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Binda F, Gambazza S, Marelli F, Rossi V, Lusignani M, Grasselli G. Upper limb peripheral nerve injuries in patients with ARDS requiring prone positioning: A systematic review with proportion meta-analysis. Intensive Crit Care Nurs 2024; 85:103766. [PMID: 39126976 DOI: 10.1016/j.iccn.2024.103766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/06/2024] [Accepted: 07/06/2024] [Indexed: 08/12/2024]
Abstract
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.
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Affiliation(s)
- Filippo Binda
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy; Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Simone Gambazza
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Laboratory of Medical Statistics, Biometry and Epidemiology 'G. A. Maccacaro', Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023-2027, University of Milan, Milano, Italy.
| | - Federica Marelli
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Veronica Rossi
- Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Maura Lusignani
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Sato A, Ajimi A, Omiya Y, Shimizu JI. Interventional study of comparing body pressure in different prone positions in healthy young women. J Phys Ther Sci 2024; 36:571-576. [PMID: 39239414 PMCID: PMC11374175 DOI: 10.1589/jpts.36.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 06/16/2024] [Indexed: 09/07/2024] Open
Abstract
[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.
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Affiliation(s)
- Akihiro Sato
- Department of Occupational Therapy, Mejiro University: 320 Ukiya, Iwatsuki-ku, Saitama-shi, Saitama 339-8501, Japan
- Doctoral Program in Human Life Science, Tokyo Kasei University, Japan
| | - Akiko Ajimi
- Department of Physical Therapy, Mejiro University, Japan
| | - Yuko Omiya
- Department of Nursing, Mejiro University, Japan
| | - Jun-Ichi Shimizu
- Graduate School of Human Life Science, Tokyo Kasei University, Japan
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Schaller SJ, Scheffenbichler FT, Bein T, Blobner M, Grunow JJ, Hamsen U, Hermes C, Kaltwasser A, Lewald H, Nydahl P, Reißhauer A, Renzewitz L, Siemon K, Staudinger T, Ullrich R, Weber-Carstens S, Wrigge H, Zergiebel D, Coldewey SM. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med 2024; 50:1211-1227. [PMID: 39073582 DOI: 10.1007/s00134-024-07532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.
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Affiliation(s)
- Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | | | | | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julius J Grunow
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Uwe Hamsen
- Ruhr University Bochum, Bochum, Germany
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany
- Akkon-Hochschule für Humanwissenschaften, Berlin, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Heidrun Lewald
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Nydahl
- University Hospital of Schleswig-Holstein, Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Anett Reißhauer
- Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Renzewitz
- Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Siemon
- Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Septomics Research Center, Jena University Hospital, Jena, Germany.
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Woolger C, Rollinson T, Oliphant F, Ross K, Ryan B, Bacolas Z, Burleigh S, Jameson S, McDonald LA, Rose J, Modra L, Costa-Pinto R. Pressure injuries in mechanically ventilated COVID-19 patients utilising different prone positioning techniques - A prospective observational study. Intensive Crit Care Nurs 2024; 82:103623. [PMID: 38215559 DOI: 10.1016/j.iccn.2024.103623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/10/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
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.
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Affiliation(s)
- Cara Woolger
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Thomas Rollinson
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia; Department of Physiotherapy, the University of Melbourne, Parkville, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Fiona Oliphant
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Kristy Ross
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Brooke Ryan
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Zoe Bacolas
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Sarah Burleigh
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Stephanie Jameson
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia; Department of Physiotherapy, the University of Melbourne, Parkville, Victoria, Australia
| | - Luke A McDonald
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Joleen Rose
- Department of Physiotherapy, Division of Allied Health, Austin Health, Heidelberg, Victoria, Australia
| | - Lucy Modra
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia
| | - Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
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Maclean N, Davies P, Lewis S. Is prone positioning a valid intervention for ARDS in the deployed intensive care unit? BMJ Mil Health 2024:e002302. [PMID: 38569719 DOI: 10.1136/military-2022-002302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.
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Affiliation(s)
| | - P Davies
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
- Joint Hosptial Group (South East), Frimley, UK
| | - S Lewis
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
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Elmaleh Y, Yavchitz A, Léguillier T, Squara PA, Palpacuer C, Grégoire C. Feasibility of Prone Positioning for Brain-injured Patients with Severe Acute Respiratory Distress Syndrome: A Systematic Review and Pilot Study (ProBrain). Anesthesiology 2024; 140:495-512. [PMID: 38088786 DOI: 10.1097/aln.0000000000004875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Prone position is a key component to treat hypoxemia in patients with severe acute respiratory distress syndrome. However, most studies evaluating it exclude patients with brain injuries without any medical evidence. METHODS This study includes a systematic review to determine whether brain-injured patients were excluded in studies evaluating prone position on acute respiratory distress syndrome; a prospective study including consecutive brain-injured patients needing prone position. The primary endpoint was the evaluation of cerebral blood flow using transcranial Doppler after prone positioning. Secondary outcomes were intracranial pressure, cerebral perfusion pressure, and tissue oxygen pressure. RESULTS From 8,183 citations retrieved, 120 studies were included in the systematic review. Among them, 90 studies excluded brain-injured patients (75%) without any justification, 16 included brain-injured patients (4 randomized, 7 nonrandomized studies, 5 retrospective), and 14 did not retrieve brain-injured data. Eleven patients were included in the authors' pilot study. No reduction of cerebral blood flow surrogates was observed during prone positioning, with diastolic speed values (mean ± SD) ranging from 37.7 ± 16.2 cm/s to 45.2 ± 19.3 cm/s for the right side (P = 0.897) and 39.6 ± 18.2 cm/s to 46.5 ± 21.3 cm/s for the left side (P = 0.569), and pulsatility index ranging from 1.14 ± 0.31 to 1.0 ± 0.32 for the right side (P = 0.145) and 1.14 ± 0.31 to 1.02 ± 0.2 for the left side (P = 0.564) before and during prone position. CONCLUSIONS Brain-injured patients are largely excluded from studies evaluating prone position in acute respiratory distress syndrome. However, cerebral blood flow seems not to be altered considering increasing of mean arterial pressure during the session. Systematic exclusion of brain-injured patients appears to be unfounded, and prone position, while at risk in brain-injured patients, should be evaluated on these patients to review recommendations, considering close monitoring of neurologic and hemodynamic parameters. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Yoann Elmaleh
- Intensive Care Unit, Rothschild Foundation Hospital, Paris, France; Quincy Anesthesiology, Private Hospital Claude Galien, Boussy Saint Antoine, France
| | - Amélie Yavchitz
- Clinical Research Department, Rothschild Foundation Hospital, Paris, France
| | - Teddy Léguillier
- Clinical Research Department, Rothschild Foundation Hospital, Paris, France
| | | | - Clément Palpacuer
- Clinical Research Department, Rothschild Foundation Hospital, Paris, France
| | - Charles Grégoire
- Intensive Care Unit, Rothschild Foundation Hospital, Paris, France
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Morata L, Vollman K, Rechter J, Cox J. Manual Prone Positioning in Adults: Reducing the Risk of Harm Through Evidence-Based Practices. Crit Care Nurse 2024; 44:e1-e9. [PMID: 38295861 DOI: 10.4037/ccn2023201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
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Adelsten J, Grønlykke L, Pedersen FM, Madsen SA, Sørensen M, Eschen CT, Møller Sørensen PH, Gjedsted J, Nielsen DV, Christensen S, Nielsen J, Jørgensen VL. Use of prone position ventilation in patients with COVID-19 induced severe ARDS supported with V-V ECMO: A danish cohort study with focus on adverse events. Perfusion 2023:2676591231198798. [PMID: 37787741 DOI: 10.1177/02676591231198798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Prone position ventilation (PPV) of patients with adult respiratory distress syndrome (ARDS) supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) may improve oxygenation and alveolar recruitment and is recommended when extensive dorsal consolidations are present, but only few data regarding adverse events (AE) related to PPV in this group of patients have been published. METHODS Nationwide retrospective analysis of 68 COVID-19 patients admitted from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. The number of patients treated with PPV, number of PPV-events, timing, the time spent in prone position, number and causes of AE are reported. Causes to stop the PPV regimen and risk factors for AE were explored. RESULTS 44 out of 68 patients were treated with PPV, and 220 PPV events are evaluated. AE were identified in 99 out of 220 (45%) PPV events and occurred among 31 patients (71%). 1 fatal PPV related AE was registered. Acute supination occurred in 19 events (9%). Causes to stop the PPV regimen were almost equally distributed between effect (weaned from ECMO), no effect, death (of other reasons) and AE. Frequent causes of AE were pressures sores and ulcers, hypoxia, airway related and ECMO circuit related. Most AE occurred during patients first or second PPV event. CONCLUSIONS PPV treatment was found to carry a high incidence of PPV related AE in these patients. Causes and preventive measures to reduce occurrence of PPV related AE during V-V ECMO support need further exploration.
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Affiliation(s)
- Janne Adelsten
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Møller Pedersen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Camilla Tofte Eschen
- Department of Anaesthesiology and Intensive Care, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Peter Hasse Møller Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Gjedsted
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorthe Viemose Nielsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jonas Nielsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Walter T, Ricard JD. Extended prone positioning for intubated ARDS: a review. Crit Care 2023; 27:264. [PMID: 37408074 DOI: 10.1186/s13054-023-04526-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023] Open
Abstract
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.
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Affiliation(s)
- Thaïs Walter
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, 92700, Colombes, France.
| | - Jean-Damien Ricard
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, 92700, Colombes, France.
- Université Paris Cité, UMR1137 IAME, INSERM, 75018, Paris, France.
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Fajardo A, Rodríguez A, Chica C, Dueñas C, Carrillo R, Olaya X, Vera F. [Prone position in the third trimester of pregnancy during the COVID-19 era: a transdisciplinary approach.]. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023; 50:100906. [PMID: 38620219 PMCID: PMC10308227 DOI: 10.1016/j.gine.2023.100906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 06/22/2023] [Indexed: 04/17/2024]
Abstract
There is very limited evidence regarding the use of prone position as part of the treatment of severe ARDS in pregnant patients. Currently, recommendations for invasive ventilatory management in this population are very scarce and are based on the extrapolation of conclusions obtained in studies of non-pregnant patients. The available literature asserts that the anatomy and physiology of the pregnant woman undergoes complex adaptive changes that must be considered during invasive ventilatory support and prone position. With prone ventilation, the benefits obtained for the couple far outweigh the eventual risks. Adequate programming of the mechanical ventilator correlates with a clear and simple concept: individualization of support. In any case, the decision on the timing of termination of pregnancy should be based on adequate multidisciplinary clinical judgment and should be supported by strict monitoring of the product.
