Effects of prone position in acute respiratory distress syndrome secondary to COVID-19: experience in a high complexity hospital

Introduction: The use of protective mechanical ventilation and prone position was recommended for the management of moderate to severe acute respiratory distress syndrome (ARDS) due to COVID-19, as a result of its reported utility on oxygenation and mortality. Our objective is to describe gasometric and mechanical behavior in subjects with ARDS due to COVID-19 managed with protective mechanical ventilation and prone position in a high complexity hospital. Method: Observational study. Subjects ≥18 years of age with ARDS due to COVID-19 were included. Protective mechanical ventilation was started from the first connection to invasive ventilation, while the prone position started with PaO2/FIO2 150. Follow-up was performed during and after the prone position. A descriptive analysis of baseline characteristics and comparison of means between groups was performed using the Dunn and Friedman test. Statistical significance corresponds to p 0.05 in all analyses. Results: 74 subjects were studied, 58% correspond to men with a mean age of 60 years. There is evidence of a significant increase in arterial oxygenation assessed by PaO2 (76 to 98 mmHg, p 0.05) and PaO2/FIO2 (100 to 161, p 0.05) during the first hour of treatment, with stability of values beyond 48 hours after supination. Pulmonary mechanics values remain constant within the established protection range (p = 0,18). Conclusion: The strategy of protective mechanical ventilation and prone position for 48 or more hours, in subjects with moderate to severe ARDS due to COVID-19, improves and maintains arterial oxygenation up to 48 hours after supination. © 2023

Analysis of Quality Metrics Relating to the Intubation of Covid-19 patients on a General ICU

Introduction: Most modern healthcare systems are striving to improve patient outcomes in an evidence-based manner. Increasingly, performance metrics are seen as key tools for accurately measuring and improving patient outcomes and healthcare value.1 However, in order to achieve better outcomes, process measures need to be identified. Process measures are evidence-based, best practices metrics that can be measured and thus, used to identify if outcomes are being met. Good process measures can improve patient outcomes by reducing the amount of variation in care delivery. During the Covid-19 pandemic, vast quantities of data were generated while managing ARDS (Acute Respiratory Distress Syndrome) on the ICU. Furthermore, there was as a concomitant evolution of treatment strategies, which made it exceedingly difficult to identify processes that were actually improving patient outcomes. Objective(s): The aim of our quality improvement project was to promote standardised high quality care for intubated Covid-19 patients by identifying potential quality indicators and trends in their management. It is our intention to expand on this work to report metrics on all severe acute respiratory failure patients. Method(s): 15 process metrics surrounding the early care of intubated of Covid-19 patients were selected via a consultant led review process and a literature review in an effort to identify markers of quality surrounding intubation on our ITU. The variables selected included: - P/F ratio 24 hours pre-intubation, CPAP (continuous positive airway pressure) duration prior to intubation, Recording intubation location, Enhanced thromboprophylaxis prescribed, Permissive hypercapnia, Driving pressure documented, prone position and paralysis initiated if P/F ratio was less than 20 kPa, Echo post intubation. Result(s): Data surrounding the intubation of Covid-19 patients was collected over an 11 week period between September and November 2021. The data was collected in a standardised fashion from patient notes and nursing notes, then stored in an excel file. Our data showed more than half the patients admitted were either intubated on the ward or immediately following arrival onto our ICU, possible indicating a delay in admitting Covid-19 patients. Our data also demonstrated heterogeneity of duration in CPAP prior to intubation which may also indicate delayed intubation for these patients.2 Conclusion(s): Our data demonstrated a reasonable degree of heterogeneity in our approach to the early care of intubated Covid-19 Patients. Areas of concern highlighted were the number of patients intubated on the ward or immediately upon arrival to ITU, rather than admitting prior to deterioration (most likely due to bed pressure) and variation in post intubation respiratory sampling between invasive and non-invasive broncheoalveolar lavage. Ongoing PDSA (plan-do-study-act) cycling are in progress to refine the data collection processes and reporting for all severe acute respiratory failure patients.

