Keywords
SARS-CoV-2 - Covid-19 - facial pressure ulcers
Introduction
The worldwide diffusion of coronavirus disease 2019 (COVID-19) caused by severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by various clinical
presentations and different related complications.
Controlling the airways often requires mechanical invasive ventilation,[1] and in cases of severe acute respiratory distress syndrome (ARDS), prone positioning
of the patient can reduce mortality[2] At the same time, however, the prone position ventilation can increase the risk
of facial pressure ulcers.[3]
We report a case of facial pressure ulcers in a 50-year-old female, mechanically ventilated
in a prone position, who was hospitalized for COVID-19.
The aim of this article is to contribute a little to better define the treatment complexities
of the COVID-19 pandemic, in which healthcare professionals across the world are still
involved.
Case Report
On March 10, 2020, a suspected 50 years-old female SARS-CoV-2 positive patient was
admitted to the Emergency Department of the SS. Antonio and Biagio and C. Arrigo Hospital.
Clinical signs were fever, asthenia, and dry cough. In the previous 3 days, the patient
had taken acetaminophen and antibiotics (amoxicillin and clavulanic acid 1 g three
times per day), as prescribed by the practitioner. The patient also experienced diarrhea
and cramp-like pain for 2 days before being admitted.
The patient’s medical history was irrelevant, and no allergies were reported.
Vital parameters at the admission were: body temperature (BT) 38.8°C, blood pressure
(BP) 120/65 mm Hg, heart rate (HR) 95/min, and respiratory rate 20/min. Pulse oximeter
saturation was 87%.
The physical examination was aspecific.
The laboratory findings revealed lymphopenya (lymphocytes 0.47 x 1000/mcl,), elevated
LDH (943 U/l), AST (75 U/l), ALT (200 U/l), GGT (41 U/l), procalcitonin (0.89 ng/mL),
PCR (9.37), fibrinogen (596 mg/dl), and D dimer (1.00 mcg/mL).
With regard to radiological examinations, a chest CT showed peripheral consolidations
and ground-glass opacities in both lungs. The SARS-CoV-2 positive nasopharyngeal swab
confirmed the suspected diagnosis.
The patient was promptly intubated and transferred to a single room of the Intensive
Care Unit of our hospital; ventilation was applied in a prone position.
After 15 days of intensive care, a plastic surgery evaluation was requested for multiple
facial skin lesions. We observed pressure ulcers and skin lesions due to maceration
involving the lips, chin, perioral aerea, both cheeks, left zygomatic region, and
superior and inferior left eyelids ([Fig. 1]).
Fig. 1 Facial skin lesions after 15 days prone ventilation
The patient was evaluated by using all the required droplet and contact precautions.
The sequence for putting on and taking off of personal protective equipment (PPE)
was respected. Some pictures of the clinical case were taken by using a camera previously
covered with adhesive film. As far as the dressing was concerned, we suggested the
application of topical 1% Silver Sulfadiazine (Sofargen-Sofar), covering the wounds
with gauzes impregnated with 0.2% Hyaluronic Acid And Sodium Salt (Connettivina-Fidia
Farmaceutici s.p.a) and sterile gauzes. On the necrotic tissue on the eyelids and
left zygomatic area, our dressing prescription was hyaluronic acid sodium salt collagenase
ointment (Bionect Start-Fidia Farmaceutici s.p.a) twice per day.
One week after the first plastic surgery evaluation, the patient clinical conditions
worsened and a tracheostomy was performed. However, skin lesions improved ([Fig. 2]). At the time of the article’s submission, the patient is still hospitalized.
Fig. 2 Outcome after topical treatment.
Discussion
As reported by the Italian Ministry of Health, on April 2 at 5 pm in Italy, there
are 85388 SARS-CoV-2 positive patients, 4068 of whom have been currently hospitalized
in intensive care units in Italy, and 452 in Piedmont. Given the aggressive pulmonary
involvement associated with COVID-19, noninvasive or invasive oxygen therapy is often
required. On the basis of the potential risk of viral aerosolisation and the need
for careful isolation precautions, noninvasive ventilation may be insufficient to
manage COVID-19 induced respiratory failure.[1] Moreover, there may be a poor response to noninvasive ventilation.[1] Invasive ventilation is associated with reduced aerosolisation and is thus considered
safer for staff and other patients.[1]
As reported in the literature, prone ventilation is likely to reduce mortality among
patients with severe ARDS when applied for at least 12 hours daily.[2] However, the prone position increases the risk of medical device-related pressure
ulcers in the facial area.[3]
Despite the great effort made by all the healthcare professionals involved in the
COVID 19 pandemic management, pressure ulcer preventive measures should be implemented.
As suggested in the literature, a thin silicone foam dressing can represent a valid
precaution approach.[4] The frequent mobilization of the patients is mandatory to reduce the risk of facial
pressure ulcers and avoid any cicatricial or permanent discromic effect. In this case,
the suggested topical treatment promoted wound healing.
Conclusion
This is the first report regarding facial pressure ulcer in COVID-19 affected patients.
Considering the high number of hospitalized patients in intensive care units, it is
of paramount importance to be aware of all the COVID-19 related complications with
the aim to avoid possible discomfort of patients.
