Critically Ill Patients with COVID-19: A Narrative Review on Prone Position

Effect of the prone position on mechanical power in elective surgical patients under general anesthesia: A prospective observational study

OBJECTIVES

To evaluate how the prone position influences mechanical power (MP) during elective surgical procedures.

METHODS

In this prospective study carried out at Karadeniz Ereğli Government Hospital, Zonguldak, Turkey, from January 2024 to February 2024, 76 patients under general anesthesia were evaluated at different time points during the surgical procedure. Hemodynamic, laboratory, and mechanical ventilation data were also recorded.

RESULTS

The MP increased in the prone position at the beginning of surgery. Transitioning to the supine position at the end of surgery led to a decrease in MP. At the end of surgery, the mean MP in supine and prone positions was found to be higher compared to those measured in the first hour of surgery. Mechanical power and body mass index (BMI) exhibited a significant positive correlation.

CONCLUSION

Position changes influence MP. Returning to the prone position increases MP. An increase in BMI is associated with an increase in MP.ANZCTR Reg. No.: ACTRN12623001281684.

Prone positioning effect on tracheal intubation rate, mortality and oxygenation parameters in awake non-intubated severe COVID-19-induced respiratory failure: a review of reviews

BACKGROUND

Prone positioning (PP) is a low-cost method with minimal risk to the patient that improves the oxygenation of patients with acute hypoxic respiratory failure (AHRF) due to COVID-19 pneumonia, thereby reducing their need for tracheal intubation (TI) and transferring to the intensive care unit (ICU). We aimed to overview the results of all previous systematic reviews and meta-analyses to examine the net effect of PP on oxygenation, the rate of TI and mortality in COVID-19 patients.

METHODS

We searched PubMed, Scopus, Web of Science, Google Scholar, and Cochrane Library databases from December 2019 through 2022 without publication language restriction for systematic reviews and meta-analysis studies on PP vs. supine position (SP) in conscious patients with hypoxic respiratory failure COVID-19. After study selection, data were extracted from published meta-analyses and pooled by comprehensive meta-analysis (CMA) software version 2.2.064 to achieve effect sizes. They were analyzed for TI and mortality rates dichotomous variables, and the results were shown as pooled odds ratios (OR) with a 95% confidence interval (CI). Continuous variables such as oxygenation indices (PaO2/FiO2 and SpO2) were also analyzed, and the data were shown as mean differences (MD) with lower and upper CI. The level of statistical significance was set at p ≤ 0.05.

RESULTS

Twelve systematic reviews and meta-analyses with 19,651 patients and six systematic reviews with 2,911 patients were included in this Review of Reviews (total: 22,562). PP treatment significantly reduced the rate of TI (OR = 0.639, %95 CI (0.492, 0.829); P-value = 0.001) and decreased mortality (OR = 0.363, %95 CI (0.240, 0.549), P-value < 0.001). There was no difference in PaO2/FiO2 (MD = 3.591[- 40.881, 48.062]; P-value = 0.874) and SpO2 percent (MD = 1.641[- 4.441, 7.723]; P-value = 0.597).

CONCLUSION

Prone positioning can be recommended in conscious ICU patients with COVID-19 pneumonia to reduce mortality and intubation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42022326951. Registered 25 April 2022.

High-Flow Nasal Oxygen for Severe COVID-19 Pneumonia in Greek Patients: A Prospective Observational Study

INTRODUCTION

High-flow nasal oxygen (HFNO) and prone positioning may improve outcomes of coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU). The aim of this study was to describe outcomes following the timely application of HFNO and prone positioning in COVID-19 patients treated in a ward setting.

METHODS

The study included 89 prospectively recruited subjects at the COVID-19 ward unit of the University Hospital of Heraklion, Greece, between March and December 2020.

RESULTS

Seventy-four (83%) of the 89 subjects in the study had severe COVID-19. Of those, 33 (45%) required HFNO treatment and prone positioning and 15 (45%) were transferred to the ICU, with 4 of them being intubated. Severe COVID-19 and HFNO needs were associated with an increased pneumonia severity index (PSI) score on admission and a worse PaO2/FiO2 ratio. In multivariate analysis, PSI was the only independent predictor of subsequent HFNO needs (OR=1.022). Overall intubation and mortality rates were 5.6% and 3.4%, respectively.

