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Surgical Treatment of Sacral Pressure Wounds in Patients with COVID-19: a Case Series

Published:December 01, 2022DOI:https://doi.org/10.1016/j.bjps.2022.11.060

      Abstract

      Introduction

      The COVID 19 pandemic has resulted in an increased number of patients requiring intubation and intensive care. This has led to an increased incidence of sacral pressure ulcers requiring surgical management. We report our experience of COVID 19 related sacral pressure ulcers requiring surgical reconstruction.

      Methods

      A case series study was performed with 12 patients who presented grade IV sacral pressure ulcers after hospitalization for COVID-19 in a single institution. The mean age was 49.8 years and the most frequent comorbidities were arterial hypertension, diabetes and obesity, each present in 6 patients. All of them were submitted to surgical reconstruction with fasciocutaneous flaps after improvement of their clinical status. Follow up time was of at least 30 days after reconstruction. Preoperative laboratory tests and surgical outcomes were compared to data available in the literature.

      Results

      No major dehiscence was observed and minor dehiscence happened in 2 cases (16.7%). Out of the 12 patients, 8 (66.7%) had hemoglobin levels less than 10.0 and 5 (41.7%) had albumin levels less than 3.0, though this did not lead to a higher rate of complications.

      Conclusion

      This study showed that ambulating patients with grade IV pressure ulcer after COVID- 19 infection may undergo debridement, negative-pressure wound therapy and closure with local flaps with adequate results and minimal complication rate.

      Keywords

      Introduction

      As of September 2020, Brazil had the third highest number of COVID-19 cases in the world, with more than 4 million confirmed cases.
      As a reference in the treatment of the disease in the city of São Paulo, and because it has about 7% of the total ICU beds in the municipality (

      Paulo. G, do E de S. Boletim SP Contra o Novo Coronavírus. Gov do Estado São Paulo [Internet]. 2020; Available from: https://www.seade.gov.br/coronavirus/

      ), the Hospital of Clinics, Faculty of Medicine, University of São Paulo (HC-FMUSP) complex concentrates the most severe cases and consequently has a higher proportion of intubated patients in their ICUs.
      A rapid increase of sedated and intubated patients happened during the COVID-19 pandemic. This led to a higher incidence of hospital acquired pressure sores in intensive care units. In the largest center of COVID-19 treatment in Brazil, an immediate response of the Plastic Surgery department was necessary for the surgical treatment of grade IV sacral pressure lesions.

      Methods

      A case series study was performed with patients who presented grade IV sacral pressure lesions after hospitalization for COVID-19 in a single institution. Patients treated between March and June were recruited, and cases with grade IV sacral pressure ulcers (
      • Edsberg L.E.
      • Black J.M.
      • Goldberg M.
      • McNichol L.
      • Moore L.
      • Sieggreen M.
      Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System.
      ) that developed during hospitalization for COVID-19 in our institution and that were treated surgically were included. Patients with positive rt-PCR for COVID-19 at the time of reconstruction, sacral ulcers unrelated to COVID-19 and those who lost follow-up (minimum of 30 days after the operation) were excluded. All of them were submitted to surgical reconstruction with fasciocutaneous flaps after improvement of their clinical status, 18 to 45 days (average of 31,1 days) after they were extubated Preoperative laboratory tests and surgical outcomes were compared to data available in the literature. Surgeries performed consisted of debridement associated with negative-pressure wound therapy followed by wound closure through fasciocutaneous flaps performed from the unilateral or bilateral gluteal region.

      Results

      No major dehiscence was observed and minor dehiscence happened in 2 cases (16.7%). Out of the 12 patients, 8 (66.7%) had hemoglobin levels less than 10.0 and 5 (41.7%) had albumin levels less than 3.0. Even so, this did not lead to a higher rate of complications.

      Discussion

      Certain populations are at an increased risk of developing pressure injuries such as patients with hip fractures (range 8.8 to 55%), spinal cord injuries (range 33 to 60%) (

      Lindholm C, Sterner E, Romanelli M, Pina E, Torra Y Bou J, Hietanen H, et al. Hip fracture and pressure ulcers - The Pan-European Pressure Ulcer Study - Intrinsic and extrinsic risk factors. In: International Wound Journal [Internet]. Blackwell Publishing Ltd; 2008 [cited 2020 Jun 23]. p. 315 –28. Available from: https://scinapse.io/papers/2131934040

      ) elderly patients with immobility and cachexia, as well as trauma patients in the lower limbs. Although previous studies have shown that the development of pressure injuries in the hospital environment does not result in higher mortality in ICU patients, they can indirectly contribute to mortality in certain patients (
      • Moore Z.
      US Medicare data show incidence of hospital-acquired pressure ulcers is 4.5%, and they are associated with longer hospital stay and higher risk of death.
      ).
      In a cohort of 99 patients admitted due to COVID-19, the length of hospital stay averaged 22 days in patients with moderate pulmonary conditions and 25 days in patients with severe conditions (

      Liu X, Zhou H, Zhou Y, Wu X, Zhao Y, Lu Y, et al. Risk factors associated with disease severity and length of hospital stay in COVID-19 patients [Internet]. Vol. 81, Journal of Infection. W.B. Saunders Ltd; 2020 [cited 2020 Jul 1]. p. e95 –7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0163445320302164

