Medical Device-Related Pressure Injuries: an integrative literature review

Galetto, Sabrina Guterres da Silva; Nascimento, Eliane Regina Pereira do; Hermida, Patrícia Madalena Vieira; Malfussi, Luciana Bihain Hagemann de

doi:10.1590/0034-7167-2018-0530

Sabrina Guterres da Silva Galetto Corresponding Author: Sabrina Guterres da Silva Galetto E-mail: sabrinaguterres@gmail.com

Universidade Federal de Santa Catarina. Programa de Pós-Graduação em Enfermagem. Florianópolis-SC, Brasil.

https://orcid.org/0000-0003-4137-1687

Eliane Regina Pereira do Nascimento

Universidade Federal de Santa Catarina. Programa de Pós-Graduação em Enfermagem. Florianópolis-SC, Brasil.

https://orcid.org/0000-0003-2215-4222

Patrícia Madalena Vieira Hermida

Universidade Federal de Santa Catarina. Programa de Pós-Graduação em Enfermagem. Florianópolis-SC, Brasil.

https://orcid.org/0000-0002-7969-357X

Luciana Bihain Hagemann de Malfussi

Universidade Federal de Santa Catarina. Programa de Pós-Graduação em Enfermagem. Florianópolis-SC, Brasil.

https://orcid.org/0000-0002-3199-9529

Corresponding Author: Sabrina Guterres da Silva Galetto E-mail: sabrinaguterres@gmail.com

