Prone positioning plexopathies - A retrospective case series

ABSTRACT

Introduction: Due to the COVID-19 pandemic, and increased use of prone positioning, there has been an increase in observed plexopathies. Objectives: To retrospectively analyse data of all COVID-19 admissions to the ICU of an acute hospital, to identify both the prevalence and risk factors for nerve injuries post prone positioning. As well as reviewing current guidance to facilitate best practice and optimise rehabilitation following nerve injury. Methods: Data from the Norfolk and Norwich University Hospital, a large teaching hospital, was retrospectively collected from the hospitals electronic clinical records system. Data was reviewed for all COVID-19 patients admitted from March-June 2020 and October 2020-March 2021. Patients with nerve injuries were diagnosed from physiotherapy assessment as there were no electrophysiology studies available. Results: 45 patients were admitted during the first wave. Of these, 1 peroneal nerve injury was identified (2.2% of all patients). Throughout the second wave 225 patients were admitted, with 10 isolated nerve injuries identified in 7 patients. These included 6 lower limb injuries (peroneal nerve) and 4 upper limb injuries (brachial plexus or ulnar nerve). This equates to 3.1% of patients. All these patients were nursed prone during their ITU admission, and no nerve injuries were found in patients who were not proned. Characteristics of the patients can be seen in Table 1. In comparison, Miller et al. (2021) found 5.9% of all COVID-19 patients admitted to a large UK hospital suffered an upper limb nerve injury. Malik et al. (2020) found nerve injuries (upper and lower) in 14% of patients. However, both studies took place in rehab settings, not acute. On average, nerve injuries were diagnosed on day 26 of admission. Early diagnosis is difficult due to prolonged sedation, delirium, and ICU-acquired weakness masking nerve injuries. Therefore, it is likely that the incidence of injury is higher than demonstrated in this series. Data was missing for 4 patients who were transferred in from other ICUs in the region. However, number of prone episodes varied from 1 to 6, and total hours spent in prone varied from 15 to 106. Conclusion: This case series demonstrates that nerve injuries are a consequence of prone positioning. Although a very small sample, there seems to be no relation to the frequency of proning or the number of hour's proned. Achieving optimum positioning to avoid complications is imperative. This was likely made more difficult in the pandemic due to the cohort of patients (high BMI, large number of co-morbidities) and undue stress with temporary surge support staff and an extreme number of patients. Guidance has now been published for positioning to avoid brachial plexus injuries (Quick & Brown, 2020). However, there is no guidance published regarding lower limb injuries, which in this case series were more common. In our trust we are in the process of adjusting our proning SOP accordingly to include the above guidelines, as well as an awareness of lower limb positioning to avoid compression or traction. It is important that there is a clear individualised pathway in place.