study showed that the risk of pressure injury in patients undergoing open-heart surgery is influenced by body mass index, surgery duration, and hypothermia. Preventive measures should be enhanced, especially for patients with prolonged surgeries and high BMI. Pressure sore open heart surgery operating theatre 3S Pressure Scale Nursing Care What is already known on this topic? Prolonged surgeries, high body mass index (BMI), and intraoperative hypothermia increase the risk of pressure injuries. The 3S Operating Theatre Pressure Injury Risk Diagnosis Scale is one of the tools used to assess intraoperative pressure injury risk. Studies evaluating pressure injury risk factors in open-heart surgery patients are limited. What does this study contribute to this topic? The risk of pressure injury was found to be moderate in patients undergoing open-heart surgery. Prolonged surgery duration, high BMI, and intraoperative hypothermia were identified as risk factors. The applicability of the 3S Scale in this patient group was evaluated. INTRODUCTION Pressure injuries in the operating room are a serious health concern that arise due to prolonged immobility, surgical positioning, anesthesia duration, and intraoperative physiological changes. 1 – 3 The National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) emphasize that surgical procedures pose a high risk for the development of pressure injuries and that special precautions should be taken during the intraoperative period. 4 Patients undergoing open heart surgery are at a higher risk of developing pressure injuries due to prolonged surgical durations, hypotension, significant blood loss, and mechanical ventilation. 5 , 6 Studies conducted in Turkey indicate that the incidence of intraoperative pressure injuries ranges between 24.1% and 25.0%, with the majority of patients developing Stage I pressure injuries within the first 24 hours postoperatively. 7 Additionally, it has been reported that operating room nurses and surgical teams lack sufficient knowledge regarding pressure injuries and that preventive interventions are not adequately implemented. 8 Given that pressure injuries are a preventable health issue, further research is needed to ensure patient safety and improve preventive measures in this field. 9 Pressure injuries that occur in the operating room are a significant health concern caused by prolonged immobility, the inability to feel pain under anesthesia, and intraoperative physiological changes. 5 Therefore, various assessment scales have been developed to determine the risk of pressure injuries during the intraoperative period. The 3S Operating Theatre Pressure Injury Risk Diagnosis Scale (3S IPIRAS) is specifically designed to assess the risk of intraoperative pressure injuries, and its validity and reliability have been studied in surgical patients. 10 Studies evaluating the risk factors for intraoperative pressure injuries in surgical patients using the 3S scale have shown that prolonged surgery (exceeding six hours), low serum albumin levels, and obesity play a significant role in the development of pressure injuries. 11 Comparisons of the predictive validity of the 3S, Braden, and Munro scales have demonstrated that the 3S scale has high predictive validity in assessing intraoperative risk in surgical patients. 7 These findings highlight the necessity of conducting patient-specific risk assessments to prevent intraoperative pressure injuries and demonstrate that the 3S scale is an effective tool in this field. However, the use of the 3S scale in patients undergoing open heart surgery is limited, and although multidisciplinary measures have demonstrated efficacy, further evidence is needed in this area. 12 Patients undergoing open heart surgery are at high risk for intraoperative pressure injuries due to prolonged surgery durations, hemodynamic changes, and immobility. In the existing literature, studies on the prevention of pressure injuries primarily focus on general surgical patients, while research on patients undergoing open heart surgery remains limited. In this context, the findings of this study have the potential to provide unique data on pressure injury management in the operating room and improve risk assessment processes in clinical practices. Additionally, it is expected to enhance scientific data on the use of the 3S scale in this patient group and guide future research. Accordingly, this study aims to determine the risk of intraoperative pressure injury development and the contributing factors in patients undergoing open heart surgery. The following hypotheses were tested within the scope of this study. H1₁: The risk of pressure injury in patients undergoing open-heart surgery shows a significant difference according to individual and surgical variables. H1₂: The risk of pressure injury in patients undergoing open-heart surgery is significantly affected by patient-related and surgical variables. METHODS Ethical Aspect of the Research Written approval for the study was obtained from the XXX University Health Sciences Scientific Research and Publication Ethics Committee (Document Date and Number: 2022/110) and XXX University Chief Physician (Document Date and Number: 2022/188775). Patients were informed about the study, and written consent was obtained indicating their voluntary participation. 13 All stages of the study were conducted in accordance with the ethical principles outlined in the World Medical Association Declaration of Helsinki. 14 Type, Location, and Time of the Study This study was designed as cross-sectional research. The study was conducted on patients undergoing open heart surgery at a university hospital in Şanlıurfa. The data collection process took place between January 15, 2023, and April 1, 2023. Throughout the study period, an effort was made to reach all patients scheduled for surgery, and those who voluntarily agreed to participate were included in the research. The STROBE checklist was used in reporting this study. Population and Sample of the Study The population of the study consisted of patients who were scheduled to undergo open heart surgery at a university hospital in Şanlıurfa during the study period. The sample consisted of patients who met the inclusion criteria and voluntarily agreed to participate in the study. The sample size was calculated and determined using the G*Power 3.1.9.7 program. The calculation was conducted based on the assumption that a Point Biserial Correlation analysis would be performed to examine the relationship between pressure injury risk and patient characteristics. Cohen’s (d) medium effect size was used in the calculation. 15 With a one-tailed hypothesis, α error = 0.05, β error = 0.05, power (1-β) = 95%, and correlation p H1 = 0.30, it was determined that the sample should consist of at least 111 patients. As a result of considering possible data losses, the sample size was increased by 20%, and data were collected from a total of 147 patients. Inclusion Criteria for the Study a) patients aged 18 and over, b) patients who can read and write in Turkish, c) patients without any communication impairments (hearing, vision, etc.), d) patients who had undergone open-heart surgery for the first time during the study period, e) patients without a history of chronic pressure injury, f) patients without neurological or musculoskeletal diseases that could affect the development of pressure injuries, g) patients who did not use continuous corticosteroids or immunosuppressive drugs, h) patients who were operated on under general anesthesia, ı) patients who voluntarily consented to participate in the study were included in the research. Exclusion Criteria for the Study a) patients who developed serious complications during or after surgery and whose follow-up was not possible, b) patients who initially volunteered but later withdrew from the study at any stage were excluded from the research. Data Collection Tools The research data were collected using the "Patient Identification Form" and the "3S Operating Theatre Pressure Injury Risk Diagnosis Scale." Patient Identification Form This form included questions aimed at determining patients' demographic characteristics such as age, gender, height, body weight, and educational status. Additionally, it included information regarding patients' smoking and alcohol consumption, existing chronic diseases, preoperative mobility status, medications administered, and overall health status. 3S Operating Theatre Pressure Injury Risk Diagnosis Scale This scale was developed by Gao et al. (2015) 10 to assess the risk of pressure injury development during surgery. The Turkish validity and reliability study of the scale was conducted by Soyer and Özbayır (2018). 