Nerve Compression Injuries After Prolonged Prone Position Ventilation in Patients With SARS-CoV-2: A Case Series

Safety and efficacy of enteral nutrition during prone ventilation: A meta-analysis

BackgroundProne ventilation improves lung function in patients with acute respiratory distress syndrome by enhancing oxygenation; however, managing enteral nutrition during prone ventilation is challenging due to body position changes.ObjectiveThe objective of the study was to assess the safety and efficacy of enteral nutrition during prone ventilation. A meta-analysis was conducted to evaluate the efficacy and safety of enteral nutrition in the prone position in critically ill ventilated patients.MethodsBy searching databases such as PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and WanFang Data, the relevant literature was retrieved from their inception to 24 December 2024. The Newcastle-Ottawa Scale was used to evaluate article quality. Egger's test was used to check for publication bias, and Review Manager 5.4 was used to conduct the analyses.ResultsAmong 81 publications, five studies with a total sample size of 319 were included in this study. Enteral nutrition in the prone position, compared with that in the supine position, was associated with a lower energy achievement rate (mean difference: -0.88; 95% confidence interval: -1.83 to 0.06; P < 0.00001), no significant difference in mortality (odds ratio: 1.11; 95% confidence interval: 0.65 to 1.88; P = 0.7), a greater incidence of ventilator-associated pneumonia (odds ratio: 2.11; 95% confidence interval: 1.12 to 3.96; P = 0.02), more frequent vomiting (odds ratio: 2.38; 95% confidence interval: 1.61 to 3.50; P < 0.0001), a greater gastric residual volume (odds ratio: 2.72; 95% confidence interval: 1.47 to 5.03; P = 0.001), and increased interruptions in enteral nutrition (odds ratio: 4.75; 95% confidence interval: 2.22 to 10.17; P < 0.0001). The Egger's test suggested no significant publication bias in the meta-analysis of mortality, gastric residual volume, adequate enteral nutrition achievement, and ventilator-associated pneumonia.ConclusionA greater gastric residual volume, more frequent vomiting, and greater incidences of ventilator-associated pneumonia and enteral feeding interruptions are linked to enteral nutrition during prone ventilation. There was no statistically significant difference in mortality between the prone and supine positions. However, the prone position showed a slight trend toward reducing energy achievement rates, although this difference was not statistically significant.Trial registration number: PROSPERO CRD: 42023441409.

Infectious Neuropathies

This review explores diverse infectious etiologies of peripheral nervous system (PNS) dysfunction, spanning sensory and motor neurons, nerves, and associated structures. Progress in viral and bacterial infections reveals multifaceted mechanisms underlying neuropathies, including viral neurotoxicity and immune-mediated responses. Latest diagnostic advances facilitate early PNS complication detection, with ongoing research offering promising treatment avenues. Emerging pathogens like severe acute respiratory syndrome coronavirus 2, Zika virus, and EV-D68 highlight the evolving infectious neuropathy paradigm. Recognizing characteristic patterns and integrating clinical factors are pivotal for precise diagnosis and tailored intervention. Challenges persist in assessment and management due to varied pathogenic mechanisms. Advancements in understanding pathogenesis have improved targeted therapies, yet gaps remain in effective treatments. Ongoing research is crucial for optimizing approaches and improving patient outcomes.

Upper limb peripheral nerve injuries in patients with ARDS requiring prone positioning: A systematic review with proportion meta-analysis

OBJECTIVE

To investigate the prevalence of upper limb peripheral nerve injuries (PNI) in adult patients admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) undergoing prone positioning.

METHODS

This systematic review with meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Four electronic databases including PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, and EMBASE were searched from inception to January 2024. The quality of the included studies was evaluated according to the Joanna Briggs Institute Critical Appraisal Tools. A proportion meta-analysis was conducted to examine the combined prevalence of upper limb PNI among patients requiring prone positioning.

RESULTS

A total of 8 studies (511 patients) were pooled in the quantitative analysis. All studies had a low or moderate risk of bias in methodological quality. The overall proportion of patients with upper limb PNI was 13% (95%CI: 5% to 29%), with large between-study heterogeneity (I2 = 84.6%, P<0.001). Both ulnar neuropathy and brachial plexopathy were described in 4 studies.

CONCLUSION

During the COVID-19 pandemic, prone positioning has been used extensively. Different approaches among ICU teams and selective reporting by untrained staff may be a factor in interpreting the large variability between studies and the 13% proportion of patients with upper limb PNI found in the present meta-analysis. Therefore, it is paramount to stress the importance of patient assessment both after discharge from the ICU and during subsequent follow-up evaluations.

