How to write surgery consultation for a patient with lip injury due to prolonged ventilator

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endotracheal tube lip pressure injury oral mucosa

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surgery consultation note template lip injury prolonged intubation ventilator pressure ulcer

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https://pmc.ncbi.nlm.nih.gov/articles/PMC7543895

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PMID: 40506056

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Here is a complete, practical guide to writing a surgery consultation note for a lip injury caused by prolonged mechanical ventilation (endotracheal tube-related pressure injury):

Surgery Consultation Note: Lip Injury from Prolonged Ventilator (ETT Pressure Injury)

Background

This is formally classified as a Medical Device-Related Pressure Injury (MDRPI) - specifically an Oral Endotracheal Tube-Related Mucous Membrane Pressure Injury (OETMMPI). MDRPIs account for 34.5% of all hospital-acquired pressure ulcers, and the mouth/lips are involved in 3.4% of those cases. The lower lip is the most common site (35.3% of oral ETT injuries), with injury onset most frequently on Day 2 post-intubation and mean onset at ~4.7 days. (Yi et al., Nursing in Critical Care, 2025)

Sample Consultation Note Template

DATE / TIME: [insert] REQUESTING SERVICE: ICU / Medical Team CONSULTING SERVICE: Plastic Surgery / General Surgery / Oral & Maxillofacial Surgery PATIENT: [Name, Age, Sex, MRN] REASON FOR CONSULTATION: Evaluation and management of lip pressure injury secondary to prolonged endotracheal intubation.

HISTORY OF PRESENT ILLNESS (HPI)

[Patient name] is a [age]-year-old [sex] with a history of [relevant PMH] who was admitted on [date] for [admitting diagnosis, e.g., acute respiratory failure, ARDS, post-operative respiratory insufficiency]. The patient required mechanical ventilation via oral endotracheal tube (ETT) beginning [date], with a total intubation duration of [X days]. [If applicable: Patient was placed in prone position for [X hours/days] for refractory hypoxia.]

Following extubation on [date], nursing staff identified a [superficial / partial thickness / full thickness] wound on the [upper / lower / bilateral] lip, consistent with a pressure injury from the ETT. Plastic Surgery / Surgery service is now consulted for wound assessment and management recommendations.

PAST MEDICAL HISTORY

[List relevant conditions - especially cardiovascular disease, diabetes, immunosuppression, malnutrition - as these are recognized risk factors for MDRPI]
Intubation duration: [X days] - note: risk increases significantly after 4 days of intubation
Prone positioning: [Yes / No / X hours]

PHYSICAL EXAMINATION

Vital Signs: [As per chart]

Wound Assessment:

Parameter	Findings
Location	[Upper lip / Lower lip / Oral commissure / Bilateral]
Size	[X cm x Y cm]
Depth / Stage	[Stage 1 / 2 / 3 / 4 / Unstageable, per NPIAP staging]
Wound bed	[Viable pink/red tissue / slough / eschar / exposed muscle/bone]
Wound edges	[Defined / undermined / macerated]
Periwound skin	[Intact / erythematous / macerated / necrotic]
Exudate	[None / minimal serous / purulent]
Signs of infection	[Yes - describe / No]
Surrounding landmarks	[Vermilion border involved: Yes/No; Commissure involved: Yes/No]

Oral cavity: [Inspect for additional sites - palate, tongue, mouth corners per OETMMPI pattern]

STAGING (NPIAP Classification)

Stage 1: Non-blanchable erythema of intact skin
Stage 2: Partial thickness skin/mucosa loss - shallow open ulcer, pink/red wound bed
Stage 3: Full thickness tissue loss, no bone/muscle/tendon exposed
Stage 4: Full thickness tissue loss with exposed bone, muscle, or tendon
Unstageable: Full thickness loss, base obscured by slough/eschar

ASSESSMENT

[Patient name] has a [Stage X] medical device-related pressure injury (MDRPI) of the [upper/lower] lip, resulting from prolonged endotracheal intubation for [X days]. The wound [is/is not] infected. [Note presence/absence of vermilion border disruption, which impacts cosmetic outcome and may require surgical correction.]