Code	Title	Year/Country	Outlining/number of patients	Objectives	Main results	NE
S1	Face masks for noninvasive ventilation: fit, excess skin hydration, and pressure ulcers⁽¹¹11 Visscher MO, White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face masks for noninvasive ventilation: fit, excess skin hydration, and pressure ulcers. Respir Care [Internet]. 2015 [cited 2018 Feb 07];60(11):1536-47. Available from: http://rc.rcjournal.com/content/60/11/1536 http://rc.rcjournal.com/content/60/11/15... ⁾	2015 United States	Prospective cohort N=50	To investigate the factors that contribute to the development of PI-related mask of NIV.	Of the participants, 72% presented PI related to the NIV mask with 61 sites involved. Stage 1 injuries were the most common. The risk of injury was higher for the oronasal mask. The skin hydration differences were correlated with the occurrence of injuries, and coverages were indicated between the mask and the skin for MDRI prevention.	IV
S2	Unusual cause of a facial pressure ulcer: the helmet securing the Sengstaken-Blakemore tube⁽¹²12 Kim SM, Ju RK, Lee JH, Jun YJ, Kim Yj. Unusual cause of a facial pressure ulcer: the helmet securing the Sengstaken-Blakemore tube. J Wound Care [Internet]. 2015 [cited 2018 Feb 07];24(Suppl-6). Available from: https://www.magonlinelibrary.com/doi/10.12968/jowc.2015.24.Sup6.S14 https://www.magonlinelibrary.com/doi/10.... ⁾	2015 Korea	Case N=1	Report a case of atypical facial PI developed by a helmet for SBT fixation.	Woman, 59 years old with high digestive hemorrhage, using SBT. Traction force was applied with 1 kg at the proximal end of the SBT and a metal frame U-shaped helmet around the face. After three days of use, there was evidence of an injury in the frontal region of the skull with cutaneous necrosis. There are general recommendations for the prevention of MDRI such as: Evaluating the skin daily and applying protective dressing.	VI
S3	Facial skin breakdown in patients with non-invasive ventilation devices: report of two cases and indications for treatment and prevention⁽¹³13 Maruccia M, Ruggieri M, Onesti MG. Facial skin breakdown in patients with non-invasive ventilation devices: report of two cases and indications for treatment and prevention. Int Wound J [Internet]. 2015 [cited 2018 Feb 07];12(4):451-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23870043 https://www.ncbi.nlm.nih.gov/pubmed/2387... ⁾	2015 Italy	Case N=2	To report two cases of PI related to NIV.	Case 1: Premature newborn (28 weeks), using nasal cannula with continuous positive pressure. After 4 weeks he had an injury in nasal columella. Case 2: Elderly (71 years) in NIV per nasal oral mask. After 11 days he had injury with necrosis on nasal, nasolabial and ment. Both were in critical condition, with need for NIV 24h/day. Treatment and prevention measures such as disinfection, use of hyaluronic acid and gauze protection of risk areas were reported.	VI
S4	Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: a prospective cohort study⁽¹⁴14 Tayyib N, Coyer F, Lewis P. Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: a prospective cohort study. Int Wound J [Internet]. 2015 [cited 2018 Feb 07]; 3(5):912-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25662591 https://www.ncbi.nlm.nih.gov/pubmed/2566... ⁾	2015 Saudi Arabia	Prospective cohort N=84	To identify the incidence and risk factors associated with the development of PI in adult patients at two ICUs.	The incidence of PI was 39.3%, being 8.3% MDRI. Among the factors predictive of PI are: Age, length of stay in the ICU, history of cardiovascular and renal diseases, time of operation, emergency hospitalization, mechanical ventilation and lower scores on the Braden Scale. No preventive measures and treatment of MDRI were presented.	IV
S5	Device-related atypical pressure ulcer after cardiac surgery⁽¹⁵15 Glasgow D, Millen IS, Nzewi OC, Varadaraiaran B. Device-related atypical pressure ulcer after cardiac surgery. J Wound Care [Internet]. 2014 [cited 2018 Feb 07];23(8):383-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25139595 https://www.ncbi.nlm.nih.gov/pubmed/2513... ⁾	2014 United Kingdom	Case N=1	To report a case of MDRI and to propose an algorithm for the prevention of these injuries.	Man, 60 years old, submitted to cardiac surgery. After postoperative complications and prolonged hospitalization in ICU, he developed stage IV MDRI in the posterior cervical region attributed to fixation of the orotracheal tube. Among the measures to prevent PI related to the use of ventilation devices it is proposed to move the device.	VI
S6	A prospective window into medical device-related pressure ulcers in intensive care⁽¹⁶16 Coyer FM, Stotts NA, Blackman . A prospective window into medical device-related pressure ulcers in intensive care. Int Wound J [Internet]. 2014 [cited 2018 Feb 07];11(6):656-64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23374630 https://www.ncbi.nlm.nih.gov/pubmed/2337... ⁾	2014 Australia/United States	MulticentricCross-sectional N=483	To determine the prevalence, severity, location, etiology, treatment and healing of MDRI in ICU patients.	The prevalence of MDRI was 3.1%. Nine of the 15 patients were followed up, with an occurrence of 11 injuries. There were two of stage 1, eight of stage 2 and one of stage 3, most of them in the head and neck. Endotracheal and nasogastric tubes caused most of the injuries. For prevention and treatment indicated: Repositioning and padding of the device, in addition to skin cleansing and moisturizing.	VI
S7	Cohort study of atypical pressure ulcers development⁽¹⁷17 Jaul E. Cohort study of atypical pressure ulcers development. Int Wound J [Internet]. 2014 [cited 2018 Feb 07];11(6):696-700. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23374746 https://www.ncbi.nlm.nih.gov/pubmed/2337... ⁾	2014 Israel	Cohort N=174	To analyze the occurrence of atypical PIs and the circumstances of causality.	The rate of occurrence of the injuries was 21%. The etiology was determined, respectively, by severe spasticity, use of medical devices and bone deformities. To prevent PI related to TCT and IC, care is advised with the fixation of the shoelace and the probe.	IV
S8	A prospective pilot study of atypical pressure ulcer presentation in a skilled geriatric nursing unit⁽¹⁸18 Jaul E. A prospective pilot study of atypical pressure ulcer presentation in a skilled geriatric nursing unit. Ostomy Wound Manage [Internet]. 2011 [cited 2018 Feb 07];57(2):49-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21350272 https://www.ncbi.nlm.nih.gov/pubmed/2135... ⁾	2011 Israel	Descriptive N=32	To describe the occurrence, causes, prevention, evaluation and treatment of atypical PIs.	The occurrence rate of PIs was 40% (n= 13). Of these, six were associated with medical devices, four with increased spasticity and three with bone deformity - observed at the site of increased tone and muscle pressure. It is indicated to replace the urethral catheter with suprapublic to prevent MDRI.	VI
S9	Medicaldevice related pressure ulcers in hospitalized patients⁽¹⁹19 Black JM, Cuddigan JE, Walko MA, Didier LA, Lander MJ, Kelpe MR. Medical device related pressure ulcers in hospitalized patients. Int Wound J [Internet]. 2010 [cited 2018 Feb 07];7(5):358-65. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20561094 https://www.ncbi.nlm.nih.gov/pubmed/2056... ⁾	2010 United States	Cross-sectional N=2079	To quantify and identify risk factors for MDRI.	The PI rate was 54%. The proportion of patients with MDRI was 34.5%. Patients in use of devices were more likely to develop PI of any kind. The general recommendations for the prevention of MDRI are focused on skin evaluation, repositioning and fixation of the device, work and multiprofessional education.	VI