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Affiliation(s)
- Aurio Fajardo
- Servicio de Medicina Interna - Unidad de Paciente Crítico. Head of WeVent (International Mechanical Ventilation Group), Viña del Mar, Chile
| | - Asariel Rodríguez
- Unidad de Cuidados Intensivos Obstétricos. Hospital Materno Infantil RPG, TGZ. México
| | - Carmen Chica
- Asociación Colombiana de Medicina Crítica y Cuidado Intensivo (AMCI), Bogotá, Colombia
| | - Carmelo Dueñas
- Neumología y Medicina Crítica. Jefe UCI Gestión Salud, Cartagena, Colombia
| | - Raúl Carrillo
- Academia Nacional de Medicina. Subdirección de Áreas Críticas, Instituto Nacional de Rehabilitación, México
| | - Ximena Olaya
- Universidad de Manizales, COINT Grupo de Investigación, Colombia
| | - Fabricio Vera
- Medicina Crítica. Hospital General Manta del IESS, Manabí, Ecuador
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Demir U, Taşkın Ö, Yılmaz A, Soylu VG, Doğanay Z. Does prolonged prone position affect intracranial pressure? prospective observational study employing Optic nerve sheath diameter measurements. BMC Anesthesiol 2023; 23:79. [PMID: 36918795 PMCID: PMC10012287 DOI: 10.1186/s12871-023-02037-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Our aim in this observational prospective study is to determine whether the prone position has an effect on intracranial pressure, by performing ultrasound-guided ONSD (Optic Nerve Sheath Diameter) measurements in patients with acute respiratory distress syndrome (ARDS) ventilated in the prone position. METHODS Patients hospitalized in the intensive care unit with a diagnosis of ARDS who were placed in the prone position for 24 h during their treatment were included in the study. Standardized sedation and neuromuscular blockade were applied to all patients in the prone position. Mechanical ventilation settings were standardized. Demographic data and patients' pCO2, pO2, PaO2/FiO2, SpO2, right and left ONSD data, and complications were recorded at certain times over 24 h. RESULTS The evaluation of 24-hour prone-position data of patients with ARDS showed no significant increase in ONSD. There was no significant difference in pCO2 values either. PaO2/FiO2 and pO2 values demonstrated significant cumulative increases at all times. Post-prone SPO2 values at the 8th hour and later were significantly higher when compared to baseline (p < 0.001). CONCLUSION As a result of this study, it appears that the prone position does not increase intracranial pressure during the first 24 h and can be safely utilized, given the administration of appropriate sedation, neuromuscular blockade, and mechanical ventilation strategy. ONSD measurements may increase the safety of monitoring in patients ventilated in the prone position.
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Affiliation(s)
- Ufuk Demir
- grid.412062.30000 0004 0399 5533Department of Anesthesiology and Reanimation, Faculty of Medicine, Kastamonu University, 37100 Kastamonu, Turkey
| | - Öztürk Taşkın
- grid.412062.30000 0004 0399 5533Department of Anesthesiology and Reanimation, Faculty of Medicine, Kastamonu University, 37100 Kastamonu, Turkey
| | - Ayşe Yılmaz
- grid.412062.30000 0004 0399 5533Department of Anesthesiology and Reanimation, Faculty of Medicine, Kastamonu University, 37100 Kastamonu, Turkey
| | - Veysel G. Soylu
- grid.412062.30000 0004 0399 5533Department of Intensive Care, Faculty of Medicine, Kastamonu University, Kastamonu, Turkey
| | - Zahide Doğanay
- grid.412062.30000 0004 0399 5533Department of Anesthesiology and Reanimation, Faculty of Medicine, Kastamonu University, 37100 Kastamonu, Turkey
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Vasquez DN, Giannoni R, Salvatierra A, Cisneros K, Lafosse D, Escobar MF, Montenegro M, Juárez P, Visani L, Mandich V, Barrozo E, Kirschbaum M, Das Neves AV, Valenti MF, Canseco MC, Romero I, Macharé P, Marquez AK, Rodriguez E, Palacio C, Rapela L, Amillategui Scenna JM, Nuñez R, Torres S, González MA, Franconieri L, Nasner D, Okurzaty P, Plotnikow GA, Intile AD. Ventilatory Parameters in Obstetric Patients With COVID-19 and Impact of Delivery: A Multicenter Prospective Cohort Study. Chest 2023; 163:554-566. [PMID: 36257474 PMCID: PMC9573860 DOI: 10.1016/j.chest.2022.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/28/2022] [Accepted: 10/05/2022] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Current evidence on obstetric patients requiring advanced ventilatory support and impact of delivery on ventilatory parameters is retrospective, scarce, and controversial. RESEARCH QUESTION What are the ventilatory parameters for obstetric patients with COVID-19 and how does delivery impact them? What are the risk factors for invasive mechanical ventilation (IMV) and for maternal, fetal, and neonatal mortality? STUDY DESIGN AND METHODS Prospective, multicenter, cohort study including pregnant and postpartum patients with COVID-19 requiring advanced ventilatory support in the ICU. RESULTS Ninety-one patients were admitted to 21 ICUs at 29.2 ± 4.9 weeks; 63 patients (69%) delivered in ICU. Maximal ventilatory support was as follows: IMV, 69 patients (76%); high-flow nasal cannula, 20 patients (22%); and noninvasive mechanical ventilation, 2 patients (2%). Sequential Organ Failure Assessment during the first 24 h (SOFA24) score was the only risk factor for IMV (OR, 1.97; 95% CI, 1.29-2.99; P = .001). Respiratory parameters at IMV onset for pregnant patients were: mean ± SD plateau pressure (PP), 24.3 ± 4.5 cm H2O; mean ± SD driving pressure (DP), 12.5 ± 3.3 cm H2O; median static compliance (SC), 31 mL/cm H2O (interquartile range [IQR], 26-40 mL/cm H2O); and median Pao2 to Fio2 ratio, 142 (IQR, 110-176). Respiratory parameters before (< 2 h) and after (≤ 2 h and 24 h) delivery were, respectively: mean ± SD PP, 25.6 ± 6.6 cm H2O, 24 ± 6.7 cm H2O, and 24.6 ± 5.2 cm H2O (P = .59); mean ± SD DP, 13.6 ± 4.2 cm H2O, 12.9 ± 3.9 cm H2O, and 13 ± 4.4 cm H2O (P = .69); median SC, 28 mL/cm H2O (IQR, 22.5-39 mL/cm H2O), 30 mL/cm H2O (IQR, 24.5-44 mL/cm H2O), and 30 mL/cm H2O (IQR, 24.5-44 mL/cm H2O; P = .058); and Pao2 to Fio2 ratio, 134 (IQR, 100-230), 168 (IQR, 136-185), and 192 (IQR, 132-232.5; P = .022). Reasons for induced delivery were as follows: maternal, 43 of 71 patients (60.5%); maternal and fetal, 21 of 71 patients (29.5%); and fetal, 7 of 71 patients (9.9%). Fourteen patients (22.2%) continued pregnancy after ICU discharge. Risk factors for maternal mortality were BMI (OR, 1.10; 95% CI, 1.006-1.204; P = .037) and comorbidities (OR, 4.15; 95% CI, 1.212-14.20; P = .023). Risk factors for fetal or neonatal mortality were gestational age at delivery (OR, 0.67; 95% CI, 0.52-0.86; P = .002) and SOFA24 score (OR, 1.53; 95% CI, 1.13-2.08; P = .006). INTERPRETATION Contrary to expectations, pregnant patient lung mechanics were similar to those of the general population with COVID-19 in the ICU. Delivery was induced mainly for maternal reasons, but did not change ventilatory parameters other than Pao2 to Fio2 ratio. SOFA24 score was the only risk factor for IMV. Maternal mortality was associated independently with BMI and comorbidities. Risk factors for fetal and neonatal mortality were SOFA24 score and gestational age at delivery.
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Affiliation(s)
| | - Roberto Giannoni
- Hospital Regional Ramón Carrillo, Santiago del Estero, Argentina
| | | | | | - Diego Lafosse
- Hospital Materno Infantil Dr. F Escardó, Tigre, Buenos Aires, Argentina
| | | | - Martín Montenegro
- Hospital Materno Infantil Ramón Sardá, City of Buenos Aires, Argentina
| | - Paula Juárez
- Hospital de la Madre y el Niño, La Rioja, Argentina
| | - Lucía Visani
- Hospital Cuenca Alta Néstor Kirchner, Cañuelas, Buenos Aires, Argentina
| | | | - Erika Barrozo
- Maternidad Provincial Teresita Baigorria, San Luis, Argentina
| | | | - Andrea V Das Neves
- Hospital Interzonal General de Agudos Gral. San Martín, La Plata, Buenos Aires, Argentina
| | - María F Valenti
- Argentine Society of Critical Care Medicine, City of Buenos Aires, Argentina
| | - María C Canseco
- Instituto de Maternidad y Ginecología nuestra Señora de las Mercedes, San Miguel de Tucumán, Tucumán, Argentina
| | | | - Pedro Macharé
- Hospital Mi Pueblo, Florencio Varela, Buenos Aires, Argentina
| | - Ana K Marquez
- Hospital Municipal de Morón, Morón, Buenos Aires, Argentina
| | - Eva Rodriguez
- Hospital Simplemente Evita, González Catán, Buenos Aires, Argentina
| | | | - Laura Rapela
- Hospital Municipal del Carmen, Chacabuco, Buenos Aires, Argentina
| | | | - Rosshanna Nuñez
- Hospital Mariano y Luciano de la Vega, Moreno, Buenos Aires, Argentina
| | - Sebastián Torres
- Sanatorio Anchorena San Martín, San Martín, Buenos Aires, Argentina
| | - Miguel A González
- Hospital del Este "Eva Perón", San Miguel de Tucumán, Tucumán, Argentina
| | | | | | - Patricia Okurzaty
- Hospital Materno Infantil Ramón Sardá, City of Buenos Aires, Argentina
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Okin D, Huang CY, Alba GA, Jesudasen SJ, Dandawate NA, Gavralidis A, Chang LL, Moin EE, Ahmad I, Witkin AS, Hardin CC, Hibbert KA, Kadar A, Gordan PL, Lee H, Thompson BT, Bebell LM, Lai PS. Prolonged Prone Position Ventilation Is Associated With Reduced Mortality in Intubated COVID-19 Patients. Chest 2023; 163:533-542. [PMID: 36343687 PMCID: PMC9635255 DOI: 10.1016/j.chest.2022.10.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear. RESEARCH QUESTION Does a prolonged (24 or more h) PPV strategy improve mortality in intubated COVID-19 patients compared with intermittent (∼16 h with daily supination) PPV? STUDY DESIGN AND METHODS Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 and May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias. RESULTS Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR], 0.475; 95% CI, 0.336-0.670; P < .001) and 90-day (aHR, 0.638; 95% CI, 0.461-0.883; P = .006) mortality compared with intermittent PPV. In patients with Pao2/Fio2 ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR, 0.357; 95% CI, 0.213-0.597; P < .001) and 90-day mortality (aHR, 0.562; 95% CI, 0.357-0.884; P = .008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median, 1; 95% CI, 1-2 vs 3; 95% CI, 1-4; P < .001). PPV strategy was not associated with overall PPV-related complications, although patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension. INTERPRETATION Among intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.
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Affiliation(s)
- Daniel Okin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Ching-Ying Huang
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | | | - Leslie L Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Emily E Moin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Imama Ahmad
- Department of Medicine, Salem Hospital, Salem, MA
| | - Alison S Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - C Corey Hardin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Kathryn A Hibbert
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA
| | - Patrick L Gordan
- Divison of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Hang Lee
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Peggy S Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA.