16 The scale evaluated a total of nine criteria, including overall body skin condition, preoperative mobility status, body mass index, skin stress, intraoperative blood loss, duration of surgery and surgical stress, body temperature during surgery, and surgical position. It was structured as a four-point Likert scale, with items scored between 1 and 4. The total score ranged from 9 to 36, with higher scores indicating an increased risk of pressure injury. The Cronbach’s alpha coefficient of the original scale was found to be 0.71, while the Turkish version had a Cronbach’s alpha coefficient of 0.68. Data Collection The research data were collected in two stages: one day before surgery between 08:00 and 10:00 in the morning and during the surgery. Pilot Study A pilot study was conducted with 5 patients to assess the suitability of the data collection forms. Since no revisions were necessary, the data obtained from the pilot study were included in the research. Patients were visited in their rooms one day prior to surgery and informed about the study. Written consent was obtained from those who voluntarily agreed to participate. Participants were asked to respond to the questions in the Patient Identification Form. Additionally, data were collected for the skin of the whole body, preoperative limb activity (limitations), and body height/weight ratio items of the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale. On the day of surgery, patients were evaluated using the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale based on the following items: skin under stress, intraoperative bleeding, operation time, intraoperative surgical stress, intraoperative body temperature, and intraoperative body position. The data collection process took approximately 15–20 minutes for each evaluation. Statistical Analysis of Data In the statistical analysis of the study, the SPSS Statistics 23.0 (IBM, USA) program was used. In this study, the dependent variable is the total score of the 3S Operating Theatre Pressure Injury Risk Assessment Scale. The independent variables are age, gender, education level, body mass index, presence of chronic disease, type of surgery, duration of surgery, and intraoperative hypothermia degree. The normality distribution of the data was evaluated using the Kolmogorov-Smirnov and Shapiro-Wilk tests. For normally distributed data, Independent Samples t-Test was used for comparisons between two independent groups, One-Way ANOVA was applied for comparisons among three or more groups, and the Tukey HSD Post-Hoc Test was used to determine differences between groups. Multiple Linear Regression was conducted to identify the factors affecting the 3S Operating Theatre Pressure Injury Risk Assessment Scale score. In the model, the total scale score was considered as the dependent variable, while age, body mass index (BMI), surgery duration, and degree of hypothermia were included as independent variables. A statistical significance threshold of p < 0.05 was applied to all analyses. RESULTS The demographic and clinical characteristics of the 147 patients included in the study were evaluated. Regarding age distribution, 66.7% of the patients were 65 years old or younger, while 33.3% were 66 years old or older. In terms of gender, 63.1% of the patients were male, and 36.9% were female. Regarding the patients’ educational status, 35.4% were literate or had completed primary education, 40.6% had completed secondary education, and 24.0% had a bachelor's degree or higher. Regarding BMI, 27.9% of the patients had a BMI of 24.9 or lower, while 72.1% had a BMI of 25 or higher. It was found that 39.6% of the participants had at least one chronic disease, whereas 60.4% had no chronic conditions. Based on the type of surgery, 65.0% of the patients underwent bypass surgery, 24.3% had heart valve surgery, and 10.7% underwent aneurysm surgery. In terms of surgery duration, 30.2% of the patients had an operation lasting 3 hours or less, 55.5% had a duration of 4–5 hours, and 14.3% had a surgery duration of 6 hours or more. When evaluating the degree of hypothermia, 71.4% of the patients experienced mild hypothermia (35 − 32°C), while 28.6% suffered moderate hypothermia (31 − 28°C) (Table 1 ). Table 1 Descriptive characteristics of patients and the comparison of the mean scores of the 3S Intraoperative Pressure Injury Risk Assessment Scale (N = 147) n(%) Mean ± SD* Test /p Age (Mean ± SD*:61,51 ± 11,66) ≤ 65 ≥ 66 98(66.7) 49(33.3) 23.04 ± 2.32 23.27 ± 2.41 t = 0.562, p = 0.575 Gender Male Female 85(63.1) 62(36.9) 23.19 ± 2.21 23.21 ± 2.66 t = 0.011, p = 0.992 Education Status Literate &Primary Education Secondary Education Bachelor's Degree and Above 42(35.4) 61(40.6) 44(24.0) 23.39 ± 2.32 22.93 ± 2.48 23.38 ± 2.29 F = 0.657, p = 0.520 BMI** ≤ 24.9 ≥ 25 41(27.9) 106(72.1) 22.85 ± 2.29 24.07 ± 2.41 t=-2.837, p = 0.005 Chronic disease Yes No 56(39,60) 91(60,40) 23.46 ± 1.91 23.01 ± 2.65 t=-1.139, p = 0.256 Type of surgery Bypass Heart Valve Aneurysm 97(65,00) 44(24,30) 6(10,70) 23.20 ± 2.41 23.17 ± 2.31 23.16 ± 2.78 F = 0.092, p = 0.998 Operation Duration ≤ 3 4–5 ≥ 6 48(30,20) 76(55,50) 23(14,30) 22.55 ± 2.57 23.12 ± 1.95 24.70 ± 2.30 F = 8.202, p = 0.001 Post hoc : 1–3, p = 0.001 2–3, p = 0.008 Degree of Hypothermia Mild hypothermia (35 − 32°C) Moderate hypothermia (31 − 28°C) 105(71.4) 42(28.6) 22.52 ± 2.58 23.46 ± 2.25 t = 2.195, p = 0.030 Mean ± SD*:Mean ± Standard Deviation, BMI: body mass index, t: Independent samples t-test, F: One-way ANOVA test, Tukey HSD There was no statistically significant difference in the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale scores of patients undergoing open-heart surgery when compared based on age, gender, education level, presence of chronic disease, and type of surgery (p > 0.05). In terms of BMI, patients with BMI ≥ 25 had higher risk scores, and this difference was statistically significant (p = 0.005). When compared based on surgery duration, patients who underwent surgery for 6 hours or more had higher pressure injury risk scores, and the difference between groups was statistically significant (p = 0.001). In the post-hoc analysis, the difference between groups 1–3 and 2–3 was statistically significant (p = 0.001, p = 0.008). When compared based on the degree of hypothermia, a significant difference was found between the mild and moderate hypothermia groups (p = 0.030). (Table 1 ). Table 2 presents the distribution of pressure injury risk scores according to the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale in patients undergoing open-heart surgery. The score for skin of the whole body was 2.20 ± 0.99, preoperative limb activity was 3.72 ± 0.45, body mass index was 2.44 ± 0.94, skin under stress was 2.34 ± 0.85, intraoperative bleeding was 3.21 ± 0.71, operation time was 2.76 ± 0.78, intraoperative surgical stress was 2.81 ± 0.86, intraoperative body temperature was 2.67 ± 1.17, and intraoperative body position was 1.00 ± 0.00. The total scale score was calculated to be 23.19 ± 2.38 (Table 2 ). Table 2 Distribution of Pressure Injury Risk Scores According to the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale in Patients Undergoing Open-Heart Surgery (N = 147) Mean ± SD* Min-Max Skin of the whole body 2.20 ± 0.99 1–4 Preoperative limb activity (limitations) 3.72 ± 0.45 3–4 Body height/weight ratio 2.44 ± 0.94 1–4 Skin under stress 2.34 ± 0.85 1–4 Intraoperative bleeding 3.21 ± 0.71 1–4 Operation time 2.76 ± 0.78 1–4 Intraoperative surgical stress 2.81 ± 0.86 1–4 Intraoperative body temperature 2.67 ± 1.17 1–4 Intraoperative body position 1.00 ± 00.00 1–1 Total scale score 23.19 ± 2.38 15–28 Mean ± SD*:Mean ± Standard Deviation, Table 3 presents the results of the multiple linear regression analysis for factors affecting the 3S Operating Theatre Pressure Injury Risk in patients undergoing open-heart surgery. The age variable had no significant effect on pressure injury risk (p = 0.847). A positive and statistically significant relationship was found between BMI and pressure injury risk (p = 0.025). As the duration of surgery increased, the risk of pressure injury also increased significantly (p = 0.001). No significant relationship was found between the degree of hypothermia and pressure injury risk (p = 0.143). According to the regression analysis results, BMI and surgery duration were identified as significant factors increasing the risk of pressure injury (Table 3). Tablo 3. Multiple Linear Regression Models for Factors Affecting 3S Operating Theatre Pressure Injury Risk in Patients Undergoing Open-Heart Surgery Variables Β(Odds Ratio ) T/p 95 %CI Min-Max Age -0.003 t=-0.193 p=0.847 -0.036-0.030 BMI 0.198 t=2.267 p=0.025 -0.025-0.370 Operation Duration 0.940 t=3.924 p=0.001 0.466-1.413 Degree of Hypothermia 0.166 t=1.473 p=0.143 -0.057-0.388 BMI: Body Mass Index DISCUSSION The main finding of this study, conducted to determine the risk of pressure injury and the factors influencing this risk in patients undergoing open-heart surgery, is