Meralgia Paraesthetica after Prone Position Ventilation in a Patient with COVID-19

Background and objectives: One of the most feared complications of COVID-19 is respiratory failure caused by acute respiratory distress syndrome. In order to improve oxygenation and survival, patients admitted to intensive care units and intubated may undergo prone position mechanical ventilation. Prolonged prone positioning may cause meralgia paraesthetica due to lateral femoral cutaneous nerve entrapment between the inguinal ligament and the anterior superior iliac spine. Reports of the first two cases have been recently published. Case presentation: We describe the case of a 52-year-old man with respiratory failure during COVID-19 infection, who underwent prone position ventilation for 16 hours a day over 19 days and developed persistent burning pain and dysaesthesia on the lateral surface of the thigh bilaterally, diagnosed as meralgia paraesthetica. Conclusion: This is the second report describing meralgia paraesthetica following prone position ventilation in COVID-19. Given the ongoing pandemic and the inevitability of more patients with severe respiratory distress requiring prone position ventilation, this disabling entrapment condition should be considered and possibly prevented.

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Standard care vs. awake prone position in adult non-intubated patients with acute hypoxaemic respiratory failure secondary to COVID-19 infection – A multi-centre feasibility randomized controlled trial

10.1101/2021.03.13.21253499 ◽

2021 ◽

Author(s):

Devachandran Jayakumar ◽

Pratheema Ramachandran ◽

Ebenezer Rabindrarajan ◽

Bharath Kumar Tirupakuzhi Vijayaraghavan ◽

Nagarajan Ramakrishnan ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Standard Care ◽

Distress Syndrome ◽

Prone Positioning ◽

Hypoxic Respiratory Failure ◽

Secondary Outcomes

AbstractBackgroundThe primary manifestation of Corona Virus Disease −2019 (COVID-19) is acute hypoxic respiratory failure secondary to pneumonia and/or acute respiratory distress syndrome. Prone position has been shown to improve outcomes in ventilated patients with moderate to severe acute respiratory distress syndrome. The feasibility and safety of awake prone positioning and its impact on outcomes if any, in non-intubated patients with mild to moderate acute respiratory distress syndrome secondary to COVID-19 is unknown. Results of the observational studies published thus far in this pandemic have been conflicting. In this context, we conducted a multi-centre, parallel group, randomised controlled feasibility study on awake prone positioning in non-intubated patients with COVID-19 pneumonia requiring supplemental oxygen.Methods60 patients diagnosed with acute hypoxic respiratory failure secondary to COVID −19 pneumonia requiring 4 or more litres of oxygen to maintain a saturation of ≥ 92% were recruited in this study. Thirty patients each were randomised to either standard care or awake prone group. Patients randomised to the standard care were allowed to change their position as per comfort and patients randomized to the prone group were encouraged to self-prone for at least 6 hours a day. The primary outcome was the proportion of patients adhering to the protocol in each group. Secondary outcomes include failure of therapy leading to escalation of respiratory support, number of hours prone, maximum hours of continuous prone positioning in a day, length of stay in ICU, ICU mortality, total number of patients needing intubation and adverse events.ResultsIn the prone group, 43% (13 out of 30) of patients were able to self-prone for 6 or more hours a day. The median maximum prone duration per session was 2 hours. In the supine group, 47% (14 out of 30) were completely supine and 53% spent some hours in the prone position, but none exceeded 6 hours. There was no significant difference in any of the secondary outcomes between the two groups and there were no adverse events.InterpretationAwake proning in non-intubated patients with acute hypoxic respiratory failure is feasible and safe under clinical trial conditions. The results of our feasibility study will potentially help in the design of larger definitive trials to address this key knowledge gap.

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Use of the prone position in the acute respiratory distress syndrome: how should we assess benefit?

