Lessons from an ICU recovery clinic: two cases of meralgia paresthetica after prone positioning to treat COVID-19-associated ARDS and modification of unit practices

Abstract

Prone positioning is one of the few interventions in acute respiratory distress syndrome (ARDS) which has a proven mortality reduction [1]. Due to the coronavirus disease 2019 (COVID-19) pandemic, severe ARDS cases have sharply increased worldwide, increasing the need for proning. Some centers have also encouraged non-intubated patients with hypoxemia due to COVID-19 to self-prone [2] Although generally considered low risk, pressure-related complications can occur during proning and differ from those that occur in supine patients. We present two cases of COVID-19-associated ARDS treated with prone positioning who developed meralgia paresthetica that was diagnosed in our ICU recovery clinic. Meralgia paresthetica (MP) results from compression injury of the lateral femoral cutaneous nerve between the anterior superior iliac spine and the inguinal ligament (Fig. 1); this mononeuropathy results in sensory abnormalities in the anterolateral thigh [3]. To our knowledge, there is only one other reported case of MP in prone positioning for ARDS, although it has been reported after surgical prone positioning in up to 24% of cases [4, 5]. The first patient was a 53-year-old man with diabetes (well-controlled, glycosylated hemoglobin 6.5 to 7.0%), obesity (BMI 30.9), and hypertension, who was mechanically ventilated for 11 days. He had a single session of proning for 16 h. He was extubated and discharged home on day 19 of admission. During his ICU recovery clinic visit (2 months after discharge), he reported isolated left-sided, welldemarcated anterior thigh numbness, new since his hospital stay. He had no associated weakness or pain, though did also endorse some non-painful numbness and tingling in

Central and peripheral nervous system complications of COVID-19: a prospective tertiary center cohort with 3-month follow-up

“…Two of our patients were diagnosed with meralgia paresthetica, which has been reported as a complication following mechanical ventilation in the prone position in non-COVID-19 [ 36 ] and in COVID-19 patients [ 37 ]. As prone positioning in acute respiratory distress syndrome (ARDS) is strongly recommended [ 38 ] (and was performed in 61.7% of our ICU population), attention to peripheral nerve injury in COVID-19 ICU survivors seems warranted [ 39 ].…”

“…Our patient with rhabdomyolysis and acute myopathy had no obvious cause for muscle injury other than COVID-19, but we were unable to obtain a muscle biopsy to determine if there were signs of direct viral invasion or inflammatory cell infiltrates. Two of our patients were diagnosed with meralgia paresthetica, which has been reported as a complication following mechanical ventilation in the prone position in non-COVID- 19 [36] and in COVID-19 patients [37]. As prone positioning in acute respiratory distress syndrome (ARDS) is strongly recommended [38] (and was performed in 61.7% of our ICU population), attention to peripheral nerve injury in COVID-19 ICU survivors seems warranted [39].…”

Central and peripheral nervous system complications of COVID-19: A prospective tertiary center cohort with 3-month follow-up

“…Two of our patients were diagnosed with meralgia paresthetica, which has been reported as a complication following mechanical ventilation in the prone position in non-COVID-19 [34] and in COVID-19 patients [35]. As prone positioning in acute respiratory distress syndrome (ARDS) is strongly recommended [36] (and was performed in 61.7% of our ICU population), attention to peripheral nerve injury in COVID-19 ICU survivors seems warranted [37].…”

Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers

“…The latter complication is a result of compression injury of the lateral femoral cutaneous nerve. 36 The side of the swimmers position changes frequently, preferably every 2 or 3 hours. Full flexion of the knees should be possible, with a maximum range of ankle motion to prevent stiffness and pointed feet.…”