      ). The average length of stay presented in our paper was 59 days. This may imply that these were more severe cases, since the meantime of intubation was 14 days and the meantime in the ICU was 21 days.
      As for the best time to reconstruct sacral lesions, in this study, of the 12 patients, 8 (66.7%) had hemoglobin levels less than 10.0 and 5 (41.7%) had albumin levels less than 3.0. This did not lead to a higher rate of complications.
      Chronic pressure injuries can have a relatively well-defined bursa in continuity with the base of the injury and methylene blue can be used to demarcate its margins. The approach commonly performed by plastic surgeons in the surgical treatment consists of complete excision of the injury, including devitalized tissue, scar and bursa; removal of possibly exposed bone and padding of any bony prominences; filling dead space; and covering the lesion with large pedicled regional flaps. The flap design should be as large as possible, placing the suture line as far away from the direct pressure zone as possible. The design must also preserve territories of adjacent flaps and allow for new advancement or rotation in cases of complications or recurrence.
      Recent innovations that include NPWT combined with instillation have further increased the arsenal against difficult-to-treat wounds or high-risk complications cases. In this series of cases, it was used just the conventional NPWT.
      The patients in this study, who had hospitalization and prolonged immobilization due to COVID-19, did not have paraplegia. They were ambulating, with preserved sensitivity and had the possibility of frequent decubitus changes, allowing for an easier postoperative period with fewer complications.

      Conclusion

      This study showed that ambulating patients with grade IV pressure injury after COVID- 19 infection may undergo debridement, negative-pressure wound therapy and closure with local flaps with adequate results and minimal complication rate. These findings led us to conduct a prospective cohort to investigate rates of surgical complication and preoperative optimization in ambulating patients with grade IV sacral pressure injury after COVID-19 infection.

      Consent

      Written consent of the patient taken for the publication of this case report and images.

      Ethical approval

      Not required

      Uncited Link

      Figure 1, table 1
      Figure 1:
      Figure 1Intraoperative flap dissection and Immediate post-op.
      Table 1
      PATIENTGENDERAGECOMORBIDITIESCT SCAN SUGESTIVE OF COVID-19POSITIVE PCR-SARS-COV 2OROTRACHEAL INTUBATIONDAYS OF INTUBATIONDAYS OF ICU STAY BEFORE RECONSTRUCTIONDAYS OF HOSPITALIZATION
      1M69HYPERTENSION, SMOKINGYESNOYES202357
      2M41HIPERTENSION, DIABETES, OBESITY, SMOKINGYESYESYES141457
      3M56HYPERTENSION, SMOKINGYESNOYES113464
      4M50NONEYESYESYES162163
      5M43NONEYESNOYES242873
      6M82HYPERTENSION, DIABETESYESYESNO01054
      7M29NONEYESNOYES192955
      8M28NONEYESYESYES172045
      9M47HYPERTENSION, DIABETES, OBESITYYESYESYES203484
      10M50DIABETES, OBESITYYESYESYES7946
      11M48HYPERTENSION, DIABETES, OBESITYYESYESYES193252
      12F54OBESITY, SMOKINGYESYESYES91147
      PATIENTDEBRIDEMENTS BEFORE RECONSTRUCTIONDAYS OF NEGATIVE PRESSURE THERAPYTYPE OF FASCIOCUTANEOUS FLAP RECONSTRUCTIONCOMPLICATIONCOMPLICATION: DAYS AFTER SURGERYNEED FOR REOPERATIONDAYS OF PLASTIC SURGERY FOLLOW UP
      127UNILATERALNONENO27
      228ROTATION + CONTRALATERAL ADVANCEMENTNONENO23
      317BILATERALMINOR DEHISCENCE7NO21
      415ROTATION + CONTRALATERAL ADVANCEMENTNONENO18
      5415UNILATERALNONENO25
      617UNILATERALNONENO19
      700UNILATERALNONENO22
      814UNILATERALNONENO23
      9310UNILATERALNONENO53
      1000UNILATERALNONENO21
      11111BILATERALMINOR DEHISCENCE6NO41
      1218BILATERALNONENO41

      Declaration of Competing Interest

      None declared

      Funding

      None

      References

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        • Edsberg L.E.
        • Black J.M.
        • Goldberg M.
        • McNichol L.
        • Moore L.
        • Sieggreen M.
        Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System.
        J Wound Ostomy Continence Nurs. 2016; 43: 585-597https://doi.org/10.1097/won.0000000000000281
      2. Lindholm C, Sterner E, Romanelli M, Pina E, Torra Y Bou J, Hietanen H, et al. Hip fracture and pressure ulcers - The Pan-European Pressure Ulcer Study - Intrinsic and extrinsic risk factors. In: International Wound Journal [Internet]. Blackwell Publishing Ltd; 2008 [cited 2020 Jun 23]. p. 315 –28. Available from: https://scinapse.io/papers/2131934040

        • Moore Z.
        US Medicare data show incidence of hospital-acquired pressure ulcers is 4.5%, and they are associated with longer hospital stay and higher risk of death.
        Evid Based Nurs. 2013; 16 (–9): 118
      3. Liu X, Zhou H, Zhou Y, Wu X, Zhao Y, Lu Y, et al. Risk factors associated with disease severity and length of hospital stay in COVID-19 patients [Internet]. Vol. 81, Journal of Infection. W.B. Saunders Ltd; 2020 [cited 2020 Jul 1]. p. e95 –7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0163445320302164