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

Impact of new lighting technology versus traditional fluorescent bulbs on sedation and delirium in the ICU

BACKGROUND

Critically ill patients frequently encounter disruptions in their circadian rhythms in the intensive care unit (ICU) environment. New lighting systems have been developed to enhance daytime light levels and to promote circadian alignment.

OBJECTIVES

To investigate the impact of implementing an innovative lighting technology that mimics natural light and reproduce the colour of the sky.

DESIGN

Prospective, observational, non-randomized comparative trial. ICU patients were exposed to either a cutting-edge lighting system based on new technology (intervention group) or a conventional lighting system using fluorescent bulbs (control group).

SETTING

An Italian intensive care unit with ten beds and five windowless rooms, thereby denying access to natural light. Three rooms had new lighting technology.

MAIN OUTCOME MEASURES

The two groups were compared to assess the prevalence or absence of delirium and the need for sedatives during ICU stay. The secondary aim was to assess the presence of anxiety, depression, and post-traumatic stress disorder in patients at 3, 6, and 12 months after ICU discharge.

RESULTS

86 patients were included: 52 (60 %) in the intervention group and 34 (40 %) in the control group. Seventy-nine patients (82 %) were alive at ICU discharge. Fourteen patients (16 %) developed delirium (intervention group: n = 8 [15 %] vs. control group: n = 6 [18 %] in the control group, (P=0.781). The use of sedative drugs and neuromuscular blocking agents was similar in both the groups. No differences in the incidence of anxiety, depression, or post-traumatic stress disorders were observed among patients who underwent follow-up visits.

CONCLUSIONS

Compared to traditional fluorescent tube lighting, the innovative lighting system did not provide any significant benefit in reducing the frequency of delirium or the necessity for sedative medications.

IMPLICATIONS FOR CLINICAL PRACTICE

A single intervention, the use of lights that mimic sunny light and the sky, did not result in a statistically significant reduction in the incidence of delirium. Delirium has a multifactorial aetiology, necessitating interventions that are multifaceted and address different domains.

A prediction model for nonresponsive outcomes in critically ill patients with acute respiratory distress syndrome undergoing prone position ventilation: A retrospective cohort study

OBJECTIVE

This study aimed to develop a reliable and effective nomogram model to identify high-risk populations with non-response to prone position ventilation (PPV) in acute respiratory distress syndrome (ARDS) patients.

METHODS

This retrospective cohort study included 175 patients with ARDS undergoing PPV. An improvement of ≥ 20 mmHg in the PaO2/FiO2 after the first PPV was defined as a 'response'. For the construction of the model, all patients were randomly assigned to the train and validation cohort according to 2:1. Multivariate logistic regression was useed to develop the nomogram. The area under the receiver operating characteristic curve (AUC), decision curve and calibration curve were assessed to evaluate the efficiency, clinical utility and calibration of the model.

RESULTS

The overall rate of non-response to PPV in ARDS patients was approximately 32.6 %. In the training cohort and validation cohort, the rate are 29.9 % and 34.5 % respectively. Murray score ≥ 2.5 (OR: 4.29), procalcitonin (PCT) ≥ 2 ng/mL (OR: 2.52), N-terminal pro-B-type natriuretic peptide (Nt-proBNP) ≥ 2000 pg/ml (OR: 2.44), and hemoglobin ≤ 90 g/L (OR: 2.39) were independently associated with the rate of non-response to PPV and combined in prediction model. The model demonstrated good predictive value with AUC of 0.817 and 0.828 in the train and validation cohort. Calibration curve showed good calibration and decision curve analysis indicated favorable clinical utility.

CONCLUSIONS

This study constructed a risk prediction model for non-response to PPV, which demonstrated good predictive value and clinical utility.

IMPLICATIONS FOR CLINICAL PRACTICE

Early identification of prone position response in ARDS is essential for timely alternative treatments, improving patient prognosis and healthcare efficiency. The predictive model included representative indicators of patients with ARDS, encompassing parameters such as the acute lung injury (Murray score), cardiac function (Nt-proBNP), infectious status (PCT), and hemoglobin levels.

Awake prone positioning and ventilation distribution as assessed by electric impedance tomography in patients with non-COVID-19 acute hypoxemic respiratory failure: A prospective physiology study

Background

Awake prone positioning (APP) can reportedly reduce the need for intubation and help improve prognosis of patients with acute hypoxemic respiratory failure (AHRF) infected with COVID-19. However, its physiological mechanism remains unclear. In this study, we evaluated the effect of APP on lung ventilation in patients with moderate-to-severe AHRF to better understand the effects on ventilation distribution and to prevent intubation in non-intubated patients.