that surgery duration, body mass index, and the degree of hypothermia significantly affect the risk of pressure injury. The hypotheses tested in this study were confirmed, and it was determined that individual and surgical variables play a decisive role in pressure injury risk. The findings highlight the need to develop preventive strategies, particularly for patients undergoing prolonged surgeries and those with a high BMI. Additionally, intraoperative temperature regulation has been identified as a critical factor in reducing risk. The results of this study are consistent with the existing literature and provide significant contributions to the field by evaluating risk factors specific to open-heart surgery patients. In Table 1 , it was determined that age, gender, education level, presence of chronic disease, and type of surgery did not have a significant effect on the risk of pressure injury; however, a high BMI increased the risk. Özdemir et al. (2023) 5 and Eberhardt et al. (2021) 9 stated that obese patients are more prone to pressure injuries and that appropriate support surfaces can reduce this risk, whereas Yılmaz and Başlı (2021) 17 reported no significant relationship between BMI and pressure injury. Additionally, the risk of pressure injury increases as surgery duration extends, with a notable rise in risk for surgeries lasting more than six hours. Tura et al. (2023) 7 highlighted that prolonged surgeries elevate the risk, while Kottner et al. (2020) 4 emphasized the protective effects of position changes and support surfaces. These findings highlight the need for enhanced preventive measures, particularly for patients undergoing prolonged surgeries and those with a high BMI. In Table 1 , it was observed that the risk of pressure injury increases as surgery duration extends, with a significant rise in risk for surgeries lasting more than six hours. Therefore, preventive measures such as position changes, support surfaces, and regular monitoring of skin integrity should be implemented during prolonged surgeries. Many studies support the association between longer surgery duration and an increased risk of pressure injury. Özdemir et al. (2023) 5 and Eberhardt et al. (2021) 9 reported that prolonged immobility reduces tissue perfusion, creating conditions for pressure injuries. Tura et al. (2023) 7 highlighted that, in addition to surgery duration, patient positioning, support surfaces, and intraoperative temperature regulation also influence the risk. Celik et al. (2024) 18 emphasized that, alongside surgery duration, the patient's overall health status and surgical practices play a crucial role. Hajhosseini et al. (2020) 19 identified reduced tissue perfusion as the primary mechanism leading to pressure injuries, while Kottner et al. (2020) 4 highlighted the critical importance of position changes and support surfaces. Kaya and Ursavaş (2023) 8 demonstrated that using supportive surfaces during surgery provides effective protection, whereas Alshahrani et al. (2021) 20 emphasized the need for surgical teams to regularly monitor skin integrity and take preventive measures. The literature consistently indicates that longer surgeries increase the risk of pressure injuries and highlights the necessity of systematic interventions to alleviate this risk. As displayed in Table 1 , it was determined that as hypothermia increases, the risk of pressure injury also rises, with moderate hypothermia carrying a higher risk. Low body temperature can reduce blood flow, delaying the healing process; therefore, maintaining body temperature during surgery is crucial. The literature has shown that hypothermia increases the risk of pressure injury. Özdemir et al. (2023) 5 and Eberhardt et al. (2021) 9 reported that patients with moderate hypothermia are under a higher risk compared to those with mild hypothermia. Tura et al. (2023) 7 emphasized that hypothermia alone is not the sole factor, however, when combined with prolonged surgery duration and immobility, significantly increases the risk of pressure injury. Kottner et al. (2020) 4 indicated that appropriate warming strategies can support wound healing and reduce this risk. Theoretically, Hajhosseini et al. (2020) 19 stated that hypothermia induces vasoconstriction, reducing tissue oxygenation and contributing to pressure injuries. Kaya and Ursavaş (2023) 8 highlighted the protective effect of intraoperative temperature regulation, while Alshahrani et al. (2021) 20 suggested that the use of heated operating tables and warm air blowers can help mitigate this risk. The literature consistently demonstrates that intraoperative hypothermia increases the risk of pressure injuries and underscores the importance of effective temperature regulation during surgery. In Table 2 , the total score of the 3S Operating Theatre Pressure Injury Risk Assessment Scale indicates that patients have a moderate risk of pressure injury. This finding highlights the need for preventive measures based on individual risk factors during the surgical process. The moderate risk level identified by the 3S scale is also supported by the literature. Özdemir et al. (2023) 5 and Eberhardt et al. (2021) 9 reported that pressure injury risk is generally at a moderate level but may increase depending on surgery duration and patient characteristics. Tura et al. (2023) 7 emphasized the efficacy of the 3S scale in risk assessment, while Kottner et al. (2020) 4 stated that pressure injuries are preventable. These findings underscore the importance of implementing protective measures tailored to individual risk factors during surgery. Table 3 presents the results of the multiple linear regression analysis evaluating the factors affecting the 3S Operating Theatre Pressure Injury Risk Assessment Scale score in patients undergoing open-heart surgery. According to the findings, the patients’ age and the degree of hypothermia did not have a significant effect on pressure injury risk, whereas BMI and surgery duration had a significant impact. As BMI increased, the risk of pressure injury also increased, indicating that overweight patients are at higher risk. The strongest association was found with surgery duration, as the risk of pressure injury significantly increased with longer surgery times. These results highlight the need for enhanced preventive measures, particularly for patients with prolonged surgery durations and high BMI. The findings in Table 3 are consistent with previous studies in the literature. Özdemir et al. (2023) 5 reported that patients with a high BMI are at a greater risk of pressure injury and that this risk increases as BMI rises. Similarly, Eberhardt et al. (2021) 9 found that prolonged surgeries elevate the risk of pressure injuries, as extended surgical duration negatively affects tissue perfusion, leading to injury development. Tura et al. (2023) 7 , using the 3S scale, identified surgery duration as one of the most significant predictors of pressure injury risk. Kottner et al. (2020) 4 emphasized that pressure injuries are largely preventable and that proper repositioning and the use of supportive surfaces during long surgical procedures can significantly reduce this risk. The results of this study align with the existing literature, reinforcing the importance of implementing preventive measures, particularly for patients with prolonged surgery durations and high BMI. The findings of this study indicate that the risk of pressure injury in patients undergoing open-heart surgery is associated with surgery duration, BMI, and intraoperative hypothermia. The results highlight that pressure injuries are largely preventable and emphasize the need to strengthen protective measures, particularly for patients undergoing prolonged surgeries and those with high BMI. Theoretically, this study underscores the necessity for a more comprehensive evaluation of risk factors during the surgical process, while in practice, it highlights the importance of protecting patients through position changes, supportive surfaces, and intraoperative temperature regulation Future research should assess the efficacy of risk assessment scales in different patient populations and develop more effective protocols for preventing pressure injuries. Additionally, multi-center studies should be conducted to provide stronger evidence via larger datasets. CONCLUSION This study revealed that the risk of pressure injury in patients undergoing open-heart surgery is moderate, with prolonged surgery duration, high body mass index, and intraoperative hypothermia being significant contributing factors. The findings indicate that pressure injuries are largely preventable and emphasize the need for implementing preventive strategies based on individual risk factors to enhance patient safety during surgical procedures. In particular, increasing interventions such as appropriate position changes, the use of supportive surfaces, and the regulation of body temperature is essential in prolonged surgeries. This study contributes to both clinical practice and future research by supporting the development of evidence-based nursing care to prevent pressure injuries. Limitations This study has certain limitations. It was conducted in a single center, which may limit the generalizability of the findings to patient populations in different hospitals. The data collection process was restricted to a specific time frame, inhibiting long-term follow-up. Lastly, assessments conducted using the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale may be subject to subjective bias. Future research should consider multi-center studies and examine larger patient groups. Declarations Author Contribution E.