Electrocardiogram monitoring in the prone position in coronavirus disease 2019 acute respiratory distress syndrome

Abstract

Aims Prone positioning is increasingly used for treating coronavirus disease 2019 (COVID-19)-induced acute respiratory distress syndrome (ARDS). In these high-risk patients for cardiovascular events who may spend more than 16 h a day in the prone position, an adequate monitoring of electrocardiogram (ECG) is mandatory. However, effects of prone positioning on the ECG are unknown as is the validity of the ECG recorded with electrodes placed dorsally. We aimed to compare ECG data obtained in the prone position from five electrodes positioned conventionally and dorsally, and to assess the effects of the change of position (from supine to prone) on the ECGs in patients with COVID-19 ARDS. Methods and results In patients with COVID-19 ARDS for whom the prone position was indicated, seven-lead ECG (frontal plane leads and V6) performed in the supine and the prone position with electrodes positioned conventionally and dorsally were compared. A total of 22 patients [20 (91%) males] were included. Among them, 10 (45%) patients had structural or ischaemic heart disease. After prone positioning, PR duration significantly increased and QRS duration significantly decreased whereas QT interval did not significantly change. In the prone position, there were excellent correlations between QRS axis, PR, RR, QRS, and QT intervals durations measured with electrodes placed on the torso and dorsally (with no change in the position of V6). Conclusion Prone positioning induced significant change in the ECG. In the prone position, ECG can be reliably monitored with four electrodes translated from conventional position to the back and with a precordial electrode left in V6 position.

Easily Neglected Manifestations in Electrocardiogram in the Prone Position

“…9 The difference in QT and PR intervals between these 2 ECG modalities is controversial. 6,7,10 Moreover, the prone ECG may cause STsegment elevation of the anterior chest, which results in precordial leads being neglected. 6 At present, the diagnostic criteria for STEMI are based on a supine ECG of at least 2 contiguous leads with ST-segment elevation of at least 1 mm.…”

“…(4) Intervals: QRS durations in the prone position are significantly shorter than those in the supine position . The difference in QT and PR intervals between these 2 ECG modalities is controversial . Moreover, the prone ECG may cause ST-segment elevation of the anterior chest, which results in precordial leads being neglected …”

Comparison of parameter types for the calibration of noninvasive continuous cardiac output monitoring of patients undergoing lumbar spinal surgery in the prone position

“…In addition to the comparable trending ability of esCCO with that of TEE, esCCO is noninvasive and easily accessible. A recent study revealed an excellent correlation between the ECG parameters in the supine and prone positions when detecting the QRS axis, PR, RR, QRS, and QT intervals with electrodes placed on the torso and dorsal aspect [23]. In addition, since the distance from the heart to the fingertip, where the upstroke of pulse oximetry is detected, does not change according to the patient's position, the prone position does not influence the quality of PWTT and esCCO.…”

“…Judging from a previous study [23] and the principle of the esCCO system, the prone position itself may not interfere with the ability of esCCO to estimate CO. Further studies should determine the ability of esCCO under different circumstances as it may be useful and feasible for continuous monitoring CO in other noncardiac surgeries performed in the prone position.…”

Prone Positioning and Neuromuscular Blocking Agents as Adjunctive Therapies in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome

“…54 Finally, the reduction in magnitude of QRS complexes on surface electrocardiography in PP suggests a reduction in cardiac volume and an increase in PR length linked to a better venous return. 55…”