Incidence of pressure ulcers in ICU patients with ARDS positioned in the prone position: a retrospective single-centre cohort study

OBJECTIVES: This study addresses the incidence, characteristics, risk factors of pressure ulcers in patients treated prone according to a standardized protocol, with validated, reliable ulcer assessment. METHODS: In this retrospective single-centre cohort study, adult, mechanically ventilated COVID-19 ARDS patients undergoing prone positioning according to a standardized protocol were included. Incidence, location, and category of ulcers were determined from photographic documentation, cases without photos were excluded. Three independent assessors classified ulcers, with interrater agreement calculated. Descriptive statistics, group comparisons, and regression analyses evaluated associations with prone positioning frequency and duration. RESULTS: Between March 2020 and February 2023 105 patients with a mean age of 65 years were included (74.3% male). Forty patients (38.1%) developed at least one pressure ulcer. Category 2 pressure ulcer were the most frequent (85.9%), with the chin (32.4%) and forehead (21.1%) as the most common locations. The likelihood of developing a pressure ulcer increased significantly with increasing numbers of prone sessions (5-7 sessions (p < 0.001; OR = 5.9; 95% CI: 2.5-16.2) and ≥8 sessions (p < 0.001; OR = 7.6; 95% CI: 3.3-20.8)) and increasing SAPS II score (p < 0.05; OR = 1.0; 95% CI: 1.0-1.0). CONCLUSIONS: Despite standardized protocols, pressure ulcers remain common during prolonged prone positioning, especially on the face. These findings emphasize the need for validated diagnostic tools, targeted facial protection, and optimized micro-positioning strategies to reduce risk. IMPLICATIONS FOR CLINICAL PRACTICE: Special vigilance is crucial after the fifth prone session. Hourly micro-positioning without head rotation may reduce risk. Comparing standardized protocols identifies measures to reduce pressure ulcers and enhances comparability.