İ. and K.A. wrote the main manuscript text and A.A. prepared figures 1-3. All authors reviewed the manuscript. References Riemenschneider KJ. Prevention of Pressure Injuries in the Operating Room: A Quality Improvement Project. J Wound Ostomy Continence Nurs. 2018 Mar/Apr;45(2):141–145. 10.1097/WON.0000000000000410 . PMID: 29521925. Angmorterh SK, England A, Webb J, et al. An investigation of pressure ulcer risk, comfort, and pain in medical imaging. J Med Imaging Radiat Sci. 2019;50(1):43–52. 10.1016/j.jmir.2018.07.003 . Kim HM, Lee H, Ha T, Na S. Perioperative factors associated with pressure ulcer development after major surgery. Korean J Anesthesiol. 2017;71(1):48–56. 10.4097/kjae.2018.71.1.48 . Kottner J, Cuddigan J, Carville K, Balzer K, Berlowitz D, Law S, Litchford M, Mitchell P, Moore Z, Pittman J, Sigaudo-Roussel D, Yee CY, Haesler E. 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Investigation of related factors of operating room nurses' attitudes and awareness towards surgery-related pressure injury prevention in Turkey, Croatia, and Italy. J Tissue Viability. 2024;33(3):418–24. Epub 2024 May 17. PMID: 38821842. Hajhosseini B, Longaker MT, Gurtner GC. Pressure Injury. Ann Surg. 2020;271(4):671–679. 10.1097/SLA.0000000000003567 . PMID: 31460882. Alshahrani B, Sim J, Middleton R. Nursing interventions for pressure injury prevention among critically ill patients: A systematic review. J Clin Nurs. 2021;30(15–16):2151–68. 10.1111/jocn.15709 . Epub 2021 Feb 27. PMID: 33590917. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6507141","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446545466,"identity":"055a2ec5-3cdc-4cdb-8342-ab2cec95745f","order_by":0,"name":"İzzettin Ekinci","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBACNiA8wMAgIWfADOIWAPEBIrUYQ7QYgLUwNhDSBAKJGxiI1cLH3pZ4uKDGIn07O+/hFx8MGOT4biSwP67AZwfPsQOHZxyTyN3ZzJdmOcOAwVjyRgJj4xl8WiTSGw7zNkjkbjjMY2bMYwB0IUgLPpexyT8Ha0k3gGqpJ6xFgu0ASEsCUIvxY6CWBAOCWnjSEg7zHJMw3NnMY8Y4w0DCcOaZh40z8WmRbz9m/Jmnpk7enP+M8YcPFTbyfMeTD3zEpwXVkcA4BdKEYhIJMH8gWukoGAWjYBSMKAAAHDZJcOIhfPgAAAAASUVORK5CYII=","orcid":"","institution":"Bingöl University","correspondingAuthor":true,"prefix":"","firstName":"İzzettin","middleName":"","lastName":"Ekinci","suffix":""},{"id":446545468,"identity":"d5edc32e-0b68-41b6-a846-a398e18c23bd","order_by":1,"name":"Aynur Koyuncu","email":"","orcid":"","institution":"Hasan Kalyoncu University","correspondingAuthor":false,"prefix":"","firstName":"Aynur","middleName":"","lastName":"Koyuncu","suffix":""},{"id":446545469,"identity":"352c86fb-c98b-4254-847e-5ac86b6d8063","order_by":2,"name":"Ayla Yava","email":"","orcid":"","institution":"Hasan Kalyoncu University","correspondingAuthor":false,"prefix":"","firstName":"Ayla","middleName":"","lastName":"Yava","suffix":""}],"badges":[],"createdAt":"2025-04-22 20:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6507141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6507141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82703329,"identity":"fa1e7526-2a13-4674-b8b7-9a97613b04dd","added_by":"auto","created_at":"2025-05-14 09:53:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":949899,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6507141/v1/fff57318-d94f-4bbd-988f-4cb590af217a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigation of Operating Theatre Pressure Injury Risk and Influencing Factors in Patients Undergoing Open Heart Surgery: A Single-Center Cross-Sectional Study","fulltext":[{"header":"What is already known on this topic?","content":"\u003cul\u003e\n\u003cli\u003eProlonged surgeries, high body mass index (BMI), and intraoperative hypothermia increase the risk of pressure injuries.\u003c/li\u003e\n\u003cli\u003eThe 3S Operating Theatre Pressure Injury Risk Diagnosis Scale is one of the tools used to assess intraoperative pressure injury risk.\u003c/li\u003e\n\u003cli\u003eStudies evaluating pressure injury risk factors in open-heart surgery patients are limited.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat does this study contribute to this topic?\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eThe risk of pressure injury was found to be moderate in patients undergoing open-heart surgery.\u003c/li\u003e\n\u003cli\u003eProlonged surgery duration, high BMI, and intraoperative hypothermia were identified as risk factors.\u003c/li\u003e\n\u003cli\u003eThe applicability of the 3S Scale in this patient group was evaluated.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003ePressure injuries in the operating room are a serious health concern that arise due to prolonged immobility, surgical positioning, anesthesia duration, and intraoperative physiological changes.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) emphasize that surgical procedures pose a high risk for the development of pressure injuries and that special precautions should be taken during the intraoperative period. \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Patients undergoing open heart surgery are at a higher risk of developing pressure injuries due to prolonged surgical durations, hypotension, significant blood loss, and mechanical ventilation. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Studies conducted in Turkey indicate that the incidence of intraoperative pressure injuries ranges between 24.1% and 25.0%, with the majority of patients developing Stage I pressure injuries within the first 24 hours postoperatively.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Additionally, it has been reported that operating room nurses and surgical teams lack sufficient knowledge regarding pressure injuries and that preventive interventions are not adequately implemented.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Given that pressure injuries are a preventable health issue, further research is needed to ensure patient safety and improve preventive measures in this field.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePressure injuries that occur in the operating room are a significant health concern caused by prolonged immobility, the inability to feel pain under anesthesia, and intraoperative physiological changes.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Therefore, various assessment scales have been developed to determine the risk of pressure injuries during the intraoperative period. The 3S Operating Theatre Pressure Injury Risk Diagnosis Scale (3S IPIRAS) is specifically designed to assess the risk of intraoperative pressure injuries, and its validity and reliability have been studied in surgical patients.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Studies evaluating the risk factors for intraoperative pressure injuries in surgical patients using the 3S scale have shown that prolonged surgery (exceeding six hours), low serum albumin levels, and obesity play a significant role in the development of pressure injuries.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Comparisons of the predictive validity of the 3S, Braden, and Munro scales have demonstrated that the 3S scale has high predictive validity in assessing intraoperative risk in surgical patients.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e These findings highlight the necessity of conducting patient-specific risk assessments to prevent intraoperative pressure injuries and demonstrate that the 3S scale is an effective tool in this field. However, the use of the 3S scale in patients undergoing open heart surgery is limited, and although multidisciplinary measures have demonstrated efficacy, further evidence is needed in this area.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePatients undergoing open heart surgery are at high risk for intraoperative pressure injuries due to prolonged surgery durations, hemodynamic changes, and immobility. In the existing literature, studies on the prevention of pressure injuries primarily focus on general surgical patients, while research on patients undergoing open heart surgery remains limited. In this context, the findings of this study have the potential to provide unique data on pressure injury management in the operating room and improve risk assessment processes in clinical practices. Additionally, it is expected to enhance scientific data on the use of the 3S scale in this patient group and guide future research. Accordingly, this study aims to determine the risk of intraoperative pressure injury development and the contributing factors in patients undergoing open heart surgery.