STRATEGIES FOR THE PREVENTION OF FACIAL PRESSURE INJURIES CAUSED BY THE USE OF THE PRONE POSITION

Objective: Identify the main strategies for preventing facial pressure injuries caused by the use of the prone position. Methods: Integrative literature review, carried out during the month of March 2021. Articles were searched in the MEDLINE, LILACS, BDENF and IBECS databases. The selected articles were written in English, Portuguese and Spanish, between 2016 and 2021. Duplicates and those that did not include the topic addressed were excluded. Initially, 29 articles were identified. After applying the inclusion and exclusion criteria, 10 articles resulted for analysis. Results: Of the complications related to the use of the prone position, 10 (100%) of the studies address the pressure injury as the main complication of this therapeutic maneuver. As for prevention strategies, the studies analyzed cite the change in position associated with the use of pads and hydrocolloids as the main preventive methods. Conclusion: The following strategies to prevent facial pressure injury by using the prone position were identified: change of decubitus at pre-established times; use of devices that provide relief from pressure points, such as pads and hydrocolloids; and the use of low-cost and easily accessible materials, such as adapted surgical sponges, respecting the anatomical structures of each patient.


INTRODUCTION
The prone position (PP) is a promising strategy to improve hypoxemia in patients with acute lung injury and acute respiratory distress syndrome (ARDS). During its application, there is ventilation of areas of the lung that are in collapse, accompanied by redistribution of blood flow and consequent improvement in the ventilation/ perfusion ratio 1 .
In view of the COVID-19 pandemic, and as a consequence of the hemodynamic instability of the patients, there was a need to opt for therapeutic methods that would improve the respiratory failure caused by the disease. One of these methods was the adoption of PP 2 .
However, the use of this position brought with it some complications, such as the high incidence of pressure injury (PI), which occurred in up to 80% of patients placed in a prone position for more than 16 hours a day 2 . A study conducted at MedStar Georgetown University Hospital and MedStar Washington Hospital Center, in the city of Washington, United States, between March 1 and July 26, 2020, found that 47.6% of patients in PP developed facial PI. The most commonly affected site was the masseter, with a total of 84%, followed by the ears, with 50%. The mean duration of PP for patients who developed PI was 6.79 days 3 .
Strategies for the prevention of facial pressure injuries caused by the use of the prone position resulting from friction 4 . In the Intensive Care Units (ICU) of Brazil, the prevalence of PI varies between 35.2% and 63.6% and the incidence between 11.1% and 64.3% 5 .
The nursing team plays an important role in the prevention of PI in the hospital, using preventive measures.
For this, the health education of these professionals must be constant, as it is an essential tool to develop quality nursing care 6 .
Assessing the risk of developing PI is essential for planning and implementing prevention and treatment strategies for these injuries. Adequate monitoring must be carried out in order to correctly establish treatment measures and improvement in care 7 .
Given the context of high incidence of PI cases caused by the use of PP, the following guiding question emerged: what are the facial PI prevention strategies used in patients under PP? Thus, this study aims to identify in the literature the main strategies used by the nursing staff to prevent facial PI caused by the use of PP. The search strategy used was composed of descriptors belonging to the Medical Subject Headings (MeSH) or its analogues, available in the Descritores em Ciências da Saúde (DeCS), namely: "prone position", "pressure injury"

METHODS
and "disease prevention", used in Portuguese and English, according to the database, with the terms combined by means of the Boolean operator AND.
The search was carried out by three independent researchers, simultaneously. The sequence of use of descriptors and crossings in each database was standardized, and then the results obtained were compared. The articles in the sample were selected according to the sequence: a) title reading; b) summary reading; and c) reading the full text. In cases where there were disagreements, there was discussion between the three evaluators, and subsequent analysis by a fourth evaluator to reach a consensus.
The level of evidence was determined according to the following classification: level I -meta-analysis of controlled and randomized studies; level II -experimental study; level III -quasi-experimental study; level IVdescriptive/non-experimental study or with a qualitative approach; level V -case report or experience; level VIconsensus and expert opinion 9 .
Thus, 29 publications were detected, of which, after applying the inclusion and exclusion criteria, 10 were selected for the sample of this review. No other studies were included after the manual search process. For selection of publications, the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 10 were followed, according to Fig. 1.

