Extravasation Injuries, Pressure Ulcers and Ocular Surface Disorders in a Tertiary Paediatric Intensive Care Unit in South India

Introduction: Extravasation injuries, pressure ulcers (PU), and ocular surface disorders (OSD) like exposure keratitis are common problems that we encounter in critically ill children admitted in Paediatric Intensive Care unit (PICU). There is sparse data regarding these injuries due to under reporting by staffs in intensive care unit. The primary aim of this study was to know the prevalence of extravasation injuries, ocular surface disorders and pressure ulcers in tertiary intensive care unit of south India. The secondary objective of this study was to re-evaluate the prevalence of these injuries after interventions. Methods: During pre-intervention period, number of children with extravasation injuries, pressure ulcers and ocular surface disorders were identified. The qualitative improvement practices was implemented to decrease the prevalence of these injuries. This was followed by re-evaluation of these injuries during post-intervention period. Results: During pre-intervention period the overall prevalence of these injuries was 36/273 (13.2%). The prevalence of extravasation injuries, pressure ulcers and ocular surface disorders was 16/273 (5.9%), 12/273 (4.4%) and 8/273 (2.9%) respectively. The qualitative improvement practices were implemented in intensive care unit. During post-intervention period, the prevalence of these injuries was reduced to 10/157 (6.4%). The extravasation injuries reduced to 4/157 (2.5%), PUs to 4/157 (2.5%) and OSD to 2/157 (1.3%). Conclusions: The extravasation injuries, PUs and OSD are common problems in critically ill children. The qualitative improvement practices should be implemented and reinforced in intensive care units to prevent these injuries.


INTRODUCTION
Extravasation injuries, pressure ulcers (PU) and ocular surface disorders (OSD) are common problems that are seen in critically ill children of P a e d i a t r i c I n t e n s i v e C a r e U n i t ( P I C U ) . Extravasation is the inadvertent administration of intravenous medicines from the vein into surrounding tissue either by leakage or direct exposure caused by improper cannula placement and venepuncture techniques. 1 The incidence of extravasation injuries in admitted patients is reported as 0.1% to 6.5% but the true incidence may be higher because of poor documentation and reporting. [2][3][4] Extravasation injuries can cause pain, redness, and swelling, damage to vessels, nerves or tendon and can predispose to local and invasive infection.
Pressure ulcer is a localised injury to the skin and or underlying tissue as a result of pressure or pressure in combination with shear forces. 5 Critically ill children admitted in PICU are at risk for pressure ulcers due to immature skin, decreased perfusion, decreased mobility, altered neurologic responsiveness, volume overload, moisture, and medical devices. 6 The PU occurs usually at pressure dependent regions of bony prominence due to prolonged contact with a firm surface. Ocular surface disorders (OSD) have been reported to occur in up to 60% of critically ill patients. Critically ill patients in intensive care unit have impaired ocular defence mechanisms because of different associated conditions like multi-organ dysfunction syndrome, metabolic disturbances, mechanical ventilation and unconsciousness. 7,8 The use of sedation and muscle relaxants inhibit contraction of the orbicularis oculi muscle that results in incomplete eyelid closure. Lagopthalmos has been reported to occur in 20% to 75% of sedated patients in intensive care units. 7-11 There is drying of the eyes, desiccation of the cornea epithelial cells, corneal ulceration and increased risk of microbial keratitis due to incomplete closure of eye lids. This may lead to corneal thinning and perforation if untreated.
There is sparse data of extravasation, PU and OSD in critically ill children in our settings. This may be due to under reporting of these events in PICU. The primary aim of this study was to know the prevalence of extravasation injuries, PU and OSD in tertiary care PICU of South India. The secondary objective of this study was to re-evaluate the prevalence of these injuries after implementation of qualitative improvement interventions.

METHODS
This was a cross-sectional quality improvement study. This study was done in tertiary care paediatric critical care unit of South India. The preintervention period was from 1st of October 2018 to 31st December 2018. The post-intervention period was from 1st January 2019 to 30th March 2019. The prevalence of extravasation injuries, ocular surface disorders and pressure ulcers was seen during first three months. The guidelines and practices which were followed in PICU were implemented and reinforced to reduce the prevalence of these injuries. After intervention of these guidelines, again the prevalence of these injuries were seen to see whether these injuries are decreasing after intervention.
Extravasation injuries have been classified into four stages of increasing severity, which are thought to be useful in predicting injury prognosis and in determining the best treatment results. 12 The four stages are: Stage 1: a painful intravenous site, no erythema and swelling, flushes with difficulty. Stage 2: a painful intravenous site, slight swelling, redness, no blanching, brisk capillary refill below infiltration site, good pulse volume below infiltration site. Stage 3: a painful intravenous site, marked swelling, blanching, cool to touch, brisk capillary refill below infiltration site, good pulse volume below infiltration site. Stage 4: a painful intravenous site, very marked swelling, blanching, cool to touch, capillary refill of > 4 seconds, decreased or absent pulse, skin breakdown or necrosis.
Ocular surface disorders (OSD) 13 1. Exposure keratopathy represents a dryness of the cornea due to incomplete lid closure. 2. Chemosis is conjuctival edema. Pressure Ulcers (PU): PUs are classified by the depth and severity. 5 Stage I is non-blanchable erythematous skin that may be painful, soft, and warmer or cooler than adjacent tissue. Stage II involves partial dermal loss (e.g. shallow open ulcer or intact blister). Stage III has dermal loss wherein subdermal elements (e.g. subcutaneous fat) are visualised. Stage IV is full-thickness tissue loss with exposed bone, tendon, or muscle. Unstageable ulcers are full-thickness wounds covered by slough and/or eschar.
The pre-interventional and post-interventional data were analysed using Microsoft Excel 2010.