CONCLUSION

This study shows that for patients with severe COVID-19 hospitalized in medical wards, standard COVID-19 treatment, along with the timely utilization of HFNO and prone positioning, resulted in excellent outcomes with fewer ICU admission rates.

Increasing Supportive Care for Patients With COVID-19-Related Respiratory Deterioration in Non-ICU Settings

BACKGROUND

Prepandemic hospital guidelines were unable to support an acute influx of patients with respiratory deterioration. New processes for general care practice were needed to facilitate patient care.

PURPOSE

To develop and evaluate guidelines to safely treat patients with COVID-19 respiratory deterioration in the general care setting.

METHODS

A quality improvement project with 2 PDSA (Plan-Do-Study-Act) cycles was used to develop guidelines for high-flow oxygen and prone positioning, along with frequent monitoring and collaboration with virtual critical care support.

RESULTS

Over 6 months, 126 patients with COVID-19 were cared for on general care units. Zero intubations occurred on the general care units, with 211 patient hospital days spent in general care that previously would have required an intensive care unit bed.

CONCLUSIONS

Patients in the general care setting with respiratory decline can safely be managed with appropriate monitoring criteria, oxygen device settings, and nursing support unitizing technology.

Laryngeal complications after endotracheal intubation and prone positioning in patients with coronavirus disease 2019

Objectives

Laryngeal complications have been reported after endotracheal intubation and prone positioning in patients with critical coronavirus disease 2019 (COVID-19), but their association is unclear. In this study, we investigated the rate of laryngeal complications in patients with COVID-19 compared to an alternative condition (control group).

Methods

We retrospectively analyzed the data of 40 patients who underwent endotracheal intubation for either COVID-19 or an alternative condition (control group). Data on age, sex, body mass index (BMI), cardiovascular disease (CVD) risk factors, use of prone therapy, duration of endotracheal intubation, and duration from extubation/tracheostomy to laryngeal evaluation were collected from medical records.

Results

There were no significant differences in BMI, frequency of CVD risk factors, duration of endotracheal intubation, or duration from extubation/tracheostomy to laryngeal evaluation between the two groups. In the COVID-19 group, all patients adopted the prone position. In comparison, only one patient in the control group adopted the prone position. Significant differences were observed between the two groups regarding the incidence of vocal fold immobility and laryngeal granuloma.

Conclusion

Laryngeal complications were more common in the COVID-19 group than in the control group. Prone positioning may be a risk factor for these complications.

Level of Evidence

4.

Facial Pressure Sores in COVID-19 Patients during Prone Positioning: A Case Series and Literature Review

COVID-19 has been a source of several stays in intensive care units, increasing the number of prone positioning. In parallel, complications increased, such as facial ulcers. Herein, we present a literature review and a case series about facial pressure sores in COVID-19 patients during prone positioning. This study aimed to show that such facial pressure sores may require surgical intervention in specific cases.

Determination of the Effect of the Fowler and Prone Position on Oxygen Saturation in Patients Diagnosed with COVID-19

Objective: This study was conducted to investigate the effect of the Fowler position and prone position on oxygen saturation in patients receiving treatment in clinics with the diagnosis of COVID-19 disease. Method: A total of 40 patients, admitted to the pandemic ward who met the inclusion criteria, were included in the quasi-experimental type study without any sampling. The patients were first given the Fowler position and then the prone position. There was a time interval of 15 minutes wait between the two positions. For each position, peripheral oxygen saturation, heart rate, respiratory and blood pressure values were obtained at initial position placement, after the 30th minute and every hour for the first four hours. Results: The mean age of the participants was 57.57±12.64 years. Respiratory distress, cough, fever, weakness, sweating and headache were the main symptoms. A total of 22.5% of them had a diagnosis of hypertension and Diabetes Mellitus. The requirement for the positioning was found to be 95% in the first five days after admittance. After treatment, 85% of them were discharged home. The mean oxygen saturation values of the patients for every hour in the Prone position were 93.15±1.718 (p=0.035), 93.60±1.809 (p=0.019), 93.93±1.774 (p=0.006) and 94.15±1.718 (p=0.002), respectively in the first four hours. These findings were statistically significant compared to the Fowler position. Respiratory values in the prone position were 17.30±1.159 (p=0.005), 17.20±1.344 (p=0.010), 17.20±1.181 (p=0.005), and 17.05±1.280 (p=0.001), respectively in the first four hours, which were statistically lower than in the Fowler position. There was no significant difference in the mean heart rate and blood pressure in both positions (p>0.05). Conclusion: The prone position was found to have a positive effect on oxygen saturation levels when Fowler and Prone positions were applied in patients receiving treatment with the diagnosis of COVID-19 in hospital wards. Therefore, it is recommended that patients admitted with the diagnosis of COVID-19 be placed in the prone position at regular intervals.

Critical Care Management of Severe COVID-19 in Pregnant Patients

Since December 2019, the coronavirus disease (COVID-19) pandemic has had a disastrous impact worldwide. COVID-19 is caused by the SARS-CoV-2 virus and was declared a pandemic by the WHO on March 11, 2020. The virus has been linked to a wide range of respiratory illnesses, ranging from mild symptoms to acute pneumonia and severe respiratory distress syndrome. Pregnant women are more vulnerable to COVID-19 complications owing to the physiological and immunological changes caused by pregnancy. According to the CDC, pregnant patients with COVID-19 are commonly hospitalized and often require admission to ICUs and ventilator support. Therefore, it is especially important for pregnant women to adhere to disease prevention measures to lower the risk of contracting the disease. In addition, the guidelines of several clinical societies and local health authorities should be followed when caring for pregnant women with suspected or confirmed COVID-19. In this review article, we discuss the epidemiology of COVID-19 during delivery, its effect on the physiological and immunological changes during pregnancy, the classification of COVID-19 severity, maternal and fetal risks, antenatal care, respiratory management, treatment/medication safety, timing and mode of delivery, anesthetic considerations, and the outcome of critically ill pregnant patients with COVID-19, as well as their post-delivery care and weaning from mechanical ventilation.

Out-of-hospital and in-hospital cardiac arrest during the COVID-19 pandemic: changes in demographics, outcomes and management

During the COVID-19 pandemic, prehospital and hospital services were put under great stress because of limited resources and increased workloads. One expected effect was the increased number of out-of-hospital (OHCA) and in-hospital (IHCA) cardiac arrests that occurred during 2020 compared to previous years. Both direct and indirect mechanisms were involved. In the former case, although the exact mechanisms by which Sars-Cov-2 causes cardiac arrest (CA) are still unknown, severe hypoxia, a dysregulated immune host response and sepsis are probably implicated and are often seen in COVID-19 patients with poor outcomes. In the latter case, the strain on hospitals, changes in treatment protocols, governments' actions to limit the spread of the disease and fear of the contagion naturally affected treatment efficacy and disrupted the CA chain of survival; as expected in OHCA, only a small proportion of patients were positive to COVID-19, and yet reported outcomes were worse during the pandemic. CA patient characteristics were reported, along with modifications in patient management. In this review, we summarise the evidence to date regarding OHCA and IHCA epidemiology and management during the COVID-19 pandemic.

Maternal and Neonatal Outcomes of Critically Ill Pregnant and Puerperal Patients Diagnosed with COVID-19 Disease: Retrospective Comparative Study

BACKGROUND

We assessed maternal and neonatal outcomes of critically ill pregnant and puerperal patients in the clinical course of coronavirus disease 2019 (COVID-19).

METHODS

Records of pregnant and puerperal women with polymerase chain reaction positive COVID-19 virus who were admitted to our intensive care unit (ICU) from March 2020 to August 2021 were investigated. Demographic, clinical and laboratory data, pharmacotherapy, and neonatal outcomes were analyzed. These outcomes were compared between patients that were discharged from ICU and patients who died in ICU.

RESULTS

Nineteen women were included in this study. Additional oxygen was required in all cases (100%). Eight patients (42%) were intubated and mechanically ventilated. All patients that were mechanically ventilated have died. Increased levels of C-reactive protein (CRP) was seen in all patients (100%). D-dimer values increased in 15 patients (78.9%); interleukin-6 (IL-6) increased in 16 cases (84.2%). Sixteen patients used antiviral drugs. Eleven patients were discharged from the ICU and eight patients have died due to complications of COVID-19 showing an ICU mortality rate of 42.1%. Mean number of hospitalized days in ICU was significantly lower in patients that were discharged (P = 0.037). Seventeen patients underwent cesarean-section (C/S) (89.4%). Mean birth week was significantly lower in patients who died in ICU (P = 0.024). Eleven preterm (57.8%) and eight term deliveries (42.1%) occurred.

