Perioral pressure ulcers in patients with COVID-19 requiring invasive mechanical ventilation

Abstract

Background Facial pressure ulcers are a rare yet significant complication. National Institute for Health and Care Excellence (NICE) guidelines recommend that patients should be risk-assessed for pressure ulcers and measures instated to prevent such complication. In this study, we report case series of perioral pressure ulcers developed following the use of two devices to secure endotracheal tubes in COVID-19 positive patients managed in the intensive care setting. Methods A retrospective analysis was conducted on sixteen patients identified to have perioral pressure ulcers by using the institutional risk management system. Data parameters included patient demographics (age, gender, comorbidities, smoking history and body mass index (BMI)). Data collection included the indication of admission to ITU, duration of intubation, types of medical devices utilised to secure the endotracheal tube, requirement of vasopressor agents and renal replacement therapy, presence of other associated ulcers, duration of proning and mortality. Results Sixteen patients developed different patterns of perioral pressure ulcers related to the use of two medical devices (Insight, AnchorFast). The mean age was 58.6 years. The average length of intubation was 18.8 days. Fourteen patients required proning, with an average duration of 5.2 days. Conclusions The two devices utilised to secure endotracheal tubes are associated with unique patterns of facial pressure ulcers. Measures should be taken to assess the skin regularly and avoid utilising devices that are associated with a high risk of facial pressure ulcers. Awareness and training should be provided to prevent such significant complication. Level of evidence: Level IV, risk/prognostic study.

Oral Complications of ICU Patients with COVID-19: Case-Series and Review of Two Hundred Ten Cases

“…On reviewing the emerging evidence on ICU-related complications in COVID-19 patients, fourteen studies (one cohort study [20], two case-control studies [21,22], one cross-sectional study [23], two case-series [24,25], and eight case-reports [26][27][28][29][30][31][32][33]) with two hundred ten patients met the inclusion criteria. The majority of the cases were from the Americas (USA n = 103, 49.5%; Brazil n = 4, 1.9%), followed by Europe (Spain n = 57, 27.1%; UK n = 16, 7.6%; France n = 2, 1%; and Italy n = 2, 1%), and Middle East (Iran n = 26, 12.4%).…”

“…The perioral (facial) pressure ulcers have been the most prevalent ICU-related oral complication in COVID-19 patients reported by ten studies in one hundred seventy-nine patients; 73.75% of them were males, and the vast majority were of old age [20][21][22][23]25,[29][30][31][32][33]. Prolonged pronation and endotracheal intubation were the most evident risk factors for perioral pressure ulcers.…”

Oral Manifestations of COVID-19 in Hospitalized Patients: A Systematic Review

“…A total of 35 articles were judged as low risk [21,26,, 12 as a moderate risk [67][68][69][70][71][72][73][74][75][76][77][78], and 12 as high risk [79][80][81][82][83][84][85][86][87][88][89][90] (Table S1).…”

Eruptions and related clinical course among 296 hospitalized adults with confirmed COVID-19

“…This occurrence has also been described in case series of COVID-19 patients with ulcerated and/or necrotic lesions at sites in direct contact with medical devices. 5,6 Whether this is simply a pressure phenomenon related to devices used to secure endotracheal tubes with or without prolonged intubation 7 or whether microvascular injury with COVID-19 predisposed patients to ulceration warrants further investigation. Most patients in our study with purpura or necrosis were also mechanically ventilated, which raises the question of whether this presentation is the result of microvascular injury in critically ill patients or whether they are the result of iatrogenic (ie, vasopressor, anticoagulation) exposures or other unknown factors.…”