IMPLICATIONS FOR CLINICAL PRACTICE

Specialized training is essential to ensure safe prone positioning, with careful consideration given to arms and head placement to mitigate potential nerve injuries. Therefore, healthcare protocols should incorporate preventive strategies, with patient assessments conducted by expert multidisciplinary teams.

The effect of swimmer position during prone ventilation on the onset of brachial plexus injury in the intensive care unit: A multiprofessional clinical study protocol

BACKGROUND

Prone positioning improves oxygenation in adults with acute respiratory distress syndrome (ARDS) and has been extensively applied in intensive care units (ICU) during the COVID-19 pandemic. Although some complications due to the manoeuvre are well known, brachial plexus injury after prone positioning is reported as a rare complication and the phenomenon could be either very rare or underestimated.

AIM

This study aimed to evaluate the effect of swimmer position during prone ventilation on the onset of brachial plexus injury in patients admitted to ICU for ARDS. The study will also evaluate the safety of prolonged prone positioning collecting data on any adverse events occurred.

STUDY DESIGN

A prospective, observational cohort study will be conducted in a tertiary level ICU in the metropolitan area of Milano (Italy) specialized in advanced treatment of patients with ARDS. This observational study will report clinical data on the electromyography (EMG) and the muscle strength assessment, including comorbidities and cardio-respiratory status. A baseline EMG will be performed within 2 h from the first pronation manoeuvre and immediately at the end of each pronation cycle. The functional assessment of patients will be also performed at the end of ICU stay and at hospital discharge.

RESULTS

The primary outcome is to estimate the prevalence of brachial plexus injury in patients with ARDS placed in the swimmer position during prone ventilation. Secondary outcomes will also include the safety of the manoeuvre by evaluation of all adverse events classified as skin or ocular damage, loss of tube and vascular access and new pressure ulcers.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study will contribute to understand the possible benefits/harms of prone ventilation performed using swimmer position. Eventually, this will call for the development of specific and tailored rehabilitation programs for patients with upper limb injuries during ICU stay, including also timely follow-up upon ICU-discharge.

One-Year Recovery Among Survivors of Prolonged Severe COVID-19: A National Multicenter Cohort

OBJECTIVES

Understanding the long-term effects of severe COVID-19 illness on survivors is essential for effective pandemic recovery planning. Therefore, we investigated impairments among hospitalized adults discharged to long-term acute care hospitals (LTACHs) for prolonged severe COVID-19 illness who survived 1 year.

DESIGN

The Recovery After Transfer to an LTACH for COVID-19 (RAFT COVID) study was a national, multicenter, prospective longitudinal cohort study.

SETTING AND PATIENTS

We included hospitalized English-speaking adults transferred to one of nine LTACHs in the United States between March 2020 and February 2021 and completed a survey.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Validated instruments for impairments and free response questions about recovering. Among 282 potentially eligible participants who provided permission to be contacted, 156 (55.3%) participated (median age, 65; 38.5% female; 61.3% in good prior health; median length of stay of 57 d; 77% mechanically ventilated for a median of 26 d; 42% had a tracheostomy). Approximately two-thirds (64%) had a persistent impairment, including physical (57%), respiratory (49%; 19% on supplemental oxygen), psychiatric (24%), and cognitive impairments (15%). Nearly half (47%) had two or more impairment types. Participants also experienced persistent debility from hospital-acquired complications, including mononeuropathies and pressure ulcers. Participants described protracted recovery, attributing improvements to exercise/rehabilitation, support, and time. While considered life-altering with 78.7% not returning to their usual health, participants expressed gratitude for recovering; 99% returned home and 60% of previously employed individuals returned to work.

CONCLUSIONS

Nearly two-thirds of survivors of among the most prolonged severe COVID-19 illness had persistent impairments at 1 year that resembled post-intensive care syndrome after critical illness plus debility from hospital-acquired complications.

Systemic manual therapy to treat long term residuals following COVID-19-related ICU stay: A case report

OBJECTIVE

The purpose of this case is to describe an outpatient treatment course using previously published systemic manual therapy protocol to treat a 65-year-old patient who, after prolonged COVID-related intubation, presented with polyneuropathy, organ failure and other residuals.

DESIGN

A single-subject case study.

METHODS

Review of clinical records and follow-up interview.

RESULTS

The patient identified problem scale (PIP) had improved from a high score of 52 to 11; QUICKDASH score improved from 68 to 16. All individual problems had either resolved or remained at a minimal level and the patient had generally returned to his prior level of function including return to work.

DISCUSSION AND CONCLUSION

It appears that Despite factors such as age, length of ICU stay, length of symptoms before initiation of physical therapy, and complicated hospital stay including multiple organ failure, after receiving physical therapy consists of the systemic manual therapy protocols, the patient rapidly improved during the outpatient episode.

