The risk of pressure ulcers in a proned COVID population.

The utilisation of prone positioning has been vital during the COVID-19 pandemic, however risks the development of anterior pressure ulcers. An observational study was performed to examine the prevalence of pressure ulcers in this population and define risk factors. Eighty-seven patients admitted to critical care were studied. Of 62 patients with >1 day in prone position, 55 (88.7%) developed anterior pressure ulcers, 91% of which were anterior. The most commonly affected site were the oral commisures (34.6%), related to endotracheal tube placement. Prone positioning (p < .001) and the number of days prone (OR 3.11, 95% CI 1.46-6.62, p = 0.003) were a significant risk factors in development of an anterior ulcer. Prone positioning is therefore a significant cause of anterior pressure ulcers in this population.

An appraisal of the methodology and quality of evidence of systematic reviews on the efficacy of prone positional ventilation in adult patients with acute respiratory distress syndrome: an umbrella review.

The objective of the study was to evaluate all available systematic reviews on the use of prone positional ventilation in adult patients with acute respiratory distress syndrome (ARDS). An umbrella review on the efficacy of prone positional ventilation in adult patients ventilation in adult patients with acute respiratory distress syndrome was conducted. We performed a systematic search in the database of Medline (Pubmed), Scopus, Cochrane Library, Web of Science, and Epistemonikos. The ROBIS tools and GRADE methodology were used to assess the risk of bias and certainty of evidence. We estimated the necessary number of patients to be treated to have benefit. For the synthesis of the result, we selected the review with the lowest risk of bias. Sixteen systematic reviews including 64 randomized clinical trials and evaluating the effect of prone positional ventilation, with or without other ventilation strategies were included. Aoyama 2019 observed prone positioning, without complementary ventilation strategies, leading to a reduction in the 28-day mortality only when compared to high-frequency oscillatory ventilation (RR 0.61; 95% CI 0.39-0.95) and lung-protective ventilation in the supine position (RR 0.69; 95% CI 0.48-0.98), with an ARR of 9.32% and 14.94%, an NNTB of 5.89 and 8.04, and a low and moderate certainty of evidence, respectively. Most reviews had severe methodological flaws that led to results with very low certainty of evidence. The review with the lowest risk of bias presented results in favor of prone positional ventilation compared with high-frequency oscillatory ventilation and lung-protective ventilation. There is a need to update the available reviews to obtain more accurate results.

Ulnar Neuropathy After Intermittent Prone Positioning for COVID-19 Infection: A Preliminary Report of 3 Cases.

CASE: We describe a preliminary report of 3 cases of ulnar neuropathy after coronavirus disease 2019 (COVID-19) infection and treatment with intermittent prone positioning. CONCLUSION: Ulnar neuropathy may be associated with recent COVID-19 infection. The natural process of the disease and intermittent prone positioning are likely risk factors contributing to this finding. Conservative management seems to lead to improvement of symptoms.

[Meralgia paraesthetica as complication of patient positioning : A not fully controllable risk]. / Meralgia paraesthetica als Lagerungsschaden : Kein voll beherrschbares Risiko.

Meralgia paraesthetica (MP) is the consequence of an entrapment or stretch injury of the lateral femoral cutaneous nerve at the crossing region with the inguinal ligament where the nerve exits the pelvis. It results in temporary or permanent sensory loss, paraesthesia and pain in the anterolateral region of the thigh. Idiopathic forms are known for example as seat belt syndrome or jeans syndrome. An MP can also occur as a complication of surgical or intensive care patient positioning. In focus are the lithotomy position, prone position and beach chair position.We analyzed 21 complaints about MP occurring for the first time postoperatively, which had been submitted to the expert committee for medical treatment errors at the North Rhine Medical Association over the past 10 years. Among these, six cases could be identified as positioning damage after a lithotomy position. In three cases MP occurred after supine positioning but the etiology could not be clarified with certainty. In 12 cases MP was recognized as a direct surgical complication.The pathophysiology, incidence and course as well as legal implications of position-related MP are discussed. Pressure damage to the nerve at its intersection with the inguinal ligament is assumed to be the main pathomechanism. Although all the cases presented here occurred after lithotomy positioning, the complication also appears to occur with other types of positioning according to the literature data, the most common being prone positioning. This also explains the increasingly published case reports of MP after prone positioning in COVID-19 patients for respiratory treatment. Safe avoidance of the positioning-related complication does not appear to be possible due to the anatomical variability of the course of the nerve and the unclear pathomechanisms.