Risk device	Localization of MDRI	Occurrence (%)	Study
Non-Invasive Ventilation Mask	Nose base Face Fontal region of the skull Chin Nasal columella Nasolabial region	39.0 30.0 10.0 3.0 UOS* UOS*	S1S1S1S1S3S3
Orotracheal tube	Ear Neck Lip Nose Cervical posterior Scalp	37.5 25.0 12.5 12.5 40.0 UOS*	S4S4S4S4S7S5
Tracheostomy	Cervical posterior Neck Stoma region	66.0 10.0 UOS*	S8S7S7
Nasogastric tube	Nose	40.0	S6
Gastrostomy tube	Region underlying the stoma	10.0	S7
Sengstaken-Blakemore tube helmet	Frontal region	UOS*	S2
Cervical collar	Occipital region Chin Occipital region	10.0 10.0 UOS*	S7 S7 S9
Indwelling Catheter	Urethra Genital organ and urethral meatus	20.0 17.0	S7 S8
Radial Artery Catheter	Arm	UOS*	S9
Immobilization splint	Hand	UOS*	S9
Anti-embolism socks	Heel	UOS*	S9

Specific recommendations	Study
NIV mask
- Apply silicone or hydrogel foam cover between the mask and the skin.	S1
- Protect the skin under the mask with padded bandage made with gauze, containing sodium chloride and hyaluronic acid. Associated with the use of this protection, it is essential to systematically control the contact points between the skin and the rigid parts of the mask, with rigorous follow-up (skin check every 3-4 hours), especially in premature and elderly, which represent Patients at higher risk of developing PI.	S3
- Remove or move the mask from NIV 4/4h and evaluate the skin under the device.	S5
Tracheostomy tube
- Use hydrocolloid plaque in the posterior cervical region for prevention and treatment of injuries caused by tracheostomy shoelace.	S7
- Replace shoelace with a smooth, wider plastic frame.	S7
- Assess the need to decrease the diameter of the cannula.	S7
Orotracheal tube
- Move the device every 2 hours to evaluate the skin and labial mucosa.	S5
Indwelling Catheter
- Fix the probe to the side of the thigh, reducing the traction force of it.	S7
- Replace the urethral catheter with a suprapubbic.	S8
General recommendations	Study
- Choose the size of the device according to the characteristics of the patient.	S2
- Question the need to maintain the use of the device or if it does not need to be replaced.	S5
- Consider the application of protective dressing to reduce shear and friction (transparent films/hydrocolloid/silicone/foam), as well as the use of dermal gel pads to reduce pressure and methods that decrease moisture (textile product with silver to remove moisture in skin folds, especially in obese patients).	S2, S5, S6
- Remove or move the device daily to evaluate the skin, in addition to inspect it every 8 to 12h, and perform periodic repositioning of the device.	S2, S5, S6, S9
- Avoid placing device on pressure sites with pre-existing Injury.	S2
- Work in a multidisciplinary team and perform continuous education on the correct use of devices and measures to prevent skin rupture.	S2, S9
- Evaluate the fixation of the device and/or fixation method, as well as check the tension and adjust, if necessary, as in case of edema.	S2, S5, S9
- Ensure that the devices are not placed directly under the patient bedridden or motionless.	S2
- Perform the cleansing of the skin or wound with saline and chlorhexidine, in addition to moisturize the skin with moisturizing agents including paraffin, melolin and vaseline.	S6

[1] Corresponding Author: Sabrina Guterres da Silva Galetto E-mail: sabrinaguterres@gmail.com

Brasil

Brasil

Medical Device-Related Pressure Injuries: an integrative literature review

Lesiones por Presión Relacionadas a Dispositivos Médicos: revisión integrativa de la literatura

ABSTRACT

Objetives:

Method:

Results:

Conclusion: