Skin Failure Among Critically Ill Patients Afflicted with Coronavirus Disease 2019 (COVID-19)

Abstract

Objective: To characterize skin integrity among coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU), and identify risk factors for skin failure (SF) in these patients. Design: The characteristic, profound pro-inflammatory, hypercoagulable state of COVID-19 is manifested by the high severity of illness and extensive organ dysfunction observed in these patients. SF in critically ill patients, although described previously, exhibits a uniquely complex pathogenesis in this population. Patients: Retrospective review of all COVID-19 patients (confirmed positive for severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) admitted to a single surgical ICU for at least 48 hours between March-June 2020. Interventions: Data were extracted from a COVID-19 institutional data repository that harvested data from electronic health records and other clinical data sources. Demographics; coagulation/inflammation biomarkers; number, location, and stage of SF lesions; resource utilization; and outcomes were captured. Measurements and Main Results: 64 patients met inclusion criteria; 51 (80%) developed SF (SF+ ). Forty-three (85%) developed stage 3 or higher SF (χ2 = 22.66, P < .0001). Thirty-nine of 51 (76%) SF+ patients developed more than one SF lesion (χ2 = 13.26, P = .0003). SF+ patients manifested a profound pro-inflammatory, hypercoagulable phenotype (lower serum albumin and higher ferritin, interleukin [IL]-6 and D-dimer concentrations [all, P < .001]). Durations of mechanical ventilation, vasopressor therapy, and ICU length of stay were significantly longer (all, P < .05) in the SF + patients. Conclusions: The unique characteristics of COVID-19 dermatopathology and the strong correlation between markers of inflammation and development of SF reflect COVID-19-related organ dysfunction and its deleterious effects on the microcirculation. Considering that skin is invaded directly by SARS-CoV-2 and affected by COVID-19-related immune complex deposition and microthrombosis, SF may reflect disease as opposed to pressure injuries related to processes of care. In the context of COVID-19 critical illness, SF should not be considered a “never event.”

Impacto Da Pandemia De Covid-19 Na Incidência De Lesão Por Pressão

“…No geral, a incidência de lesão por pressão variou de 33% (13) a 80% (19) , com uma mediana de 54% (IQR 43% -73%) (Figura 2).…”

“…A NOS avalia os estudos em 3 categorias: a seleção dos grupos de estudo; a comparabilidade dos grupos; e a determinação da exposição ou desfecho de interesse (10) . para leitura de texto completo, dos quais 10 (2,(12)(13)(14)(15)(16)(17)(18)(19)(20) foram incluídos no presente estudo (Figura 1). (12) a 284 (13) pacientes.…”

“…Quanto à metodologia, 30% (03) eram estudos de coorte retrospectivos baseados em revisão de registro (14,15,16) , 20% (02) caso-controle (13,17) e 50% (05) estudos transversais (18,2,12,19,20) . Os estudos incluídos foram realizados 70% na Europa (2,12,13,14,16,17,18,20) , 20% na América do Norte (15,19) e 10% na Ásia Oriental (18) . As informações apresentam-se sumarizadas na tabela 1.…”

“…A maior parte das lesões documentadas eram em estágio II (30% IQR 23%-69%) (2,12,14,16,17) . No entanto, em dois estudos as lesões em estágio III ultrapassaram 30% dos casos (14,19).…”

“…Em relação ao local da lesão, face/rosto prevaleceram em função de alguns estudos incluírem apenas pacientes submetidos a posição prona (12,14,15,16,17,20) . Nos artigos que avaliaram a incidência de LPP no geral, a região sacra aparece com maior prevalência, seguido da região da face/rosto (2,13,18,19) . Na face, as regiões do queixo (12,16,20) e bochechas (3,11) são as mais acometidas.…”