Pressure Injuries Due to Prone Positioning in Patients with COVID-19.

Preemptive interventions are needed to prevent pressure injuries in patients with COVID-19 who are placed in the prone position.Risk factors for pressure injuries in these patients include severe obesity, a long duration of prone positioning, male sex, a high D-dimer level, and the use of commercial endotracheal tube holders.

Respiratory decompensation with proning - when prone positioning can worsen respiratory mechanics.

Prone positioning recently gain- ed more popularity from its use in COVID-19 management. It is gene--rally considered to improve respiratory mechanics via increased lung compliance. In surgery, prone positioning is typically encountered when it is a necessity to access certain posterior anatomic structures. Though certain post-operative complications from prone positioning are well known (e.g., postoperative vision loss), the potential intraoperative complications that it can have for respiratory com-pliance and O2 saturation, in the setting of general anaesthesia, are perhaps less familiar, as only a few studies showed improved respiratory mechanics in the setting of ge-neral anaesthesia [1-3] and one study showed that prone positioning led to a 30-35% drop in respiratory compliance under general anaesthesia [4]. As the following case illustrates, proning is a critical point in the intraoperative course as it can sometimes lead to negative respiratory sequelae disrupting homeostasis.

Masseter muscle pressure injury: First report of a prone position complication in patients with COVID-19.

We report the case of a 59-year-old, obese woman who underwent prolonged prone position during the medical management of an acute respiratory distress syndrome induced by SARS-CoV-2 infection, complicated by a masseter muscle pressure injury. Such side effect may be underestimate in intensive care units and should be prevent by prophylactic dressings on facial weight-bearing sites. The understanding of facial deep tissue injury is essential to guide clinical detection and management of such a complication in COVID-19 patients.

Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients.

OBJECTIVE: To investigate short and long-term complications due to standard (≤24 hours) and extended (>24 hours) prone position in COVID-19 patients. METHODS: Retrospective cohort study conducted in an Italian general intensive care unit. We enrolled patients on invasive mechanical ventilation and treated with prone positioning. We recorded short term complications from the data chart and long-term complications from the scheduled follow-up visit, three months after intensive care discharge. RESULTS: A total of 96 patients were included in the study. Median time for each prone positioning cycle (302 cycles) was equal to 18 (16-32) hours. In 37 (38%) patients at least one cycle of extended pronation was implemented. Patients with at least one pressure sore due to prone position were 38 (40%). Patients with pressure sores showed a statistically significative difference in intensive care length of stay, mechanical ventilation days, numbers of prone position cycles, total time spent in prone position and the use of extended prone position, compared to patients without pressure sores. All lesions were low grade. Cheekbones (18%) and chin (10%) were the most affected sites. Follow-up visit, scheduled three months after intensive care discharge, was possible in 58 patients. All patients were able to have all 12 muscle groups examined using theMedical Research Council scale examination. No patient reported sensory loss or presence of neuropathic pain for upper limbs. CONCLUSIONS: Extended prone position is feasible and might reduce the workload on healthcare workers without significant increase of major prone position related complications.

Association of Severe Tongue Edema With Prone Positioning in Patients Intubated for COVID-19.