Risk factors present in this patient: [prolonged intubation >4 days / cardiovascular disease / prone positioning / poor nutritional status / anticoagulation]

PLAN / RECOMMENDATIONS

Conservative (Stage 1-2 injuries, or for initial management of Stage 3-4 pending OR scheduling):

Wound care:
- Clean wound with normal saline or antiseptic mouthwash [e.g., chlorhexidine 0.12%] twice daily
- Apply topical agent: [Options - dexpanthenol cream (promotes epithelialization and collagen synthesis), petroleum-based ointment, or hydrocolloid dressing]
- For small superficial ulcers: topical moderate-potency corticosteroid e.g., 0.1% triamcinolone acetonide or 1% hydrocortisone hemisuccinate 3-4 times/day may accelerate healing
- Sunscreen/photoprotection once healing begins to prevent post-inflammatory hyperpigmentation
- For hyperpigmented healing lesions: consider tyrosinase inhibitors (hydroquinone, azelaic acid)
Infection management:
- Antiseptic mouthwash for all patients
- Oral antibiotics for select cases with clinical signs of infection ([describe if present])
- Infectious disease consultation if atypical or severe
Nutritional optimization:
- Consult dietitian for protein/caloric optimization to support wound healing
- Correct any deficiencies (zinc, Vitamin C, albumin)
Anticoagulation consideration:
- If patient requires therapeutic anticoagulation, note that lip wounds are prone to bleeding - this may prompt earlier surgical closure rather than secondary intention healing

Surgical (Stage 3-4, non-healing, or wounds involving vermilion border):

Operative management:
- Full-thickness excision of necrotic/non-viable tissue
- Layered closure respecting natural lip borders (vermilion border, Cupid's bow)
- If defect is large: consider full-thickness wedge resection to prevent dog-ear formation
- Closure under local anesthesia + monitored anesthesia care (MAC) if patient clinically stable
- Reconstructive options for large defects: local flap (Abbé, Karapandzic) if >1/3 lip width involved - typically deferred until wound is stable
Follow-up:
- Wound reassessment in [2-3 days] for conservative management
- Post-operative follow-up at [1 week] if surgical repair performed
- Monitor for scar formation - intralesional steroids or laser available for hypertrophic scarring if needed

PREVENTIVE NOTE (for future admissions)

Reposition ETT every 2-4 hours (left/right corner of mouth) and document
Use foam or hydrocolloid dressings between tube and lip
Prefer tube-holding devices over adhesive tape
Wrap ETT in gauze prior to lip contact
Perform daily oral assessment with documentation (lower lip, palate, tongue, commissures)
Minimize prone positioning duration when possible; use alternate-side rotation

SIGNATURE

Consultant: [Name, Specialty, Pager/Phone] Attending: [Name] Date/Time of Consultation: [insert] Communication: Findings communicated to [requesting team member] at [time]

Key Clinical Points to Remember

Factor	Detail
Most common site	Lower lip (35.3% of oral ETT injuries)
Peak onset	Day 2 post-intubation; mean 4.7 days
Independent risk factors	Cardiovascular disease, intubation >4 days, prolonged ICU stay
Prone positioning	Significantly increases lip injury risk
Anticoagulation	Favors early surgical closure over secondary intention
Cosmetically sensitive	Always respect vermilion border during repair

Sources:

Yi et al. (2025) - Characteristics and Risk Factors of OETMMPI in ICUs - Nursing in Critical Care (PMID 40506056)
Carney et al. (2020) - Medical device-related pressure ulcer of the lip in COVID-19 patient - Case report and literature review (PMC7543895)
National Pressure Injury Advisory Panel (NPIAP) staging system

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