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14
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Morata L, Vollman K, Rechter J, Cox J. Manual Prone Positioning in Adults: Reducing the Risk of Harm Through Evidence-Based Practices. Crit Care Nurse 2023; 43:59-66. [PMID: 36720277 DOI: 10.4037/ccn2023174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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15
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Poole D, Pisa A, Fumagalli R. Prone position for acute respiratory distress syndrome and the hazards of meta-analysis. Pulmonology 2023:S2531-0437(23)00009-0. [PMID: 36907814 PMCID: PMC9874051 DOI: 10.1016/j.pulmoe.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 12/17/2022] [Accepted: 12/25/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Researchers have tried unsuccessfully for many years using randomized controlled trials to show the efficacy of prone ventilation in treating ARDS. These failed attempts were of use in designing the successful PROSEVA trial, published in 2013. However, the evidence provided by meta-analyses in support of prone ventilation for ARDS was too low to be conclusive. The present study shows that meta-analysis is indeed not the best approach for the assessment of evidence as to the efficacy of prone ventilation. METHODS We performed a cumulative meta-analysis to prove that only the PROSEVA trial, due to its strong protective effect, has substantially impacted on the outcome. We also replicated nine published meta-analyses including the PROSEVA trial. We performed leave-one-out analyses, removing one trial at a time from each meta-analysis, measuring p values for effect size, and also the Cochran's Q test for heterogeneity assessment. We represented these analyses in a scatter plot to identify outlier studies influencing heterogeneity or overall effect size. We used interaction tests to formally identify and evaluate differences with the PROSEVA trial. RESULTS The positive effect of the PROSEVA trial accounted for most of the heterogeneity and for the reduction of overall effect size in the meta-analyses. The interaction tests we conducted on the nine meta-analyses formally confirmed the difference in the effectiveness of prone ventilation between the PROSEVA trial the other studies. CONCLUSIONS The clinical lack of homogeneity between the PROSEVA trial design and the other studies should have discouraged the use of meta-analysis. Statistical considerations support this hypothesis, suggesting that the PROSEVA trial is an independent source of evidence.
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Affiliation(s)
- D Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy.
| | - A Pisa
- Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan, Italy
| | - R Fumagalli
- Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan, Italy; Department of Anesthesia and Intensive Care, Niguarda Hospital, Milan, Italy
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16
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Gattinoni L, Brusatori S, D’Albo R, Maj R, Velati M, Zinnato C, Gattarello S, Lombardo F, Fratti I, Romitti F, Saager L, Camporota L, Busana M. Prone position: how understanding and clinical application of a technique progress with time. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:3. [PMCID: PMC9995262 DOI: 10.1007/s44254-022-00002-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Historical background The prone position was first proposed on theoretical background in 1974 (more advantageous distribution of mechanical ventilation). The first clinical report on 5 ARDS patients in 1976 showed remarkable improvement of oxygenation after pronation. Pathophysiology The findings in CT scans enhanced the use of prone position in ARDS patients. The main mechanism of the improved gas exchange seen in the prone position is nowadays attributed to a dorsal ventilatory recruitment, with a substantially unchanged distribution of perfusion. Regardless of the gas exchange, the primary effect of the prone position is a more homogenous distribution of ventilation, stress and strain, with similar size of pulmonary units in dorsal and ventral regions. In contrast, in the supine position the ventral regions are more expanded compared with the dorsal regions, which leads to greater ventral stress and strain, induced by mechanical ventilation. Outcome in ARDS The number of clinical studies paralleled the evolution of the pathophysiological understanding. The first two clinical trials in 2001 and 2004 were based on the hypothesis that better oxygenation would lead to a better survival and the studies were more focused on gas exchange than on lung mechanics. The equations better oxygenation = better survival was disproved by these and other larger trials (ARMA trial). However, the first studies provided signals that some survival advantages were possible in a more severe ARDS, where both oxygenation and lung mechanics were impaired. The PROSEVA trial finally showed the benefits of prone position on mortality supporting the thesis that the clinical advantages of prone position, instead of improved gas exchange, were mainly due to a less harmful mechanical ventilation and better distribution of stress and strain. In less severe ARDS, in spite of a better gas exchange, reduced mechanical stress and strain, and improved oxygenation, prone position was ineffective on outcome. Prone position and COVID-19 The mechanisms of oxygenation impairment in early COVID-19 are different than in typical ARDS and relate more on perfusion alteration than on alveolar consolidation/collapse, which are minimal in the early phase. Bronchial shunt may also contribute to the early COVID-19 hypoxemia. Therefore, in this phase, the oxygenation improvement in prone position is due to a better matching of local ventilation and perfusion, primarily caused by the perfusion component. Unfortunately, the conditions for improved outcomes, i.e. a better distribution of stress and strain, are almost absent in this phase of COVID-19 disease, as the lung parenchyma is nearly fully inflated. Due to some contradictory results, further studies are needed to better investigate the effect of prone position on outcome in COVID-19 patients. Graphical Abstract ![]()
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | | | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
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Noeding Fischer CHRM, Bocanegra Román NFA, Nieto-Gutierrez W. An appraisal of the methodology and quality of evidence of systematic reviews on the efficacy of prone positional ventilation in adult patients with acute respiratory distress syndrome: an umbrella review. Intern Emerg Med 2022; 18:691-709. [PMID: 36585553 DOI: 10.1007/s11739-022-03174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/06/2022] [Indexed: 12/31/2022]
Abstract
The objective of the study was to evaluate all available systematic reviews on the use of prone positional ventilation in adult patients with acute respiratory distress syndrome (ARDS). An umbrella review on the efficacy of prone positional ventilation in adult patients ventilation in adult patients with acute respiratory distress syndrome was conducted. We performed a systematic search in the database of Medline (Pubmed), Scopus, Cochrane Library, Web of Science, and Epistemonikos. The ROBIS tools and GRADE methodology were used to assess the risk of bias and certainty of evidence. We estimated the necessary number of patients to be treated to have benefit. For the synthesis of the result, we selected the review with the lowest risk of bias. Sixteen systematic reviews including 64 randomized clinical trials and evaluating the effect of prone positional ventilation, with or without other ventilation strategies were included. Aoyama 2019 observed prone positioning, without complementary ventilation strategies, leading to a reduction in the 28-day mortality only when compared to high-frequency oscillatory ventilation (RR 0.61; 95% CI 0.39-0.95) and lung-protective ventilation in the supine position (RR 0.69; 95% CI 0.48-0.98), with an ARR of 9.32% and 14.94%, an NNTB of 5.89 and 8.04, and a low and moderate certainty of evidence, respectively. Most reviews had severe methodological flaws that led to results with very low certainty of evidence. The review with the lowest risk of bias presented results in favor of prone positional ventilation compared with high-frequency oscillatory ventilation and lung-protective ventilation. There is a need to update the available reviews to obtain more accurate results.
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Cost-effectiveness of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome in Colombia. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2022; 42:707-716. [PMID: 36511675 PMCID: PMC9831195 DOI: 10.7705/biomedica.6386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 12/14/2022]
Abstract
Introduction: Extracorporeal membrane oxygenation therapy is expensive. There is evidence in the literature that it can be a cost-effective intervention in developed countries; however, in countries with low gross domestic product per capita, such as Colombia, there are still some doubts.
Objective: To determine the incremental cost-effectiveness ratio of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome in Colombia.
Materials and methods: Cost-effectiveness analysis in healthcare in relation to adult patients diagnosed with acute respiratory distress syndrome with mechanical ventilation with low volumes compared to extracorporeal membrane oxygenation. The direct medical costs and the incremental cost-effectiveness ratio were determined at 6 months.
Results: The expected cost per patient on protective mechanical ventilation was COP$17,609,909. The cost of extracorporeal membrane oxygenation therapy support in surviving patients was COP$ 98,784,116. The average cost-effectiveness ratio of extracorporeal membrane oxygenation was COP$ 141,662,435 for each life saved (USD$ 41,276).
Conclusions: Support with extracorporeal membrane oxygenation therapy had an average cost of COP$ 141,662,435 for each life saved equivalent to USD$ 41,276. The incremental cost-effectiveness ratio COP$ was 608,783,750 (USD$ 177,384); almost ten times higher than the decision rule of three gross domestic product per capita (COP$ 59,710,479).
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19
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Boffi A, Ravenel M, Lupieri E, Schneider A, Liaudet L, Gonzalez M, Chiche JD, Piquilloud L. Physiological response to prone positioning in intubated adults with COVID-19 acute respiratory distress syndrome: a retrospective study. Respir Res 2022; 23:320. [DOI: 10.1186/s12931-022-02247-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/09/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background
COVID-19 related acute respiratory distress syndrome (ARDS) has specific characteristics compared to ARDS in other populations. Proning is recommended by analogy with other forms of ARDS, but few data are available regarding its physiological effects in this population. This study aimed to assess the effects of proning on oxygenation parameters (PaO2/FiO2 and alveolo-arterial gradient (Aa-gradient)), blood gas analysis, ventilatory ratio (VR), respiratory system compliance (CRS) and estimated dead space fraction (VD/VT HB). We also looked for variables associated with treatment failure.
Methods
Retrospective monocentric study of intubated COVID-19 ARDS patients managed with an early intubation, low to moderate positive end-expiratory pressure and early proning strategy hospitalized from March 6 to April 30 2020. Blood gas analysis, PaO2/FiO2, Aa-gradient, VR, CRS and VD/VT HB were compared before and at the end of each proning session with paired t-tests or Wilcoxon tests (p < 0.05 considered as significant). Proportions were assessed using Fischer exact test or Chi square test.
Results
Forty-two patients were included for a total of 191 proning sessions, median duration of 16 (5–36) hours. Considering all sessions, PaO2/FiO2 increased (180 [148–210] vs 107 [90–129] mmHg, p < 0.001) and Aa-gradient decreased (127 [92–176] vs 275 [211–334] mmHg, p < 0.001) with proning. CRS (36.2 [30.0–41.8] vs 32.2 [27.5–40.9] ml/cmH2O, p = 0.003), VR (2.4 [2.0–2.9] vs 2.3 [1.9–2.8], p = 0.028) and VD/VT HB (0.72 [0.67–0.76] vs 0.71 [0.65–0.76], p = 0.022) slightly increased. Considering the first proning session, PaO2/FiO2 increased (186 [165–215] vs 104 [94–126] mmHg, p < 0.001) and Aa-gradient decreased (121 [89–160] vs 276 [238–321] mmHg, p < 0.001), while CRS, VR and VD/VT HB were unchanged. Similar variations were observed during the subsequent proning sessions. Among the patients who experienced treatment failure (defined as ICU death or need for extracorporeal membrane oxygenation), fewer expressed a positive response in terms of oxygenation (defined as increase of more than 20% in PaO2/FiO2) to the first proning (67 vs 97%, p = 0.020).
Conclusion
Proning in COVID-19 ARDS intubated patients led to an increase in PaO2/FiO2 and a decrease in Aa-gradient if we consider all the sessions together, the first one or the 4 subsequent sessions independently. When considering all sessions, CRS increased and VR and VD/VT HB only slightly increased.
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20
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Patton D, Latimer S, Avsar P, Walker RM, Moore Z, Gillespie BM, O'Connor T, Nugent L, Budri A, Brien NO, Chaboyer W. The effect of prone positioning on pressure injury incidence in adult intensive care unit patients: A meta-review of systematic reviews. Aust Crit Care 2022; 35:714-722. [PMID: 34916149 DOI: 10.1016/j.aucc.2021.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Numerous systematic reviews have examined the impact of prone positioning on outcomes, including pressure injury (PI). The objective of this meta-review was to synthesise the evidence on the effect of prone positioning on the incidence and location of PIs in adult intensive care unit patients. REVIEW METHOD This is a meta-review of published systematic reviews. Five databases were searched; data were extracted by three authors and adjudicated by a fourth. The AMSTAR-2 tool was used to quality appraise the selected articles, which was completed by three authors with a fourth adjudicating. RESULTS Ten systematic reviews were synthesised. The cumulative incidence of PI in 15,979 adult patients ranged from 25.7% to 48.5%. One study did not report adult numbers. Only one review reported the secondary outcome of PI location. PIs were identified in 13 locations such as the face, chest, iliac crest, and knees. Using the AMSTAR-2, three reviews were assessed as high quality, six as moderate quality, and one as low quality. CONCLUSION The high incidence of PI in the prone position highlights the need for targeted preventative strategies. Care bundles may be one approach, given their beneficial effects for the prevention of PI in other populations. This review highlights the need for proactive approaches to limit unintended consequences of the use of the prone position, especially notable in the current COVID-19 pandemic.
