Pressure injury: A non-negligible comorbidity for critical Covid-19 patients

Abstract

A multidisciplinary team from Peking Union Medical College Hospital (PUMCH) managed an ICU from Feb 4th to April 12th, in the Sino–French New City Branch of Tongji Hospital, Wuhan, a designated hospital for Covid-19.1Zhang Y. Xiao M. Zhang S. et al.Coagulopathy and antiphospholipid antibodies in patients with Covid-19.N Engl J Med. 2020; 382: e38Crossref PubMed Scopus (1415) Google Scholar Among the 109 critically ill patients admitted to the unit, 46 (42.2%) patients (27 male, 19 female) with a median age of 66 years eventually developed various stages of pressure injury (Table 1, Figure S1–4 in the Supplementary Appendix), despite of all the proper management.Table 1Characteristics of 46 Critical Covid-19 Patients with Pressure Injury.CharacteristicTotal (N = 46)Stage I (N = 7)Stage II (N = 33)Stage III–IV /Unstageable (N = 6)General characteristicsMedian age (IQR) — yr66(60–70)68(63–72)65(57–68)69(66–70)Male sex — no. (%)27(58.7)5(71.4)18(54.5)4(66.7)Female sex — no. (%)19(41.3)2(28.6)15(45.5)2(33.3)Median interval from onset to intubation (IQR) — days18(12–24)17(13–24)18(13–21)20(14–23)Symptoms — no. (%)Fever40(87.0)5(71.4)29(87.9)6(100.0)Shortness of breath38(82.6)4(57.1)29(87.9)5(83.3)Cough36(78.3)5(71.4)26(78.8)5(83.3)Fatigue20(43.5)5(71.4)12(36.4)3(50.0)Diarrhea10(21.7)1(14.3)8(24.2)1(16.7)Sputum production10(21.7)1(14.3)8(24.2)1(16.7)Headache8(17.4)2(28.6)5(15.2)1(16.7)Nausea or vomiting7(15.2)2(28.6)4(12.1)1(16.7)Myalgia6(13.0)1(14.3)4(12.1)1(16.7)Palpitation4(8.7)04(12.1)0Pressure injury-related characteristicsMedian interval from intubation to pressure injury event (IQR) — days9(6–12)9(7–12)9(6–12)7(6–10)Location — no. (%) Sacrum41(89.1)6(85.7)29(87.9)6(100.0) Face11(23.9)1(14.3)8(24.2)2(33.3) Heel10(21.7)06(18.2)4(66.7) Hip4(8.7)03(9.1)1(16.7) Elbow3(6.5)1(14.3)2(6.1)0 Scapula2(4.3)01(3.0)1(16.7)Median size (IQR) — cm247(22–88)45(23–49)46(21–68)106(67–591)Vasopressor support — no. (%)35(76.1)3(42.9)26(78.8)6(100.0)Coexisting acro-ischemia — no. (%)16(34.8)1(14.3)10(30.3)5(83.3)Intermittent haemodialysis —no. (%)11(23.9)09(27.3)2(33.3)Wound swab sampling — no. (%)*Stage I pressure injury describes intact skin with non-blanchable erythema. No swab sample was obtained in this stage.23(50.0)NA17(51.5)5(83.3)Coexisting disorder — no. (%)Hypertension26(56.5)6(85.7)15(45.5)5(83.3)Diabetes8(17.4)2(28.6)4(12.1)2(33.3)Cerebrovascular disease7(15.2)1(14.3)4(12.1)2(33.3)Coronary heart disease7(15.2)06(18.2)1(16.7)Cancer†Any type of cancer was included in this category.5(10.9)05(15.2)0Chronic obstructive pulmonary disease4(8.7)1(14.3)2(6.1)1(16.7)Chronic renal disease2(4.3)1(14.3)01(16.7)Median laboratory values (IQR) ‡All the laboratory values were obtained from laboratory reports before medical intervention.White-cell count (per mm3)10,940(6400–15,380)13,360(6510–17,120)10,830(8710–14,350)12,070(5970–21,840)Differential count (per mm3)Total neutrophils9820(6270–13,660)12,490(5540–15,650)9690(7750–12,550)9930(5600–19,920)Total lymphocytes550(410–780)660(470–820)560(440–750)370(180–630)Total monocytes420(280–570)370(270–780)430(310–550)330(140–480)Hemoglobin (g/l)81(69–92)92(87–96)78(68–90)80(76–85)Platelet count (per mm3)181,000(118,300–243,500)248,000(205,500–290,500)180,000(119,000–230,000)73,000(37,000–205,800)Albumin (g/l)23.9(21.5–26.0)25.2(24.2–36.5)23.0(21.2–24.8)25.3(24.0–27.9)Creatinine (µmol/l)103(67–127)96(62–126)93(60–121)124(114–133)Prothrombin time (s)16.2(15.0–17.4)15.3(15.2–16.5)16.2(14.9–17.7)16.8(15.1–17.1)Activated partial-thromboplastin time (s)43.5(41.5–47.7)44.7(39.5–46.0)43.0(40.8–48.3)45.9(44.2–47.6)Fibrinogen (g/l)4.3(3.2–5.9)5.9(5.0–8.4)4.3(3.1–5.8)3.7(2.4–4.0)Fibrin degradation products (mg/l)§The reference value for the fibrin degradation products level was 150 mg/l or less.53.0(18.9–150.0)14.2(6.0–19.6)71.8(27.6–150.0)94.5(37.3–150.0)D-dimer (mg/l)¶The reference value for the D-dimer level was 21 mg/l or less.21(5.5–21.0)3.9(2.3–4.9)21.0(13.2–21.0)11.1(5.2–18.9)High-sensitivity C-reactive protein (mg/l)75.6(43.4–140.2)54.6(21.9–65.9)99.9(47.0–161.4)54.7(41.3–109.4)PrognosisDischarged from ICU — no. (%)16(34.8)3(42.9)10(30.3)3(50.0)Died in ICU — no. (%)30(65.2)4(57.1)23(69.7)3(50.0) Stage I pressure injury describes intact skin with non-blanchable erythema. No swab sample was obtained in this stage.† Any type of cancer was included in this category.‡ All the laboratory values were obtained from laboratory reports before medical intervention.§ The reference value for the fibrin degradation products level was 150 mg/l or less.¶ The reference value for the D-dimer level was 21 mg/l or less. Open table in a new tab All these 46 patients were in critical condition and received mechanical ventilation. The median interval from symptom onset to invasive ventilation was only 18 days. Forty-one (89.1%) of them had at least one of the coexisting disorders when admitted, including hypertension (56.5%), diabetes (17.4%), cerebrovascular disease (15.2%), and coronary heart disease (15.2%). Compared with the general population of Covid-19 patients in China,2Guan W. Ni Z. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (17327) Google Scholar our patients had a higher incidence of shortness of breath (82.6%) early. Other common symptoms included fever (87.0%), cough (78.3%) and fatigue (43.5%). Gastrointestinal symptoms, such as diarrhea (21.7%) and nausea or vomiting (15.2%) were also not uncommon. Except mechanical ventilation and coexisting disorders, other risk factors for pressure injury including malnutrition, anemia, vasopressor support, intermittent haemodialysis, and sedation were also commonly seen in our patients (Table 1). It is worth mentioning that 16 (34.8%) patients presented acro-ischemia (Figure S6–9 in the Supplementary Appendix), which is a demonstration of impaired microcirculation of the skin. As one of the indicators of poor prognosis in severe Covid-19 patients,1Zhang Y. Xiao M. Zhang S. et al.Coagulopathy and antiphospholipid antibodies in patients with Covid-19.N Engl J Med. 2020; 382: e38Crossref PubMed Scopus (1415) Google Scholar,3Tang N. Li D. Wang X. et al.Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia.J Thromb Haemost. 2020; 18: 844-847Crossref PubMed Scopus (3429) Google Scholar abnormal coagulation may also indicate the vulnerability of soft tissues. The median interval from intubation to the presence of pressure injury was 8 days. Sacrum (89.1%) was the most common location to emerge pressure injury, as might be expected, followed by the face (23.9%) due to the prone position ventilation adopted to optimize oxygenation, heels (21.7%) and hips (8.7%). Swab samples were taken from the pressure wounds of 22 (47.8%) laboratorially confirmed cases (Figure S5 in the Supplementary Appendix). No SARS-CoV-2 virus was found on reverse transcriptase polymerase chain reaction assay. Sixteen (34.8%) patients successfully detached from ventilators were transferred from ICU to general wards. Although the development of pressure injury is not a direct cause of mortality, it significantly increases morbidity, nursing burden and healthcare costs, and should not be neglected in the treatment of critical Covid-19 patients.