RESULTS
Ten studies were selected to elaborate the results, 2 (20%) of the articles were in LILACS; 1 (10%) in IBECS; and 7 (70%) on MEDLINE. Among those chosen, 1 (10%) was published in magazines that address different themes; 8 (80%) published in nursing journals that focus mainly on publications aimed at stomatherapy; and 1 (10%) in a specific journal that had dermatological issues as its main theme.
Based on the general analysis carried out in the selected studies, it was concluded that 7 (70%) of the studies were published in 2020; 1 (10%) in the year 2019; 1 (10%) in the year 2017; and 1 (10%) in 2016. Among these works, the international ones stand out, with the highest rate of publications, which totaled 8 (80%) of the selected articles. In the case of nationals, 2 (20%). As for the countries of origin of international articles, 5 (50%) were carried out in the United States; 1 (10%) in France; 1 (10%) in Italy; and 1 (10%) in Spain. Of the national articles, 1 (10%) was carried out in Porto Alegre; and 1 (10%) in São Paulo.
Regarding methodology, 8 (80%) of the studies used the qualitative approach, and only 2 (20%) used the mixed approach. As for the level of evidence, 9 (90%) of them used level IV, which deals with the descriptive/non-experimental study or qualitative approach, and 1 (10%) study used the level of evidence V, which deals with the case report or experience.
Regarding the profile of patients for the indication of the prone position as a therapeutic method, and, consequently, facial PI as a complication, 6 (60%) studies 2,11,12,19,20,22 describe patients with COVID-19, and 4 (40%) studies 17,18,21,23 report patients with respiratory distress syndrome using mechanical ventilation. Of the complications related to the use of PP, 10 (100%) studies address PI as the main complication of this therapeutic maneuver.
Strategies for the prevention of facial pressure injuries caused by the use of the prone position With regard to prevention strategies, 10 (100%) studies cite the change of position associated with the use of pads and hydrocolloids as the main preventive methods. However, other methods were mentioned that also had an effect on the prevention of facial PI, as shown in Table 1.  Martel 11 et al, 2020

Author / Year Prevention Strategies Outcome
Cushion use, daily skin hydration, keeping the skin away from moisture, changing position after using the prone position.
It was found that standard nursing care, which is already used in the intensive care environment, provides great results in the prevention of pressure injuries. In order to identify the incidence of serious complications recorded and possible factors related to treatment in the prone position, a study was carried out in the adult ICU of a hospital in Spain, with a diagnosis of ARDS treated with PP. The only serious complication recorded was PI, with an incidence of 25.7%. The possible factor related to PI was the greater number of hours of PP in patients who developed PI. It was also observed that when the nutritional contribution was adequate, there was a lower incidence of PI 17 .
In a second study, to identify the main risk factors for the development of PI, patients were divided into two groups: patients with lesions and patients without PI due to prone. When comparing the two groups, there was a statistically significant difference for the following risk factors: duration of the PP session, total number of PP sessions, and, consequently, the total time spent in PP 18 .
According to the articles above, the biggest complication of PP is PI caused by medical devices. Thus, there is a need for greater attention to these patients, as well as preventive strategies designed by the nursing staff to avoid this type of complication.