RESULTS
The overall prevalence of extravasation injuries, PU and OSD was 36/273 (13.2%) during preintervention period. Out of 36 children, 20/36 (55.5%) were males and 16/36 (44.4%) were females and ratio was 1.25:1. These injuries were most common in < one year of age (14/36-39%) followed by five to 10 years, one to five years and 10 to 15 years as shown in Figure 1.  6%). The device related PUs were related to Non-invasive ventilation like nasal CPAP, BiPAP, ECG leads and pulse oximeter probe. Out of eight OSD, 5/8 (62.5%) had exposure keratitis and 3/8 (37.5%) had conjunctival chemosis. Nobody had conjunctivitis or purulent keratitis. OSD was most common in 6/8 (75%) of children who who were mechanically ventilated, were on sedation and paralysis and stayed for more than one week in PICU.  For ocular surface disorders, eye examination was done as a part of checklist in each shift by nurse and doctor. In mechanically ventilated children, artificial tear eye drops was kept hourly and lacrigel ointment was kept every six hours. Eye taping was done routinely in all mechanically ventilated children and this practice was reinforced in unit. The ophthalmological evaluation was done if any signs of OSD was identified and managed according to the ophthalmologist plan.
For pressure ulcers, position was changed every two hours for mechanically ventilated children as well as for those who had muscle weakness or paralysis. Daily assessment of skin for pressure ulcers was done in each shift by nurse and doctor and it was mentioned in a checklist. To avoid PUs, NIMBUS bed was used in children who required mechanical ventilation for more than one week as well as on children with muscle weakness and paralysis. The routine use of coconut oil to prevent dryness in PICU was reinforced. For the pressure ulcers related to device, examination of skin around and beneath the device was done in every shift by nurse and doctor and was mentioned in checklist. The routine use of duoderm for application of mask in children requiring non-invasive ventilation and invasive ventilation was reinforced.
During post-intervention period, the overall prevalence of extravasation injuries, OSD and PUs was reduced to 10/157 (6.4%). The prevalence of extravasation injuries was reduced to 4/157 (2.5%). Out of four extravasation injuries three had stage 1 and one had stage 2 injuries. The prevalence of PUs was reduced to 4/157 (2.5%). Out of four PUs, three had stage I and one had stage II pressure ulcer. The device related pressure ulcer was reduced to one. The prevalence of OSD was reduced to 2/157 (1.3%). Out of two OSD, one had exposure keratitis and one had conjunctival chemosis. The prevalence of extravasation injuries, PUs and OSD during pre-intervention and postintervention is summarised in Figure 2.

DISCUSSION
Extravasation injuries are more common in paediatric population due to the fragility of vessels.
There is a lack of literature about extravasation injuries in the paediatric population. Extravasation injuries are caused by accidental leakages of medications that are given intravenously. They can cause complications in form of short-term pain and longer-term scarring. These injuries may be severe in small children due to their fragile veins and skin. Children in PICU are at increased risk of ocular surface disorders due to poor eyelid closure, decreased blink reflex, and increased exposure to pathogenic micro-organisms. PUs are also common in PICU especially in bedridden patients.
The overall prevalence of extravasation injuries, OSD and PUs was 13.2%. The prevalence of extravasation injuries was 5.9% which was higher compared to Ya-Min Yan et al. 14  Nobody had conjunctivitis or purulent keratitis. In our study OSD was found in eight patients who stayed in PICU for more than seven days and who was mechanically ventilated and was on sedation and paralysis which was similar to the findings by the study of Imanaka et al. 24 Out of eight patients who had sedatives or muscle relaxants administered continuously for more than 48 hours in the PICU, 5/8 (62.5%) developed keratitis which was comparable to the study by Imanaka et al. 22 where it was 60%. According to Marty et al. 26 a leadership team approach was assembled to reduce the PU rate by 50% in the PICU and NICU. QI intervention done were frequent, thorough skin assessments, preventative interventions comprehensive education, clinical staff empowerment (e.g. skin champions), and systems change (e.g., skin rounds). After this intervention they were able to achieve the aim to reduce PUs by less than 50%.
The limitation of this study was that prevalence of these injuries was seen only for three months after post-intervention. Hence, there is lacking evidence whether there was persistence decrease of these injuries after intervention.

CONCLUSIONS
Extravasation injuries, OSD and PUs are one of the serious issues in paediatric critical care unit if not treated timely. The implementation and continuous reinforcement of guidelines will definitely help to reduce these injuries in critically ill children.