Methods

The prospective study was performed in the Department of Critical Care Medicine at Shanghai General Hospital, China, from January 2021 to November 2022. The study included patients with AHRF (partial pressure of oxygen [PaO2]/inspired oxygen concentration [FiO2] <200 mmHg or oxygen saturation [SpO2]/FiO2 <235) treated with high-flow nasal oxygen. Electrical impedance tomography (EIT) measurements including center of ventilation (COV), global inhomogeneity (GI) index, and regional ventilation delay (RVD) index were performed in the supine position (T0), 30 min after the start of APP (T1), and 30 min returning to supine position after the APP (T2). Clinical parameters like SpO2, respiratory rate (RR), FiO2, heart rate (HR), and ROX (the ratio of SpO2 as measured by pulse oximetry/FiO2 to RR) were also recorded simultaneously at T0, T1, and T2. To evaluate the effect of the time points on the variables, Mauchly's test was performed for sphericity and repeated measures analysis of variance was applied with Bonferroni's post hoc multiple comparisons.

Results

Ten patients were enrolled. The PaO2/FiO2 ratio was (111.4±33.4) mmHg at the time of recruitment. ROX showed a significant increase after initiation of APP {median (interquartile range [IQR]): T0: 7.5 (6.0-10.1) vs. T1: 7.6 (6.4-9.3) vs. T2: 8.3 (7.2-11.0), P=0.043}. RR (P=0.409), HR (P=0.417), and SpO2/FiO2 (P=0.262) did not change significantly during prone positioning (PP). The COV moved from the ventral area to the dorsal area (T0: 48.8%±6.2% vs. T1: 54.8%±6.8% vs. T2: 50.3%±6.1%, P=0.030) after APP. The GI decreased significantly after APP (T0: median=42.7 %, [IQR: 38.3%-47.5%] vs. T1: median=38.2%, [IQR: 34.6%-50.7%] vs. T2: median=37.4%, [IQR: 34.2%-41.4%], P=0.049). RVD (P=0.794) did not change after APP.

Conclusions

APP can improve ventilation distribution and homogeneity of lung ventilation as assessed by EIT in non-intubated patients with AHRF.Trail Registration Chinese Clinical Trial Registry Identifier: ChiCTR2000035895.

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.

Prone position in obese patients with acute respiratory distress syndrome after cardio-thoracic surgery

OBJECTIVES

Prone positioning (PP) has benefits in patients with acute respiratory distress syndrome. The objective of this study was to compare the effects and complications of PP in obese versus non-obese patients with moderate-to-severe acute respiratory distress syndrome after cardiothoracic surgery.

METHODS

We retrospectively analysed a database established in 2014-2021 in an intensive care unit. The primary end point was the change in PaO2/FiO2 induced by PP. Secondary end points included pressure ulcers, mediastinitis and intensive care unit mortality. The groups with versus without obesity (body mass index >30 kg/m2) were compared, and a mixed linear model was built to identify factors associated with the PaO2/FiO2 change.

RESULTS

81 patients with acute respiratory distress syndrome (36 with vs 45 without obesity) and 189 PP sessions were included. PP duration was 17.2 ± 4.5 h in obese and 18.0 ± 3.8 h in non-obese patients (P = 0.23). Mean number of sessions was 2.6 ± 1.4 in obese and 2.1 ± 1.3 in non-obese patients (P = 0.10). Median PaO2/FiO2 increase after the 1st PP session was 75.0% [14.5-123.0] and 72% [15.5-130.5] in the groups with versus without obesity (P = 0.67). Stage 3/4 pressure ulcers were more common in the obese group (44.4% vs 22.2%; P = 0.03) and occurred chiefly on the face. No significant differences between the obese and non-obese groups were found for mediastinitis (16.7% vs 8.9%, P = 0.33) or intensive care unit mortality (22% vs 20%, P = 0.81).

CONCLUSIONS

Improvement of oxygenation was not statistically different between patients with versus without obesity. Pressure ulcers were more common in the obese group, whereas mediastinitis was not. No patient experienced wound dehiscence.

Effect of Extended Prone Positioning in Intubated COVID-19 Patients with Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis

INPLASY REGISTRATION NUMBER

INPLASY202390072.

