Reducing the Risk and Impact of Brachial Plexus Injury Sustained From Prone Positioning-A Clinical Commentary

Navigation-Assisted One-Staged Posterior Spinal Fusion Using Pedicle Screw Instrumentation in Adolescent Idiopathic Scoliosis-A Case Series

Background and Objectives: Adolescent idiopathic scoliosis (AIS) is a prevalent three-dimensional spinal disorder, with a multifactorial pathogenesis, including genetics and environmental aspects. Treatment options include non-surgical and surgical treatment. Surgical interventions demonstrate positive outcomes in terms of deformity correction, pain relief, and improvements of the cardiac and pulmonary function. Surgical complications, including excessive blood loss and neurologic deficits, are reported in 2.27-12% of cases. Navigation-assisted techniques, such as the O-arm system, have been a recent focus with enhanced precision. This study aims to evaluate the results and complications of one-stage posterior instrumentation fusion in AIS patients assisted by O-arm navigation. Materials and Methods: This retrospective study assesses 55 patients with AIS (12-28 years) who underwent one-stage posterior instrumentation correction supported by O-arm navigation from June 2016 to August 2023. We examined radiological surgical outcomes (initial correction rate, loss of correction rate, last follow-up correction rate) and complications as major outcomes. The characteristics of the patients, intraoperative blood loss, operation time, number of fusion levels, and screw density were documented. Results: Of 73 patients, 55 met the inclusion criteria. The average age was 16.67 years, with a predominance of females (78.2%). The surgical outcomes demonstrated substantial initial correction (58.88%) and sustained positive radiological impact at the last follow-up (56.56%). Perioperative complications, including major and minor, occurred in 18.18% of the cases. Two patients experienced a major complication. Blood loss (509.46 mL) and operation time (402.13 min) were comparable to the literature ranges. Trend analysis indicated improvements in operation time and blood loss over the study period. Conclusions: O-arm navigation-assisted one-stage posterior instrumentation proves reliable for AIS corrective surgery, achieving significant and sustained positive radiological outcomes, lower correction loss, reduced intraoperative blood loss, and absence of implant-related complications. Despite the challenges, our study demonstrates the efficacy and maturation of this surgical approach.

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

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

Functional improvements of patients admitted to an inpatient rehabilitation facility after bilateral lung transplant due to severe COVID-19 pulmonary disease

BACKGROUND

Coronavirus disease (COVID-19) has introduced a new subset of patients with acute end-stage lung damage for which lung transplantation has been successfully performed.

OBJECTIVE

To describe the inpatient rehabilitation course of patients who underwent bilateral lung transplant due to severe COVID-19 pulmonary disease.

DESIGN

Retrospective chart review.

SETTING

Free-standing, academic, urban inpatient rehabilitation hospital.

PARTICIPANTS

Seventeen patients aged 28-67 years old (mean 53.9 ± 10.7) who developed COVID-19 respiratory failure and underwent bilateral lung transplant.

INTERVENTIONS

Patients participated in a comprehensive inpatient rehabilitation program including physical, occupational, and speech therapy tailored to the unique functional needs of each individual.

MAIN OUTCOME MEASURES

Primary outcome measures of functional improvements, include mobility and self-care scores on section GG of the Functional Abilities and Goals of the Improving Post-Acute Care Transformation Act, as defined as quality measures by the Centers for Medicare and Medicaid Services. Other functional measures included 6 minute walk test, Berg balance scale, Mann Assessment of Swallowing Ability (MASA), and Cognition and Memory Functional Independence Measure (FIM) scores. Wilcoxon signed rank sum test was used to evaluate statistical significance of change between admission and discharge scores.

RESULTS

Fourteen patients completed inpatient rehabilitation. Self-care (GG0130) mean score improved from 20.9 to 36.1. Mobility (GG0170) mean score improved from 30.7 to 70.7. Mean 6-minute walk distance improved from 174.1 to 467.6 feet. Mean Berg balance scores improved from 18.6/56 to 36.3/56. MASA scores improved from 171.3 to 182.3. All functional measures demonstrated statistically significant improvements with p value ≤ .008, except for cognition and memory FIM scores, which did not show a statistically significant difference. A majority (76%) of patients discharged home.

CONCLUSION

This new and unique patient population can successfully participate in a comprehensive inpatient rehabilitation program and achieve functional improvements despite medical complications.

Enterocutaneous Fistula in a COVID-19 Obese Patient During Prolonged Prone Position for Severe Acute Respiratory Distress Syndrome

Prone position (PP) has been widely used in patients under mechanical ventilation for COVID-19 acute respiratory distress syndrome (ARDS), usually for many hours per day. Complications are not rare, although most of them are mild. To our knowledge, we report the first case of enterocutaneous fistula after prolonged use of PP in the literature. Morbid obesity; yielding increased abdominal wall pressure when the patient was prone; pre-existing intestinal hernias; and increased vasopressor doses for septic shock due to secondary infections resulted in necrosis of the small intestine, the abdominal wall, and the skin leading to enterocutaneous fistula. Clinicians managing patients with COVID-19 should keep in mind this complication, especially when proning obese patients with a history of intestinal surgery, as the presence of intestinal hernias might be missed during a clinical examination.