Prone positioning during CPAP therapy in SARS-CoV-2 pneumonia: a concise clinical review

During the COVID-19 pandemic, the number of patients with hypoxemic acute respiratory failure (ARF) due to SARS-CoV-2 pneumonia threatened to overwhelm intensive care units. To reduce the need for invasive mechanical ventilation (IMV), clinicians tried noninvasive strategies to manage ARF, including the use of awake prone positioning (PP) with continuous positive airway pressure (CPAP). In this article, we review the patho-physiologic rationale, clinical effectiveness and practical issues of the use of PP during CPAP in non-intubated, spontaneously breathing patients affected by SARS-CoV-2 pneumonia with ARF. Use of PP during CPAP appears to be safe and feasible and may have a lower rate of adverse events compared to IMV. A better response to PP is observed among patients in early phases of acute respiratory distress syndrome. While PP during CPAP may improve oxygenation, the impact on the need for intubation and mortality remains unclear. It is possible to speculate on the role of PP during CPAP in terms of improvement of ventilation mechanics and reduction of strain stress.

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

In patients with COVID-19 different methods improving therapy have been used, including one of the anatomical position-prone position, to support ventilation. The aim of this review was to summarize the cases of brachial plexopathy as a consequence of the prone position in COVID-19 patients, and thus bring closer the issue of the brachial plexus in the face of clinical aspects of its function, palsy, and consequences. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed, inclusion criteria were created according to Patients, Interventions, Comparisons, Outcomes (PICO). PubMed and Scopus were searched until April 1, 2023 by entering the key term with Boolean terms. The risk of bias was assessed using JBI's critical appraisal tools. Fifteen papers with 30 patients were included in the review. This study showed that brachial plexopathy after the prone position occurs more often among males, who are at least 50 years old with comorbidities like hypertension, overweight, and diabetes mellitus. The most common symptoms were weakness, pain, and motion deficits. Duration of the prone position session and the number of episodes were different as well as the modification of positioning. Brachial plexopathy is a significant problem during prone position, especially when hospitalization is prolonged, patients are males, have comorbidities, and changes in body weight. Attention should be drawn to understand the anatomy of the brachial plexus, correct positioning, avoiding factors worsening the prognosis, and proper nutrition of the patients.

Infectious Neuropathies

OBJECTIVE

This article discusses the clinical manifestations and management of infectious peripheral neuropathies.

LATEST DEVELOPMENTS

Several infectious etiologies of peripheral neuropathy are well-recognized and their treatments are firmly established. The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with several central and peripheral nervous system manifestations, including peripheral neuropathies. Additionally, some COVID-19 vaccines have been associated with Guillain-Barré syndrome. These disorders are an active area of surveillance and research. Recent evidence-based guidelines have provided updated recommendations for the diagnosis and treatment of Lyme disease.

ESSENTIAL POINTS

Infectious agents of many types (primarily bacteria and viruses) can affect the peripheral nerves, resulting in various clinical syndromes such as mononeuropathy or mononeuropathy multiplex, distal symmetric polyneuropathy, radiculopathy, inflammatory demyelinating polyradiculoneuropathy, and motor neuronopathy. Knowledge of these infections and the spectrum of peripheral nervous system disorders associated with them is essential because many have curative treatments. Furthermore, understanding the neuropathic presentations of these disorders may assist in diagnosing the underlying infection.

[Functional evaluation in patient with critical SARS-CoV-2 disease: Cohort study in a third level hospital rehabilitation unit]

INTRODUCTION

SARS-COV-2 pneumonia is a highly contagious respiratory disease that causes respiratory, physical and psychological dysfunctions. We present the results of patient assessment when they were discharged from the ICU.

MATERIAL AND METHOD

Cohort study of patients affected by SARS-COV-2 pneumonia admitted to the intensive care unit from 01/10/2020 to 31/07/2021. We collect sociodemographic data, personal history, ICU and hospital stay, Barthel, FAC and mMRC (pre-admission/initial assessment/discharge), development of osteomuscular and/or neurological pathology and need for rehabilitation treatment.

RESULTS

A total of 341 patients were evaluated, of which 224 met criteria. The average age was 63 years (68.75% men). Mean ICU/hospital stay were 27/44 days. They were assessed by physiatry, after that, we provide a guide developed by physiatry, solving doubts about the disease and setting exercises of intensity and progressive difficulty, to be carried out during the admission and at home. Neurological pathology was present at 42.86% patients, of whom a 83.33% were peripheral nervous system disease. The total of the sample needed respiratory physiotherapy and a 72.32% motor physiotherapy.

CONCLUSIONS

In our study, a high number of patients have needed rehabilitation treatment in order to get functional recovery, highlighting the development of post-COVID neurological pathology. SARS-COV-2 generates other complications, not only respiratory, subsidiary to be assessed and treated by rehabilitation services for a comprehensive recovery that minimizes sequelae.