Experience achieved after implementation of the Veno-Venous ExtraCorporeal Membrane Oxygenation(ECMO) retrieval program in the region of Madrid (Spain). Hospital Universitario 12 de Octubre

Objectives: The objetive of this study is to describe the cases trasferred to an ECMO referral;s centre (Hospital Universitario 12 de Octubre, Madrid (Spain)), to investigate characteristics before ECMO and while the patient was on ECMO, to analyse the presence or not of complications secondary to transfer and cannulation and finally to analyse the ICU outcome. Method(s): This is a Prospective study done from November 1st, 2020 to December 31st, 2022. The cases were accepted either for emergency ECMO cannulation in the hospital of origin and retrieval or for conventional transfer. We analysed basic decriptive variables such as male proportion, age, IMC and etiology of ARDS and variables before ECMO such as prone position, duration of non-invasive ventilation, invasive ventilation and ICU leght of stay before ECMO. We recorded ELSO, SOFA and APACHE Severity Scores. We also analysed several variables on ECMO: if prone position on ECMO was done, median days of ECMO and succesfull weaning from ECMO. We also recorded whether there were complications or not in the transfer and cannulation. Finally ICU survival was examined. Result(s): 31 cases were accepted. 22 (71 %) were male. 29 cases were accepted for emergency ECMO cannulation. Median age was 47 years and IMC 31.1. The etiology of SDRA was COVID 19 infection in 23 cases (74% cases). Lenght of non invasive and invasive ventilation before ECMO were 4 days and 3 days respectively and lenght of ICU admission before ECMO was 2 days. Prone position was 1 day and 2 prone sessions were done before ECMO. Severity scores: APACHE 10 , SOFA 4 , ELSO 3 . On ECMO Prone position was done on 15 cases(48.4%) . Median days on ECMO were 13.5 days. Succesfull weaning from ECMO were achieved on 20 cases(61%), 2 cases remain on ECMO. No complications were seen on transfer or cannulation. ICU Survivors were 16(51.6%). Conclusion(s): After 2 years of experience on ECMO retrieval in the region of Madrid ECMO availability was achieved. Our results are similar than ELSO mortality.

The application experience of focused ultrasound heart examination in patients with COVID-19 in Prone-position.

Aim of the study. To study the experience of using focused transthoracic echocardiography in patients with COVID-19 in prone position (fEchoPr) in intensive care units (ICU). Materials and methods. The retrospective observational study included 53 patients (period from 15 April to 31 December 2020). Inclusion criteria: confirmed diagnosis of COVID-19, availability of fEchoPr data, outcome certainty (discharge/death). We analyzed electronic medical records. The fEchoPr was performed in patients in the prone position with a bolster under the left side of the chest and left arm raised ('swimmer's position'). We assessed the systolic function of the right ventricle (RV) (tricuspid annular plane systolic excursion (TAPSE)), RV size, RV/LV ratio, systolic function of the left ventricle (LV) (left ventricular outflow tract velocity time integral. (LVOT VTI)), and pulmonary hypertension (PH) (tricuspid regurgitation peak gradient (PGTR). Depending on the results, the patients were divided into 2 groups: informative (+fEchoPr) and non-informative (-fEchoPr) examinations. Results. There was no statistically significant difference in the groups (+fEcho n = 35 vs -fEcho n = 18) by age (65.6 +/- 15.3 vs 60.2 +/- 15.8, p > 0.05), by gender (male: 23 (65.7%) vs 14 (77.8%), p > 0.05), by body mass index (31.3 +/- 5.3 kg/m2 vs 29.5 +/- 5.4 kg/m2, p > 0.05), by mechanical ventilation support (24 (68.6%) vs 17 (94.4%), p = 0.074), by NEWS scale indicators (6.9 +/- 3.7 vs 8.5 +/- 3.5 points), by mortality (82.8% vs 94.4%, p > 0.05). Correlation analysis revealed a moderate inverse relationship between being on mechanical ventilation and the informative value of the study (Spearman's r = -0.30 at p = 0.033). In the +fEchoPr group, the correct measurement of TAPSE and RV/LV was carried out in 100%: a decrease in RV systolic function was recorded in 5 patients (14%), expansion of the RV in 13 patients (37%). Signs of PH were detected in 11 patients (31%), PGTR could not be measured in 10 patients (28%). LV systolic dysfunction was detected in 7 patients (20%). No pathology was detected in 16 patients (46%). One patient was diagnosed with infective endocarditis of native mitral valve, which was later confirmed by autopsy. Conclusion. In 66% of cases, fEchoPr examinations were informative, especially in terms of assessing the state of the right heart. fEchoPr examination is an affordable, valid and reproducible method to assess and monitor the state of the heart in ICU patients.Copyright © 2021 VIDAR Publishing House. All Rights Reserved.