\u003c/p\u003e \u003cp\u003eThe following hypotheses were tested within the scope of this study.\u003c/p\u003e \u003cp\u003eH1₁: The risk of pressure injury in patients undergoing open-heart surgery shows a significant difference according to individual and surgical variables.\u003c/p\u003e \u003cp\u003eH1₂: The risk of pressure injury in patients undergoing open-heart surgery is significantly affected by patient-related and surgical variables.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthical Aspect of the Research\u003c/h2\u003e \u003cp\u003e Written approval for the study was obtained from the XXX University Health Sciences Scientific Research and Publication Ethics Committee (Document Date and Number: 2022/110) and XXX University Chief Physician (Document Date and Number: 2022/188775). Patients were informed about the study, and written consent was obtained indicating their voluntary participation.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e All stages of the study were conducted in accordance with the ethical principles outlined in the World Medical Association Declaration of Helsinki.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eType, Location, and Time of the Study\u003c/h3\u003e\n\u003cp\u003eThis study was designed as cross-sectional research. The study was conducted on patients undergoing open heart surgery at a university hospital in Şanlıurfa. The data collection process took place between January 15, 2023, and April 1, 2023. Throughout the study period, an effort was made to reach all patients scheduled for surgery, and those who voluntarily agreed to participate were included in the research. The STROBE checklist was used in reporting this study.\u003c/p\u003e\n\u003ch3\u003ePopulation and Sample of the Study\u003c/h3\u003e\n\u003cp\u003eThe population of the study consisted of patients who were scheduled to undergo open heart surgery at a university hospital in Şanlıurfa during the study period. The sample consisted of patients who met the inclusion criteria and voluntarily agreed to participate in the study.\u003c/p\u003e \u003cp\u003eThe sample size was calculated and determined using the G*Power 3.1.9.7 program. The calculation was conducted based on the assumption that a Point Biserial Correlation analysis would be performed to examine the relationship between pressure injury risk and patient characteristics. Cohen\u0026rsquo;s (d) medium effect size was used in the calculation.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e With a one-tailed hypothesis, α error\u0026thinsp;=\u0026thinsp;0.05, β error\u0026thinsp;=\u0026thinsp;0.05, power (1-β)\u0026thinsp;=\u0026thinsp;95%, and correlation p H1\u0026thinsp;=\u0026thinsp;0.30, it was determined that the sample should consist of at least 111 patients. As a result of considering possible data losses, the sample size was increased by 20%, and data were collected from a total of 147 patients.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion Criteria for the Study\u003c/strong\u003e \u003cp\u003ea) patients aged 18 and over, b) patients who can read and write in Turkish, c) patients without any communication impairments (hearing, vision, etc.), d) patients who had undergone open-heart surgery for the first time during the study period, e) patients without a history of chronic pressure injury, f) patients without neurological or musculoskeletal diseases that could affect the development of pressure injuries, g) patients who did not use continuous corticosteroids or immunosuppressive drugs, h) patients who were operated on under general anesthesia, ı) patients who voluntarily consented to participate in the study were included in the research.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion Criteria for the Study\u003c/strong\u003e \u003cp\u003ea) patients who developed serious complications during or after surgery and whose follow-up was not possible, b) patients who initially volunteered but later withdrew from the study at any stage were excluded from the research.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cp\u003eThe research data were collected using the \"Patient Identification Form\" and the \"3S Operating Theatre Pressure Injury Risk Diagnosis Scale.\"\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePatient Identification Form\u003c/strong\u003e \u003cp\u003eThis form included questions aimed at determining patients' demographic characteristics such as age, gender, height, body weight, and educational status. Additionally, it included information regarding patients' smoking and alcohol consumption, existing chronic diseases, preoperative mobility status, medications administered, and overall health status.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e3S Operating Theatre Pressure Injury Risk Diagnosis Scale\u003c/strong\u003e \u003cp\u003eThis scale was developed by Gao et al. (2015)\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e to assess the risk of pressure injury development during surgery. The Turkish validity and reliability study of the scale was conducted by Soyer and \u0026Ouml;zbayır (2018).\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e The scale evaluated a total of nine criteria, including overall body skin condition, preoperative mobility status, body mass index, skin stress, intraoperative blood loss, duration of surgery and surgical stress, body temperature during surgery, and surgical position. It was structured as a four-point Likert scale, with items scored between 1 and 4. The total score ranged from 9 to 36, with higher scores indicating an increased risk of pressure injury. The Cronbach\u0026rsquo;s alpha coefficient of the original scale was found to be 0.71, while the Turkish version had a Cronbach\u0026rsquo;s alpha coefficient of 0.68.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eThe research data were collected in two stages: one day before surgery between 08:00 and 10:00 in the morning and during the surgery.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePilot Study\u003c/strong\u003e \u003cp\u003eA pilot study was conducted with 5 patients to assess the suitability of the data collection forms. Since no revisions were necessary, the data obtained from the pilot study were included in the research.\u003c/p\u003e \u003c/p\u003e \u003cp\u003ePatients were visited in their rooms one day prior to surgery and informed about the study. Written consent was obtained from those who voluntarily agreed to participate. Participants were asked to respond to the questions in the Patient Identification Form. Additionally, data were collected for the skin of the whole body, preoperative limb activity (limitations), and body height/weight ratio items of the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale.\u003c/p\u003e \u003cp\u003eOn the day of surgery, patients were evaluated using the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale based on the following items: skin under stress, intraoperative bleeding, operation time, intraoperative surgical stress, intraoperative body temperature, and intraoperative body position. The data collection process took approximately 15\u0026ndash;20 minutes for each evaluation.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis of Data\u003c/h2\u003e \u003cp\u003eIn the statistical analysis of the study, the SPSS Statistics 23.0 (IBM, USA) program was used.