Inpatient Rehabilitation Issues Related to COVID-19

Patients who are hospitalized due to COVID-19 are predisposed to requiring acute inpatient rehabilitation. Multiple factors have posed challenges to inpatient rehabilitation during the COVID-19 pandemic, such as staff shortages, restrictions with therapy, and barriers to discharge. Despite these challenges, data have shown that inpatient rehabilitation plays a key role in functional gains for this patient population. There remains a need for more data on the current challenges that are faced in the inpatient rehabilitation setting, as well as better understanding of long-term functional outcomes following COVID-19.

Prone Position Ventilation in Severe ARDS due to COVID-19: Comparison between Prolonged and Intermittent Strategies

Ventilation in a prone position (PP) for 12 to 16 h per day improves survival in ARDS. However, the optimal duration of the intervention is unknown. We performed a prospective observational study to compare the efficacy and safety of a prolonged PP protocol with conventional prone ventilation in COVID-19-associated ARDS. Prone position was undertaken if P/F < 150 with FiO₂ > 0.6 and PEEP > 10 cm H₂O. Oxygenation parameters and respiratory mechanics were recorded before the first PP cycle, at the end of the PP cycle and 4 h after supination. We included 63 consecutive intubated patients with a mean age of 63.5 years. Of them, 37 (58.7%) underwent prolonged prone position (PPP group) and 26 (41.3%) standard prone position (SPP group). The median cycle duration for the SPP group was 20 h and for the PPP group 46 h (p < 0.001). No significant differences in oxygenation, respiratory mechanics, number of PP cycles and rate of complications were observed between groups. The 28-day survival was 78.4% in the PPP group versus 65.4% in the SPP group (p = 0.253). Extending the duration of PP was as safe and efficacious as conventional PP, but did not confer any survival benefit in a cohort of patients with severe ARDS due to COVID-19.

Upper Extremity Neuropathies Following Severe COVID-19 Infection: A Multicenter Case Series

OBJECTIVE

The purpose of the study is to examine presentation, injury patterns, and clinical course, for COVID-19-related peripheral nerve injury following mechanical ventilation.

METHODS

A multicenter retrospective study of patients with COVID-19 complicated by acute respiratory distress syndrome (ARDS) that required mechanical ventilation was undertaken. Patient records were reviewed for intensive care unit and intubation characteristics, prone or lateral decubitus positioning, and the onset of neuropathy diagnosis.

RESULTS

Between September 2020 and January 2022, 11 patients were diagnosed with peripheral neuropathy, including 9 with brachial plexopathy following COVID-19 infection. Each patient developed ARDS requiring mechanical ventilation for a median of 39 days. Six patients (54.5%) underwent prone positioning and 1 lateral decubitus. Neuropathies involved 5 brachial pan-plexopathies, 2 incomplete brachial plexopathies, 2 lower trunk plexopathies, 1 radial neuropathy, and 1 bilateral ulnar neuropathy. At a mean follow-up of 10.2 months, patients with brachial pan-plexopathies demonstrated signs of reinnervation proximally, and 1 resolved to a radial mononeuropathy; however, the majority have demonstrated minimal clinical improvements.

CONCLUSIONS

Our series demonstrates that peripheral neuropathies and especially brachial plexopathies have occurred following mechanical ventilation for ARDS-related COVID-19 infections. Contrary to prior COVID-19 studies, only 54.5% of these patients underwent prone positioning. Aside from a traumatic disturbance of prone positioning, the increased incidence of neuropathy may involve an atraumatic effect of COVID-19 via direct invasion of nerves, autoantibody targeting of nervous tissue, or hypercoagulation-induced microthrombotic angiopathy.

Ultrasound-based neuropathy diagnosis in COVID-19 patients in post-intensive care rehabilitation settings. A retrospective observational study

OBJECTIVES

using ultrasound scanning to examine the correlation between increase of Common Fibular Nerve's (CFN) Cross Sectional Area (CSA) and functional impairment of foot dorsiflexor muscles as an early sign of peripheral neuropathy.

DESIGN

retrospective observational study.

SETTING

in-patient rehabilitation unit between November 2020 and July 2021.

PARTICIPANTS

26 inpatients who underwent prolonged hospitilization in ICU'S and were diagnosed with CRYMINE after SARS-COV-2 infection. Physical examination and ultrasound scanning of the CFN and EMG/ENG were carried out on each patient.

INTERVENTIONS

not applicable MAIN OUTCOME MEASURE(S): CFN's CSA at the peroneal head.

RESULTS

we verified a significant increase in the CSA of the CFN measured at the peroneal head in more than 90% of the nerves tested. A cut off value of CFN's CSA of 0,20 cm was used to identify pathological nerves. No correlations with other variables (BMI, ICU days) were found.

