Introduction

Mucosal membrane pressure injuries are device-related pressure injuries (DRPI) of the mucous membrane.¹ These hospital-acquired injuries are generally considered preventable.²

Incidence and Prevalence

The incidence and prevalence of mucosal membrane PIs are reported as relatively low, but these injuries are more common in the intensive care unit (ICU) than in acute hospital care. One study reported an incidence of hospital-acquired mucosal membrane PIs of 0.1% in a non-ICU setting and an incidence of 2.4% in the ICU.³ Tube-based life support devices used in the ICU may cause oral and nasal mucosal membrane PIs.⁴ In the acute hospital setting, indwelling urinary catheters raise the risk of urethral erosion and infection.⁵

Etiology

Mucosal membrane pressure injuries are caused by local ischemia secondary to the use of medical devices such as^2,3:

• Endotracheal or nasogastric tubes
• Oxygen cannulas or masks
• Urinary or fecal containment devices

Presentation

Mucosal membrane PIs manifest differently from PIs of the skin.² The erythema present in stage 1 pressure injuries is not visible in a mucosal membrane PI, nor is wound depth, because of the anatomy of the tissue, but pain and swelling are present.⁶ To complicate assessment further, mucosal membrane PIs often bleed, leading to blood clots, or coagulum, which resemble the yellow, loosely adherent look of slough in the wound bed.^2,6,7 Because of the anatomic properties of mucosal tissue, the National Pressure Injury Advisory Panel classifies these injuries as unable to be assigned a stage.^1,6

Risk Factors

Risk factors for mucosal membrane PIs can include a combination of medical devices, the care setting, medications, and/or a patient’s individual characteristics. Specific to oral mucosal membrane PIs, risk factors include the ICU setting, endotracheal tube holder use, patient immobility, undernutrition, and corticosteroid use.⁸

Because of the higher incidence of these injuries in the ICU, this setting is considered a separate risk factor.³ In both ICU and acute hospital care, medical devices such as endotracheal and gastric tubes increase the risk of nasal or oral mucosal membrane PIs,⁴ and indwelling urinary catheters raise the risk of urethral erosion and infection.⁵

Patient-related risk factors for nasal mucosal membrane PIs include a high Acute Physiology and Chronic Health Evaluation II score, cognitive disorders, diabetes, hypoproteinemia, fever, and vasoconstrictor use.⁴

An additional risk factor for mucosal membrane PIs in ICU patients is COVID-19, as a result of patient immobility, sedation, vasopressor use, and hypoxia.⁹

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Clinical Implications

The adverse effects of a mucosal membrane PI extend far beyond the wound itself. For example, the pain of oral PIs can interfere with a patient’s ability to eat adequately, and urinary devices can lead to urinary tract infections² or urethral injury^.5 Patients who acquire mucosal membrane PIs are usually very ill, and the addition of a mucosal injury increases their already heavy burden of illness.²

Management

The British Columbia Provincial Nursing Skin & Wound Committee recommended using the following protocol, when possible, to manage mucosal membrane PIs¹⁰:

• Examine the mucosa under and adjacent to medical devices twice per shift or more often.
• Ensure that medical-related devices are the correct size.
• Reposition medical devices as needed.
• Refer the patient to the appropriate health care professional to help with medical device fitting, if needed.

Prevention

Prevention includes meticulous assessment and ongoing monitoring of at risk tissue adjacent to or under devices, checking for issues with device placement and securement, and the use of stabilizing devices to reduce pressure.^2,11

Staff education is also a vital component of mucosal membrane PI prevention. In patients at risk, nursing staff must know what to look for, such as poorly secured endotracheal tubes, urinary catheters that are pulling, or food avoidance related to oral pain.² In long-term care settings, an effective tool for staff education is the use of regular device-related rounds, to ensure appropriate device placement and assess the integrity of patients’ vulnerable tissues.¹¹

Conclusion

Mucosal membrane PIs can cause morbidity in patients who are already seriously ill. As with all PIs, prevention of mucosal membrane PIs is the goal.

References

1. Hess CT. Classification of pressure injuries. Adv Skin Wound Care. 2020;33(10):558-559. doi:10.1097/01.ASW.0000697324.90597.6d
2. Lazarevski L. Putting money where your mouth is: a refresher on mucosal medical device–related pressure injuries. WoundSource. 2020. Accessed September 28, 2023. https://www.woundsource.com/blog/putting-money-where-your-mouth-refresh…
3. Fulbrook P, Lovegrove J, Butterworth J. Incidence and characteristics of hospital-acquired mucous membrane pressure injury: a five-year analysis. J Clin Nurs. 2023;32 (13-14):3810-3819. Accessed September 28, 2023. https://onlinelibrary.wiley.com/doi/10.1111/jocn.16473
4. Nan R, Su Y, Pei J, Chen H, He L, Dou X, Nan S. Characteristics and risk factors of nasal mucosal pressure injury in intensive care units. J Clin Nurs. 2023;32(1-2):346-356. Accessed September 28, 2023. https://onlinelibrary.wiley.com/doi/10.1111/jocn.16193
5. Woodmansee BK, Anderson JA. Medical device-related pressure injury due to urinary catheterization: a case report. Wound Manag Prev. 2022;68(12):5-9. Accessed September 28, 2023. https://www.hmpgloballearningnetwork.com/site/wmp/case-report/medical-d…
6. Edsberg LE, Black JM, 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(6):585-597. Accessed September 30, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098472/
7. Fulbrook P, Lovegrove J, Butterworth J. Incidence and characteristics of hospital-acquired mucous membrane pressure injury: A five-year analysis. J Clin Nurs. 2022; https://onlinelibrary.wiley.com/doi/full/10.1111/jocn.16473
8. Choi BK, Kim MS, Kim SH. Risk prediction models for the development of oral-mucosal pressure injuries in intubated patients in intensive care units: a prospective observational study. J Tissue Viability. 2020;29(4):252-257. Accessed September 28, 2023. https://www.sciencedirect.com/science/article/abs/pii/S0965206X20300802
9. Singh C, Tay J, Shoqirat N. Skin and mucosal damage in patients diagnosed with COVID-19: a case report. J Wound Ostomy Continence Nurs. 2020(5):435-438. Accessed September 28, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722287/
10. British Columbia Provincial Nursing Skin & Wound Committee guideline: assessment and treatment of pressure injuries in adults & children. Connecting Learners With Knowledge. 2018. Accessed September 30, 2023. www.clwk.ca/get-resource/pressure-injury-guideline
11. Hovan HM. Medical device–related pressure injury: creating a culture of prevention. WoundSource. 2019. Accessed September 28, 2023. https://www.woundsource.com/blog/medical-device-related-pressure-injury…