Extended Prone Position and 90-Day Mortality in Mechanically Ventilated Patients With COVID-19

BACKGROUND

Prone positioning (PP) has demonstrated its potential for improving outcomes in patients with ARDS who require invasive mechanical ventilation. However, the ability of prolonged proning to reduce mortality in patients with COVID-19 specifically, sessions lasting > 24 h remains uncertain.

METHODS

In this retrospective cohort study, we examined 158 subjects with COVID-19 pneumonia who required mechanical ventilation due to moderate-to-severe ARDS. Seventy-six subjects were placed in standard PP and 82 in extended PP, defined as prone sessions lasting at least 32 h. Our primary aim was to evaluate the effect of EPP on 90-d survival in subjects with COVID-19 with acute severe respiratory failure. To ensure the reliability of our findings and to minimize bias, we applied 3 adjustment approaches: cardinality matching (CM), matching weighting (MW), and inverse probability of treatment weighting with stabilized and trimmed weights (SW). We used Kaplan-Meier curves and Cox proportional hazard models to analyze the effects of EPP on 90-d mortality and sensitivity analysis by calculating E-values.

RESULTS

The overall crude 90-d mortality rate was 31.7%. The unadjusted 90-d mortality rates were 19.5% in the EPP group and 44.7% in the SPP group (hazard ratio [HR] 0.35 [95% CI 0.19- 0.63], P < .001). After adjustment for confounding factors using CM, MW, and SW, baseline covariates were balanced between the 2 groups. Subjects in the EPP group exhibited lower 90-d mortality rates after adjustment using CM (HR 0.42 [95% CI 0.23-0.79], P = .007), MW (HR 0.45 [95% CI 0.21-0.95], P = .036), or SW (HR 0.29 [95% CI 0.15-0.56], P < .001).

CONCLUSIONS

Extended PP was associated with improved 90-d survival in subjects with COVID-19 undergoing mechanical ventilation for severe ARDS. These findings suggest the potential benefit of EPP in the management of COVID-19-related respiratory failure. Further research and prospective studies are warranted to confirm and elucidate the underlying mechanisms of this association.

Interventional study of comparing body pressure in different prone positions in healthy young women

[Purpose] Although prone positioning is used to increase oxygenation in various respiratory conditions, this positioning can lead to facial and limb pressure ulcers. The aim in this study was to investigate body pressure variations in the prone position for different facial orientations and upper extremity positions. [Participants and Methods] Nineteen healthy young women participated in this study. Body pressure (maximum body pressure on the face, chest, elbows, and knees) was measured in six different prone positions with different face orientations and upper extremity positions, and the median value of each body pressure measurement was compared among postures. [Results] Face pressure tended to decrease when face orientation coincided with the raised side of the upper limb. In contrast, elbow pressure tended to be lower when the orientation of the face did not coincide with that of the raised side of the upper limb. [Conclusion] Pressure on the face and elbows can be reduced by placing the upper limbs in the prone position. This suggests that targeted and specific positioning may be useful for limiting the incidence and severity of pressure ulcers in these areas.

The occurrence of pressure injuries and related risk factors in patients undergoing extracorporeal membrane oxygenation for respiratory failure: A retrospective single centre study

INTRODUCTION

Limited data is available regarding the incidence of pressure injuries in patients who have undergone Extracorporeal Membrane Oxygenation (ECMO), a life-saving technique that provides respiratory support for hypoxemia that does not respond to conventional treatment.

AIM

To assess the incidence of pressure injuries and identify the risk factors in Acute Respiratory Distress Syndrome patients receiving ECMO.

METHODS

A retrospective observational study utilizing prospectively collected data was performed in an Italian intensive care unit, between 1 January 2012 and 30 April 2022 enrolling all consecutive patients with Acute Respiratory Distress Syndrome who underwent ECMO.

RESULTS

One hundred patients were included in this study. 67 patients (67%) developed pressure injuries during their intensive care unit stay, with a median of 2 (1-3) sites affected. The subgroup of patients with pressure injuries was more hypoxic before ECMO implementation, received more frequent continuous renal replacement therapy and prone positioning, and showed prolonged ECMO duration, intensive care unit and hospital length of stay compared to patients without pressure injuries. The logistic model demonstrated an independent association between the pO2/FiO2 ratio prior to ECMO initiation, the utilization of the prone positioning during ECMO, and the occurrence of pressure injuries.