Ultrasound-guided central venous access for patients in the Intensive Care Unit in prone position: report of three cases.

The prone position is extensively used to improve oxygenation in patients with severe acute respiratory distress syndrome caused by SARS-CoV-2 pneumonia. Occasionally, these patients exhibit cardiac and respiratory functions so severely compromised they cannot tolerate lying in the supine position, not even for the time required to insert a central venous catheter. The authors describe three cases of successful ultrasound-guided internal jugular vein cannulation in prone position. The alternative approach here described enables greater safety and well-being for the patient, reduces the number of episodes of decompensation, and risk of tracheal extubation and loss of in-situ vascular lines.

Exploring the learning needs of clinicians in Belgium and Sweden regarding prone positioning and skin damage prevention: A qualitative study.

INTRODUCTION: During the coronavirus pandemic (COVID -19), the use of prone positioning in critically ill patients with acute respiratory distress syndrome (ARDS) increased substantially. As a result, clinicians had to (re)learn how to treat the patient in the prone position while preventing adverse events such as pressure ulcers, skin tears and moisture-associated skin damage. AIM: The purpose of the study was to determine participants' learning needs related to patients in the prone position and the prevention of skin damage, such as pressure ulcers, and what they perceived as a positive or negative learning experience. DESIGN: This study used a qualitative methodological framework and employed an exploratory design. PARTICIPANTS: A purposive sample of clinicians (n = 20) with direct or indirect work experience with prone ventilated patients was recruited in Belgium and Sweden. METHODS: Individual semi-structured interviews were conducted in Belgium and Sweden between February and August 2022. Data were analysed thematically using an inductive approach. The COREQ guideline was utilised to comprehensively report on the study. FINDINGS: Two themes were identified: 'Adapting to a crisis' and 'How to learn', with the latter having two subthemes: 'balancing theory and practice' and 'co-creating knowledge'. Unexpected circumstances necessitated a personal adaption, a change in learning methods and a pragmatic adaptation of protocols, equipment and working procedures. Participants recognised a multifaceted educational approach which would contribute to a positive learning experience regarding prone positioning and skin damage prevention. The importance of poising theoretical teaching with practical hands-on training was highlighted with an emphasis on interaction, discussion, and networking between peers. CONCLUSIONS: The study findings highlight learning approaches which may help inform the development of befitting educational resources for clinicians. Prone therapy for ARDS patients is not limited to the pandemic. Therefore, educational efforts should continue to ensure patient safety in this important area.

Evaluation of the efficiency and complications of the consecutive proning in COVID-19 ICU: a retrospective study.

PURPOSE: We aimed to evaluate and compare the efficacy and complications of three consecutive prone positions (PP) in COVID-19 ICU. MATERIALS AND METHOD: Patients with ARDS and placed in PP for 3 times (PP1, PP2, PP3) consecutively were included. Arterial blood gases (ABG), partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratios, partial pressure of carbondioxide (PaCO2), PEEP, and FiO2 were recorded before (bPP), during (dPP), and after (aPP) every prone positioning. Eye, skin, nerve, and tube complications related to PP were collected. RESULTS: In all positions, PaO2 value during PP was significantly higher than PaO2 before and after prone position (p = 0.001). PaO2 values were similar in all (PP1, PP2, PP3) bPP arterial blood gases. We found difference in PaO2 values during prone position between the first (PP1) and second proning (PP2). When each prone was evaluated within itself, PaO2/FiO2 increases after proning compared to before proning. PaO2/FiO2 during PP were higher compared to before proning ones. PaO2/FiO2 during PP1 was significantly higher compared to during PP3 (p = 0.005). In PP3, PEEP values bPP, dPP, and aPP were significantly higher than PEEP values after the second prone (p = 0.02, p = 0.001, p = 0.01). In the third prone, PaCO2 levels were higher than in PP1 and PP2. There were eye complications in 13, tube-related complications in 10, skin complications in 30, and nerve damage in 1 patient. CONCLUSION: We believe that a more careful decision should be made after the second prone position in patients who have to be placed in sequential prone position.

Prone Position Ventilation in Severe ARDS due to COVID-19: Comparison between Prolonged and Intermittent Strategies.