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Affiliation(s)
- Declan Patton
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; Faculty of Science, Medicine and Health, University of Wollongong, Australia; School of Nursing and Midwifery, Griffith University, Queensland, Australia.
| | - Sharon Latimer
- School of Nursing and Midwifery, Griffith University, Queensland, Australia; Nursing and Midwifery Education and Research Unit, Gold Coast University Hospital, Southport, Queensland, Australia; National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Queensland, Australia.
| | - Pinar Avsar
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
| | - Rachel M Walker
- School of Nursing and Midwifery, Griffith University, Queensland, Australia; Division of Surgery, Princess Alexandra Hospital, Brisbane, Australia; National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Queensland, Australia.
| | - Zena Moore
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; School of Nursing and Midwifery, Griffith University, Queensland, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia; Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Belgium; Lida Institute, Shanghai, China; University of Wales, Cardiff, UK; National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Queensland, Australia.
| | - Brigid M Gillespie
- School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, Griffith University, Queensland, Australia; Nursing and Midwifery Education and Research Unit, Gold Coast University Hospital, Southport, Queensland, Australia; National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Queensland, Australia.
| | - Tom O'Connor
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Fakeeh College of Health Sciences, Jeddah, Saudi Arabia; School of Nursing and Midwifery, Griffith University, Queensland, Australia; Lida Institute, Shanghai, China.
| | - Linda Nugent
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Fakeeh College of Health Sciences, Jeddah, Saudi Arabia.
| | - Aglecia Budri
- Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
| | - Niall O Brien
- Library, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
| | - Wendy Chaboyer
- School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland; School of Nursing and Midwifery, Griffith University, Queensland, Australia; National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Queensland, Australia.
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21
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Chong WH, Saha BK, Tan CK. Clinical Outcomes of Routine Awake Prone Positioning in COVID-19 Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Prague Med Rep 2022; 123:140-165. [PMID: 36107444 DOI: 10.14712/23362936.2022.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Before coronavirus disease 2019 (COVID-19) emerged, proning had been demonstrated to improve oxygenation in those with acute hypoxic respiratory failure and be performed in non-intensive care settings. This benefit was further exemplified by the COVID-19 pandemic, leading to awake prone positioning (APP). We assessed the efficacy of routine APP versus standard care in preventing death and invasive mechanical ventilation (IMV) in non-intubated hypoxic COVID-19 patients. PubMed, Cochrane Library, Scopus, and medRxiv databases were used from January 1st, 2020, to January 15th, 2022, to identify randomized controlled trials (RCTs). Routine APP group were encouraged to be self-prone, whereas the standard care group received care according to local clinical practice and allowed APP crossover as rescue therapy. We included eight COVID-19 RCTs assessing 809 APP vs. 822 standard care patients. APP group had less IMV requirement (26.5% vs. 30.9%; OR - odds ratio 0.77; P=0.03) than the standard care group, with subgroup analysis showing greater benefit (32.5% vs. 39.1%; OR 0.75; P=0.02) for those mainly requiring oxygen support of non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC). The time to IMV initiation was similar (mean 8.3 vs. 10.0 days; P=0.66) for patients requiring NIMV and HFNC. Patients mainly receiving supplemental oxygen and non-rebreather masks had improved oxygenation parameters, although not statistically significant. Other outcomes involving all-cause hospital mortality, hospital and ICU (intensive care unit) length of stay, and adverse events were comparable. APP appeared to be an important modality for reducing IMV requirements, especially in those requiring NIMV and HFNC.
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Affiliation(s)
- Woon Hean Chong
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore.
| | - Biplab K Saha
- Department of Pulmonary and Critical Care, Ozarks Medical Center, West Plains, USA
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
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22
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Moser CH, Peeler A, Long R, Schoneboom B, Budhathoki C, Pelosi PP, Brenner MJ, Pandian V. Prevention of Endotracheal Tube-Related Pressure Injury: A Systematic Review and Meta-analysis. Am J Crit Care 2022; 31:416-424. [PMID: 36045034 DOI: 10.4037/ajcc2022644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hospital-acquired pressure injuries, including those related to airway devices, are a significant source of morbidity in critically ill patients. OBJECTIVE To determine the incidence of endotracheal tube-related pressure injuries in critically ill patients and to evaluate the effectiveness of interventions designed to prevent injury. METHODS MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for studies of pediatric or adult patients in intensive care units that evaluated interventions to reduce endotracheal tube-related pressure injury. Reviewers extracted data on study and patient characteristics, incidence of pressure injury, type and duration of intervention, and outcomes. Risk of bias assessment followed the Cochrane Collaboration's criteria. RESULTS Twelve studies (5 randomized clinical trials, 3 quasi-experimental, 4 observational) representing 9611 adult and 152 pediatric patients met eligibility criteria. The incidence of pressure injury was 4.2% for orotracheal tubes and 21.1% for nasotracheal tubes. Interventions included anchor devices, serial endotracheal tube assessment or repositioning, and barrier dressings for nasotracheal tubes. Meta-analysis revealed that endotracheal tube stabilization was the most effective individual intervention for preventing pressure injury. Nasal alar barrier dressings decreased the incidence of skin or mucosal injury in patients undergoing nasotracheal intubation, and data on effectiveness of serial assessment and repositioning were inconclusive. CONCLUSIONS Airway device-related pressure injuries are common in critically ill patients, and patients with nasotracheal tubes are particularly susceptible to iatrogenic harm. Fastening devices and barrier dressings decrease the incidence of injury. Evidence regarding interventions is limited by lack of standardized assessments.
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Affiliation(s)
- Chandler H Moser
- Chandler H. Moser is a PhD candidate, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Anna Peeler
- Anna Peeler is a PhD candidate, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Robert Long
- Robert Long is chief of anesthesia nursing, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Bruce Schoneboom
- Bruce Schoneboom (retired) was associate dean for Practice, Innovation, and Leadership, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Chakra Budhathoki
- Chakra Budhathoki is a biostatistician, School of Nursing and Biostatistics Core, Johns Hopkins University
| | - Paolo P Pelosi
- Paolo P. Pelosi is a chief professor, Anaesthesia and Intensive Care, and director, Specialty School in Anaesthesiology, University of Genoa, and head of the Anaesthesia and Intensive Care Unit at IRCCS San Martino-IST Hospital, Genoa, Italy
| | - Michael J Brenner
- Michael J. Brenner is an associate professor, Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, and President, Global Tracheostomy Collaborative, Raleigh, North Carolina
| | - Vinciya Pandian
- Vinciya Pandian is an associate professor, School of Nursing and Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University
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23
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Prone position reduces the risk of patients with mild or moderate COVID-19 progressing to severe or even critical cases: a retrospective study. Eur J Med Res 2022; 27:149. [PMID: 35962440 PMCID: PMC9372953 DOI: 10.1186/s40001-022-00776-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/27/2022] [Indexed: 01/08/2023] Open
Abstract
Background To investigate whether prone position can reduce the risk of patients with mild or moderate COVID-19 who progress to severe or critical illness. Methods The prone position group was treated in prone position on the day of admission in addition to conventional treatment. Indicators such as saturation of pulse oximetry (SpO2), heart rate, blood pressure, respiratory rate, and prone position-related adverse events were recorded before prone ventilation, 5 min after prone position and 30 min after prone position. Meanwhile, the cases of severe and critical patients, the percentage of transformation and the final clinical outcome of this group were analyzed. Conversion rates and mortality were calculated for patients with mild or moderate COVID-19 retrieved from the database who received only conventional care without combined prone positioning as control group. Results (1) A total of 34 patients were included in prone position group. There were significant differences in SpO2 between the first 4 days after admission and the day of discharge (F = 3.17, P < 0.001). (2) The main complications were back and neck muscle soreness (55.9%), followed by abdominal distension (8.9%). (3) In control group, a total of 4873 cases of mild and moderate patients were included from 19 literatures, with an average deterioration rate of 22.7% and mortality rate of 1.7%. (4) In prone position group, there were no severe or critical transformation cases and also no death cases. The prone position group had a significantly lower deterioration rate when compared with the control group (χ2 = 9.962, P < 0.01). Conclusion Prone position improves SpO2 in patients with mild or moderate COVID-19. It can also reduce the percentage of mild or moderate patients progressing to severe or critical patients. The application of prone position is a simple, feasible, safe and effective treatment method in such patients.
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24
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Meta-Analysis of the Effect of Glucocorticoids on Adult Acute Respiratory Distress Syndrome. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4020489. [PMID: 35990837 PMCID: PMC9385278 DOI: 10.1155/2022/4020489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
Objectives The aim of this study is to investigate the effect of glucocorticoids in adult patients with acute respiratory distress syndrome (ARDS) by meta-analysis. Methods PubMed, Cochrane Library, Embase, CNKI, Wanfang Database, and Chinese Biomedical literature database were searched. A randomized controlled trial (RCTS) on glucocorticoid therapy in adult patients with ARDS was conducted from the time of database construction to December 2021. The content is about the randomized controlled trial (RCT) of glucocorticoid treatment for adult patients with ARDS, without limiting the dose and course of glucocorticoid treatment. The quality of the included RCTS was evaluated by using the bias risk assessment tool of the Cochrane Collaboration network, and the basic information, clinical features, and target outcomes of the literature were extracted. The effects of glucocorticoids on mortality and oxygenation index (PaO2/FiO2) in adult ARDS patients were evaluated by meta-analysis. Results A total of 1,441 ARDS patients in 10 RCTs were finally included, including 734 patients in the glucocorticoid treatment group (hormone group) and 707 patients in the conventional treatment group (control group). The 10 studies included have a good overall design and high quality. Compared with controls, glucocorticoid use was significantly associated with a decrease in mortality in adult ARDS patients (relative risk (RR) = 0.73, 95% confidence interval (95% CI) = 0.59–0.90, P = 0.003). Analysis showed that glucocorticoids significantly reduced the mortality in ARDS patients treated with medium and low doses of steroids (RR = 0.73, 95% CI = 0.58–0.92, P = 0.007). In patients with early administration of steroids, intervention with glucocorticoids was significantly associated with the decreased mortality in adult ARDS patients compared with controls (RR = 0.74, 95% CI 0.56–0.99, P = 0.04). Among patients with more than 7 days of hormone therapy, treatment with glucocorticoids was significantly associated with decreased mortality in adult ARDS patients (RR = 0.66, 95% CI = 0.50–0.88, P = 0.005) compared with controls. Glucocorticoids tended to improve PaO2/FiO2 in adult ARDS patients compared with controls, but the difference was not statistically significant (weighted mean difference (WMD) = 11.60, 95% = CI = 15.02–38.22, P = 0.39). Conclusion Glucocorticoid therapy can reduce mortality in adult ARDS patients, and the benefit is more pronounced in patients with medium- and low-dose hormone therapy, early hormone administration, and hormone therapy for more than 7 days. However, no improvement in PaO2/FiO2 by glucocorticoid treatment was found, which needs to be confirmed by further studies.