OBJECTIVES/HYPOTHESIS: Prone positioning is frequently used in patients intubated for COVID-19-related lung injury to improve oxygenation. At our institution, we observed severe tongue edema develop in some of these patients. Hence, we sought to determine the incidence of tongue edema in this cohort and whether prone positioning was a risk factor associated with this complication. STUDY DESIGN: Retrospective cohort study. METHODS: A single-system retrospective cohort study of patients intubated for respiratory failure secondary to COVID-19 who subsequently developed clinically notable tongue edema from March 13 to July 5, 2020. RESULTS: 260 patients were intubated for COVID-19-related respiratory failure during the study period. 158 patients (60.8%) underwent at least one episode of proning. Twelve patients in total (4.6%) developed clinically significant tongue edema. Eleven of the twelve patients (91.7%) who developed tongue edema underwent proning prior to the development of edema. Prone positioning was associated with an increased incidence of tongue edema (odds ratio [OR] 7.56, 95% confidence interval [CI] 0.96-59.46, P = .027). In all proned patients who developed edema, this complication was noted during proning or shortly after supination (range, 0-4 days). Tongue edema was primarily managed with conservative measures; one patient required tracheostomy for definitive management. CONCLUSIONS: Tongue edema appears to develop in a subset of patients with COVID-19 who are intubated. It appears to be associated with prone positioning but is likely multifactorial in nature. Further investigation into its incidence and pathophysiology is warranted. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:287-289, 2022.

Infection related catheter complications in patients undergoing prone positioning for acute respiratory distress syndrome: an exposed/unexposed study.

BACKGROUND: Prone positioning (PP) is a standard of care for patients with moderate-severe acute respiratory distress syndrome (ARDS). While adverse events associated with PP are well-documented in the literature, research examining the effect of PP on the risk of infectious complications of intravascular catheters is lacking. METHOD: All consecutive ARDS patients treated with PP were recruited retrospectively over a two-year period and formed the exposed group. Intensive care unit (ICU) patients during the same period without ARDS for whom PP was not conducted but who had an equivalent disease severity were matched 1:1 to the exposed group based on age, sex, centre, length of ICU stay and SAPS II (unexposed group). Infection-related catheter complications were defined by a composite criterion, including catheter tip colonization or intravascular catheter-related infection. RESULTS: A total of 101 exposed patients were included in the study. Most had direct ARDS (pneumonia). The median [Q1-Q3] PP session number was 2 [1-4]. These patients were matched with 101 unexposed patients. The mortality rates of the exposed and unexposed groups were 31 and 30%, respectively. The incidence of the composite criterion was 14.2/1000 in the exposed group compared with 8.2/1000 days in the control group (p = 0.09). Multivariate analysis identified PP as a factor related to catheter colonization or infection (p = 0.04). CONCLUSION: Our data suggest that PP is associated with a higher risk of CVC infectious complications.

Full-Thickness Facial Pressure Injury and Buried Dentition from Prone Positioning in a Patient with COVID-19.

ABSTRACT: Prone positioning is recognized for its efficacy in the treatment of acute respiratory distress syndrome related to COVID-19. Here the authors present a case of a facial pressure injury and buried dentition that occurred as a result of prolonged prone positioning in a patient who was COVID-19 positive. The patient was treated with primary closure of the injury and pressure offloading.

Brachial plexopathy as a complication of COVID-19.

COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.

The Face of COVID-19: Facial Pressure Wounds Related to Prone Positioning in Patients Undergoing Ventilation in the Intensive Care Unit.

In the setting of COVID-19 (coronavirus disease 2019)-associated moderate and severe acute respiratory distress, persistently hypoxemic patients often require prone positioning for >16 hours. We report facial pressure wounds and ear necrosis as a consequence of prone positioning in patients undergoing ventilation in the intensive care unit in a tertiary medical center in New York City.

Nerve Compression Injuries After Prolonged Prone Position Ventilation in Patients With SARS-CoV-2: A Case Series.

BACKGROUND: Prone positioning improves oxygenation in adult respiratory distress syndrome. This procedure has been widely used during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. However, this procedure can also be responsible for nerve damage and plexopathy. METHODS: We retrospectively reviewed a series of 7 infectious patients with coronavirus disease 2019 who underwent prone positioning ventilation at the San Raffaele Hospital of Milan, Italy, during the SARS-CoV-2 pandemic. RESULTS: Clinical and neurophysiological data of 7 patients with nerve compression injuries have been reported. CONCLUSIONS: Health care workers should take into consideration the risk factors for prone positioning-related plexopathy and nerve damage, especially in patients with coronavirus disease 2019, to prevent this type of complication.

