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

  • Author Footnotes
    1 Nanze Yu and Zhijin Li contributed equally to this manuscript.
    Nanze Yu
    Footnotes
    1 Nanze Yu and Zhijin Li contributed equally to this manuscript.
    Affiliations
    Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
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  • Zhijin Li
    Affiliations
    Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
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  • Xiao Long
    Affiliations
    Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
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  • Jiuzuo Huang
    Affiliations
    Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
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  • Wei Cao
    Affiliations
    Department of Infections Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Yan Zhang
    Affiliations
    Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Yang Yang
    Affiliations
    Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Zhengyin Liu
    Affiliations
    Department of Infections Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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  • Zhifei Liu
    Affiliations
    Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
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  • Shuyang Zhang
    Affiliations
    Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
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  • Xiaojun Wang
    Correspondence
    Corresponding author.
    Affiliations
    Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
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  • Author Footnotes
    1 Nanze Yu and Zhijin Li contributed equally to this manuscript.
Published:August 12, 2020DOI:https://doi.org/10.1016/j.bjps.2020.08.006
      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.
      • Zhang Y.
      • Xiao M.
      • Zhang S.
      • et al.
      Coagulopathy and antiphospholipid antibodies in patients with Covid-19.
      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.
      Characteristic Total (N = 46) Stage I (N = 7) Stage II (N = 33) Stage III–IV /Unstageable (N = 6)
      General characteristics
      Median age (IQR) — yr 66(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) — days 18(12–24) 17(13–24) 18(13–21) 20(14–23)
      Symptoms — no. (%)
      Fever 40(87.0) 5(71.4) 29(87.9) 6(100.0)
      Shortness of breath 38(82.6) 4(57.1) 29(87.9) 5(83.3)
      Cough 36(78.3) 5(71.4) 26(78.8) 5(83.3)
      Fatigue 20(43.5) 5(71.4) 12(36.4) 3(50.0)
      Diarrhea 10(21.7) 1(14.3) 8(24.2) 1(16.7)
      Sputum production 10(21.7) 1(14.3) 8(24.2) 1(16.7)
      Headache 8(17.4) 2(28.6) 5(15.2) 1(16.7)
      Nausea or vomiting 7(15.2) 2(28.6) 4(12.1) 1(16.7)
      Myalgia 6(13.0) 1(14.3) 4(12.1) 1(16.7)
      Palpitation 4(8.7) 0 4(12.1) 0
      Pressure injury-related characteristics
      Median interval from intubation to pressure injury event (IQR) — days 9(6–12) 9(7–12) 9(6–12) 7(6–10)
      Location — no. (%)
       Sacrum 41(89.1) 6(85.7) 29(87.9) 6(100.0)
       Face 11(23.9) 1(14.3) 8(24.2) 2(33.3)
       Heel 10(21.7) 0 6(18.2) 4(66.7)
       Hip 4(8.7) 0 3(9.1) 1(16.7)
       Elbow 3(6.5) 1(14.3) 2(6.1) 0
       Scapula 2(4.3) 0 1(3.0) 1(16.7)
      Median size (IQR) — cm2 47(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) 0 9(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) NA 17(51.5) 5(83.3)
      Coexisting disorder — no. (%)
      Hypertension 26(56.5) 6(85.7) 15(45.5) 5(83.3)
      Diabetes 8(17.4) 2(28.6) 4(12.1) 2(33.3)
      Cerebrovascular disease 7(15.2) 1(14.3) 4(12.1) 2(33.3)
      Coronary heart disease 7(15.2) 0 6(18.2) 1(16.7)
      Cancer
      Any type of cancer was included in this category.
      5(10.9) 0 5(15.2) 0
      Chronic obstructive pulmonary disease 4(8.7) 1(14.3) 2(6.1) 1(16.7)
      Chronic renal disease 2(4.3) 1(14.3) 0 1(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 neutrophils 9820(6270–13,660) 12,490(5540–15,650) 9690(7750–12,550) 9930(5600–19,920)
      Total lymphocytes 550(410–780) 660(470–820) 560(440–750) 370(180–630)
      Total monocytes 420(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)
      Prognosis
      Discharged 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)
      low asterisk 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.
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