Introduction

Medical device-related pressure injuries (MDRPIs) are defined as injuries associated with using devices applied for diagnostic or therapeutic purposes, where the injury tends to have the same configuration as the device.¹ Individuals using medical devices are more than twice as likely to develop pressure injuries (PIs) than those who do not use medical devices.^2,3 In addition to prolonged exposure to mechanical loads of the device, many medical devices that attach to the skin are based on generic designs that use stiff polymer materials and are typically secured using tape or strapping. This mismatch in mechanical properties creates deformation and stress on the tissue in contact with the devices. Furthermore, a medical device can result in an altered microclimate at the skin-device interface.¹ Potential sources of MDRPI include:

• Respiratory devices
• Orthopedic devices
• Urinary/fecal collection devices
• Feeding tubes
• Surgical drains
• Arterial/venous catheters
• Blood pressure cuffs
• Compression stockings and devices
• Objects without a medical function left in the bed/chair

Studies have found the most frequent locations of MDRPIs to be the ears and nose,^4,5 with other common sites being the lower extremities, pelvic area, upper extremities, and back.⁵

How to Prevention Medical Device-Related Pressure Injuries

Assessment of Device Placement

Unfortunately, prevention of MDRPIs is difficult because the device cannot always be moved or removed, as medical devices are often integral to the individual’s care. Regular skin assessment is crucial and allows prompt detection of moisture, chafing, irritation, and/or MDRPIs. Ideally, this inspection should occur twice daily if not medically contraindicated.⁵ If a device cannot be removed, the skin at the device's borders should be examined, and the patient should be asked about any pain or altered sensation in the area beneath the device. During these skin assessments, the bed or chair should also be searched for any loose devices, such as television remotes and cell phones, that could cause undue pressure on the skin.

Dressings: Risks and Benefits

Prophylactic dressings may be used beneath a medical device to reduce the risk of MDRPIs. However, excessive layers of dressings should be avoided as this may increase the pressure between the device and the skin. The wound care professional should also ensure that the dressing does not compromise the medical device's functionality. When choosing a prophylactic dressing, clinicians should consider any friction at the skin-dressing interface as well as the ease of application and removal of the dressing.¹ Foam dressings can be useful in managing moisture and the skin’s microclimate, for example, in the case of a tracheostomy tube. However, applying an opaque dressing prevents direct visualization of the underlying skin, and frequent removal of an adhesive dressing causes epidermal stripping. Thus, the risks and benefits of dressings must be weighed in each case.

Repositioning and Offloading of Medical Devices

When possible, the medical device and patient should be regularly repositioned or rotated to avoid excess pressure between the device and the skin. For example, oximetry probes can be moved to different fingers or toes, earlobes, or the forehead. Furthermore, endotracheal tubes (ETTs) can be moved laterally to redistribute pressure over different parts of the mouth and lips.¹ Placement of devices directly under patients or over sites of prior or existing PIs should be avoided. Tubes that need to be securely attached to the skin should have fixation methods that do not apply excess pressure to the skin. Daily fixation changes should be exercised in the case of nasogastric tubes (NGs). Urinary catheters should be secured in a way that allows repositioning of the tubing when the patient is moved, such as a strap that can be easily moved instead of an adhesive patch. Patients should be routinely assessed if there is a continuous need for the medical device. The device should be removed as soon as medically feasible to ultimately eliminate MDRPI risk.¹

In addition, ensuring a proper fit of medical devices is essential because poorly fitting devices have been shown to contribute to device malfunction and increase pressure between the device and skin.¹ Where appropriate, clinicians should modify the device by adjusting or removing non-essential components that create a poor fit where feasible. To avoid tightness of devices, if possible, a material that accommodates expansion and worsening edema should be applied to individuals at risk of tissue volume changes.¹ Respiratory devices are one of the most frequent devices to cause MDRPIs.^4,5 If safe and appropriate, the oxygen delivery device should be alternated between a correctly fitting mask and nasal prongs to reduce pressure in these sites. Health care centers should ensure access to a wide range of mask and nasal prongs sizes to allow an optimal fit. Frequent lateral repositioning of endotracheal tubes (ETTs) can prevent MDRPIs, as demonstrated by the reduction in ETT-related pressure injuries (PIs) from 16% to 10% by repositioning the device every 4 hours instead of every 12 hours.⁴ In addition, tapes and supports from tracheostomy tubes and ETTs may need to be dried or changed.

Conclusion

Medical devices are commonly used, yet the simple presence of these devices creates risk for the patient. Wound care professionals should ensure proper risk management and vigilance in preventing MDRPIs. MDRPI prevention requires coordination among multiple disciplines and medical teams, and, as a result, all health care personnel, patients, and families should be properly educated on medical devices and PIs.

References

1. Haesler E. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance; 2019.
2. Black JM, Kalowes P. Medical device-related pressure ulcers. Chronic Wound Care Management and Research. 2016;3:91-9. https://doi.org/10.2147/CWCMR.S82370.
3. Barakat-Johnson M, Lai M, Wand T, et al. The incidence and prevalence of medical device-related pressure ulcers in intensive care: a systematic review. J Wound Care. 2019;28(8):512-21. doi: 10.12968/jowc.2019.28.8.512.
4. Galetto SG, do Nascimento ER, Hermida PM, et al. Medical device-related pressure injuries in critical patients: prevalence and associated factors. Revista da Escola de Enfermagem da USP. 2021;55: e20200397. doi: 10.1590/1980-220X-REEUSP-2020-0397.
5. Cavalcanti ED, Kamada I. Medical-device-related pressure injury on adults: an integrative review. Texto & Contexto-Enfermagem. 2020;29: e20180371. doi: https://doi.org/10.1590/1980-265X-TCE-2018-0371.