Clinical Science ◽

10.1042/cs20060068 ◽

2006 ◽

Vol 110 (6) ◽

pp. 641-643

Author(s):

David F. Treacher

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Lung Volume ◽

Distress Syndrome ◽

Prone Positioning ◽

Interesting Study ◽

Serial Measurements

Prone positioning of patients with acute respiratory failure was first suggested over 30 years ago. In the present issue of Clinical Science, Reutershan and co-workers have studied the changes in end-expiratory lung volume in 12 patients with ARDS (acute respiratory distress syndrome) over an 8 h period following manual turning from the supine to prone position. From the data presented, the authors suggest that baseline end-expiratory lung volume could be used to identify responders, and serial measurements would permit appropriate ‘dosing’ of the therapy. Although this is an interesting study that provides data that have rarely been collected when assessing the response to prone positioning, there are a number of limitations that need to be considered. However, despite the limitations, the study does stimulate a number of important questions related not only to the use of the prone position, but also to the management of patients with ARDS in general.

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Additive Effect of Nitric Oxide Inhalation on the Oxygenation Benefit of the Prone Position in the Adult Respiratory Distress Syndrome

Anesthesiology ◽

10.1097/00000542-199812000-00017 ◽

1998 ◽

Vol 89 (6) ◽

pp. 1401-1406 ◽

Cited By ~ 29

Author(s):

Peter Germann ◽

Gerald Poschl ◽

Christian Leitner ◽

Georg Urak ◽

Roman Ullrich ◽

...

Keyword(s):

Nitric Oxide ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Adult Respiratory Distress Syndrome ◽

Prone Position ◽

Supine Position ◽

Distress Syndrome ◽

Lung Injury Score ◽

Prone Positioning ◽

Nitric Oxide Inhalation

Background The response to inhaled nitric oxide and prone positioning was investigated in 47 patients with adult respiratory distress syndrome to test the hypothesis that inhalation of nitric oxide when in the prone position would result in additive improvement in oxygenation. Methods The authors prospectively studied patients of both genders who were 15 to 75 yr old and had adult respiratory distress syndrome confirmed by computed tomography (lung injury score, 3.1+/-1). Results Compared with baseline values in the supine position (T1), inhalation of 10 ppm nitric oxide for 1 h (T2) decreased the mean pulmonary artery pressure from 33+/-9 mmHg to 28+/-6 mmHg (P < 0.05; T2 vs. T1) and increased the ratio of the partial pressure of oxygen in arterial blood (PaO2) to inspired oxygen concentration (FiO2) from 115 (median first quartile [Q1] 97, median third quartile [Q3] 137) to 148 (Q1 132, Q3 196) (P < 0.05; T2 vs. T1). Cessation of nitric oxide brought the values back to baseline (T3). Two hours of prone positioning (T4) significantly increased the PaO2:FiO2 ratio (T4 vs. T3). However, after an additional hour of nitric oxide inhalation in the prone position (T5), a significant decrease of the venous admixture (from 33+/-6% to 25+/-6%; P < 0.05) and an increase of the PaO2:FiO2 ratio (from 165 [Q1 129, Q3 216] to 199 [Q1 178, Q3 316] [P < 0.05; T5 vs. T4]) were observed. Conclusions In patients with isolated severe adult respiratory distress syndrome, inhalation of nitric oxide in the prone position significantly improved oxygenation compared with nitric oxide inhalation in the supine position or in the prone position without nitric oxide. The combination of the prone position with nitric oxide inhalation in the treatment of severe adult respiratory distress syndrome should be considered.

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Prone positioning of patients with acute respiratory distress syndrome: a systematic review

American Journal of Critical Care ◽

10.4037/ajcc1999.8.6.397 ◽

1999 ◽

Vol 8 (6) ◽

pp. 397-405 ◽

Cited By ~ 36

Author(s):

