All medical devices in contact with the skin can predispose to PIs.6 As I reviewed my hospital’s data for 2020, the following devices emerged as causing the highest number of PIs: noninvasive respiratory devices, intravenous catheters, electroencephalogram leads, and pulse oximeters. Based on conversations during monthly SPS Network virtual meetings (attended by doctors, nurses, physical therapists, wound specialists, quality representatives, and any other provider related to hospitals’ PI prevention team), respiratory devices and electroencephalogram leads also seemed to dominate the larger pediatric PI arena; immobility leading to sacral injuries in older, critically children and extracorporeal membrane oxygenation-related PI were prevalent country-wide as well.
Although frequent skin assessment and body repositioning remain at the helm of PI prevention,5,6 these interventions are insufficient with device-related PIs. Barrier application has been shown to decrease pressure transmission and minimize prevalence and severity of PI across all ages.5-9 Many units have developed PI bundles. Elements of skin assessment, body and device repositioning, moisture control, support surfaces, and nutrition are commonly included. The author finds these elements to be important but not sufficient to prevent device-related PIs. A variety of foams, hydrocolloids, and contact layers can be incorporated into the bundle elements. Many contemporary studies have demonstrated success with barrier application.4-11 As COVID-19 numbers continue to increase, some units have implemented strategies of having a minimal number of providers care for patients who are infected. Adding barrier application and pressure offloading to such a policy is often employed in COVID-19 units.
Respiratory devices represent a special challenge because many noninvasive devices are produced based on adult shape and dimensions, not accounting for skin uniqueness and microclimate-induced changes in neonatal skin. Many manufacturers recommend the use of such devices without barriers, failing to recognize the effect they have on fragile pediatric skin. The author recommends barrier placement under most devices, as long as efficacy is not compromised. There is abundant literature supporting barrier placement as being beneficial in PI prevention.6-10
PI is and will continue to be one of the most challenging hospital-acquired conditions. The focus of caregivers needs to change from simply performing assessment scales (which do not decrease the prevalence of PI12) to understanding the physiology of PI development. If it is understood that deformation leads to cell injury, along with oxidative stress due to ischemia and compression of lymphatics, then practitioners will offload every device and tubing that may potentially deform underlying tissues and compress vessels. If the uniqueness of neonatal skin is understood, then adult recommendations will not be applied blindly, and practitioners will question the pitfalls that products have when used on neonatal skin. Manufacturers must recognize the effects of devices at the cellular level in neonatal and pediatric skin and the need to create and study devices based on neonatal and pediatric models. In addition, organizations must work on developing policies requiring increased attention to pediatric PIs.
The following examples show PIs that could have been prevented with appropriate barrier interphase.
Case 1. A stage 2 PI occurred from a noninvasive ventilation nasal mask in a 6-year-old patient admitted with respiratory failure secondary to pneumonia. Three (3) hours before the PI was discovered, the skin was assessed and the mask was repositioned. Mild redness was noted, yet foam was not placed. After the PI was discovered, nasal pressure interphase was changed, allowing the skin to heal (Fig. 1).
Case 2. A columellar injury was discovered in a preterm neonate after they were positioned prone and no barrier placed on the columellar, as per the cannula manufacturer’s suggestion (Fig. 2).
Case 3. A PI from an unprotected peripheral intravenous line catheter hub occurred in an agitated 1-month-old recovering from cardiac surgery (Fig. 3).
Case 4. A 2-week-old neonate had multiple comorbidities, including cleft lip and feeding insufficiency. Mucosal PI developed after friction between the alveolar ridge mucosa and orogastric tube while the child was prone (Fig. 4).
Case 5. A 16-month-old child was admitted with new-onset seizures. A stage 2 PI occurred in the form of an intact blister that was due to the pressure from an ill-fitting peripheral intravenous lines board (Fig. 5).
These examples represent the use of common daily medical devices. Understanding the pathophysiology may help clinicians to employ preventive measures, including various thin, offloading, and friction-minimizing barriers.
Dr. Boyar is director of Neonatal Wound Services, Cohen Children’s Medical Center of New York, New Hyde Park, and assistant professor of Pediatrics, Zucker School of Medicine, Hofstra/Northwell, Hempstead, NY. All photos provided are with the consent of the patients’ parents. This article was not subject to the Wound Management & Prevention peer-review process.