Ventilation in a prone position (PP) for 12 to 16 h per day improves survival in ARDS. However, the optimal duration of the intervention is unknown. We performed a prospective observational study to compare the efficacy and safety of a prolonged PP protocol with conventional prone ventilation in COVID-19-associated ARDS. Prone position was undertaken if P/F < 150 with FiO2 > 0.6 and PEEP > 10 cm H2O. Oxygenation parameters and respiratory mechanics were recorded before the first PP cycle, at the end of the PP cycle and 4 h after supination. We included 63 consecutive intubated patients with a mean age of 63.5 years. Of them, 37 (58.7%) underwent prolonged prone position (PPP group) and 26 (41.3%) standard prone position (SPP group). The median cycle duration for the SPP group was 20 h and for the PPP group 46 h (p < 0.001). No significant differences in oxygenation, respiratory mechanics, number of PP cycles and rate of complications were observed between groups. The 28-day survival was 78.4% in the PPP group versus 65.4% in the SPP group (p = 0.253). Extending the duration of PP was as safe and efficacious as conventional PP, but did not confer any survival benefit in a cohort of patients with severe ARDS due to COVID-19.

Hemodynamic Effects of Awake Prone Positioning With COVID-19 Acute Respiratory Failure.

INTRODUCTION: Awake prone positioning (PP) reduces need for intubation for patients with COVID-19 with acute respiratory failure. We investigated the hemodynamic effects of awake PP in non-ventilated subjects with COVID-19 acute respiratory failure. METHODS: We conducted a single-center prospective cohort study. Adult hypoxemic subjects with COVID-19 not requiring invasive mechanical ventilation receiving at least one PP session were included. Hemodynamic assessment was done with transthoracic echocardiography before, during, and after a PP session. RESULTS: Twenty-six subjects were included. We observed a significant and reversible increase in cardiac index (CI) during PP compared to supine position (SP): 3.0 ± 0.8 L/min/m2 in PP, 2.5 ± 0.6 L/min/m2 before PP (SP1), and 2.6 ± 0.5 L/min/m2 after PP (SP2, P < .001). A significant improvement in right ventricular (RV) systolic function was also evidenced during PP: The RV fractional area change was 36 ± 10% in SP1, 46 ± 10% during PP, and 35 ± 8% in SP2 (P < .001). There was no significant difference in PaO2 /FIO2 and breathing frequency. CONCLUSION: CI and RV systolic function are improved by awake PP in non-ventilated subjects with COVID-19 with acute respiratory failure.

A critical care follow-up service evaluation: Acquired peripheral nerve injury after admission with COVID-19 respiratory disease.

Anticipated sequelae of critical care admission for COVID-19 disease remain unclear. Our Edinburgh-based critical care follow-up service identified patterns with nerve injury in 13 of 35 patients who attended following a critical care admission between 15/03/2020 and 25/12/2020. This included 7 cases of meralgia parasthetica, 1 brachial plexopathy, 2 common peroneal neuropathies and 3 ulnar neuropathies. All cases of upper limb neuropathy and foot drop occurred in patients in whom prone positioning was used, with meralgia parasthetica occurring additionally in patients who remained supine.

Prone position in spontaneous ventilation? An induction problem: A scoping review

Intoduction: Prone position in spontaneous ventilation is not a recent strategy, and despite the many years it has been trying to consolidate, it has not been able to prove to be of real utility. During the recent pandemic, prone spontaneous ventilation re-emerged as a practical and simple alternative, although it was highly questioned due to its weak level of evidence. With time and experience, it was gradually relegated to become only an attractive hypothesis. Objective: This study aims to analyze the potential benefits of prone position in spontaneous ventilation in patients with hypoxemia caused by SARS-CoV-2. Methods: A panoramic review of the most relevant studies published in the MEDLINE, Embase and Scopus databases up to December 20, 2021 was performed. Results: After screening, 4 observational studies, 1 randomized clinical trial, and 3 systematic reviews were selected for analysis. Conclusions: By statistical analysis we concluded that prone position in spontaneous ventilation, although it could delay intubation, did not improve survival in hypoxemic subjects with viral pneumonia caused by coronavirus type 2. © 2023 Asociación Colombiana de Medicina Crítica y Cuidado lntensivo

Evaluating the Impact of Nutrition Support on Clinical Outcomes in Critically Ill Patients With COVID-19: A Retrospective Study