MA Curley

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

English Language ◽

Distress Syndrome ◽

Phase 1 ◽

Corneal Transplantation ◽

Prone Positioning ◽

Bibliographic Search

A computerized bibliographic search of published research and a citation review of English-language publications about prone positioning of patients with acute respiratory distress syndrome were done. Information on prone positioning related to technique, patients' responses, complications, and recommendations to prevent complications was extracted. In the 20 pertinent clinical studies found, 297 patients (mean age, 39 years) with acute respiratory failure were positioned prone. Timing from the onset of respiratory failure to when the patient was first positioned prone varied, as did the frequency of prone positioning. Patients spent from 30 minutes to 42 hours prone. In 47% of the studies in which abdominal position was noted, chest and pelvic cushions were used to allow the abdomen to protrude while the patient was prone. Improved oxygenation within 2 hours was reported in 69% of patients, and the improvements were cumulative and persistent. Aside from early intervention, factors predictive of patients' responses were inconsistent, and patients' initial responses were not predictive of subsequent responses. Iatrogenic critical events were rare. Dependent edema of the face was prevalent. Pressure ulcers were reported in studies with longer periods of prone positioning. The most serious complication, corneal abrasion requiring corneal transplantation, was reported in one patient. Clinical knowledge about prone positioning is limited. Phase 1 studies focusing on how to safely turn and care for critically ill patients positioned prone for prolonged periods are needed.

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Prone Positioning in Severe Acute Respiratory Distress Syndrome

50 Studies Every Intensivist Should Know ◽

10.1093/med/9780190467654.003.0021 ◽

2018 ◽

pp. 129-134

Author(s):

Andrea Coppadoro ◽

Guiseppe Foti

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Protective Ventilation ◽

Prone Positioning ◽

Stabilization Period

The PROSEVA trial shows improved survival with prone positioning in patients affected by moderate/severe ARDS. Prone positioning resulted effective in patients with moderate/severe ARDS persisting after a 12–24 hours stabilization period, admitted to centers with proven experience with prone position. Patients were ventilated with protective ventilation (6 ml/kg) and a PEEP of about 10 cm H2O. Prone position sessions lasted for at least 16 hours, and patients randomized to prone position were kept supine only if their PaO2/FiO2 consistently improved. Improved survival was not associated with improvement in pH, PaCO2, or PaO2; therefore a “response” to prone position is not necessarily a marker of improvement. Incidence of complications did not differ significantly between the two groups, except for cardiac arrests, which was higher in the supine group.

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Prone Positioning in Acute Respiratory Distress Syndrome

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0039-1685180 ◽

2019 ◽

Vol 40 (01) ◽

pp. 094-100 ◽

Cited By ~ 21

Author(s):

Luciano Gattinoni ◽

Mattia Busana ◽

Lorenzo Giosa ◽

Matteo Macrì ◽

Michael Quintel

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Prone Positioning ◽

Effective Strategies ◽

Positive Effects ◽

History Of ◽

Chest Wall Elastance

AbstractProne positioning is nowadays considered as one of the most effective strategies for patients with severe acute respiratory distress syndrome (ARDS). The evolution of the pathophysiological understanding surrounding the prone position closely follows the history of ARDS. At the beginning, the focus of the prone position was the improvement in oxygenation attributed to a perfusion redistribution. However, the mechanisms behind the prone position are more complex. Indeed, the positive effects on oxygenation and CO2 clearance of the prone position are to be ascribed to a more homogeneous inflation–ventilation, to the lung/thoracic shape mismatch, and to the change of chest wall elastance. In the past 20 years, five major trials have tried, starting from different theories, hypotheses, and designs, to demonstrate the effectiveness of the prone position, which finally found its definitive place among the different ARDS supportive therapies.

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Prone Positioning in Patients With Acute Respiratory Distress Syndrome and Other Respiratory Conditions: Challenges, Complications, and Solutions

Patient Safety ◽

10.33940/data/2020.12.1 ◽

2020 ◽

pp. 11-23

Author(s):

Lea Gardner

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Extended Period ◽

Ischemic Optic Neuropathy ◽

Safety Reporting ◽

Unplanned Extubations

Acute respiratory distress syndrome (ARDS) and respiratory failure are characterized by hypoxemia, i.e., low levels of blood oxygen. Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from January 1, 2010, through June 30, 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.