CONCLUSIONS

The incidence of pressure injuries was elevated in patients with Adult Respiratory Distress Syndrome who received ECMO. The development of pressure injuries was found to be independently associated with hypoxemia before ECMO initiation and the utilization of prone positioning during ECMO.

IMPLICATIONS FOR CLINICAL PRACTICE

Patients who require ECMO for respiratory failure are at a high risk of developing pressure injuries. To ensure optimal outcomes during ECMO implementation and treatment, it is vital to implement preventive measures and to closely monitor skin health in at-risk areas.

Pressure injuries in mechanically ventilated COVID-19 patients utilising different prone positioning techniques - A prospective observational study

OBJECTIVES

To compare the incidence and distribution of pressure injuries (PIs) with two approaches to prone positioning for mechanically ventilated COVID-19 patients, and to determine the prevalence of these PIs on intensive care unit (ICU) and hospital discharge.

DESIGN

A prospective observational study.

SETTING

Adult patients admitted to a quaternary ICU with COVID-19-associated acute lung injury, between September 2021 and February 2022.

MAIN OUTCOME MEASURES

Incidence and anatomical distribution of PIs during ICU stay for "Face Down" and "Swimmers Position" as well as on ICU and hospital discharge.

RESULTS

We investigated 206 prone episodes in 63 patients. In the Face Down group, 26 of 34 patients (76 %) developed at least one PI, compared to 10 of 22 patients (45 %) in the Swimmers Position group (p = 0.02). Compared to the Swimmers Position group, the Face Down group developed more pressure injuries per patient (median 1 [1, 3] vs 0 [0, 2], p = 0.04) and had more facial PIs (p = 0.002). In a multivariate logistic regression model, patients were more likely to have at least one PI with Face Down position (OR 4.67, 95 % CI 1.28, 17.04, p = 0.02) and greater number of prone episodes (OR 1.75, 95 % CI 1.12, 2.74, p = 0.01). Over 80 % of all PIs were either stage 1 or stage 2. By ICU discharge, 29 % had healed and by hospital discharge, 73 % of all PIs had healed.

CONCLUSION

Swimmers Position had a significantly lower incidence of PIs compared to the Face Down approach. One-quarter of PIs had healed by time of ICU discharge and three-quarters by time of hospital discharge.

IMPLICATIONS FOR CLINICAL PRACTICE

There are differences in incidence of PIs related to prone positioning approaches. This study validates and helps better inform current prone position guidelines recommending the use of Swimmers Position. The low prevalence of PIs at hospital discharge is reassuring.

Central venous accesses in prone position during the pandemic period: A narrative review

The unprecedented challenges posed by the global COVID-19 pandemic have magnified the significance of managing intensive care patients in prone positions, particularly those requiring mechanical ventilation. Central venous access is crucial for delivering essential therapies to patients, particularly in intensive care settings. However, the shift in patient management during the pandemic, necessitating prone positioning for improved oxygenation, presented unique hurdles in maintaining and establishing central venous access. Before the pandemic, scant literature detailed the insertion of vascular access devices in prone or unconventional positions. Limited case reports and letters highlighted the feasibility of procedures like ultrasound-guided central catheter placement in patients undergoing surgery or with specific clinical needs. During the pandemic, a surge in case reports and series illuminated the complexities faced by clinicians in maintaining vascular access during pronation procedures. These reports delineated critical scenarios, ranging from rapid clinical deterioration necessitating immediate interventions to challenges with vascular access device (VAD) malfunctions or misplacements during prone maneuvers. Patient selection and device types emerged as critical considerations. Various scenarios, including patients transitioning to prone position from non-invasive ventilation and those requiring additional access for therapies like dialysis, posed challenges in device selection and placement. Successful VAD insertion techniques in prone patients encompassed multiple anatomical sites, including the internal jugular, brachial, femoral, and popliteal veins. However, challenges persisted, particularly with respect to anatomical variations and technical complexities in cannulation. Further research, standardized protocols, and randomized studies are needed to refine and validate the proposed strategies in both pandemic and non-pandemic settings.

Determinants of increased nursing workload in the COVID-era: A retrospective analysis of prospectively collected data

BACKGROUND

COVID-19 is associated with increased nursing workload, therefore a high nurse-to-patient ratio would be required.

AIM

To analyse difference in nursing workload, as expressed with the Nursing Activities Score (NAS), between COVID-19 patients versus control patients without COVID-19 disease (NCOVID-19 group) in an Italian Extracorporeal Membrane Oxygenation (ECMO) centre.