Background: Patients with COVID-19 experience prolonged ICU stays. The rate of malnutrition in hospitalized patients remains controversial as well as the appropriate nutrition therapy for these patients. The purpose of the study was to evaluate the impact of nutrition support on clinical outcomes in critically ill patients with COVID-19. Method(s): This was a retrospective chart review involving 48 adults, critically ill patients admitted with confirmed SARS-CoV-2 infection. Data extracted included demographic, anthropometric, medical history, biochemical tests, medications, nutrition support protocol, clinical outcomes, length of stay, and ventilator status. We tested associations between aspects of nutrition support (such as early versus delayed feeding, adequacy, and patient positioning) and clinical outcomes (ICU length of stay, weight status, malnutrition status, refeeding syndrome, and ventilator days) using Chi-square, and t-tests, with significance established at the level of p <= 0.05. Result(s): Thirty-eight percent (18) of the patients met the criteria for malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) tool. Approximately 83% of these patients did not have a documented diagnosis of malnutrition in the electronic medical record. More than half of the patients in the study (58.3%) were placed in prone position as part of their treatment and only 7% of these had documented signs of feeding intolerance. None of the patients were switched to total parenteral nutrition (TPN). Only 37% of the patients received adequate protein within the first week of nutrition support while 98% had adequate or exceeded caloric needs. There was no difference in percent weight loss among patients who received inadequate protein compared to those who had adequate protein. Inadequate protein intake was associated with shorter ICU stays (p = 0.04) and fewer ventilator days (p = 0.01) compared to those with adequate protein. Patients who received inadequate or exceeded their calories needs also had shorter ICU stays and fewer ventilator days (p > 0.05). In the context of this study, shorter ICU stays translated into fewer days of life, as 98% of the studied population died before ICU discharge. There were no associations between early nutrition support and selected biochemical parameters. Conclusion(s): The rate of malnutrition was remarkable and largely undocumented. Most patients did not meet the minimum estimated protein needs. Studies with larger sample sizes are needed to examine appropriate protein needs and the effect of nutrition support in patients with COVID-19. Diagnosing and documenting malnutrition warrants heightened attention.

Role of Point-of-Care Ultrasound in the Management of Mechanical Ventilation

Ultrasound (US) became an essential tool in the hands of the intensivist and is now recommended both for procedural guidance and diagnostic purposes. Point-of-care ultrasound (POCUS) is an immediately available and repeatable, non-irradiating bedside tool integrating the clinical examination. Recent years were characterized by a growing interest in the fields of lung ultrasound (LUS) and diaphragm ultrasound (DUS). The combination of these two ultrasound techniques with critical care echocardiography (CCE) may integrate the classical approach to mechanically ventilated patients, both for monitoring and diagnostic purposes, finally contributing to the titration of mechanical ventilation and to the management of respiratory disease. Lung, diaphragm, and cardiac US provide significant information to improve the management of the critical patient under mechanical ventilation, from the initial assessment, through the ventilation setting (like PEEP) and its complication diagnosis (like pneumothorax, atelectasis), until the weaning process. LUS is of particular help in COVID-19 patients. It is potentially able to distinguish between the two phenotypes (type H and type L) of COVID-19, based on the different signs and patterns and also the assessment of prone positioning effects and lung recruitment maneuvers in these patients. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Airway Management During Mechanical Ventilation: COVID-19

The disease caused by the new SARS-CoV-2 can elicit a violent, dysregulated host immune response that can lead to severe results in most of these older patients as ARDS, multiple-organ failure, and death. Acute respiratory distress syndrome (ARDS) is defined as hypoxemia secondary to a rapid onset of non-cardiogenic pulmonary edema. The airway management in a patient with COVID-19 should be carried out considering several aspects. Once it is decided to intubate the patient, use a rapid induction sequence. When signs of respiratory distress are associated with severe hypoxemia, patients should be managed as soon as possible according to the pulmonary phenotypes;however, management of mechanical ventilation must be personalized;if possible, use low tidal volume with 6 mL/kg of predicted body weight. There is no consensus regarding the best PEEP value;several guidelines recommended keeping Pplat 30 cmH2O in patients with ARDS. There are no available studies that describe the clinical evolution of COVID-19 patients ventilated in the prone position;intermittent doses of neuromuscular blocking agents to facilitate lung-protective ventilation, and tracheostomy, remain necessary in some patients with COVID-19. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Algorithms to prevent pressure injury in COVID-19 patients in prone position / Algoritmos para prevenir lesão por pressão em paciente com COVID-19 em prona / Algoritmos para prevenir la úlcera por presión en pacientes con COVID-19 en prona