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Isolation of Human Surfactant from Amniotic Fluid and a Pilot Study of Its Efficacy in Respiratory Distress Syndrome

PEDIATRICS ◽

10.1542/peds.71.4.473 ◽

1983 ◽

Vol 71 (4) ◽

pp. 473-482 ◽

Cited By ~ 2

Author(s):

Mikko Hailman ◽

T. Allen Merritt ◽

Howard Schneider ◽

Benita L. Epstein ◽

Frank Mannino ◽

...

Keyword(s):

Respiratory Failure ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Amniotic Fluid ◽

Distress Syndrome ◽

Very Low Birth Weight ◽

Pulmonary Complications ◽

Low Birth Weight Infants ◽

Severe Respiratory Distress ◽

Surfactant Administration

Isolation of a sterile, surface-active human surfactant complex from amniotic fluid is described. Its effects on respiratory failure of five very low-birth-weight infants (974 ± 61 g) with severe RDS were studied before and after surfactant administration and were compared with those of a similar group of untreated infants with severe respiratory distress syndrome (RDS). Human surfactant (60 mg/kg) in 3.5 mL of saline was given as a single bolus intratracheally 6 ± 1 hours after birth with the following effects: Pao2 increased from 69 ± 11 mm Hg to 239 ± 19 mm Hg within five minutes, and within 1 hour fraction of inspired oxygen (FiO2) decreased from 0.94 ± 0.03 to 0.49 ± 0.03, mechanical ventilator pressure requirements decreased significantly, PaCo2 dropped, and the pH increased. Air bronchograms on chest roentgenograms lessened within five hours. In four infants the beneficial effects lasted eight to 15 hours, and although thereafter their respiratory conditions deteriorated somewhat, the RDS was less severe than before surfactant administration, and there were no associated pulmonary complications. However, a fifth infant had severe respiratory failure after striking improvement that lasted fewer than three hours, and subsequent interstitial emphysema, bronchopulmonary dysplasia, and intraventricular hemorrhage occurred. There were no detectable side effects with surfactant administration, although a search for immunologic complications continues. Protease activity in lung effluent from the treated infants was lower during the first week of life than among the comparison group, suggesting a lessening of lung injury by surfactant treatment. RDS among patients treated with one dose of human surfactant tended to be milder overall than RDS among control subjects.

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Severe COVID-19 acute respiratory distress syndrome in an adult with single-ventricle physiology: a case report

BMC Anesthesiology ◽

10.1186/s12871-021-01504-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Götz Schmidt ◽

Christian Koch ◽

Matthias Wolff ◽

Michael Sander

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Single Ventricle ◽

Treatment Strategies ◽

Prone Positioning ◽

Case Presentation ◽

Single Ventricle Physiology ◽

First Case

Abstract Background COVID-19 can induce acute respiratory distress syndrome (ARDS). In patients with congenital heart disease, established treatment strategies are often limited due to their unique cardiovascular anatomy and passive pulmonary perfusion. Case presentation We report the first case of an adult with single-ventricle physiology and bidirectional cavopulmonary shunt who suffered from severe COVID-19 ARDS. Treatment strategies were successfully adopted, and pulmonary vascular resistance was reduced, both medically and through prone positioning, leading to a favorable outcome. Conclusion ARDS treatment strategies including ventilatory settings, prone positioning therapy and cannulation techniques for extracorporeal oxygenation must be adopted carefully considering the passive venous return in patients with single-ventricle physiology.

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Pressure Injury Prevention in COVID-19 Patients With Acute Respiratory Distress Syndrome

Frontiers in Medicine ◽

10.3389/fmed.2020.558696 ◽

2021 ◽

Vol 7 ◽

Author(s):

Victoria Team ◽

Lydia Team ◽

Angela Jones ◽

Helena Teede ◽

Carolina D. Weller

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Endotracheal Tube ◽

Prone Position ◽

Distress Syndrome ◽

Prone Positioning ◽

Hospital Infection Control ◽

Short Period ◽

Pressure Injury

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12–16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.

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