CONCLUSION

High mortality rate was detected among critically ill pregnant/parturient patients followed in the ICU. Main predictors of mortality were the need of invasive mechanical ventilation and higher number of days hospitalized in ICU. Rate of C/S operations and preterm delivery were high. Pleasingly, the rate of neonatal death was low and no neonatal COVID-19 occurred.

Multidisciplinary team approach in critically ill COVID-19 patients reduced pronation-related complications rate: A retrospective cohort study

Background

In the pandemic scenario, critically ill COVID-19 patients' management presented an increased workload for Intensive Care Unit (ICU) nursing staff, particularly during pronation maneuvers, with high risk of complications. In this contest, some authors described an increase in complications incidence after pronation. An ICU Pronation Team (IPT) was implemented to support this maneuver.

Material and methods

Retrospective analysis was conducted on consecutive critically ill COVID-19 patients in COVID-19 Center in southern Switzerland, between March and April 2020. Aim of the study was to determine rates and characteristics of pronation-related complications managed by IPT according to standard protocols.

Results

Forty-two patients undergoing mechanical ventilation (MV) were enrolled; 296 prone/supine positioning were performed, with 3.52 cycles/patient. All patients were equipped with arterial line, central venous catheter, urinary catheter, 28 (66%) endotracheal tube, 8 (19%), tracheostomy, 6 (14%) dialysis catheter, 3 (7%) abdominal drainage and 8 (19%) femoral thermodilution catheter; mean BMI was 28.3 kg/m². One (0.3%) major complication was observed, while fourteen (33.3%) patients developed minor complications (pressure injuries). ICU length-of-stay and MV days correlated with both incidence (p = 0.029 and p = 0.015 respectively) and number (p = 0.001 and p = 0.001 respectively) of pressure sores (n = 27). Propensity matching score analysis did not show any protective factor of pronation regarding pressure injuries (p = 0.448). No other significant correlation was found.

Conclusion

Multidisciplinary healthcare professional management can reduce most severe complication related to pronation in critical care setting. Rather than from pronation, the persistent high rate of minor complications appeared to be related to disease severity.

Effect of prone position on respiratory parameters, intubation and death rate in COVID-19 patients: systematic review and meta-analysis

Prone position (PP) is known to improve oxygenation and reduce mortality in COVID-19 patients. This systematic review and meta-analysis aimed to determine the effects of PP on respiratory parameters and outcomes. PubMed, EMBASE, ProQuest, SCOPUS, Web of Sciences, Cochrane library, and Google Scholar were searched up to 1st January 2021. Twenty-eight studies were included. The Cochran's Q-test and I2 statistic were assessed heterogeneity, the random-effects model was estimated the pooled mean difference (PMD), and a meta-regression method has utilized the factors affecting heterogeneity between studies. PMD with 95% confidence interval (CI) of PaO2/FIO2 Ratio in before-after design, quasi-experimental design and in overall was 55.74, 56.38, and 56.20 mmHg. These values for Spo2 (Sao2) were 3.38, 17.03, and 7.58. PP in COVID-19 patients lead to significantly decrease of the Paco2 (PMD: - 8.69; 95% CI - 14.69 to - 2.69 mmHg) but significantly increase the PaO2 (PMD: 37.74; 95% CI 7.16-68.33 mmHg). PP has no significant effect on the respiratory rate. Based on meta-regression, the study design has a significant effect on the heterogeneity of Spo2 (Sao2) (Coefficient: 12.80; p < 0.001). No significant associations were observed for other respiratory parameters with sample size and study design. The pooled estimate for death rate and intubation rates were 19.03 (8.19-32.61) and 30.68 (21.39-40.75). The prone positioning was associated with improved oxygenation parameters and reduced mortality and intubation rate in COVID-19 related respiratory failure.

A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19

Objective:

The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients.

Methods:

Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients.

Conclusion:

Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing—the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients.

