The Down Side of Prone Positioning

Abstract

The coronavirus 2019 (COVID-19) pandemic has resulted in a surge of patients with acute respiratory distress syndrome (ARDS). Prone positioning may be used in such patients to optimize oxygenation. Severe infections may leave survivors with significant functional impairment necessitating rehabilitation. Those who have experienced prolonged prone positioning are at increased risk for complications not typically associated with critical illness. This case report describes the course and clinical findings of a survivor of ARDS due to COVID-19 who was prone positioned while in intensive care and subsequently admitted to an inpatient rehabilitation facility. Her related complications, as well as those described in the literature, are reviewed. Critical elements of a comprehensive rehabilitation treatment plan for those who have been prone positioned, including implementation of preventive strategies, as well as early recognition and treatment of related injuries, will be described.

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 ].…”

Musculoskeletal involvement of COVID-19: review of imaging

“…Iatrogenic peripheral neuropathy has been reported in the setting of COVID-19 with a higher-than-expected incidence, raising the possibility that the SARS-CoV-2 virus may predispose peripheral nerves to injury via theoretical mechanisms that have yet to be firmly established [ 12 , 19 , 20 ]. COVID-19 patients may plausibly be more susceptible to iatrogenic nerve injuries secondary to a virus-induced state of hyperinflammation or overlapping comorbidities that predispose to both nerve injury and severe COVID-19 symptoms that necessitate hospitalization [ 20 ].…”

“…Potential sites include the iliac crests, knees, anterior chest wall, and face. Obesity, male gender, and older age are risk factors for prone-related pressure injuries [ 19 ]. Imaging is generally not indicated unless there is clinical concern for superimposed infection potentially causing soft tissue abscess or osteomyelitis.…”

Cutaneous Manifestations of COVID-19 in the Inpatient Setting

“…While a pressure component may contribute to the development of retiform purpura, these lesions were also present in patients who were intermittently proned. 26 , 27 Many patients were started on therapeutic anticoagulation during their hospital course due to increasing d-dimer and suspected or confirmed thrombotic events. 20 , 28 Although anticoagulation in severe cases of COVID-19 has been shown to reduce mortality, both the exact dosing and the timing of anticoagulation initiation in these patients remain to be determined.…”

“…Additionally, acrofacial purpura and necrosis associated with minor pressure injuries due to direct contact with medical devices such as nasal cannulas, endotracheal tubes, or pulse oximeters has been reported in COVID-19 patients. 26 , 27 Importantly, given that many COVID-19 patients are placed in a prone position to improve oxygenation status, pressure-associated ulceration and necrosis can occur in a unique distribution such as the bilateral cheeks compared to the usual locations such as the sacrum and heels. As ulcerations can serve as portals of entry for microbes leading to infection, it is critical to monitor patients closely to prevent additional morbidity and mortality.…”