Reflections on recommendations for the prevention of pressure injuries during the COVID-19 pandemic

Objective: To reflect on specific recommendations for the prevention of pressure injuries in patients affected by the new coronavirus (COVID-19) in intensive care. Method: theoretical reflection study based on the concept of pressure injury defined by the National Pressure Injury Advisory Panel. Results: the contents were categorized into three thematic axes: specific risk factors for the development of pressure injuries for patients with COVID-19; international recommendations on pressure injuries in patients with COVID-19 and challenges for implementing recommendations for preventing pressure injuries in the face of the COVID-19 pandemic in the Brazilian scenario. Conclusion: to promote the prevention of pressure injuries in intensive care patients with COVID-19 it is essential that health professionals are able to implement advanced interventions, in order to mitigate the intrinsic and extrinsic risks specific to that patient. However, it is essential to recognize potentially preventable lesions, differentiating them from possible inevitable ones, as well as making a differential diagnosis of lesions resulting from the pathogenesis of the virus itself.


INTRODUCTION
The disease caused by the new coronavirus, also known as COVID-19, is a disease that affects the respiratory tract, in which the virus is extremely infectious and generates varied clinical conditions, as well as different symptoms in the affected individual. It is known that most infected people will have the mildest form of the disease. However, 14% of patients may develop their critical form, requiring oxygen therapy, and at least 5% will progress to more severe pneumonia. This group needs treatment in the intensive care unit (ICU), frequently using non-invasive ventilation (NIV) and intubation with consequent support in mechanical ventilation 1 .
Patients admitted to the ICU, intubated under mechanical ventilation, will frequently present skin lesions, especially pressure injuries (PI), due to their compromised clinical and hemodynamic conditions, immobility in the bed, decreased sensory perception, among other intrinsic and extrinsic factors that favor the development of these injuries 2 .
PI is considered to be a health-related adverse event, and in most cases it is preventable 3 . Data from a systematic review on the prevalence and incidence of PI in the ICU showed that the cumulative prevalence of PI around the world ranged from 16.9 to 23.8% 2 . In addition, there is an incidence of PI up to ten times higher in patients undergoing critical care, when compared to those hospitalized in other hospital units 4 . Thus, preventive interventions for PI need to be instituted since the patient's admission to the ICU, aiming to decrease incidence and prevalence rates, patient safety and quality of care.
However, the prevention of PI in the context of the coronavirus presents itself as an even more challenging situation, as the changes resulting from the infection expose the patient to greater instability, less tissue oxygenation, prolonged hospital stay in a critical unit and possible repositioning difficulty, factors that favor the development of PIs 5 . In addition, they are associated with aspects related to health services, such as scarcity of materials and technologies for prevention, limited human resources, among others 5 .

METHOD
This is a theoretical reflection study based on the PI concept defined by the NPIAP 5 .
Some conceptions marked out this study, forming the frame of reference for understanding the problem.
That is, these conceptions subsidized the assumptions and the delimitation for the approach of the object under study, functioning as support concepts and means for the construction of this reflection 6 .
Thus, the benchmark for this study was the

Risk factors for developing pressure injury specific to the patient with COVID-19
There are a number of factors that increase the risk of PI in critically ill patients 2 . However, the infection by COVID-19 is a new disease and its relationship with the development of PI still needs to be well defined. Thus, the NPIAP draws attention to the main intrinsic and extrinsic factors related to COVID-19 that can contribute to a higher risk of PI 7 .

International recommendations on pressure injuries in patients with COVID-19
Recommendations for preventing pressure injuries in patients submitted to prone position Thus, the NPIAP reinforces that the mere diagnosis of COVID-19 does not determine that PI is unavoidable, for that it is recommended to observe the following aspects 7 : -Conduct root cause analysis of PI, considering extrinsic and intrinsic factors to the patient and the health service; In addition, in Brazil, difficulties are faced related to the availability of adequate material resources to prevent adverse events 1 . It is known that many institutions in the country lack basic materials to maintain the integrity of the skin even before the pandemic, however in this pandemic period this problem can be even more complex, since the expansion of the number of ICU beds, as well as the creation of field hospitals may not have been provided with adequate materials, in accordance with national and international recommendations.

FINAL CONSIDERATIONS
The COVID-19 pandemic has instituted a "new normal" in Brazil and in the world, in which everyone will have to adapt and create coping strategies. Regarding PI prevention, it is essential that health professionals, especially the nursing team, are able to implement advanced interventions, in order to mitigate the intrinsic and extrinsic risks in this patient. However, it is essential that they are able to recognize potentially preventable injuries, as well as perform a differential diagnosis of injuries resulting from the pathogenesis of the virus itself.