Resumo Objetivo Elaborar e validar o conteúdo de dois algoritmos para orientar profissionais da linha de frente na prevenção e no tratamento da lesão por pressão em paciente com COVID-19 em posição prona. Métodos Estudo realizado entre setembro e novembro de 2021. Para a construção dos algoritmos, realizou-se revisão da literatura junto às bases de dados MEDLINE®, SciELO e Lilacs. Foram pesquisados artigos publicados entre 2011 e 2021. A validação dos algoritmos foi feita por 59 profissionais da saúde (enfermeiros, fisioterapeutas e médicos), que trabalhavam na linha de frente da COVID-19, utilizando-se a técnica Delphi. Para a análise de dados, foi adotado o Índice de Validade de Conteúdo e o coeficiente alfa de Cronbach. Resultados No primeiro ciclo de avaliação, os itens dos algoritmos foram considerados pelos juízes como "parcialmente adequados a totalmente adequados", e o Índice de Validade de Conteúdo variou entre 0,87 e 0,92. O coeficiente alfa de Cronbach variou entre 0,95 e 0,96, indicando excelente consistência interna do questionário de avaliação utilizado pelos juízes. Após implementados os ajustes sugeridos pelos juízes, os algoritmos foram reenviados para o segundo ciclo de avaliação, no qual todos os itens foram julgados como "adequado" e "totalmente adequado", resultando em um Índice de Validade do Conteúdo de 1,0. Conclusão Os algoritmos para orientar profissionais da saúde na prevenção e no tratamento da lesão por pressão em pacientes com COVID-19 em posição prona foram avaliados por enfermeiros, fisioterapeutas e médicos que estavam na linha de frente de combate à COVID-19, que chegaram a um consenso quanto ao conteúdo no segundo ciclo de avaliação.

Resumen Objetivo Elaborar y validar el contenido de dos algoritmos para orientar profesionales de la línea de frente sobre la prevención y tratamiento de la úlcera por presión en pacientes con COVID-19 en posición prona. Métodos Estudio realizado entre septiembre y noviembre de 2021. Para la elaboración de los algoritmos, se realizó revisión de la literatura en las bases de datos MEDLINE®, SciELO y Lilacs. Se buscaron artículos publicados entre 2011 y 2021. La validación de los algoritmos fue realizada por 59 profesionales de la salud (enfermeros, fisioterapeutas y médicos), que trabajaban en la línea de frente del COVID-19, utilizando el método Delphi. Para el análisis de datos se adoptó el Índice de Validez de Contenido y el coeficiente alfa de Cronbach. Resultados En el primer ciclo de evaluación, los ítems de los algoritmos fueron considerados por los jueces como "parcialmente adecuados a totalmente adecuados", y el Índice de Validez de Contenido varió entre 0,87 y 0,92. El coeficiente alfa de Cronbach varió entre 0,95 y 0,96, lo que indica una excelente consistencia interna del cuestionario de evaluación utilizado por los jueces. Después de implementar las mejoras sugeridas por los jueces, se reenviaron los algoritmos para el segundo ciclo de evaluación, en el cual todos los ítems fueron calificados como "adecuado" y "totalmente adecuado", con un resultado del Índice de Validez de Contenido de 1,0. Conclusión Los algoritmos para orientar profesionales de la salud sobre la prevención y el tratamiento de la úlcera por presión en pacientes con COVID-19 en posición prona fueron evaluados por enfermeros, fisioterapeutas y médicos que estaban en la línea de frente de combate al COVID-19 y llegaron a un consenso respecto al contenido en el segundo ciclo de evaluación.

Abstract Objective To develop and validate the content of two algorithms to guide frontline professionals in the prevention and treatment of pressure injuries in COVID-19 patients in prone position. Methods Study conducted between September and November 2021. A literature review was performed in MEDLINE®, SciELO and Lilacs databases to build the algorithms. Articles published between 2011 and 2021 were searched. The validation of algorithms was performed by 59 health professionals (nurses, physical therapists and physicians) who worked on the frontline of COVID-19. The Delphi technique was used, and Content Validity Index and Cronbach's alpha coefficient were adopted for data analysis. Results In the first evaluation cycle, the items of algorithms were considered as "partially adequate to totally adequate" by the judges, and the Content Validity Index ranged between 0.87 and 0.92. Cronbach's alpha coefficient ranged between 0.95 and 0.96, indicating excellent internal consistency of the evaluation questionnaire used by the judges. After implementing the adjustments suggested by judges, the algorithms were sent to a second evaluation cycle, in which all items were judged as "adequate" and "totally adequate", resulting in a Content Validity Index of 1.0. Conclusion Algorithms to guide healthcare professionals in the prevention and treatment of pressure injury in COVID-19 patients in prone position were evaluated by nurses, physical therapists and physicians working on the frontline of COVID-19. They achieved consensus on content in the second evaluation cycle.