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25
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Qian ET, Gatto CL, Amusina O, Dear ML, Hiser W, Buie R, Kripalani S, Harrell FE, Freundlich RE, Gao Y, Gong W, Hennessy C, Grooms J, Mattingly M, Bellam SK, Burke J, Zakaria A, Vasilevskis EE, Billings FT, Pulley JM, Bernard GR, Lindsell CJ, Rice TW. Assessment of Awake Prone Positioning in Hospitalized Adults With COVID-19: A Nonrandomized Controlled Trial. JAMA Intern Med 2022; 182:612-621. [PMID: 35435937 PMCID: PMC9016608 DOI: 10.1001/jamainternmed.2022.1070] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Awake prone positioning may improve hypoxemia among patients with COVID-19, but whether it is associated with improved clinical outcomes remains unknown. OBJECTIVE To determine whether the recommendation of awake prone positioning is associated with improved outcomes among patients with COVID-19-related hypoxemia who have not received mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS This pragmatic nonrandomized controlled trial was conducted at 2 academic medical centers (Vanderbilt University Medical Center and NorthShore University HealthSystem) during the COVID-19 pandemic. A total of 501 adult patients with COVID-19-associated hypoxemia who had not received mechanical ventilation were enrolled from May 13 to December 11, 2020. INTERVENTIONS Patients were assigned 1:1 to receive either the practitioner-recommended awake prone positioning intervention (intervention group) or usual care (usual care group). MAIN OUTCOMES AND MEASURES Primary outcome analyses were performed using a bayesian proportional odds model with covariate adjustment for clinical severity ranking based on the World Health Organization ordinal outcome scale, which was modified to highlight the worst level of hypoxemia on study day 5. RESULTS A total of 501 patients (mean [SD] age, 61.0 [15.3] years; 284 [56.7%] were male; and most [417 (83.2%)] were self-reported non-Hispanic or non-Latinx) were included. Baseline severity was comparable between the intervention vs usual care groups, with 170 patients (65.9%) vs 162 patients (66.7%) receiving oxygen via standard low-flow nasal cannula, 71 patients (27.5%) vs 62 patients (25.5%) receiving oxygen via high-flow nasal cannula, and 16 patients (6.2%) vs 19 patients (7.8%) receiving noninvasive positive-pressure ventilation. Nursing observations estimated that patients in the intervention group spent a median of 4.2 hours (IQR, 1.8-6.7 hours) in the prone position per day compared with 0 hours (IQR, 0-0.7 hours) per day in the usual care group. On study day 5, the bayesian posterior probability of the intervention group having worse outcomes than the usual care group on the modified World Health Organization ordinal outcome scale was 0.998 (posterior median adjusted odds ratio [aOR], 1.63; 95% credibility interval [CrI], 1.16-2.31). However, on study days 14 and 28, the posterior probabilities of harm were 0.874 (aOR, 1.29; 95% CrI, 0.84-1.99) and 0.673 (aOR, 1.12; 95% CrI, 0.67-1.86), respectively. Exploratory outcomes (progression to mechanical ventilation, length of stay, and 28-day mortality) did not differ between groups. CONCLUSIONS AND RELEVANCE In this nonrandomized controlled trial, prone positioning offered no observed clinical benefit among patients with COVID-19-associated hypoxemia who had not received mechanical ventilation. Moreover, there was substantial evidence of worsened clinical outcomes at study day 5 among patients recommended to receive the awake prone positioning intervention, suggesting potential harm. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04359797.
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Affiliation(s)
- Edward Tang Qian
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cheryl L Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Olga Amusina
- Critical Care Services, NorthShore University HealthSystem, Evanston, Illinois.,Department of Biobehavioral Nursing Science, University of Illinois, Chicago, College of Nursing, Chicago
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Hiser
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert E Freundlich
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jillann Grooms
- School of Nursing and Health Sciences, North Park University, Chicago, Illinois
| | - Megan Mattingly
- Critical Care Services, NorthShore University HealthSystem, Evanston, Illinois
| | - Shashi K Bellam
- Division of Pulmonary and Critical Care, Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Jessica Burke
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arwa Zakaria
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frederic T Billings
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill M Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R Bernard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W Rice
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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26
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Mano T, Fujimura S. Brachial Plexus Injury and Musculocutaneous Nerve Palsy During Prone Positioning in a Patient With COVID-19. Cureus 2022; 14:e24931. [PMID: 35706719 PMCID: PMC9187171 DOI: 10.7759/cureus.24931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 02/05/2023] Open
Abstract
Prone positioning is crucial in the respiratory management of patients with acute respiratory distress syndrome (ARDS) and reduces mortality. However, this may be complicated by compression-related peripheral nerve injury. We report the case of a male in his 80s with obesity admitted to the intensive care unit (ICU) with COVID-19 pneumonia who developed brachial plexus disorder in the right upper extremity and musculocutaneous neuropathy in the left. The patient's cough, dyspnea, and fatigue did not improve; therefore, he was intubated and placed in the prone position for one week. The patient complained of bilateral upper limb weakness on regaining consciousness. We diagnosed left musculocutaneous nerve palsy and right brachial plexus palsy based on physical findings and needle electromyography (EMG). Physical therapy was initiated, including joint range-of-motion exercises focused on preventing contractures in the extremities and active assistive exercises. Motor impairment improved, and the patient was discharged from the rehabilitation center.
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Affiliation(s)
- Tomoo Mano
- Department of Rehabilitation Medicine, Nara Medical University, Kashihara, JPN
| | - Shigekazu Fujimura
- Department of Rehabilitation Medicine, Nara Medical University, Kashihara, JPN
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27
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Karaaslan T, Avarisli A, Durdu B, Daskaya H. A case of meralgia paresthetica caused by prone positioning in a COVID-19 patient with acute respiratory distress syndrome. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COVID-19 critically ill patients usually require prone positioning for the treatment of respiratory failure caused by Acute Respiratory Distress Syndrome (ARDS). Prone position provides a better ventilation-perfusion compatibility, resulting in a significant improvement in oxygenation and a decrease in mortality, but prolonged prone positioning may cause Meralgia Paresthetica (MP), one of the most common mononeuropathies of the lower limb. The early diagnosis of MP is crucial to avoid a permanent damage with pain and disability, and to start immediately the correct treatment. In this article, we report a rare case of MP in a critically ill COVID-19 patient with ARDS, with the main aim to create awareness for MP among the medical team working.
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Zanchetta FC, Silva JLG, Pedrosa RBDS, Oliveira-Kumakura ARDS, Gasparino RC, Perissoto S, Silva VA, Lima MHDM. Cuidados de enfermagem e posição prona: revisão integrativa. AVANCES EN ENFERMERÍA 2022. [DOI: 10.15446/av.enferm.v40n1supl.91372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objetivo: explorar, na literatura científica, práticas atuais de cuidado de enfermagem ou intervenções para pacientes com síndrome respiratório agudo grave (SRAG) submetidos à posição prona.
Síntese do conteúdo: revisão integrativa, na qual foram realizadas buscas nas bases de dados PubMed, CINAHL, Scopus, Web of Science e LILACS em setembro de 2020 e janeiro de 2022, sem recorte temporal, por meio da questão deste estudo: “Quais são os cuidados de enfermagem para pacientes com SRAG submetidos à posição prona?”. Foram selecionados 15 artigos, a partir da busca nas bases de dados. Após a leitura, os cuidados encontrados foram categorizados em alinhamento do corpo para a prevenção de lesões neuromusculares, cuidados com equipamentos diversos, cuidados tegumentares e recomendações neurológicas.
Conclusões: o enfermeiro deve ter conhecimento sobre as implicações e as complicações de se manter um paciente na posição prona. Tal conhecimento permitirá tomadas de decisões na construção ou no seguimento de protocolos institucionais que contribuam com a prevenção de riscos e resultem em melhores desfechos para o paciente.
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29
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Prognostic value of computed tomographic findings in acute respiratory distress syndrome and the response to prone positioning. BMC Pulm Med 2022; 22:71. [PMID: 35216579 PMCID: PMC8874746 DOI: 10.1186/s12890-022-01864-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/15/2022] [Indexed: 01/06/2023] Open
Abstract
Background Prone positioning enables the redistribution of lung weight, leading to the improvement of gas exchange and respiratory mechanics. We aimed to evaluate whether the initial findings of acute respiratory distress syndrome (ARDS) on computed tomography (CT) are associated with the subsequent response to prone positioning in terms of oxygenation and 60-day mortality. Methods We retrospectively included patients who underwent prone positioning for moderate to severe ARDS from October 2014 to November 2020 at a medical center in Taiwan. A semiquantitative CT rating scale was used to quantify the extent of consolidation and ground-glass opacification (GGO) in the sternal, central and vertebral regions at three levels (apex, hilum and base) of the lungs. A prone responder was identified by a 20% increase in the ratio of arterial oxygen pressure (PaO2) to the fraction of oxygen (FiO2) or a 20 mmHg increase in PaO2. Results Ninety-six patients were included, of whom 68 (70.8%) were responders. Compared with nonresponders, responders had a significantly greater median dorsal–ventral difference in CT-consolidation scores (10 vs. 7, p = 0.046) but not in CT-GGO scores (− 1 vs. − 1, p = 0.974). Although dorsal–ventral differences in neither CT-consolidation scores nor CT-GGO scores were associated with 60-day mortality, high total CT-GGO scores (≥ 15) were an independent factor associated with 60-day mortality (odds ratio = 4.07, 95% confidence interval, 1.39–11.89, p = 0.010). Conclusions In patients with moderate to severe ARDS, a greater difference in the extent of consolidation along the dependent-independent axis on CT scan is associated with subsequent prone positioning oxygenation response, but not clinical outcome regarding survival. High total CT-GGO scores were independently associated with 60-day mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01864-9.
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30
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Body position for preventing ventilator-associated pneumonia for critically ill patients: a systematic review and network meta-analysis. J Intensive Care 2022; 10:9. [PMID: 35193688 PMCID: PMC8864849 DOI: 10.1186/s40560-022-00600-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/09/2022] [Indexed: 02/06/2023] Open
Abstract
Background The evidence about the best body position to prevent ventilator-associated pneumonia (VAP) is unclear. The aim of this study was to know what the best body position is to prevent VAP, shorten the length of intensive care unit (ICU) and hospital stay, and reduce mortality among patients undergoing mechanical ventilation (MV). Methods We performed a network meta-analysis of randomized controlled trials including intubated patients undergoing MV and admitted to an ICU. The assessed interventions were different body positions (i.e., lateral, prone, semi-recumbent) or alternative degrees of positioning in mechanically ventilated patients. Results Semi-recumbent and prone positions showed a risk reduction of VAP incidence (RR: 0.38, 95% CI: 0.25–0.52) and mortality (RR: 0.70, 95% CI: 0.50–0.91), respectively, compared to the supine position. The ranking probabilities and the surface under the cumulative ranking displayed as the first best option of treatment the semi-recumbent position to reduce the incidence of VAP (71.4%), the hospital length of stay (68.9%), and the duration of MV (67.6%); and the prone position to decrease the mortality (89.3%) and to reduce the ICU length of stay (59.3%). Conclusions Cautiously, semi-recumbent seems to be the best position to reduce VAP incidence, hospital length of stay and the duration of MV. Prone is the most effective position to reduce the risk of mortality and the ICU length of stay, but it showed no effect on the VAP incidence. Registration PROSPERO CRD42021247547 Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00600-z.
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Ajmal M, Aftab Khan Lodhi F, Nawaz G, Basharat A, Aslam A. Blastomycosis-Induced Acute Respiratory Distress Syndrome. Cureus 2022; 14:e22207. [PMID: 35308721 PMCID: PMC8925978 DOI: 10.7759/cureus.22207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 11/06/2022] Open
Abstract
Blastomycosis is a systemic mycosis endemic to the Midwestern and South Central United States. Infection is caused by inhaling spores of Blastomyces dermatitidis (B. dermatitidis) that inhabit soil. Acute respiratory distress syndrome (ARDS) is a rare complication of pulmonary blastomycosis with a significantly high mortality rate. We present a case of blastomycosis associated with severe ARDS treated with traditional prone position ventilation (PPV) and neurally adjusted ventilator assist (NAVA) along with antifungal therapy, steroids, and supportive care in a rural setting with no access to extracorporeal membrane oxygenation (ECMO). This case demonstrates that traditional therapies such as prone position ventilation can help patients with blastomycosis-associated ARDS especially in rural settings where advanced therapies such as ECMO are lacking. The use of NAVA in blastomycosis-associated ARDS needs further research.