Case series of acute peritoneal dialysis in the prone position for acute kidney injury during the Covid-19 pandemic: Prone to complications?

Patients with kidney failure and acute respiratory distress syndrome (ARDS) requiring prone position have not been candidates for peritoneal dialysis (PD) due to concern with increased intra-abdominal pressure, reduction in respiratory system compliance and risks of peritoneal fluid leaks. We describe our experience in delivering acute PD during the surge in Covid-19 acute kidney injury (AKI) in the subset of patients requiring prone positioning. All seven patients included in this report were admitted to the intensive care unit with SARS-CoV-2 infection leading to ARDS, AKI and multisystem organ failure. All required renal replacement therapy, and prone positioning to improve ventilation/perfusion mismatch. All seven were able to continue PD despite prone positioning without any detrimental effects on respiratory mechanics or the need to switch to a different modality. Fluid leakage was noted in 71% of patients, but mild and readily resolved. We were able to successfully implement acute PD in ventilator-dependent prone patients suffering from Covid-19-related AKI. This required a team effort and some modifications in the conventional PD prescription and delivery.

Facial Pressure Injuries from Prone Positioning in the COVID-19 Era.

OBJECTIVE/HYPOTHESIS: This study aimed to determine the incidence of facial pressure injuries associated with prone positioning for COVID-19 patients as well as to characterize the location of injuries and treatments provided. METHODS: This was a retrospective chart review of 263 COVID-19 positive patients requiring intubation in the intensive care units at MedStar Georgetown University Hospital and MedStar Washington Hospital Center between March 1st and July 26th, 2020. Information regarding proning status, duration of proning, presence, or absence of facial pressure injuries and interventions were collected. Paired two-tailed t-test was used to evaluate differences between proned patients who developed pressure injuries with those who did not. RESULTS: Overall, 143 COVID-19 positive patients required proning while intubated with the average duration of proning being 5.15 days. Of those proned, 68 (47.6%) developed a facial pressure injury. The most common site involved was the cheek with a total of 57 (84%) followed by ears (50%). The average duration of proning for patients who developed a pressure injury was significantly longer when compared to those who did not develop pressure injuries (6.79 days vs. 3.64 days, P < .001). CONCLUSIONS: Facial pressure injuries occur with high incidence in patients with COVID-19 who undergo prone positioning. Longer duration of proning appears to confer greater risk for developing these pressure injuries. Hence, improved preventative measures and early interventions are needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2139-E2142, 2021.

Prone position pressure sores in the COVID-19 pandemic: The Madrid experience.

BACKGROUND: In the context of the COVID-19 pandemic, prone position (PP) has been frequently used in the intensive care units to improve the prognosis in patients with respiratory distress. However, turning patients to prone imply important complications such as pressure ulcers. The aim of this paper is to describe the prevalence and characteristics of prone-positioning pressure sores (PPPS) and analyze the related risk factors. METHODS: A case-control study was performed in Gregorio Maranon hospital in Madrid during the COVID-19 pandemic between April and May 2020. We enrolled 74 confirmed COVID-19 patients in critical care units with invasive mechanical ventilation who were treated with pronation therapy. There were 57 cases and 17 controls. Demographic data, pronation maneuver characteristics and PPPS features were analyzed. RESULTS: In the case group, a total number of 136 PPPS were recorded. The face was the most affected region (69%). Regarding the severity, stage II was the most frequent. The main variables associated with an increased risk of PPPS were the total number of days under pronation cycles, and PP maintained for more than 24 h. The prealbumin level at admission was significantly lower in the case group. All of the ulcers were treated with dressings. The most frequent acute complication was bleeding (5%). CONCLUSIONS: According to our study, PPPS are related to the characteristics of the maneuver and the previous nutritional state. The implementation of improved positioning protocols may enhance results in critical patient caring, to avoid the scars and social stigma that these injuries entail.