Level of evidence:

NA

Ischemic priapism due to coagulopathy of severe COVID-19 infection

Initially thought to be a primarily respiratory disease process, the hypercoagulable state associated with COVID-19 has been associated with myriad clinical sequelae. We report a case of stuttering ischemic priapism associated with COVID-19, and describe a management approach to achieve detumescence in patients undergoing ventilatory proning limiting penile access.

Level of evidence: Not applicable for this single center case report.

Complications of prone positioning in patients with COVID-19: A cross-sectional study

OBJECTIVE

To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers.

METHODS

Cross-sectional study conducted in the hub COVID-19 centre in Milan (Italy), between March and June 2020. All patients with COVID-19 admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning were included. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression.

RESULTS

A total of 219 proning cycles were performed on 63 patients, aged 57.6 (10.8) and predominantly obese males (66.7%). The main complications recorded were: prone-related pressure ulcers (30.2%), bleeding (25.4%) and medical device displacement (12.7%), even if no unplanned extubation was recorded. The majority of patients (17.5%) experienced bleeding of upper airways. Only 15 prone positioning cycles (6.8%) were interrupted, requiring staff to roll the patient back in the supine position. The likelihood of pressure ulcers development was independently associated with the duration of prone positioning, once adjusting for age, hypoxemic level, and nutritional status (OR 1.9, 95%CI 1.04-3.6).

CONCLUSION

The use of prone positioning in patients with COVID-19 was a safe and feasible treatment, also in obese patients, who might deserve more surveillance and active prevention by intensive care unit staff.

Prone positioning in children with respiratory failure because of coronavirus disease 2019

PURPOSE OF REVIEW

Acute respiratory distress syndrome (ARDS) is a common manifestation of severe COVID-19. Prone positioning has been used successfully in adult patients with ARDS and has been shown to decrease mortality. The efficacy of prone positioning in pediatric ARDS is less clear. In this review, we discuss the physiologic principles and literature on prone positioning in adults and children relative to COVID-19.

RECENT FINDINGS

There are limited published data on prone positioning in respiratory failure because of COVID-19. The use of proning in nonintubated patients with COVID-19 may improve oxygenation and dyspnea but has not been associated with improved outcomes. Initial adult cohort studies of intubated patients undergoing prone positioning in severe ARDS related to COVID-19 have shown an improvement in mortality. Although the use of proning in children with severe COVID-19 is recommended, data supporting its use is scarce.

SUMMARY

Additional studies to evaluate the efficacy of prone positioning in pediatric ARDS are needed to provide evidence for or against this treatment strategy in children. Given the unknown evolution of this pandemic, collaborative research efforts across pediatric centers provides the greatest opportunity to develop a data driven-approach to make use of this potential therapy.

Optimal timing of tracheostomy in patients on veno-venous extracorporeal membrane oxygenation for coronavirus 2019: a case series

Aim

An early tracheostomy is often considered for patients with veno‐venous extracorporeal membrane oxygenation (VV‐ECMO). However, there is no consensus on the timing of a tracheostomy in patients on VV‐ECMO for coronavirus disease 2019 (COVID‐19). The present report described the optimal timing of tracheostomy for these patients.

Method

The present study was a single‐center case series. We retrospectively reviewed the medical records of nine consecutive patients who underwent tracheostomy either during or after VV‐ECMO treatment in our center between January 1, 2020 and December 31, 2020.

Results

All the patients received a percutaneous dilatational tracheostomy, which was performed during VV‐ECMO in four patients. Three of these patients experienced hemorrhagic complications, and the remaining patient required a circuit change on the day after the operation. Heparin was discontinued 8 h preoperatively and resumed 1–14 h later. The platelet count was below normal in two patients, but no transfusion was performed. APTT was almost normal, and D‐dimer was elevated postoperatively. The remaining five patients received a tracheostomy after weaning off VV‐ECMO, and no complication was observed. Eight patients were deeply sedated during VV‐ECMO to prioritize lung rest and prevent infecting the healthcare workers.

Conclusion

In the present study, patients who underwent a tracheostomy during VV‐ECMO tended to have more hemorrhagic complications. Because an early tracheostomy during ECMO has little benefit for patients with COVID‐19, it should be performed after weaning off VV‐ECMO to protect the safety of the healthcare workers concerned.