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Ippolito M, Cortegiani A, Biancofiore G, Caiffa S, Corcione A, Giusti GD, Iozzo P, Lucchini A, Pelosi P, Tomasoni G, Giarratano A. The prevention of pressure injuries in the positioning and mobilization of patients in the ICU: a good clinical practice document by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:7. [PMID: 37386656 DOI: 10.1186/s44158-022-00035-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND The aim of this document is to support clinical decision-making concerning positioning and mobilization of the critically ill patient in the early identification and resolution of risk factors (primary prevention) and in the early recognition of those most at risk (secondary prevention). The addresses of this document are physicians, nurses, physiotherapists, and other professionals involved in patient positioning in the intensive care unit (ICU). METHODS A consensus pathway was followed using the Nominal Focus Group and the Delphi Technique, integrating a phase of focused group discussion online and with a pre-coded guide to an individual phase. A multidisciplinary advisory board composed by nine experts on the topic contributed to both the phases of the process, to reach a consensus on four clinical questions positioning and mobilization of the critically ill patient. RESULTS The topics addressed by the clinical questions were the risks associated with obligatory positioning and therapeutic positions, the effective interventions in preventing pressure injuries, the appropriate instruments for screening for pressure injuries in the ICU, and the cost-effectiveness of preventive interventions relating to ICU positioning. A total of 27 statements addressing these clinical questions were produced by the panel. Among the statements, nine provided guidance on how to manage safely some specific patients' positions, including the prone position; five suggested specific screening tools and patients' factors to consider when assessing the individual risk of developing pressure injuries; five gave indications on mobilization and repositioning; and eight focused on the use of devices, such as positioners and preventive dressings. CONCLUSIONS The statements may represent a practical guidance for a broad public of healthcare professionals involved in the management of critically ill patients.
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Affiliation(s)
- Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Gianni Biancofiore
- UOC Anestesia e Rianimazione Trapianti Dipartimento di Patologia chirurgica, medica, molecolare e dell'Area Critica, Università di Pisa. Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Salvatore Caiffa
- Intensive Care Respiratory Physiotherapy, Rehabilitation and Functional Education, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132, Genoa, Italy
| | - Antonio Corcione
- Unit of Anaesthesia and intensive Care, Monaldi Hospital Naples, Naples, Italy
| | | | - Pasquale Iozzo
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Alberto Lucchini
- General Intensive Care Unit, Emergency Department - ASST Monza - San Gerardo Hospital, University of Milano-Bicocca, Via Pergolesi 33, Monza, MB, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Gabriele Tomasoni
- First Division of Anesthesiology and Critical Care Medicine, ASST Spedali Civili, Brescia, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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Johnson C, Giordano NA, Patel L, Book KA, Mac J, Viscomi J, Em A, Westrick A, Koganti M, Tanpiengco M, Sylvester K, Mastro KA. Pressure Injury Outcomes of a Prone-Positioning Protocol in Patients With COVID and ARDS. Am J Crit Care 2022; 31:34-41. [PMID: 34514503 DOI: 10.4037/ajcc2022242] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND During the COVID-19 outbreak, standard methods for treating acute respiratory distress syndrome (ARDS) were used for patients presenting with ARDS. One such treatment method involves placing patients prone to improve oxygenation and reduce mortality risk. Challenges in preventing pressure injuries in patients placed prone have been reported, and no studies have explored the effects of including a certified wound and skin care nurse as part of the care team on the incidence of pressure injuries in SARS-CoV-2-infected patients with ARDS. OBJECTIVES To evaluate the association between including a certified wound and skin care nurse on a multiprofessional pronation team and prevention of pressure injuries in SARS-CoV-2-infected patients with ARDS. METHODS This multicenter observational cohort study used retrospective data from the electronic health record. The intervention group consisted of SARS-CoV-2-infected patients diagnosed with ARDS who were treated by a multidisciplinary prone-positioning team that included a certified wound and skin care nurse specialist. The comparison group of SARS-CoV-2-infected patients with ARDS was treated by a multidisciplinary prone-positioning team that did not include a certified wound and skin care nurse specialist. RESULTS As shown by multivariable logistic regression mixed-effect modeling, patients in the intervention group had a 97% lower adjusted odds ratio of a pressure injury developing than did patients in the comparison group (0.03 [95% CI, 0.01-0.14]; P < .001). CONCLUSION The inclusion of a certified wound and skin care nurse on a multiprofessional prone-positioning team significantly reduced the odds of pressure injuries developing in patients infected with SARS-CoV-2.
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Affiliation(s)
- Connie Johnson
- Connie Johnson is a wound care nurse and ostomy management specialist, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Nicholas A Giordano
- Nicholas A. Giordano is an assistant professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Lopa Patel
- Lopa Patel is a professional development specialist, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Karyn A Book
- Karyn A. Book is associate chief nursing officer, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Jennifer Mac
- Jennifer Mac is a clinical nurse, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Janet Viscomi
- Janet Viscomi is a clinical nurse, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - April Em
- April Em is a physical therapist, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Anna Westrick
- Anna Westrick is an attending physician, Department of Anesthesia, and chair, Clinical Effectiveness and Quality Improvement, Penn Medicine Princeton Health
| | - Monika Koganti
- Monika Koganti is an Attending physician, Department of Pulmonary and Critical Care, and a respiratory and sleep specialist, Penn Medicine Princeton Health
| | - Mindaline Tanpiengco
- Mindaline Tanpiengco is a senior nurse manager, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Karen Sylvester
- Karen Sylvester is director of nursing, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - Kari A Mastro
- Kari A. Mastro is director of practice, innovation, and research, Penn Medicine Princeton Health; faculty lecturer, University of Pennsylvania School of Nursing, Philadelphia; and adjunct faculty, Center for Health Services Research and Policy, Rutgers' School of Nursing, Plainsboro, New Jersey
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Ryan P, Fine C, DeForge C. An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS. Crit Care Nurse 2021; 41:55-60. [PMID: 34851387 DOI: 10.4037/ccn2021900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. REVIEW OF EVIDENCE A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. IMPLEMENTATION An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. EVALUATION This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. SUSTAINABILITY Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. CONCLUSIONS Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.
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Affiliation(s)
- Patrick Ryan
- Patrick Ryan is a clinical nurse specialist-medicine, New York Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Cynthia Fine
- Cynthia Fine is a clinical program coordinator, New York Presbyterian/Columbia University Irving Medical Center
| | - Christine DeForge
- Christine DeForge is a PhD student, Columbia University School of Nursing, New York, New York
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Díaz-Bohada L, Segura-Salguero JC, Garzón-Beltrán NF, Salazar-Balcázar D, Otálora-Estéban M. Considerations of invasive mechanical ventilation in prone position. A narrative review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e1013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The evidence regarding logistic considerations and safety events associated with prone position ventilation (PPV) is summarized and a flow diagrama for safe provision of mechanical ventilation in the setting of the COVID-19 pandemic is proposed. A review of the literature was conducted in the Medline via Pubmed, Embase, and Lilacs databases, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Randomized Controlled Trials, Cochrane Database of Abstracts of Reviews of Effects, ProQuest Nursing and Allied Health Database, and Google scholar. Overall, 31 articles were selected for the analysis. The incidence of PPV-related safety events varies between 1% and 11.9% and the most frequent complications are pressure ulcers and airway complications. Early initiation of enteral nutrition is recommended, and transfers are possible in patients on PPV. There is controversy regarding contraindications and recommendations for PPV. Recommendations for its safe provision are based on expert opinions and the establishment of protocols for healthcare staff training. Clinical studies are required to determine which are the recommendations that should be considered for safe and reproducible PPV use during this pandemic.
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Ateş İ, Erden A, Gürler EK, Çağlayan A, Güçbey Ö, Karakaş Ö, Şahiner ES, Güven SC, İzdeş S, Küçükşahin O, Omma A. Compliance to not only prone but also lateral and supine positioning improves outcome in hospitalised COVID-19 patients. Int J Clin Pract 2021; 75:e14673. [PMID: 34324243 PMCID: PMC8420268 DOI: 10.1111/ijcp.14673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/23/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Positioning of the patient is a common strategy to increase oxygenation in the management of acute respiratory distress syndrome. The aim of this study is to demonstrate the effects of our positioning approach on disease outcomes in COVID-19 patients with respiratory failure, by comparing patients compliant to positioning and not. METHODS COVID-19 patients who were admitted to our internal medicine inpatient clinic and developed hypoxaemia and underwent positioning during hospital stay were retrospectively investigated for compliance to positioning. Rates of mortality, intensive care unit admission, intubation, initiation of anti-inflammatory treatment and length of hospital stay were compared between patients with and without compliance to positioning. RESULTS A total of 144 patients were enrolled in this study (97 compliant with positioning, 47 incompliant with positioning). Rates of ICU admission (7.2% vs 25.5%, p < .001), anti-inflammatory treatment initiation (68% vs 97.9%, p < .001) and length of hospital stay (5 (2-16) days vs 12 (3-20) days, p < .001) were significantly reduced in patients compliant with positioning. CONCLUSION Prone or other positioning should be considered in patients with noninvasive oxygen support for the potential to reduce rates of intensive care unit admissions, airway interventions, anti-inflammatory treatment initiation and mortality.
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Affiliation(s)
- İhsan Ateş
- Department of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Abdulsamet Erden
- Division of RheumatologyDepartment of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Elif Kübra Gürler
- Department of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Adem Çağlayan
- Department of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Özge Güçbey
- Department of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Özlem Karakaş
- Division of RheumatologyDepartment of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Enes Seyda Şahiner
- Department of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Serdar Can Güven
- Division of RheumatologyDepartment of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
| | - Seval İzdeş
- Department of Anesthesiology and Reanimation‐Critical CareYıldırım Beyazıt University, School of MedicineAnkaraTurkey
| | - Orhan Küçükşahin
- Division of RheumatologyDepartment of Internal MedicineYıldırım Beyazıt University, School of MedicineAnkaraTurkey
| | - Ahmet Omma
- Division of RheumatologyDepartment of Internal MedicineMinistry of Health Ankara City HospitalAnkaraTurkey
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Fourie A, Ahtiala M, Black J, Hevia H, Coyer F, Gefen A, LeBlanc K, Smet S, Vollman K, Walsh Y, Beeckman D. Skin damage prevention in the prone ventilated critically ill patient: A comprehensive review and gap analysis (PRONEtect study). J Tissue Viability 2021; 30:466-477. [PMID: 34583874 PMCID: PMC8463934 DOI: 10.1016/j.jtv.2021.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/24/2023]
Abstract
Background Ventilating critically ill patients with acute respiratory distress syndrome in the prone position is a life-saving strategy, but it is associated with adverse consequences such as skin damage. Aim To identify, review and evaluate international proning and skin care guidelines and make an inventory of commonly used equipment and training resources. Design A gap analysis methodology was applied. Methods 1) Comprehensive search and evaluation of proning and skin care guidelines, 2) extensive search and listing equipment and educational resources, and 3) international consultation with 11 experts (8 countries). Data sources A variety of sources researched through July 2021 were used to identify relevant literature: (1) scientific literature databases and clinical trials registries, (2) intensive care and wound care associations, (3) healthcare organisations, (4) guideline development organisations, and (5) the Google search engine. Eleven international experts reviewed the literature and provided insights in two, 2-h online sessions. Findings The search yielded 24 guidelines. One clinical practice guideline had high methodological quality. Twenty-five devices/equipment and sixteen teaching materials were identified and discussed with the expert panel. The gap analysis identified a lack of concise, accessible, evidence-based guidelines and educational materials of short duration. Conclusion This analysis forms the basis for designing a competency-based education and training intervention for an interdisciplinary team caring for the skin of critically ill patients in the prone position. Impact The results can assist the multidisciplinary team to review their current protocol for prone positioning. This is a first step in developing a training package for clinicians.