CONCLUSION

US scanning of the CFN appears to be an early and specific test in the evaluation of CPN's abnormalities in post COVID-19 patients. US scanning is a reproducible, cost effective, safe and easily administered bedside tool to diagnose a loss of motor function when abnormalities in peripheral nerves are present.

Long-term complications of prone position ventilation with relevance for acute and postacute rehabilitation: a systematic review of the literature

INTRODUCTION

Prone positioning ventilation (PPV) is an effective treatment for patients with moderate to severe acute respiratory distress syndrome (ARDS). Despite the benefits of PPV, different kinds of short and long-term consequences have been noted. This review summarizes long-term complications of PPV that impact treatment strategies and outcomes in acute and postacute rehabilitation.

EVIDENCE ACQUISITION

PubMed/Medline, Cochrane Library, Cochrane COVID-19 Study Register databases and the Google Scholar search engine were systematically searched for studies investigating long-term complications of PPV. The final search date for all sources/databases was January 31, 2022. For our methodological appraisal, we conducted a systematic review of articles without any restrictions on types of articles or publication dates. Only articles published in English and available as full texts were eligible for inclusion. After the screening process, data of interest were extracted from eligible sources: PPV sequelae and conclusions (i.e. possible effects on the course of rehabilitation and therapy strategies).

EVIDENCE SYNTHESIS

A total of 59 studies are included in this review. Long-term consequences are mainly pressure ulcers and nerve lesions that exist after discharge from the Intensive Care Unit (ICU). Publications rarely recommend treatment strategies for long-term complications after PPV. Due to the quality of the included studies, no robust conclusions as to effective strategies can be drawn.

CONCLUSIONS

Further high-quality research is required, considering the different long-term complications after PPV and their impact on rehabilitation in order to draw conclusions about viable physical therapies. Crucially, however, prone positioning (PP) sequelae pose new challenges to physicians and therapists in acute and postacute rehabilitation medicine as well as follow-up care.

SARCOPENIA IS A FREQUENT DISEASE IN SARS-COV-2 INFECTION

Objective

We aimed to investigate the clinical symptoms and specific care requirements of SARS-CoV-2 patients who were admitted to a COVID-19 Rehabilitation Unit while still infectious for SARS-CoV-2 and in the subacute phase of the disease.

Methods

Patients admitted to our COVID-19 Rehabilitation Unit from March 2020 to December 2020 were evaluated for sarcopenia, and they also completed the following assessments: functional independence measure, short physical performance battery and Hamilton Rating Scale for Depression. Age and body mass index and symptoms of dysosmia or dysgeusia were also recorded.

Results

A total of 126 patients were enrolled (50 women, median age 72 years, 18.7 years), of whom 82% of patients presented with low grip strength. Sarcopenia was diagnosed in 52 patients. Sarcopenic patients were older than non-sarcopenic ones (median age 73.4 years, IQR 13.2 vs 63.9 years, IQR 14.5, respectively, p = 0.014). Sarcopenia was associated with the presence of depression (p = 0.008), was more common in women (p = 0.023) and was associated with greater functional deficits (functional independence measure and short physical performance battery analyses, p < 0.05). Sarcopenic patients also had a lower body mass index than other patients (p < 0.01).

Conclusion

More than 40% of our patients suffered from sarcopenia, which was associated with ageing, depression, low body mass index, reduction in functional autonomy and being a woman. Such data provide evidence for the need to assist hospitalized COVID-19 patients by means of a multidisciplinary specialist team.

Masseter muscle pressure injury: First report of a prone position complication in patients with COVID-19

We report the case of a 59-year-old, obese woman who underwent prolonged prone position during the medical management of an acute respiratory distress syndrome induced by SARS-CoV-2 infection, complicated by a masseter muscle pressure injury. Such side effect may be underestimate in intensive care units and should be prevent by prophylactic dressings on facial weight-bearing sites. The understanding of facial deep tissue injury is essential to guide clinical detection and management of such a complication in COVID-19 patients.

NeuroCOVID-19: a critical review

BACKGROUND

The COVID-19 pandemic has challenged neurologists since its early days. Neurology consultation services were then overloaded by emergency department and intensive-care patients with acute neurological syndromes. These complications are better explained today, but the growing number of patients with reported longstanding neurological symptoms constitute an emerging, complex, and still poorly understood phenomenon.

OBJECTIVE

This review summarizes data on relevant neurological manifestations of acute SARS-CoV-2 infection and lasting post-infectious disease, also known as Long COVID. The complex history of Long COVID is examined to illustrate the upsides and challenges imposed by the active participation of patient communities in the production of medical knowledge.

METHODS

Narrative review.

