Prone Positioning as a Potential Risk Factor for Deep Vein Thrombosis in COVID-19 Patients: A Hypothesis Generating Observation

Abstract

Aims of the study: Virchow’s triad with stasis, activated coagulation, and endothelial damage is common in SARS-CoV2. Therefore, we sought to retrospectively assess whether the duration of prone position may serve as a risk factor for deep vein thrombosis in critically ill patients. Methods: In this single center retrospective study of a tertiary referral hospital, patients with acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia admitted to critical care underwent venous ultrasound screening for deep vein thrombosis (DVT). Data on DVT diagnosis, duration of prone positioning, demographic, respiratory, and laboratory parameters were retrospectively collected and compared between DVT and non-DVT patients. Results: 21 patients with ARDS from COVID-19 pneumonia were analyzed. DVT was detected in 11 (52%) patients (76.2% male, median age 64 (58; 68.5) years, median body mass index 31 (27; 33.8) kg/m2). In patients diagnosed with DVT, median prone ventilation had been maintained twice as long as compared to patients without DVT (57 (19; 72) versus 28 (0; 56.3) h, p = 0.227) on ICU day 5 with a trend towards longer prone position time (71 (19; 104) versus 28 (0; 73) h, p = 0.06) on ICU day 7. Conclusions: Prone ventilation and constitutional factors may constitute an additional risk factor for DVT in COVID-19 patients. Since recent studies have shown that therapeutic anticoagulation does not impact the occurrence of thromboembolic events, it may be worthwhile to consider mechanical factors potentially affecting blood flow stasis in this high-risk population. However, due to the limited number of patients, our observations should only be considered as hypothesis-generating. Future studies, sufficiently powered and preferably prospective, will be needed to confirm our hypothesis.

Brachial plexopathy as a result of anatomical prone position in COVID‐19 patients—Systematic review

“…Prone position has been widely recognized as an appropriate method to assist in ventilating a patient with ARDS (Guérin et al, 2013;Intensive Care Society, 2021). There are many variations of this positioning method (González-Seguel et al, 2021). It is caused by the constant search for the optimal position with the least possible Another important aspect of the prone position is the duration of timing in this position.…”

“…What is more hypovolemia and hypothermia have also negative influence on nerve function (King-Robson et al, 2022). During the prone position, special attention should be paid to the risk of deep vein thrombosis, as there are indications that increased blood stasis during the prone position may promote thrombosis (Gebhard et al, 2022).…”

“…According to our data, this is the first review with the main objective of analyzing brachial plexus palsy as a consequence of the prone position in COVID-19 patients. Previous reviews have included: peripheral nerve damage (Andalib et al, 2021;Finsterer et al, 2021) and its imaging (Fernandez et al, 2021), or the side effects of the prone position in COVID-19 patients in general (González-Seguel et al, 2021;Santos et al, 2021). Only one article specifically revolve around brachial plexopathy in the prone position, but focused more on patient positioning and prevention of this damage (Simpson et al, 2020).…”

“…Patients in the prone position can be placed in a complete or incomplete prone position, or in a Reverse Trendelenburg position. Other variables that affect position may include pillow use, appropriate care measures like repositioning or alternate face rotation, and characteristics of the bed or mattress(González-Seguel et al, 2021). Therefore, the mere statement that the patient was in the prone position does not precisely inform what exactly position he was in, due to the huge number of variables within the same-called "prone" position.…”

Prone Position and the Risk of Venous Thrombosis in COVID-19 Patients with Respiratory Failure

“…The number of prone positions per patient (5.3 AE 2.4 vs. 3.2 AE 2.3; p ¼ 0.04) and the cumulative number of days spent in the prone position (7.5 AE 2.7 vs. 4.8 AE 3.1; p ¼ 0.03) was significantly higher in patients with acute PE than in those without. In another study published by Gebhard et al, 5 the authors screened for deep vein thrombosis (DVT) 21 COVID-19 patients (median age, 64 years, interquartile range [IQR], 58-68 years; 76 men) who developed ARDS and required intensive management. After 7 days in the ICU, the prone position time was found to be longer in patients who were diagnosed with DVT (n ¼ 11; median prone positioning time, 71 hours; IQR: 19-104 hours) compared with those who were not (n ¼ 10; median prone positioning time, 28 hours; IQR: 0-73 hours; p ¼ 0.01).…”