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Affiliation(s)
- Anika Fourie
- Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery (UCVV), Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Maarit Ahtiala
- Service Division, Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Turku, Finland.
| | - Joyce Black
- Niedfeft Professor of Nursing, University of Nebraska Medical Center, College of Nursing, Omaha NE, USA.
| | - Heidi Hevia
- Nursing School, Nursing Department, Andres Bello University, Viña del Mar, Chile.
| | - Fiona Coyer
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Nursing, Queensland University of Technology, Brisbane, Australia.
| | - Amit Gefen
- The Herbert J. Berman Chair in Vascular Bioengineering, Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Israel.
| | - Kim LeBlanc
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada; Wound Ostomy Continence Institute/Association of Nurses Specialized in Wound Ostomy Continence, Ottawa, ON, Canada.
| | - Steven Smet
- Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery (UCVV), Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Kathleen Vollman
- Advancing Nursing LLC, Adjunct faculty Michigan State University, Northville MI, USA.
| | - Yolanda Walsh
- YL Walsh (Pty) Ltd, Adjunct Lecturer Stellenbosch University, Western Cape, South Africa.
| | - Dimitri Beeckman
- Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery (UCVV), Department of Public Health and Primary Care, Ghent University, Ghent, Belgium; Swedish Centre for Skin and Wound Research, School of Health Sciences, Örebro University, Örebro, Sweden; Research Unit of Plastic Surgery, Department of Clinical Research, Faculty of Health Sciences, Odense, Denmark.
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Akoumianaki E, Ischaki E, Karagiannis K, Sigala I, Zakyn-thinos S. The Role of Noninvasive Respiratory Management in Patients with Severe COVID-19 Pneumonia. J Pers Med 2021; 11:jpm11090884. [PMID: 34575661 PMCID: PMC8469068 DOI: 10.3390/jpm11090884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023] Open
Abstract
Acute hypoxemic respiratory failure is the principal cause of hospitalization, invasive mechanical ventilation and death in severe COVID-19 infection. Nearly half of intubated patients with COVID-19 eventually die. High-Flow Nasal Oxygen (HFNO) and Noninvasive Ventilation (NIV) constitute valuable tools to avert endotracheal intubation in patients with severe COVID-19 pneumonia who do not respond to conventional oxygen treatment. Sparing Intensive Care Unit beds and reducing intubation-related complications may save lives in the pandemic era. The main drawback of HFNO and/or NIV is intubation delay. Cautious selection of patients with severe hypoxemia due to COVID-19 disease, close monitoring and appropriate employment and titration of HFNO and/or NIV can increase the rate of success and eliminate the risk of intubation delay. At the same time, all precautions to protect the healthcare personnel from viral transmission should be taken. In this review, we summarize the evidence supporting the application of HFNO and NIV in severe COVID-19 hypoxemic respiratory failure, analyse the risks associated with their use and provide a path for their proper implementation.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Unit, University Hospital of Heraklion, 71500 Crete, Greece
- Correspondence:
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | | | - Ioanna Sigala
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
| | - Spyros Zakyn-thinos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 10676 Athens, Greece; (E.I.); (I.S.); (S.Z.-t.)
- School of Medicine, National and Kapodistrian University of Athens, 10676 Athens, Greece
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Prone Positioning Works: But for How Long and to What End Point? Crit Care Med 2021; 49:535-539. [PMID: 33616354 DOI: 10.1097/ccm.0000000000004840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Akoumianaki E, Jonkman A, Sklar MC, Georgopoulos D, Brochard L. A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea. Ann Intensive Care 2021; 11:107. [PMID: 34250563 PMCID: PMC8273031 DOI: 10.1186/s13613-021-00897-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/30/2021] [Indexed: 12/16/2022] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (ECMO) is a helpful intervention in patients with severe refractory hypoxemia either because mechanical ventilation cannot ensure adequate oxygenation or because lung protective ventilation is not feasible. Since ECMO is a highly invasive procedure with several, potentially devastating complications and its implementation is complex and expensive, simpler and less invasive therapeutic options should be first exploited. Low tidal volume and driving pressure ventilation, prone position, neuromuscular blocking agents and individualized ventilation based on transpulmonary pressure measurements have been demonstrated to successfully treat the vast majority of mechanically ventilated patients with severe hypoxemia. Veno-venous ECMO has a place in the small portion of severely hypoxemic patients in whom these strategies fail. A combined analysis of recent ARDS trials revealed that ECMO was used in only 2.15% of patients (n = 145/6736). Nevertheless, ECMO use has sharply increased in the last decade, raising questions regarding its thoughtful use. Such a policy could be harmful both for patients as well as for the ECMO technique itself. This narrative review attempts to describe together the practical approaches that can be offered to the sickest patients before going to ECMO, as well as the rationale and the limitations of ECMO. The benefit and the drawbacks associated with ECMO use along with a direct comparison with less invasive therapeutic strategies will be analyzed.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Annemijn Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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D'Souza FR, Murray JP, Tummala S, Puello F, Pavkovich DS, Ash D, Kelly SBH, Tyker A, Anderson D, Francisco MA, Pierce NL, Cerasale MT. Implementation and Assessment of a Proning Protocol for Nonintubated Patients With COVID-19. J Healthc Qual 2021; 43:195-203. [PMID: 34180868 PMCID: PMC8260339 DOI: 10.1097/jhq.0000000000000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has caused over 1,250,000 deaths worldwide. With limited therapeutic options, proning nonintubated patients emerged as a safe and affordable intervention to manage hypoxemia. METHODS A proning protocol to identify and prone eligible patients was implemented. Patients were encouraged to self-prone for 2-3 hours, 3 times daily. Investigators created educational materials for nurses and patients and developed a COVID-19-specific proning order within the electronic health record (EHR). Investigators completed an 800-person retrospective chart review to study the implementation of this protocol. RESULTS From March 22, 2020, to June 5, 2020, 586 patients were admitted to the COVID-19 floor. Of these patients, 42.8% were eligible for proning. Common contraindications were lack of hypoxia, altered mental status, and fall risk. The proning protocol led to a significant improvement in provider awareness of patients appropriate for proning, increasing from 12% to 83%, as measured by placement of a proning order into the EHR. There was a significant improvement in all appropriate patients documented as proned, increasing from 18% to 45% of eligible patients. CONCLUSIONS The creation of an effective hospital-wide proning protocol to address the exigencies of the COVID-19 pandemic is possible and may be accomplished in a short period of time.
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42
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Louis G, Belveyre T, Jacquot A, Hochard H, Aissa N, Kimmoun A, Goetz C, Levy B, Novy E. Infection related catheter complications in patients undergoing prone positioning for acute respiratory distress syndrome: an exposed/unexposed study. BMC Infect Dis 2021; 21:534. [PMID: 34098888 PMCID: PMC8182343 DOI: 10.1186/s12879-021-06197-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background Prone positioning (PP) is a standard of care for patients with moderate–severe acute respiratory distress syndrome (ARDS). While adverse events associated with PP are well-documented in the literature, research examining the effect of PP on the risk of infectious complications of intravascular catheters is lacking. Method All consecutive ARDS patients treated with PP were recruited retrospectively over a two-year period and formed the exposed group. Intensive care unit (ICU) patients during the same period without ARDS for whom PP was not conducted but who had an equivalent disease severity were matched 1:1 to the exposed group based on age, sex, centre, length of ICU stay and SAPS II (unexposed group). Infection-related catheter complications were defined by a composite criterion, including catheter tip colonization or intravascular catheter-related infection. Results A total of 101 exposed patients were included in the study. Most had direct ARDS (pneumonia). The median [Q1–Q3] PP session number was 2 [1–4]. These patients were matched with 101 unexposed patients. The mortality rates of the exposed and unexposed groups were 31 and 30%, respectively. The incidence of the composite criterion was 14.2/1000 in the exposed group compared with 8.2/1000 days in the control group (p = 0.09). Multivariate analysis identified PP as a factor related to catheter colonization or infection (p = 0.04). Conclusion Our data suggest that PP is associated with a higher risk of CVC infectious complications.
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Affiliation(s)
- Guillaume Louis
- Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée de Château, 57085, Metz, France.
| | - Thibaut Belveyre
- Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée de Château, 57085, Metz, France
| | - Audrey Jacquot
- Medical intensive Care Unit, University Hospital of Nancy, Brabois, France
| | - Hélène Hochard
- Department of Bacteriology, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France
| | - Nejla Aissa
- Department of Bacteriology, University Hospital of Nancy, Nancy, France
| | - Antoine Kimmoun
- Medical intensive Care Unit, University Hospital of Nancy, Brabois, France
| | - Christophe Goetz
- Clinical Research Support Unit, Metz-Thionville Regional Hospital, Metz, France
| | - Bruno Levy
- Medical intensive Care Unit, University Hospital of Nancy, Brabois, France
| | - Emmanuel Novy
- Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, 1 allée de Château, 57085, Metz, France
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43
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Lee PH, Kuo CT, Hsu CY, Lin SP, Fu PK. Prognostic Factors to Predict ICU Mortality in Patients with Severe ARDS Who Received Early and Prolonged Prone Positioning Therapy. J Clin Med 2021; 10:jcm10112323. [PMID: 34073532 PMCID: PMC8198972 DOI: 10.3390/jcm10112323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
Early and prolonged prone positioning (PP) therapy improve survival in advanced ARDS; however, the predictors of mortality remain unclear. The study aims to identify predictive factors correlated with mortality and build-up the prognostic score in patients with severe ARDS who received early and prolonged PP therapy. A total of 116 patients were enrolled in this retrospective cohort study. Univariate and multivariate regression models were used to estimate the odds ratio (OR) of mortality. Factors associated with mortality were assessed by Cox regression analysis and presented as the hazard ratio (HR) and 95% CI. In the multivariate regression model, renal replacement therapy (RRT; OR: 4.05, 1.54–10.67), malignant comorbidity (OR: 8.86, 2.22–35.41), and non-influenza-related ARDS (OR: 5.17, 1.16–23.16) were significantly associated with ICU mortality. Age, RRT, non-influenza-related ARDS, malignant comorbidity, and APACHE II score were included in a composite prone score, which demonstrated an area under the curve of 0.816 for predicting mortality risk. In multivariable Cox proportional hazard model, prone score more than 3 points was significantly associated with ICU mortality (HR: 2.13, 1.12–4.07, p = 0.021). We suggest prone score ≥3 points could be a good predictor for mortality in severe ARDS received PP therapy.