RESULTS

Infection with the severe acute respiratory syndrome coronavirus 2 is associated with encephalopathy/delirium, cerebrovascular disease, headache, and peripheral nervous system involvement. Long COVID is a living concept jointly defined by patient communities, physicians and scientists, including neurologists.

CONCLUSION

Co-production of Long COVID knowledge between scientists and patients has initiated an era of patient-led research and evidence-based activism that acts as a two-edged sword - putting patient's suffering in the spotlight, but with a tradeoff in methodological consistency.

Neuromuscular complications of severe COVID-19 in paediatric patients: medium-term follow-up

Neuromuscular complications in paediatric patients with severe coronavirus disease 2019 (COVID-19) are poorly characterised. However, adult patients with severe COVID-19 reportedly present with frequent neuromuscular complications that mainly include critical illness polyneuropathy (CIP), critical illness myopathy (CIM), and focal neuropathies. We examined the records of all paediatric patients with severe COVID-19 who were mechanically ventilated and experienced neuromuscular complications from our single tertiary centre between March 2020 and August 2021. During this period, 4/36 (11%) patients admitted to the paediatric ICU who were mechanically ventilated experienced neuromuscular complications (one CIM, two focal neuropathies, and one CIP associated with plexopathy). In three of them, the gamma genetic variant of SARS-CoV-2 was identified. At the 4–5 month follow-up, three of our patients exhibited slight clinical improvement. We conclude that paediatric patients with severe COVID-19 may present neuromuscular complications similar to adults (11%), and their medium-term prognosis seems unfavourable.

COVID-19 and the Peripheral Nervous System. A 2-year review from the pandemic to the vaccine era

Increasing literature has linked COVID‐19 to peripheral nervous system (PNS) diseases. In addition, as we move from the pandemic to the vaccination era, literature interest is shifting towards the potential association between COVID‐19 vaccines and PNS manifestations. We reviewed published literature on COVID‐19, COVID‐19 vaccines and PNS manifestations between 1 January 2020 and 1 December 2021. For Guillain‐Barré syndrome (GBS), isolated cranial neuropathy (ICN) and myositis associated with COVID‐19, the demographic, clinical, laboratory, electrophysiological and imaging features were included in a narrative synthesis. We identified 169 studies on COVID‐19‐associated complications, including 63 papers (92 patients) on GBS, 29 papers (37 patients) on ICN and 11 papers (18 patients) on myositis. Additional clinical phenotypes included chronic inflammatory demyelinating polyneuropathy, vasculitic neuropathies, neuralgic amyotrophy, critical care‐related complications, and myasthenia gravis. PNS complications secondary to COVID‐19 vaccines have been reported during randomized clinical trials, in real‐world case reports, and during large‐scale surveillance programs. These mainly include cases of GBS, Bell's palsy, and cases of neuralgic amyotrophy. Based on our extensive review of the literature, any conclusion about a pathophysiological correlation between COVID‐19 and PNS disorders remains premature, and solely supported by their temporal association, while epidemiological and pathological data are insufficient. The occurrence of PNS complications after COVID‐19 vaccines seems limited to a possible higher risk of facial nerve palsy and GBS, to a degree that widespread access to the ongoing vaccination campaign should not be discouraged, while awaiting for more definitive data from large‐scale surveillance studies.

Focal Peripheral Neuropathies Observed in Patients Diagnosed With COVID-19: A Case Series

ABSTRACT

A growing number of studies have documented a wide variety of neurological manifestations associated with the novel SARS-CoV-2 (COVID-19). Of the available literature, cranial neuropathies and central nervous system disorders, such as encephalopathy and ischemic strokes, remain the predominant discussion. Limited investigations exist examining peripheral neuropathies of those with COVID-19. This case series discusses eight patients who tested positive for COVID-19 and presented with localized weakness after a prolonged course of mechanical ventilation (>21 days). We retrospectively reviewed all patients' charts who received electrodiagnostic evaluation between March and November 2020 in the outpatient clinic or in the acute care hospital at the JFK Medical Center/JFK Johnson Rehabilitation Institute and Saint Peter's University Hospital of New Jersey. A total of eight COVID-19-positive patients were identified to have a clinical presentation of localized weakness after a prolonged course of mechanical ventilation. All patients were subsequently found to have a focal peripheral neuropathy of varying severity that was confirmed by electrodiagnostic testing. Patient demographics, clinical, and electrodiagnostic findings were documented. The findings of local weakness and focal peripheral neuropathies after diagnosis of COVID-19 raise significant questions regarding underlying pathophysiology and overall prognosis associated with COVID-19.

Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients

OBJECTIVE

To investigate short and long-term complications due to standard (≤24 hours) and extended (>24 hours) prone position in COVID-19 patients.