\u003c/p\u003e \u003cp\u003eIn this study, the dependent variable is the total score of the 3S Operating Theatre Pressure Injury Risk Assessment Scale. The independent variables are age, gender, education level, body mass index, presence of chronic disease, type of surgery, duration of surgery, and intraoperative hypothermia degree. The normality distribution of the data was evaluated using the Kolmogorov-Smirnov and Shapiro-Wilk tests. For normally distributed data, Independent Samples t-Test was used for comparisons between two independent groups, One-Way ANOVA was applied for comparisons among three or more groups, and the Tukey HSD Post-Hoc Test was used to determine differences between groups. Multiple Linear Regression was conducted to identify the factors affecting the 3S Operating Theatre Pressure Injury Risk Assessment Scale score. In the model, the total scale score was considered as the dependent variable, while age, body mass index (BMI), surgery duration, and degree of hypothermia were included as independent variables. A statistical significance threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was applied to all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe demographic and clinical characteristics of the 147 patients included in the study were evaluated. Regarding age distribution, 66.7% of the patients were 65 years old or younger, while 33.3% were 66 years old or older. In terms of gender, 63.1% of the patients were male, and 36.9% were female. Regarding the patients\u0026rsquo; educational status, 35.4% were literate or had completed primary education, 40.6% had completed secondary education, and 24.0% had a bachelor\u0026apos;s degree or higher. Regarding BMI, 27.9% of the patients had a BMI of 24.9 or lower, while 72.1% had a BMI of 25 or higher. It was found that 39.6% of the participants had at least one chronic disease, whereas 60.4% had no chronic conditions. Based on the type of surgery, 65.0% of the patients underwent bypass surgery, 24.3% had heart valve surgery, and 10.7% underwent aneurysm surgery. In terms of surgery duration, 30.2% of the patients had an operation lasting 3 hours or less, 55.5% had a duration of 4\u0026ndash;5 hours, and 14.3% had a surgery duration of 6 hours or more. When evaluating the degree of hypothermia, 71.4% of the patients experienced mild hypothermia (35\u0026thinsp;\u0026minus;\u0026thinsp;32\u0026deg;C), while 28.6% suffered moderate hypothermia (31\u0026thinsp;\u0026minus;\u0026thinsp;28\u0026deg;C) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDescriptive characteristics of patients and the comparison of the mean scores of the 3S Intraoperative Pressure Injury Risk Assessment Scale (N\u0026thinsp;=\u0026thinsp;147)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD*\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTest /p\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD*:61,51\u0026thinsp;\u0026plusmn;\u0026thinsp;11,66)\u003c/p\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;65\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e98(66.7)\u003c/p\u003e\n \u003cp\u003e49(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.04\u0026thinsp;\u0026plusmn;\u0026thinsp;2.32\u003c/p\u003e\n \u003cp\u003e23.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.562, p\u0026thinsp;=\u0026thinsp;0.575\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e85(63.1)\u003c/p\u003e\n \u003cp\u003e62(36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e\n \u003cp\u003e23.21\u0026thinsp;\u0026plusmn;\u0026thinsp;2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.011, p\u0026thinsp;=\u0026thinsp;0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLiterate \u0026amp;Primary Education\u003c/p\u003e\n \u003cp\u003eSecondary Education\u003c/p\u003e\n \u003cp\u003eBachelor\u0026apos;s Degree and Above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42(35.4)\u003c/p\u003e\n \u003cp\u003e61(40.6)\u003c/p\u003e\n \u003cp\u003e44(24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.32\u003c/p\u003e\n \u003cp\u003e22.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48\u003c/p\u003e\n \u003cp\u003e23.38\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.657, p\u0026thinsp;=\u0026thinsp;0.520\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI**\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;24.9\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41(27.9)\u003c/p\u003e\n \u003cp\u003e106(72.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29\u003c/p\u003e\n \u003cp\u003e24.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003et=-2.837, p\u0026thinsp;=\u0026thinsp;0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic disease\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56(39,60)\u003c/p\u003e\n \u003cp\u003e91(60,40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e\n \u003cp\u003e23.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003et=-1.139, p\u0026thinsp;=\u0026thinsp;0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of surgery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBypass\u003c/p\u003e\n \u003cp\u003eHeart Valve\u003c/p\u003e\n \u003cp\u003eAneurysm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97(65,00)\u003c/p\u003e\n \u003cp\u003e44(24,30)\u003c/p\u003e\n \u003cp\u003e6(10,70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e\n \u003cp\u003e23.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31\u003c/p\u003e\n \u003cp\u003e23.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.092, p\u0026thinsp;=\u0026thinsp;0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation Duration\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e\n \u003cp\u003e4\u0026ndash;5\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48(30,20)\u003c/p\u003e\n \u003cp\u003e76(55,50)\u003c/p\u003e\n \u003cp\u003e23(14,30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e\n \u003cp\u003e23.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e\n \u003cp\u003e24.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eF\u0026thinsp;=\u0026thinsp;8.202, p\u0026thinsp;=\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePost hoc\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e1\u0026ndash;3, p\u0026thinsp;=\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2\u0026ndash;3, p\u0026thinsp;=\u0026thinsp;0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree of Hypothermia\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMild hypothermia (35\u0026thinsp;\u0026minus;\u0026thinsp;32\u0026deg;C)\u003c/p\u003e\n \u003cp\u003eModerate hypothermia (31\u0026thinsp;\u0026minus;\u0026thinsp;28\u0026deg;C)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e105(71.4)\u003c/p\u003e\n \u003cp\u003e42(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58\u003c/p\u003e\n \u003cp\u003e23.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u0026thinsp;=\u0026thinsp;2.195, p\u0026thinsp;=\u0026thinsp;0.030\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD*:Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation, BMI: body mass index, t: Independent samples t-test, F: One-way ANOVA test, Tukey HSD\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThere was no statistically significant difference in the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale scores of patients undergoing open-heart surgery when compared based on age, gender, education level, presence of chronic disease, and type of surgery (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In terms of BMI, patients with BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 had higher risk scores, and this difference was statistically significant (p\u0026thinsp;=\u0026thinsp;0.005). When compared based on surgery duration, patients who underwent surgery for 6 hours or more had higher pressure injury risk scores, and the difference between groups was statistically significant (p\u0026thinsp;=\u0026thinsp;0.001). In the post-hoc analysis, the difference between groups 1\u0026ndash;3 and 2\u0026ndash;3 was statistically significant (p\u0026thinsp;=\u0026thinsp;0.001, p\u0026thinsp;=\u0026thinsp;0.008). When compared based on the degree of hypothermia, a significant difference was found between the mild and moderate hypothermia groups (p\u0026thinsp;=\u0026thinsp;0.030). (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the distribution of pressure injury risk scores according to the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale in patients undergoing open-heart surgery. The score for skin of the whole body was 2.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99, preoperative limb activity was 3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45, body mass index was 2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94, skin under stress was 2.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85, intraoperative bleeding was 3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71, operation time was 2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78, intraoperative surgical stress was 2.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86, intraoperative body temperature was 2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17, and intraoperative body position was 1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00. The total scale score was calculated to be 23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of Pressure Injury Risk Scores According to the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale in Patients Undergoing Open-Heart Surgery (N\u0026thinsp;=\u0026thinsp;147)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD*\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMin-Max\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkin of the whole body\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative limb activity (limitations)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBody height/weight ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkin under stress\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative bleeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative surgical stress\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative body temperature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative body position\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;00.