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Affiliation(s)
- Po-Hsin Lee
- Division of Chest, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
| | - Chen-Tsung Kuo
- Computer & Communications Center, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Chiann-Yi Hsu
- Biostatistics Task Force of Taichung Veterans General Hospital, Taichung 407219, Taiwan;
| | - Shih-Pin Lin
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
| | - Pin-Kuei Fu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan;
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402010, Taiwan
- College of Human Science and Social Innovation, Hungkuang University, Taichung 433304, Taiwan
- Department of Computer Science, Tunghai University, Taichung 407224, Taiwan
- Correspondence: ; Tel.: +886-937-701-592
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Moran JL, Graham PL. Multivariate Meta-Analysis of the Mortality Effect of Prone Positioning in the Acute Respiratory Distress Syndrome. J Intensive Care Med 2021; 36:1323-1330. [PMID: 33942659 DOI: 10.1177/08850666211014479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The efficacy of prone positioning (PP) as therapy of the acute respiratory distress syndrome (ARDS) has varied in recent meta-analyses. The efficacy question was reviewed using a cohesive multivariate meta-analysis model incorporating all available common time-point data. METHODS Data from a core group of 8 randomized controlled trials (2001-2013) utilized in 8 current meta-analyses (2014-2017) was extracted for common time points. Multivariate meta-analysis and meta-regression models for prone-hours per day, mechanical ventilation tidal-volume and baseline patient PaO2/FiO2, considered as continuous and categorical predictors, determined the pooled relative risk (RR) of mortality for prone versus supine positioning. RESULTS Mortality RR at 28-30 days, 2-3 months and 6-months was not significant overall (P > 0.05). Meta-regression of categorical predictors indicated significant mortality reduction (P ≤ 0.001) for ≥ 12 prone-hours (versus < 12), lung protective ventilation (versus none) and moderate-severe ARDS (versus all ARDS). Meta-regressions of continuous predictors were also significant (P ≤ 0.021) and yielded treatment inflection points of efficacious therapy for ≥ 12 prone-hours per day, ≤ 8.5 mL/kg tidal volume and ≤ PaO2/FiO2 ratio of 130. CONCLUSIONS The mortality treatment effect of PP in ARDS, was not demonstrated in the unadjusted meta-analysis model. Moderator effects indicated consistent significant benefit of prone positioning. In the absence of individual patient data, multivariate models provide more decisive conclusions than individual time point analyses.
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Affiliation(s)
- John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Petra L Graham
- Department of Mathematics and Statistics, Faculty of Science and Engineering, Macquarie University, North Ryde, New South Wales, Australia
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Morata L, Sole ML, Guido-Sanz F, Ogilvie C, Rich R. Manual vs Automatic Prone Positioning and Patient Outcomes in Acute Respiratory Distress Syndrome. Am J Crit Care 2021; 30:104-112. [PMID: 33644805 DOI: 10.4037/ajcc2021674] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Prone positioning is a standard treatment for moderate to severe acute respiratory distress syndrome (ARDS), but the outcomes associated with manual versus automatic prone positioning have not been evaluated. OBJECTIVE To retrospectively evaluate outcomes associated with manual versus automatic prone positioning as part of a pronation quality improvement project implemented by a multidisciplinary team. METHODS A retrospective, descriptive-comparative approach was used to analyze data from 24 months of a prone positioning protocol for ARDS. The study involved 37 patients, with 16 undergoing manual and 21 undergoing automatic prone positioning. Descriptive and nonparametric statistical analyses were used to evaluate outcomes associated with manual versus automatic prone positioning. RESULTS Outcomes were similar between the 2 groups regarding time to initiation of prone positioning, discharge disposition, and length of stay. Manually pronated patients were less likely to experience interruptions in therapy (P = .005) and complications (P = .002). Pressure injuries were the most common type of complication, with the most frequent locations in automatically pronated patients being the head (P = .045), thorax (P = .003), and lower extremities (P = .047). Manual prone positioning resulted in a cost avoidance of $78 617 per patient. CONCLUSION Manual prone positioning has outcomes similar to those of automatic prone positioning with less risk of interruptions in therapy, fewer complications, and lower expense. Further research is needed to determine whether manual prone positioning is superior to automatic prone positioning in patients with ARDS.
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Affiliation(s)
- Lauren Morata
- Lauren Morata is a clinical nurse specialist and clinical quality consultant, Lakeland Regional Health, Lakeland, Florida
| | - Mary Lou Sole
- Mary Lou Sole is dean and professor, College of Nursing, University of Central Florida, Orlando, Florida
| | - Frank Guido-Sanz
- Frank Guido-Sanz is an assistant professor, College of Nursing, University of Central Florida, Orlando, Florida
| | - Carrie Ogilvie
- Carrie Ogilvie is an associate vice-president of critical care and trauma services, Lakeland Regional Health, Lakeland, Florida
| | - Rebecca Rich
- Rebecca Rich is a critical care clinical pharmacy specialist, Lakeland Regional Health, Lakeland, Florida
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Developing and Implementing a Dedicated Prone Positioning Team for Mechanically Ventilated ARDS Patients During the COVID-19 Crisis. Jt Comm J Qual Patient Saf 2021; 47:347-353. [PMID: 33736966 PMCID: PMC7907735 DOI: 10.1016/j.jcjq.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 12/12/2022]
Abstract
Background The spread of the COVID-19 pandemic in China demonstrated at an early stage the high rate of moderate to severe acute respiratory distress syndrome (ARDS) in the patient population. An intervention that has proved beneficial is the use of prone positioning (PP) for mechanically ventilated patients with ARDS. In one institution, PP was practiced in the medical ICU for this population. However, with the dramatically increasing patient load, staff anticipated that greater capacity to provide this treatment to all qualifying patients would be required. Methods A group of physical therapists and occupational therapists (PT/OTs) with ICU experience was redeployed from their regular roles to receive training in PP from an experienced medical ICU (MICU) RN. After intensive training, the team was ready to provide PP to patients. As the workload increased, additional PT/OTs were recruited to the team. A coordinating structure comprising attending pulmonologists screened and advised on appropriate patients. A communication and feedback structure was also implemented. Results Over a period of seven weeks, the team provided PP to more than 100 patients, with 577 individual interventions in a total of 14 ICUs and one emergency department. There were no major airway or central venous access complications, and only one anterior pressure injury was recorded. Conclusion The rapid implementation of an interdisciplinary PP team in a crisis situation is feasible. It can provide a safe and efficient alternative to adding to the workload of an overloaded nursing staff.
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Allado E, Poussel M, Valentin S, Kimmoun A, Levy B, Nguyen DT, Rumeau C, Chenuel B. The Fundamentals of Respiratory Physiology to Manage the COVID-19 Pandemic: An Overview. Front Physiol 2021; 11:615690. [PMID: 33679424 PMCID: PMC7930571 DOI: 10.3389/fphys.2020.615690] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
The growing coronavirus disease (COVID-19) crisis has stressed worldwide healthcare systems probably as never before, requiring a tremendous increase of the capacity of intensive care units to handle the sharp rise of patients in critical situation. Since the dominant respiratory feature of COVID-19 is worsening arterial hypoxemia, eventually leading to acute respiratory distress syndrome (ARDS) promptly needing mechanical ventilation, a systematic recourse to intubation of every hypoxemic patient may be difficult to sustain in such peculiar context and may not be deemed appropriate for all patients. Then, it is essential that caregivers have a solid knowledge of physiological principles to properly interpret arterial oxygenation, to intubate at the satisfactory moment, to adequately manage mechanical ventilation, and, finally, to initiate ventilator weaning, as safely and as expeditiously as possible, in order to make it available for the next patient. Through the expected mechanisms of COVID-19-induced hypoxemia, as well as the notion of silent hypoxemia often evoked in COVID-19 lung injury and its potential parallelism with high altitude pulmonary edema, from the description of hemoglobin oxygen affinity in patients with severe COVID-19 to the interest of the prone positioning in order to treat severe ARDS patients, this review aims to help caregivers from any specialty to handle respiratory support following recent knowledge in the pathophysiology of respiratory SARS-CoV-2 infection.
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Affiliation(s)
- Edem Allado
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
| | - Mathias Poussel
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
| | - Simon Valentin
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Département de Pneumologie, CHRU-Nancy, Nancy, France
| | - Antoine Kimmoun
- Médecine Intensive et Réanimation Brabois, CHRU-Nancy, Nancy, France.,INSERM U1116, Université de Lorraine, Nancy, France
| | - Bruno Levy
- Médecine Intensive et Réanimation Brabois, CHRU-Nancy, Nancy, France.,INSERM U1116, Université de Lorraine, Nancy, France
| | - Duc Trung Nguyen
- ORL et Chirurgie Cervico-Faciale, CHRU-Nancy, Nancy, France.,INSERM U1254-IADI, Université de Lorraine, Nancy, France
| | - Cécile Rumeau
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,ORL et Chirurgie Cervico-Faciale, CHRU-Nancy, Nancy, France
| | - Bruno Chenuel
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
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Prone Ventilation for Patients with Mild or Moderate Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2021; 17:24-29. [PMID: 31532692 DOI: 10.1513/annalsats.201906-456ip] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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49
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Prone versus Supine Position Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: A Meta-Analysis of Randomized Controlled Trials. Emerg Med Int 2020; 2020:4973878. [PMID: 33343939 PMCID: PMC7732410 DOI: 10.1155/2020/4973878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/25/2020] [Accepted: 11/16/2020] [Indexed: 11/25/2022] Open
Abstract
The purpose of this meta-analysis was to compare the efficacy and safety of prone versus supine position ventilation for adult acute respiratory distress syndrome (ARDS) patients. The electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched from their inception up to September 2020. The relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were employed to calculate pooled outcomes using the random-effects models. Twelve randomized controlled trials that had recruited a total of 2264 adults with ARDS were selected for the final meta-analysis. The risk of mortality in patients who received prone position ventilation was 13% lower than for those who received supine ventilation, but this effect was not statistically significant (RR: 0.87; 95% CI: 0.75–1.00; P = 0.055). There were no significant differences between prone and supine position ventilation on the duration of mechanical ventilation (WMD: −0.22; P = 0.883) or ICU stays (WMD: –0.39; P = 0.738). The pooled RRs indicate that patients who received prone position ventilation had increased incidence of pressure scores (RR: 1.23; P = 0.003), displacement of a thoracotomy tube (RR: 3.14; P = 0.047), and endotracheal tube obstruction (RR: 2.45; P = 0.001). The results indicated that prone positioning during ventilation might have a beneficial effect on mortality, though incidence of several adverse events was significantly increased for these patients.
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50
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Montanaro J. Using In Situ Simulation to Develop a Prone Positioning Protocol for Patients With ARDS. Crit Care Nurse 2020; 41:e1-e13. [PMID: 33221829 DOI: 10.4037/ccn2020830] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome carries a 40% mortality rate. Prone positioning remains underused owing to clinicians' low degree of confidence, concern about the risk of adverse outcomes, and lack of staff competency training. LOCAL PROBLEM AND PURPOSE A prone positioning protocol and educational program were needed in an intensive care unit to achieve compliance with best practices for treating acute respiratory distress syndrome patients. METHODS An initial survey was conducted to measure staff confidence and competency in prone positioning. A literature review was performed, and a plan-do-study-act approach was used to develop a protocol through in situ simulation involving mock patients. A training video and a simulation scenario using a high-fidelity manikin were developed to facilitate staff education. Staff were surveyed again after training. INTERVENTIONS During the simulation scenario, interdisciplinary clinicians learned to apply the protocol and resupinate the patient during a simulated emergency. The training video was later used for "just in time" education minutes before actual prone positioning events. RESULTS A total of 25 critical care nurses, 11 respiratory therapists, and 10 physicians completed the initial survey and simulation training. The survey showed that staff lacked confidence and competency in prone positioning. Staff demonstrated competence during the simulation sessions, and posttraining surveys indicated increased confidence. After the educational program, prone positioning was successfully used for 6 critically ill acute respiratory distress syndrome patients. CONCLUSIONS In situ simulation and interdisciplinary collaboration increase standardization of high-risk, underused procedures, improving staff confidence and competence as well as patient safety.
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Affiliation(s)
- Jessica Montanaro
- Jessica Montanaro is assistant nursing care coordinator in the medical/surgical/trauma intensive care unit, Mount Sinai Morningside Hospital, New York, New York
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