Incidence of pressure ulcers due to prone position in patients admitted to the ICU for Covid-19.

The appearance of pressure ulcers (PU) is one of the frequent complications of prone position (PP), due to prolonged pressure and shear forces. OBJECTIVES: To compare the incidence of pressure ulcers secondary to prone position and describe their location among four Intensive Care Units (ICU) of public hospitals. METHODS: Multicenter descriptive and retrospective observational study. The population consisted of patients admitted to the ICU between February 2020 and May 2021, diagnosed with Covid-19 who required prone decubitus. The variables studied were sociodemographic, days of admission to the ICU, total hours on PP, PU prevention, location, stage, frequency of postural changes, nutrition and protein intake. Data collection was carried out through the clinical history of the different computerized databases of each hospital. Descriptive analysis and association between variables were performed using SPSS vs.20.0. RESULTS: A total of 574 patients were admitted for Covid-19, 43.03% were pronated. 69.6% were men, median age was 66 (IQR 55-74) and BMI 30.7 (RIC 27-34.2). Median ICU stay was 28 days (IQR 17-44.2), median hours on PD per patient 48 h (IQR 24-96). The incidence of PU occurrence was 56.3%, 76.2% of patients presented a PU, the most frequent location was the forehead (74.9%). There were significant differences between hospitals in terms of PU incidence (P = .002), location (P = .000) and median duration of hours per PD episode (P = .001). CONCLUSIONS: The incidence of pressure ulcers due to the prone position was very high. There is great variability in the incidence of pressure ulcers between hospitals, location and average duration of hours per episode of prone position.

Exogenous surfactant reduces inflammation and redox imbalance in rats under prone or supine mechanical ventilation.

Mechanical ventilation (MV) is a lifesaving therapy for patients with acute or chronic respiratory failure. Despite, it can also cause lung injury by inducing or worsening inflammatory responses and oxidative stress. Several clinical approaches have protective effects on the lungs, including the prone position and exogenous surfactant; however, few studies have evaluated the association between the two strategies, especially in individuals without previous lung injury. We tested the hypothesis that the effects of the homogenization in lung aeration caused by the prone position in association with the anti-inflammatory properties of exogenous surfactant pre-treatment could have a cumulative protective effect against ventilator-induced lung injury. Therefore, Wistar rats were divided into four experimental groups: Mechanical Ventilation in Supine Position (MVSP), Mechanical Ventilation in Prone position (MVPP), Mechanical Ventilation in Supine Position + surfactant (MVSPS), and Mechanical Ventilation in Prone Position + Surfactant (MVPPS). The intranasal instillation of a porcine surfactant (Curosurf®) was performed in the animals of MVSPS and MVPPS 1 h before the MV, all the rats were subjected to MV for 1 h. The prone position in association with surfactant decreased mRNA expression levels of pro-inflammatory cytokines in ventilated animals compared to the supine position; in addition, the NfκB was lower in MVPP, MVSPS and MVPPS when compared to MVSP. However, it had no effects on oxidative stress caused by MV. Pre-treatment with exogenous surfactant was more efficient in promoting lung protection than the prone position, as it also reduced oxidative damage in the lung parenchyma. Nevertheless, the surfactant did not cause additional improvements in most parameters that were also improved by the prone position. Our results indicate that the pre-treatment with exogenous surfactant, regardless of the position adopted in mechanical ventilation, preserves the original lung histoarchitecture, reduces redox imbalance, and reduces acute inflammatory responses caused by mechanical ventilation in healthy adult Wistar rats.