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal scale score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u0026ndash;28\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD*:Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation,\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;3 presents the results of the multiple linear regression analysis for factors affecting the 3S Operating Theatre Pressure Injury Risk in patients undergoing open-heart surgery. The age variable had no significant effect on pressure injury risk (p\u0026thinsp;=\u0026thinsp;0.847). A positive and statistically significant relationship was found between BMI and pressure injury risk (p\u0026thinsp;=\u0026thinsp;0.025). As the duration of surgery increased, the risk of pressure injury also increased significantly (p\u0026thinsp;=\u0026thinsp;0.001). No significant relationship was found between the degree of hypothermia and pressure injury risk (p\u0026thinsp;=\u0026thinsp;0.143). According to the regression analysis results, BMI and surgery duration were identified as significant factors increasing the risk of pressure injury (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTablo 3. Multiple Linear Regression Models for Factors Affecting 3S Operating Theatre Pressure Injury Risk in Patients Undergoing Open-Heart Surgery\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026Beta;(Odds Ratio )\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eT/p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95 %CI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMin-Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e-0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003et=-0.193\u003c/p\u003e\n \u003cp\u003ep=0.847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e-0.036-0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.198\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et=2.267\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep=0.025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.025-0.370\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation Duration\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.940\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et=3.924\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep=0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.466-1.413\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree of Hypothermia\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003et=1.473\u003c/p\u003e\n \u003cp\u003ep=0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e-0.057-0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI: Body Mass Index\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe main finding of this study, conducted to determine the risk of pressure injury and the factors influencing this risk in patients undergoing open-heart surgery, is that surgery duration, body mass index, and the degree of hypothermia significantly affect the risk of pressure injury. The hypotheses tested in this study were confirmed, and it was determined that individual and surgical variables play a decisive role in pressure injury risk. The findings highlight the need to develop preventive strategies, particularly for patients undergoing prolonged surgeries and those with a high BMI. Additionally, intraoperative temperature regulation has been identified as a critical factor in reducing risk. The results of this study are consistent with the existing literature and provide significant contributions to the field by evaluating risk factors specific to open-heart surgery patients.\u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, it was determined that age, gender, education level, presence of chronic disease, and type of surgery did not have a significant effect on the risk of pressure injury; however, a high BMI increased the risk. \u0026Ouml;zdemir et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e and Eberhardt et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e stated that obese patients are more prone to pressure injuries and that appropriate support surfaces can reduce this risk, whereas Yılmaz and Başlı (2021)\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e reported no significant relationship between BMI and pressure injury. Additionally, the risk of pressure injury increases as surgery duration extends, with a notable rise in risk for surgeries lasting more than six hours. Tura et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e highlighted that prolonged surgeries elevate the risk, while Kottner et al. (2020)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e emphasized the protective effects of position changes and support surfaces. These findings highlight the need for enhanced preventive measures, particularly for patients undergoing prolonged surgeries and those with a high BMI.\u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, it was observed that the risk of pressure injury increases as surgery duration extends, with a significant rise in risk for surgeries lasting more than six hours. Therefore, preventive measures such as position changes, support surfaces, and regular monitoring of skin integrity should be implemented during prolonged surgeries. Many studies support the association between longer surgery duration and an increased risk of pressure injury. \u0026Ouml;zdemir et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e and Eberhardt et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e reported that prolonged immobility reduces tissue perfusion, creating conditions for pressure injuries. Tura et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e highlighted that, in addition to surgery duration, patient positioning, support surfaces, and intraoperative temperature regulation also influence the risk. Celik et al. (2024)\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e emphasized that, alongside surgery duration, the patient's overall health status and surgical practices play a crucial role. Hajhosseini et al. (2020)\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e identified reduced tissue perfusion as the primary mechanism leading to pressure injuries, while Kottner et al. (2020)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e highlighted the critical importance of position changes and support surfaces. Kaya and Ursavaş (2023)\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e demonstrated that using supportive surfaces during surgery provides effective protection, whereas Alshahrani et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e emphasized the need for surgical teams to regularly monitor skin integrity and take preventive measures. The literature consistently indicates that longer surgeries increase the risk of pressure injuries and highlights the necessity of systematic interventions to alleviate this risk.\u003c/p\u003e \u003cp\u003eAs displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, it was determined that as hypothermia increases, the risk of pressure injury also rises, with moderate hypothermia carrying a higher risk. Low body temperature can reduce blood flow, delaying the healing process; therefore, maintaining body temperature during surgery is crucial. The literature has shown that hypothermia increases the risk of pressure injury. \u0026Ouml;zdemir et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e and Eberhardt et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e reported that patients with moderate hypothermia are under a higher risk compared to those with mild hypothermia. Tura et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e emphasized that hypothermia alone is not the sole factor, however, when combined with prolonged surgery duration and immobility, significantly increases the risk of pressure injury. Kottner et al. (2020)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e indicated that appropriate warming strategies can support wound healing and reduce this risk. Theoretically, Hajhosseini et al. (2020)\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e stated that hypothermia induces vasoconstriction, reducing tissue oxygenation and contributing to pressure injuries. Kaya and Ursavaş (2023)\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e highlighted the protective effect of intraoperative temperature regulation, while Alshahrani et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e suggested that the use of heated operating tables and warm air blowers can help mitigate this risk. The literature consistently demonstrates that intraoperative hypothermia increases the risk of pressure injuries and underscores the importance of effective temperature regulation during surgery.