METHODS

Retrospective cohort study conducted in an Italian general intensive care unit. We enrolled patients on invasive mechanical ventilation and treated with prone positioning. We recorded short term complications from the data chart and long-term complications from the scheduled follow-up visit, three months after intensive care discharge.

RESULTS

A total of 96 patients were included in the study. Median time for each prone positioning cycle (302 cycles) was equal to 18 (16-32) hours. In 37 (38%) patients at least one cycle of extended pronation was implemented. Patients with at least one pressure sore due to prone position were 38 (40%). Patients with pressure sores showed a statistically significative difference in intensive care length of stay, mechanical ventilation days, numbers of prone position cycles, total time spent in prone position and the use of extended prone position, compared to patients without pressure sores. All lesions were low grade. Cheekbones (18%) and chin (10%) were the most affected sites. Follow-up visit, scheduled three months after intensive care discharge, was possible in 58 patients. All patients were able to have all 12 muscle groups examined using theMedical Research Council scale examination. No patient reported sensory loss or presence of neuropathic pain for upper limbs.

CONCLUSIONS

Extended prone position is feasible and might reduce the workload on healthcare workers without significant increase of major prone position related complications.

Cervical Spinal Cord Injury During Prone Position Ventilation in the COVID-19 Pandemic

The prone positioning of patients experiencing acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been proven effective in optimizing oxygenation and lung function. However, such patients may be at risk of developing complications due to the prolonged prone position in intensive critical care. A 45-year-old COVID-19 female, not known with cervical spine disease, presented with progressive severe COVID-19-related hypoxemia that required intensive care unit admission for pulmonary care. She was positioned prone and ventilated for several weeks. She developed a rapidly advanced decreased level of consciousness and flaccid quadriparesis. CT and MRI scans of the cervical spine revealed C4/C5 fracture-dislocation with spinal cord compression in asymptomatic ankylosing spondylitis and focal ossification of a posterior longitudinal ligament. In addition, the patient had severe ARDS-SARS-CoV-2 hemodynamic instability. Surgery was not performed due to her critical condition, and the patient died from multi-organ failure. Patients with underlying cervical spine disease or deformity can be subjected to hyperextension and develop fatigue (stress) spinal fracture, leading to spinal cord compression. To our knowledge, this is the first case of spontaneous cervical spine fracture dislocation in a COVID-19 patient after several weeks in prone position ventilation in ICU. Hence, our case report raises the awareness of the possibility of devastating spinal cord injuries in prone position ventilation during the COVID-19 pandemic and the need for early screening using plain X-rays of these patients for cervical spine disease.

Muscle strength and functional outcome after prone positioning in COVID-19 ICU survivors

Objective

To evaluate the muscle strength and functional level of patients discharged from intensive care unit (ICU) in relation to the swimmer position as a nurse intervention during pronation.

Methods

Prospective study conducted in the hub COVID-19 center in Milan (Italy), between March and June 2020. All patients with COVID-19 discharged alive from ICU who received invasive mechanical ventilation were included. Forward continuation ratio model was fitted to explore the statistical association between muscle strength grades and body positioning during ICU stay.

Results

Over the 128 patients admitted to ICU, 87 patients were discharged alive from ICU, with available follow-up measures at hospital discharge. Thirty-four patients (39.1%) were treated with prone positioning as rescue therapy, for a total of 106 pronation cycles with a median duration of 72 (IQR 60–83) hours. Prone positioning did not influence the odds of showing particular level of muscle strength, in any of the evaluated districts, namely shoulder (OR 1.34, 95%CI:0.61–2.97), elbow (OR 1.10, 95%CI:0.45–2.68) and wrist (OR 0.97, 95%CI:0.58–1.63). Only in the shoulder district, age showed evidence of association with strength (OR 1.06, 95%CI:1.02–1.10), affecting people as they get older. No significant sequalae related to swimmer position were reported by physiotherapists or nurses.

Conclusion

Swimmer position adopted during prone ventilation is not associated with worse upper limb strength or poor mobility level in COVID-19 survivors after hospital discharge.

Implementation of a Follow-Up Program for Intensive Care Unit Survivors

In Intensive Care Unit (ICU) survivors, critical illness has an impact on an individual’s long-term health status and quality of life. Adults who have recovered from intensive care management could develop muscle weakness, neurocognitive impairment, difficulties in managing activities of daily living and to returning to work, and psychological problems such as depression and anxiety. A prospective, observational study was designed. Data were collected from January to December 2018 from a structured follow-up program, at 3 time points after ICU discharge: at seven days, a visit in the general ward, a phone interview at three months and an ambulatory visit at six months. A total of 95 patients were enrolled, 36% female, with a median age of 65 (55–73) years and a median ICU length of stay of 13 (8–20) days. At the seven days follow-up, patients who had a positive Hospital Anxiety and Depression Scale showed a significantly longer time of intubation (p = 0.048) and length of ICU stay (p = 0.023). At three months, we observed a significant relationship between a positive Hospital Anxiety and Depression Scale and a median value of EuroQol-5D (p = 0.048). At six months, we observed that patients who had a positive Post-Traumatic Symptom Scale were significantly younger than the other group. Findings from the present study suggest that a longer time of intubation and length of ICU stay are associated with a higher level of anxiety and depression immediately after ICU discharge. Follow-up programs are recommended to assess and rehabilitate cognitive function at ICU discharge.

