Cutaneous Manifestations of COVID-19 in Critical Care.

SARS-CoV-2 infection can cause virus-mediated endothelial dysfunction, which in turn may lead to coagulopathy and ischemic microangiopathy. In the critical care population, cutaneous skin manifestations related to vascular compromise due to COVID-19 include livedo and purpura. These lesions can be difficult to differentiate from other dermatologic conditions seen in this population, including skin failure and deep-tissue pressure injuries. In addition, similarities in underlying pathophysiological mechanisms of these skin conditions can cause diagnostic overlap. Skin failure is known to occur in critical care patients owing to disease severity and shunting of blood to vital organs. COVID-19-related ischemic lesions can mimic the clinical course of deep-tissue pressure injury. The viral endothelial dysfunction present in patients with COVID-19 decreases tissue tolerance, which can result in an increased risk of hospital-acquired pressure injury. Extrinsic factors can also complicate diagnosis of cutaneous lesions in patients with COVID-19.

Cutaneous Anomalies of the Critically Ill Patient.

Critically ill patients are at high risk for organ failure, including that of the integumentary system. Nurses working in intensive care are adept at performing comprehensive assessments that include the skin. Although pressure injury is a well-known complication associated with critical illness, patients may also have debilitating and life-threatening dermatoses. Conditions such as skin failure and medical adhesive-related skin damage are commonly seen in the critically ill. Infectious processes, such as Fournier gangrene, invasive candidiasis, mucormycosis, and herpetic lesions, can result in severe or superimposed critical illness and elude detection. Similarly, cutaneous manifestations of COVID-19 may develop prior to commonly recognized symptoms of infection. Nurses and providers caring for critically ill patients should be aware of common, but less widely known, skin conditions to facilitate early detection and treatment.

Skin Failure Among Critically Ill Patients Afflicted with Coronavirus Disease 2019 (COVID-19).

Objective: To characterize skin integrity among coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU), and identify risk factors for skin failure (SF) in these patients. Design: The characteristic, profound pro-inflammatory, hypercoagulable state of COVID-19 is manifested by the high severity of illness and extensive organ dysfunction observed in these patients. SF in critically ill patients, although described previously, exhibits a uniquely complex pathogenesis in this population. Patients: Retrospective review of all COVID-19 patients (confirmed positive for severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) admitted to a single surgical ICU for at least 48 hours between March-June 2020. Interventions: Data were extracted from a COVID-19 institutional data repository that harvested data from electronic health records and other clinical data sources. Demographics; coagulation/inflammation biomarkers; number, location, and stage of SF lesions; resource utilization; and outcomes were captured. Measurements and Main Results: 64 patients met inclusion criteria; 51 (80%) developed SF (SF+ ). Forty-three (85%) developed stage 3 or higher SF (χ2 = 22.66, P < .0001). Thirty-nine of 51 (76%) SF+ patients developed more than one SF lesion (χ2 = 13.26, P = .0003). SF+ patients manifested a profound pro-inflammatory, hypercoagulable phenotype (lower serum albumin and higher ferritin, interleukin [IL]-6 and D-dimer concentrations [all, P < .001]). Durations of mechanical ventilation, vasopressor therapy, and ICU length of stay were significantly longer (all, P < .05) in the SF + patients. Conclusions: The unique characteristics of COVID-19 dermatopathology and the strong correlation between markers of inflammation and development of SF reflect COVID-19-related organ dysfunction and its deleterious effects on the microcirculation. Considering that skin is invaded directly by SARS-CoV-2 and affected by COVID-19-related immune complex deposition and microthrombosis, SF may reflect disease as opposed to pressure injuries related to processes of care. In the context of COVID-19 critical illness, SF should not be considered a "never event."