Pressure injury prevention strategies in patients with COVID-19
The prevention of PI requires daily inspection of hygiene as well as the state of hydration, control of moisture and skin temperature, in addition to reducing pressure on bony prominences. For this, it is necessary to change the position every 2 hours. However, the serious condition in which patients find themselves makes difficult this type of action 2 .
Individuals placed on PP are at increased risk of developing facial PI. Current evidence suggests that positioning devices to discharge the load from pressure points on the face and body are a useful addition within the overall PI prevention strategy 19 .
The use of surgical foams is a simple technique used to relieve pressure and prevent facial PI. It is low cost and easily accessible material. They can be cut and adjusted according to the needs of each patient, reducing the incidence of injuries induced by treatment in prone 20 .
A university hospital, with five years of experience in standardizing PP, aimed to identify the occurrence of PI in prone patients. As a result of the study, the low incidence of PI was obtained, concluding that this result was a consequence of the adoption of the following preventive strategies: daily skin hydration, use of an air mattress, use of hydrocolloid dressings at the highest risk points for PI, use of cushions for positioning, in addition to the standardization of nursing care, the use of checklists and, finally, specific training for the team that attends to this type of patient 21 .
In a similar study, they analyzed two cases aiming to emphasize the risk of PI on the face in the prone position, in addition to highlighting the importance of adequate preventive actions. In case 1, the patient was male, 27 years old, morbidly obese. Case 2 was a 50-year-old patient with no comorbidity. Both patients were admitted to the ICU for treatment through mechanical ventilation due to COVID-19. The two patients followed the PP protocol lasting at least 12 hours each, but the first had 6 sessions, the second 9 sessions 22 .
In the first case studied, during the protocol, several facial PI (NPUAP stage 2 and 3) occurred on the right side of the face. The patient had keratitis and a corneal ulcer in the right eye. In addition, the use of an inappropriate cushion resulted in pressure on the patient's cheek next to the masseter. In the second case, the patient had PI (NPUAP stage 2) on the left cheek and on the left labial commissure, under the tape used to secure the breathing tube 22 .
To avoid these complications, there are some strategies: a) the intensive care team must be trained; b) the PP must be supervised; c) regular changes in head position are necessary during each PP session, and the breathing tube position must be changed between each PP session; d) the circumferential fixation must be protected with gauze or replaced by a specific endotracheal tube support, equipped with a silicone protection in contact with the cheek and labial commissure; and e) use of a softer and more specific head cushion, with space for the breathing tube, better distribution of pressure points across the face or silicone gels or silicone foam dressings 22 .
Patients infected with COVID-19 who did not receive PI preventive measures developed multiple necrotic facial lesions related to prone positioning during treatment. Those who were previously treated with a prophylactic dressing, cut pieces of silicone-based foam dressing applied to the forehead, cheeks, corner of lips, chin and under the nose did not develop PI during prone therapy 23 .
Nursing, in this context, must pay attention frequently and critically reflect on its action. It must be dynamic, creative and proactive, as it is observed in the aforementioned studies that when creativity was combined with specific preventive strategies and put into practice, the result was a low incidence of PI in patients.
One of the limitations of this study was the lack of research related to the prevention of facial PI in patients treated in PP, since, in most of the studies found, interventions were aimed at preventing PI in other settings. Thus, it is expected that this work can contribute to the reflection of academics and nursing professionals about this theme and it is recommended that further research be carried out.

CONCLUSION
Strategies for the prevention of facial PI in patients undergoing PP are a set of attitudes that must be taken in advance, so that they arise in order to prevent complications. The most common in the studies in question were the change of decubitus at pre-established times and the use of devices that provide relief from pressure points, such as pads and hydrocolloids.
Thus, it is important that these preventive strategies are carried out more constantly, and that they are adopted as a routine in health services, especially in ICUs. Visibility should also be given to strategies that are little seen, such as the use of low-cost and easily accessible materials, such as adapted surgical sponges, respecting the anatomical structures of each patient. Therefore, it is suggested to carry out more training for professionals from the entire team, in which the focus should be on the introduction and practice of preventive and strategic actions in health services. Barbosa WCF e Machado BAS; Supervision: Silva JS.