\u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the total score of the 3S Operating Theatre Pressure Injury Risk Assessment Scale indicates that patients have a moderate risk of pressure injury. This finding highlights the need for preventive measures based on individual risk factors during the surgical process. The moderate risk level identified by the 3S scale is also supported by the literature. \u0026Ouml;zdemir et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e and Eberhardt et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e reported that pressure injury risk is generally at a moderate level but may increase depending on surgery duration and patient characteristics. Tura et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e emphasized the efficacy of the 3S scale in risk assessment, while Kottner et al. (2020)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e stated that pressure injuries are preventable. These findings underscore the importance of implementing protective measures tailored to individual risk factors during surgery.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;3 presents the results of the multiple linear regression analysis evaluating the factors affecting the 3S Operating Theatre Pressure Injury Risk Assessment Scale score in patients undergoing open-heart surgery. According to the findings, the patients\u0026rsquo; age and the degree of hypothermia did not have a significant effect on pressure injury risk, whereas BMI and surgery duration had a significant impact. As BMI increased, the risk of pressure injury also increased, indicating that overweight patients are at higher risk. The strongest association was found with surgery duration, as the risk of pressure injury significantly increased with longer surgery times. These results highlight the need for enhanced preventive measures, particularly for patients with prolonged surgery durations and high BMI.\u003c/p\u003e \u003cp\u003eThe findings in Table\u0026nbsp;3 are consistent with previous studies in the literature. \u0026Ouml;zdemir et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e reported that patients with a high BMI are at a greater risk of pressure injury and that this risk increases as BMI rises. Similarly, Eberhardt et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e found that prolonged surgeries elevate the risk of pressure injuries, as extended surgical duration negatively affects tissue perfusion, leading to injury development. Tura et al. (2023)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, using the 3S scale, identified surgery duration as one of the most significant predictors of pressure injury risk. Kottner et al. (2020)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e emphasized that pressure injuries are largely preventable and that proper repositioning and the use of supportive surfaces during long surgical procedures can significantly reduce this risk. The results of this study align with the existing literature, reinforcing the importance of implementing preventive measures, particularly for patients with prolonged surgery durations and high BMI.\u003c/p\u003e \u003cp\u003eThe findings of this study indicate that the risk of pressure injury in patients undergoing open-heart surgery is associated with surgery duration, BMI, and intraoperative hypothermia. The results highlight that pressure injuries are largely preventable and emphasize the need to strengthen protective measures, particularly for patients undergoing prolonged surgeries and those with high BMI. Theoretically, this study underscores the necessity for a more comprehensive evaluation of risk factors during the surgical process, while in practice, it highlights the importance of protecting patients through position changes, supportive surfaces, and intraoperative temperature regulation Future research should assess the efficacy of risk assessment scales in different patient populations and develop more effective protocols for preventing pressure injuries. Additionally, multi-center studies should be conducted to provide stronger evidence via larger datasets.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study revealed that the risk of pressure injury in patients undergoing open-heart surgery is moderate, with prolonged surgery duration, high body mass index, and intraoperative hypothermia being significant contributing factors. The findings indicate that pressure injuries are largely preventable and emphasize the need for implementing preventive strategies based on individual risk factors to enhance patient safety during surgical procedures. In particular, increasing interventions such as appropriate position changes, the use of supportive surfaces, and the regulation of body temperature is essential in prolonged surgeries. This study contributes to both clinical practice and future research by supporting the development of evidence-based nursing care to prevent pressure injuries.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations\u003c/strong\u003e \u003cp\u003eThis study has certain limitations. It was conducted in a single center, which may limit the generalizability of the findings to patient populations in different hospitals. The data collection process was restricted to a specific time frame, inhibiting long-term follow-up. Lastly, assessments conducted using the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale may be subject to subjective bias. Future research should consider multi-center studies and examine larger patient groups.\u003c/p\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE.İ. and K.A. wrote the main manuscript text and A.A. prepared figures 1-3. 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PMID: 33590917.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pressure sore, open heart surgery, operating theatre, 3S Pressure Scale, Nursing Care","lastPublishedDoi":"10.21203/rs.3.rs-6507141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6507141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim: \u003c/strong\u003eThis study was conducted to determine the risk of operating theatre pressure injury and the factors influencing this risk in patients undergoing open heart surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e Ethical approval was obtained before starting the study (Approval No: 2022/110). The study was conducted as a cross-sectional study between January 15, 2023 and April 1, 2023\u003cstrong\u003e.\u003c/strong\u003eThe sample of the study consisted of 147 patients who underwent open heart surgery at a university hospital in Şanlıurfa\u003cstrong\u003e.\u003c/strong\u003e The research data were collected using the Patient Identification Form and the 3S Operating Theatre Pressure Injury Risk Diagnosis Scale. Data were collected one day prior to and on the day of the surgery. SPSS 23.0 (IBM) was used for data analysis, and p\u0026lt;0.05 was considered the threshold to be statistically significant. This study utilized the STROBE checklist for reporting purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe average age of the patients was 61.51 ± 11.66, with 63.1% being male and 40.6% having completed secondary education. Significant factors found to affect the risk of intraoperative pressure injury included a high body mass index (p = 0.005), prolonged surgery duration (p = 0.001), and moderate hypothermia (p = 0.030). Although the overall risk of pressure injury was found to be moderate, undergoing surgery for 6 hours or more (p = 0.001) and having a high BMI (p= 0.005) were determined to significantly increase this risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study showed that the risk of pressure injury in patients undergoing open-heart surgery is influenced by body mass index, surgery duration, and hypothermia. Preventive measures should be enhanced, especially for patients with prolonged surgeries and high BMI.\u003c/p\u003e","manuscriptTitle":"Investigation of Operating Theatre Pressure Injury Risk and Influencing Factors in Patients Undergoing Open Heart Surgery: A Single-Center Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-24 09:54:06","doi":"10.21203/rs.3.rs-6507141/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"94619976-5e30-4724-8f5e-8c878707f59f","owner":[],"postedDate":"April 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-14T09:53:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-24 09:54:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6507141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6507141","identity":"rs-6507141","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}