STUDY DESIGN

Retrospective analysis of prospectively collected data, enrolling consecutive patients admitted to a general Intensive Care Unit, between 1st May 2019 and 28th February 2021. A multivariate analysis was then performed to assess if COVID-19 disease was an independent predictor of higher NAS and to assess which other factors and procedures are independently associated with increased workload.

RESULTS

We enrolled 574 patients, of which 135 (24%) were in the COVID-19 group and 439 (76%) in the NCOVID-19 group. The average NAS was higher in the COVID-19 group (79 ± 11 vs. 65 ± 15, T = -10.026; p < 0.001). Prone positioning, continuous renal replacement therapy (CRRT) and ECMO were used more frequently in the COVID-19 group. A higher fraction of patients in the COVID group showed colonization from multidrug resistant bacteria. COVID-19 group had a higher duration of mechanical ventilation and longer ICU stay. The COVID-19 diagnosis was independently associated with a higher NAS. Other independent predictors of higher NAS were the use of prone positioning and continuous renal replacement therapy (CRRT). Colonization from multidrug resistant bacteria and ECMO support were not independently associated with higher NAS.

CONCLUSIONS

The higher nursing workload in COVID-19 patients is mainly due to specific procedures required to treat the most hypoxemic patients, such as prone positioning. Colonization with multidrug resistant bacteria and ECMO support were not independently associated with a higher NAS.

RELEVANCE TO CLINICAL PRACTICE

Higher workload in COVID-19 patients was due to specific interventions, such as prone positioning and CRRT, with the related nursing activities, as continuous presence at patient's bed, mobilization, positioning and complex hygienic procedures.

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.

Prone Positioning for Patients With COVID-19-Induced Acute Hypoxemic Respiratory Failure: Flipping the Script

During the COVID-19 pandemic, prone positioning (PP) emerged as a widely used supportive therapy for patients with acute hypoxemic respiratory failure caused by COVID-19 infection. In particular, awake PP (APP)-the placement of non-intubated patients in the prone position-has gained popularity and hence is detailed first herein. This review discusses recent publications on the use of PP for non-intubated and intubated subjects with COVID-19, highlighting the physiological responses, clinical outcomes, influential factors affecting treatment success, and strategies to improve adherence with APP. The use of prolonged PP and the use of PP for patients undergoing extracorporeal membrane oxygenation are also presented.

Effect of the duration of prone position in ARDS patients during the SARS-CoV-2 pandemic

OBJECTIVE

To describe the characteristics of patients with acute respiratory distress syndrome (ARDS) due to bilateral COVID-19 pneumonia on invasive mechanical ventilation (IMV), and to analyze the effect of prone position >24 h (prolonged) (PPP) compared to prone decubitus <24 h (PP).

DESIGN

A retrospective observational descriptive study was carried out, with uni- and bivariate analyses.

SETTING

Department of Intensive Care Medicine. Hospital General Universitario de Elche (Elche, Alicante, Spain).

PARTICIPANTS

Patients with SARS-CoV-2 pneumonia (2020-2021) on IMV due to moderate-severe ARDS, ventilated in prone position (PP).

INTERVENTIONS

IMV. PP maneuvers.

MAIN VARIABLES OF INTEREST

Sociodemographic characteristics, analgo-sedation, neuromuscular blockade (NMB), PD duration, ICU stay and mortality, days of IMV, non-infectious complications, healthcare associated infections.

RESULTS

Fifty-one patients required PP, and of these, 31 (69.78%) required PPP. No differences were observed in terms of patient characteristics (gender, age, comorbidities, initial severity, antiviral and antiinflammatory treatment received). Patients on PPP had poorer tolerance to supine ventilation (61.29% vs 89.47%, p = 0.031), longer hospital stay (41 vs 30 days, p = 0.023), more days of IMV (32 vs 20 days, p = 0.032), longer duration of NMB (10.5 vs 3 days, p = 0.0002), as well as a higher percentage of episodes of orotracheal tube obstruction (48.39% vs 15%, p = 0.014).

CONCLUSIONS

PPP was associated with greater resource use and complications in patients with moderate-severe ARDS due to COVID-19.

COVID-19 and Hospital-Acquired Pressure Injuries: A Systematic Review

OBJECTIVE

To investigate the relationship between COVID-19-related variables and hospital-acquired pressure injury (HAPI) incidence.

DATA SOURCES

The authors searched four databases: Cochrane, MEDLINE, EMBASE, and CINAHL. The literature search contained key terms such as "COVID-19," "hospital-acquired pressure injuries," "pressure ulcer," "pressure injury," "decubitus ulcer," and "hospitalization."