Median Nerve Mononeuropathy and Meralgia Paresthetica After Prone Positioning in a Patient with COVID-19 ARDS: A Case Report

CASE

Throughout the COVID-19 pandemic, prone positioning has decreased mortality in patients with severe acute respiratory distress syndrome. We present the unique case of a patient who developed left median nerve mononeuropathy and bilateral meralgia paresthetica after prone positioning while afflicted with COVID-19. These nerve injuries have been rarely reported in the literature and never before in the same patient.

CONCLUSION

Our case highlights the importance of increased care when positioning patients prone by padding bony prominences, evenly distributing pressure across known sites of peripheral nerve entrapment, and giving consideration to prone-positioning time intervals when caring for intubated patients.

Post-extubation dysphagia and dysphonia amongst adults with COVID-19 in the Republic of Ireland: A prospective multi-site observational cohort study

Objectives

This study aims to (i) investigate post‐extubation dysphagia and dysphonia amongst adults intubated with SARS‐COV‐2 (COVID‐19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post‐extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort.

Design

A multi‐site prospective observational cohort study.

Participants

One hundred adults with confirmed COVID‐19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive.

Main Outcome Measures

Oral intake status, level of diet modification and perceptual voice quality.

Results

Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% not allowed oral intake. Age (OR 1.064; 95% CI 1.018–1.112), proning (OR 3.671; 95% CI 1.128–11.943) and pre‐existing respiratory disease (OR 5.863; 95% CI 1.521–11.599) were predictors of oral intake status post‐extubation. Two‐thirds (66%) presented with dysphonia post‐extubation. Intubation injury (OR 10.471; 95% CI 1.060–103.466) and pre‐existing respiratory disease (OR 24.196; 95% CI 1.609–363.78) were predictors of post‐extubation voice quality. Thirty‐seven per cent required dysphagia intervention post‐extubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge.

Discussion

Post‐extubation dysphagia and dysphonia were prevalent amongst adults with COVID‐19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Biosensing surfaces and therapeutic biomaterials for the central nervous system in COVID-19

COVID-19 can affect the central nervous system (CNS) indirectly by inflammatory mechanisms and even directly enter the CNS. Thereby, COVID-19 can evoke a range of neurosensory conditions belonging to infectious, inflammatory, demyelinating, and degenerative classes. A broad range of non-specific options, including anti-viral agents and anti-inflammatory protocols, is available with varying therapeutic. Due to the high mortality and morbidity in COVID-19-related brain damage, some changes to these general protocols, however, are necessary for ensuring the delivery of therapeutic(s) to the specific components of the CNS to meet their specific requirements. The biomaterials approach permits crossing the blood-brain barrier (BBB) and drug delivery in a more accurate and sustained manner. Beyond the BBB, drugs can protect neural cells, stimulate endogenous stem cells, and induce plasticity more effectively. Biomaterials for cell delivery exist, providing an efficient tool to improve cell retention, survival, differentiation, and integration. This paper will review the potentials of the biomaterials approach for the damaged CNS in COVID-19. It mainly includes biomaterials for promoting synaptic plasticity and modulation of inflammation in the post-stroke brain, extracellular vesicles, exosomes, and conductive biomaterials to facilitate neural regeneration, and artificial nerve conduits for treatment of neuropathies. Also, biosensing surfaces applicable to the first sensory interface between the host and the virus that encourage the generation of accelerated anti-viral immunity theoretically offer hope in solving COVID-19.

Doctor-Should I get the COVID-19 vaccine? Infection and immunization in individuals with neuromuscular disorders

The clinical course of neuromuscular disorders (NMDs) can be affected by infections, both in immunocompetent individuals, and in those with reduced immunocompetence due to immunosuppressive/immunomodulating therapies. Infections and immunizations may also trigger NMDs. There is a potential for reduced efficacy of immunizations in patients with reduced immunocompetence. The recent vaccination program for coronavirus disease-2019 (COVID-19) raises several questions regarding the safety and efficacy of this vaccine in individuals with NMDs. In this Practice Topic article, we address the role of vaccine-preventable infections in NMDs and the safety and efficacy of immunization in individuals with NMDs, with emphasis on vaccination against COVID-19.