Abstract
Prone ventilation is an effective and increasingly utilised tool in the management of Acute Respiratory Distress Syndrome (ARDS), a common sequela of COVID-19 infection. However, its use is associated with a significant risk of pressure ulcers.
We report a unique case of prone positioning, catheter-related penile pressure ulcer. Clinical awareness, early recognition and regular repositioning is crucial in the prevention of this complication.
Keywords: Pressure ulcer, Prone positioning, Catheter, COVID-19
Abbreviations
- ARDS
Acute Respiratory Distress Syndrome
- COVID-19
Coronavirus
- PCR
Polymerase chain reaction
- FiO2
Fraction of Insired Oxygen
Section headings
Trauma and Reconstruction.
Consent
Consent was obtained for the publication of this case report.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
1. Introduction
Prone ventilation is an effective and increasingly utilised tool in the management of Acute Respiratory Distress Syndrome (ARDS), a common sequela of COVID-19 infection. In the setting of ARDS, prone ventilation using 16-h prone, 8-h supine rotations, has been associated with significant improvements in 90-day mortality.1 Significant logistical challenges and complications are associated with prone ventilation. High rates of pressure ulcers are observed with prone positioning. Development of pressure ulcers is multi-factorial, relating to physiological and external conditions.
Penile pressure injuries related to prone positioning are a rare complication within the literature. Our literature review revealed two previous cases.2,3 Significant increases in utilisation of prone ventilation for COVID-19 ARDS has been observed, compared to management of historic ARDS. Additionally, current practices reflect the use of longer prone durations, as well as lower thresholds and shorter time to initiation of prone ventilation. In this context, penile pressure ulcers may represent an underdiagnosed and emerging complication. We report a case of penile pressure injury related to an indwelling catheter, and use of prone ventilation in the management of COVID-19.
2. Case presentation
A man in his 50's was referred to the Emergency Department following onset of dyspnoea. He was healthy for his age, with no known co-morbidities, though was an ex-smoker.
Initial observations revealed an oxygen saturation of 43% on room air, and a temperature of T38.8 °C. Blood gas analysis was consistent with severe type 1 respiratory failure, chest X-ray demonstrated bilateral diffuse infiltrates, and PCR testing confirmed COVID-19 infection. He was admitted to the Intensive Care Unit for ventilatory support, requiring Continuous Positive Airway Pressure therapy. Disease modifying therapies including Dexamethasone, Remdesivir and Sarilumab were administered. Additionally, antibiotic therapy (IV Ceftriaxone and Azithromycin) was empirically commenced for presumed superimposed bacterial pneumonia.
Increasing ventilatory and oxygen requirements necessitated intubation on the 5th day of ICU admission. Following intubation, an indwelling catheter was inserted for urinary drainage and urine output monitoring. Refractory hypoxia persisted despite a FiO2 100%. A CT-Pulmonary Angiogram was performed, demonstrating bilateral occlusive segmental and sub-segmental pulmonary emboli, for which therapeutic Clexane low-molecular weight heparin was commenced. Prone ventilation was commenced the following day, with a 16-h prone, 8-h supine regimen.
Following one week of prone ventilation, penile pressure ulcers were observed tracking ventrally (Fig. 1). The prepuce was mildly swollen consistent with dependent oedema. The glans demonstrated no signs of ischemia. Ulcer appearance was consistent with a stage II injury (National Pressure Ulcer Advisory Panel staging system). The identified etiology was consistent with a catheter related pressure injury while prone.
Fig. 1.
Cylindrical penile pressure ulcers tracking ventrally, consistent with indwelling catheter etiology.
Treatment consisted of local wound cares, pressure offloading, nutritional optimisation, and ongoing management of severe COVID-19 ARDS. The wound was managed with a paraffin-based dressing. The catheter direction was alternated throughout the day, and extra padding was utilised in between the bed, catheter, and penis. The size and severity of the wound did not necessitate the use of negative pressure wound therapy. Nutritional status was optimised through a tailored nasogastric feed regimen. No antibiotics were commenced due to the absence of signs for cellulitis. Supportive management of severe COVID-19 ARDS continued.
Fortunately, following identification of the penile ulcers, only two further days of prone ventilation were required, allowing for removal of the instigating mechanism. On serial review, five days following penile ulcer diagnosis, wound appearance had improved, with only mild slough and swelling noted. Complete resolution of the penile ulcers was observed at approximately 6 weeks following initial diagnosis.
3. Discussion
Pressure ulcers manifest from a combination of physiologic and external conditions. External pressure on soft tissues results in impaired blood supply, tissue ischemia and cell membrane rupture. Additionally, tissue distortion leads to impaired lymphatic drainage, increased interstitial fluid and waste build-up. Risk factors for pressure ulcers include diabetes, smoking, malnutrition, immunosuppression, vascular disease and prolonged immobility.4 Similar risk factors predispose patients to developing severe cases of COVID-19 infections.
While mechanical ventilation remains the foundation of management for severe respiratory failure, adjuncts including prone ventilation have been observed to improve oxygenation and mortality outcomes.1 The World Health Organisation recommends prone positioning from 12 to 16 hours per day for adults with severe COVID-19 ARDS.5
The use of prone ventilation however is associated with significant risks and challenges including labour-intensive positioning changes, and increased risks of pressure ulcers. Treatments for pressure ulcers centre around the management of reversible disease states, optimisation of nutrition and removal of instigating factors. Wounds should be cleaned, with debridement of surface contamination. Frequency of wound dressing changes are dictated by degree of wound contamination and exudate. Heavily contaminated ulcers may benefit from use of negative pressure wound therapy. However, in this case the wound remained clean and hence no debridement was required.
Penile pressure ulcers related to prone positioning are a rare complication within the literature. In the reported cases, an additional insult or risk factor for uneven pressure distribution, such as erections2 and penile prosthetics3 was present. Preventative measures should focus on clinical awareness of this potential complication, with regular monitoring and positioning changes. The use of a polyurethane ring cushion specifically for the penis and scrotum has been recommended.3
To our knowledge, this represents the first reported case of penile pressure injury relating to prone positioning and indwelling catheter use. However, in light of the continuing COVID-19 pandemic, and our increasing use of prone ventilation, this may be an underdiagnosed and emerging complication. Clinician awareness, regular monitoring and offloading will be key in the prevention of future episodes of this complication.
4. Conclusion
Prone positioning as a ventilatory adjunct is often used in the management of COVID-19 Pneumonitis. Its use is associated with a significant risk of pressure ulcers. We report a unique case of prone positioning, catheter-related penile pressure ulcer. Clinical awareness, early recognition and regular repositioning is crucial in the prevention of this complication.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
The authors thank the Westmead Intensive Care Unit.
Contributor Information
Henry Wang, Email: henry.wang@health.nsw.gov.au.
Ankur Dhar, Email: ankur.dhar@health.nsw.gov.au.
Manish Patel, Email: manish.patel1@health.nsw.gov.au.
Lawrence Kim, Email: hyunchul.kim@health.nsw.gov.au.
References
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