STUDY SELECTION

The systematic search of the literature identified 489 publications that matched the inclusion criteria. Articles were included in the review if they were peer-reviewed publications that reported HAPI incidence for patients who were hospitalized and COVID-19 positive. Two reviewers performed the screen simultaneously, and 19 publications were included.

DATA EXTRACTION

Two reviewers followed a standardized extraction form that included study and patient characteristics, COVID-19 status, HAPI characteristics, prone positioning, length of hospitalization, and HAPI prevention and treatment strategies.

DATA SYNTHESIS

The authors carried out a narrative synthesis of the extracted data because the data obtained were too heterogeneous for meta-analysis. The primary outcome was HAPI incidence.

CONCLUSIONS

This review identified that HAPI incidence was high among men who were COVID-19 positive, had longer hospital stays, experienced prone positioning, and had care teams without a skin and wound care expert. Future research should use more robust methodology and focus on quantitative modeling to iteratively improve inpatient HAPI guidelines.

Extended prone positioning for intubated ARDS: a review

During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in prone position until significant clinical improvement was achieved. One center reported extending prone positioning for organizational reasons relying on a predetermined fixed duration. A recent study argued that a clinically driven extension of prone positioning beyond 24 h could be associated with reduced mortality. On a patient level, the main benefit of extending prone positioning beyond 24 h is to maintain a more homogenous distribution of the gas-tissue ratio, thus delaying the increase in overdistention observed when patients are returned to the supine position. On an organizational level, extending prone positioning reduces the workload for both doctors and nurses, which might significantly enhance the quality of care in an epidemic. It might also reduce the incidence of accidental catheter and tracheal tube removal, thereby convincing intensive care units with low incidence of ARDS to prone patients more systematically. The main risk associated with extended prone positioning is an increased incidence of pressure injuries. Up until now, retrospective studies are reassuring, but prospective evaluation is needed.

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit

Critical patients have conditions that may favor the occurrence of hospital-acquired pressure injury (HAPI). The objective of this study was to identify the incidence and factors associated with the occurrence of HAPI in patients with coronavirus disease 2019 admitted to the intensive care unit (ICU) who used the prone position. Retrospective cohort study carried out in an ICU of a tertiary university hospital. Two hundred four patients with positive real-time polymerase chain reactions were evaluated, of which 84 were placed in the prone position. All patients were sedated and submitted to invasive mechanical ventilation. Of the prone patients, 52 (62%) developed some type of HAPI during hospitalization. The main place of occurrence of HAPI was the sacral region, followed by the gluteus and thorax. Of the patients who developed HAPI, 26 (50%) had this event in places possibly associated with the prone position. The factors associated with the occurrence of HAPI in patients prone to coronavirus disease 2019 were the Braden Scale and the length of stay in the ICU. The incidence of HAPI in prone patients was extremely high (62%), which denotes the need to implement protocols in order to prevent the occurrence of these events.

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.

COVID-19 and Hospital-Acquired Pressure Injuries: A Systematic Review

OBJECTIVE

To investigate the relationship between COVID-19 related variables and hospital-acquired pressure injuries (HAPI) incidence.

DATA SOURCES

The authors searched four databases: Cochrane, MEDLINE, EMBASE, and CINAHL. The literature search contained key terms such as COVID-19, hospital-acquired pressure injuries, pressure ulcer, pressure injury, decubitus ulcer, and hospitalization.

STUDY SELECTION

The systematic search of the literature identified 489 publications that matched the inclusion criteria. This included peer-reviewed publications that reported HAPI incidence for patients who were hospitalized and COVID-19 positive. Two reviewers performed the screen simultaneously and 19 publications were included.

DATA EXTRACTION

Two reviewers followed a standardized extraction form that included study and patient characteristics, COVID-19 status, HAPI characteristics, prone positioning, length of hospitalization, and HAPI prevention and treatment strategies.

DATA SYNTHESIS

A narrative synthesis of the extracted data was carried out because the data obtained were too heterogeneous for meta-analysis. The primary outcome was HAPI incidence.

CONCLUSIONS

This review identified that HAPI incidence was high among men who were COVID-19 positive, had longer hospital stays, experienced prone positioning, and had care teams without a skin and wound care expert. Future research should employ more robust methodology and focus on quantitative modeling to iteratively improve in-patient HAPI guidelines.