COVID-19 and intensive care

COVID-19 caused by SARS-CoV2 has spread rapidly across the world, resulting in many patients in need of intensive care support. Severe pneumonia, acute respiratory distress syndrome (ARDS), sepsis/septic shock, and multi-organ failure may occur during the disease course among many other complications. There still is not a definite cure, but supportive care is important to minimize complications. Patients in need of respiratory support and interventions should preferably be placed in negative pressure isolation rooms, with utmost care to decrease viral spread. Points to consider during oxygen therapy, non-invasive and invasive mechanical ventilation, and shock management of COVID-19 patients are discussed. Patients with mild hypoxia may be managed with conventional oxygen therapy, while others will benefit from high flow nasal oxygen therapy and mechanical ventilation. Although corticosteroids are not recommended for other viral pneumonia, there are recent reports suggesting that steroids may have a place in the treatment of COVID-19 patients with hypoxia. Shock may complicate the course of the disease and a search for the etiology of shock should be carefully planned. Thromboembolic events are common;prophylaxis and/or treatment of thromboembolic events should be managed according to the guidelines. Meanwhile, the results of ongoing randomized, controlled trials on antiviral and immunomodulatory agents are expected to offer better treatment options for COVID-19 patients in the near future.Copyright © 2020 Bilimsel Tip Yayinevi. All rights reserved.

The impact of proning on nutritional therapy in mechanically ventilated COVID-19 patients

Introduction: Critically ill COVID-19-patients are at high risk of developing ICU-related malnutrition. This study aimed to examine the impact of proning on providing nutritional therapy for mechanically ventilated COVID-19-patients by comparing the achievement of nutritional goals and possible complications in patients who were proned vs. those who were not. Method(s): This is a single-center retrospective cohort study. We included all adult COVID-19 patients admitted to the ICU from 01/03/2020 until 31/05/2020 who required invasive mechanical ventilation (IMV), excluding those referred for ECMO. Data were extracted from electronic patient files. Weight-based nutrition targets were set in agreement with ESPEN guidelines [1]. Result(s): 32 patients were included (prone n = 16). Both groups were comparable in age, sex, comorbidities, biochemical markers and Nutrition Risk Screening on admission. Time on IMV was longer in the prone group (p = 0.032). The total time in prone position ranged from 19.5 h to 13.16 d. All patients received a NG tube, 1 proned patient received a jejunal tube. 6 received TPN (p = 0.654). Metoclopramide was used more often in the prone group (p = 0.028). The prevalence of vomiting (n = 4 vs. n = 5), large gastric residuals (n = 0 vs. n = 3) and VAP (n = 11 vs. n = 10) were comparable for the non-prone vs. prone group, resp. Table 1 shows the percentage of targets reached. These were lower in the prone group, though not statistically significant. However, when correcting for SAPS III-score, the impact of proning declined. Conclusion(s): These limited data suggest there is no significant difference in feeding COVID-19 patients on IMV that need proning vs. those who do not, except for metoclopramide use. Overall, reaching nutrition targets in these patients is challenging. This model suggests that disease impact is a greater influence on reaching nutritional goals than proning itself.

Prolonged prone position in COVID-19-associated ARDS: a prospective study

Introduction: Ventilation in prone-position (PP) improves survival in moderate-to-severe ARDS. However, optimal duration of the intervention to gain maximum benefit is unknown. We sought to examine the efficacy and safety of a prolonged PP protocol in COVID-19-associated ARDS. Method(s): This was a prospective observational study. We included consecutive intubated and mechanically ventilated patients with ARDS and positive PCR for SARS-CoV-2 who underwent at least one session of PP from March 2021 to August 2021. PP was undertaken if P/F < 150 with FiO2 > 0.6 and PEEP > 10cmH2O. Oxygenation parameters and respiratory mechanics were recorded before PP, at the end of PP session and 4 h after supine repositioning. Patients with PP longer than 24 h (prolonged group) were compared to patients who were proned for less than 24 h (control group). The duration of PP was at the discretion of the treating intensivist. Result(s): We recorded 56 patients (62.7% male). Five patients were excluded because PP was terminated in less than 4 h. Mean age of the 51 studied patients was 61.4 years. Patients in the prolonged group had significantly higher BMI than controls. Baseline oxygenation and respiratory mechanics were similar between groups. PP duration was 39.8 versus 20.5 h (p < 0.001). Increase of P/F was higher in the prolonged PP group during proning (103.8 +/- 70.8 vs 66 +/- 53.9, p < 0.05) and after supination (76.3 +/- 64.6 vs 48.6 +/- 34.9, p = 0.058). No change in respiratory mechanics was observed in either group. 28-day survival was 75% in the prolonged PP group and 69.5% in the control group (p = 0.665). Duration of mechanical ventilation, number of PP cycles and rate of complications were similar between groups. Conclusion(s): In patients with ARDS due to COVID-19 prolonged PP resulted in better oxygenation, but had no impact on outcome. However, it is both feasible and safe and can be an alternative in conditions of increased work load as was the case during the recent pandemic.