Reducing neuropathies between the 2020 and 2021 Covid-19 surges in a large UK intensive care unit: A quality improvement project

BACKGROUND

Peripheral nerve injuries (PNIs) can be acquired by patients in intensive care unit (ICU) who are critically unwell with Covid pneumonitis. Prone position ventilation has been linked to this life-changing complication.

AIM

To reduce the occurrence and severity of PNIs for patients with Covid pneumonitis requiring prone positioning whilst sedated and ventilated in ICU.

STUDY DESIGN

This study is a quality improvement project that evolved over the course of the first two surges of Covid pneumonitis admissions within the ICU at the Queen Elizabeth Hospital Birmingham (Surge 1: March 2020-July 2020, 93 prone ventilation survivors; Surge 2: September 2020-May 2021, 309 prone ventilation survivors). Implementation of updated prone positioning guidelines that aimed to reduce the risk of PNI. This was supplemented by face-to-face teaching for ICU professionals. The number of patients who sustained PNI and the severity of such injuries were recorded.

RESULTS

During the first surge 21 patients (22.6%) had at least one high grade PNI. During the second surge there were 12 patients (3.9%) sustaining an intermediate or high grade PNI. For PNI patients, there was an increase in the mean proning episodes (6-13) and duration (17.8-18.6 h). This represents an 82% reduction in PNI cases. High grade injuries reduced from 14/21 (66%) to 4/12 (33%).

CONCLUSIONS

Optimizing the position of patients in the prone position in ICU with Covid pneumonitis may be key in reducing the development of PNI. Changes to pharmacological management may have influenced the results seen in this study.

RELEVANCE TO CLINICAL PRACTICE

Clinicians working within ICU with acutely unwell patients with Covid pneumonitis should acknowledge the heightened risk of PNI and take relevant steps to reduce the risk of injury acquisition.

Neuromuscular Complications of COVID-19: Evidence from the Third Year of the Global Pandemic

Accumulating evidence in the third year of the global pandemic suggests that coronavirus disease 2019 (COVID-19) can cause neuromuscular complications during or after the acute phase of infection. Direct viral infection and immune-mediated mechanisms have been hypothesized. Furthermore, in patients with underlying autoimmune neuromuscular diseases, COVID-19 infection may trigger a disease flare. COVID-19 vaccines appear to be safe and effective at preventing severe illness from COVID-19. Certain vaccines are associated with an increased risk of Guillain-Barré syndrome and possibly Bell's palsy, but the absolute incidence is low, and benefits likely outweigh the risks. Newer prophylactic therapies and treatments are also becoming available for patients who may not mount a sufficient response to vaccination or have contraindications. In this article, we discuss the current available evidence on neuromuscular complications of COVID-19 and clinical considerations regarding vaccination.

Prone position plexopathy: an avoidable complication of prone positioning for COVID-19 pneumonitis?

Prone positioning is a mainstay of management for those presenting to the intensive care unit with moderate-to-severe acute respiratory distress syndrome due to COVID-19. While this is a necessary and life-saving intervention in selected patients, careful positioning and meticulous care are required to prevent compression and traction of the brachial plexus, and resultant brachial plexopathy. We describe two patients who developed a brachial plexus injury while undergoing prone positioning for management of COVID-19 pneumonitis. Both patients were diabetic and underwent prolonged periods in the prone position during which the plexopathy affected arm was abducted for 19 and 55 hours, respectively. We discuss strategies to reduce the risk of this rare but potentially disabling complication of prone positioning.

Physiotherapy management for COVID-19 in the acute hospital setting and beyond: an update to clinical practice recommendations

This document provides an update to the recommendations for physiotherapy management for adults with coronavirus disease 2019 (COVID-19) in the acute hospital setting. It includes: physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the use of physiotherapy treatments and personal protective equipment. New advice and recommendations are provided on: workload management; staff health, including vaccination; providing clinical education; personal protective equipment; interventions, including awake proning, mobilisation and rehabilitation in patients with hypoxaemia. Additionally, recommendations for recovery after COVID-19 have been added, including roles that physiotherapy can offer in the management of post-COVID syndrome. The updated guidelines are intended for use by physiotherapists and other relevant stakeholders caring for adult patients with confirmed or suspected COVID-19 in the acute care setting and beyond.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Shoulder Pain in COVID-19 Survivors Following Mechanical Ventilation

COVID-19 has caused a certain proportion of patients to be hospitalized in intensive care units (ICU) and may cause musculoskeletal and neurological deficits following intubation and mechanical ventilation. The aim of this study was to quantify and describe the presence of shoulder pain in patients released from hospitals after suffering COVID-19. Patients with positive Apley tests were sent to a physiatrist for a clinical evaluation, ultrasound and electromyography (EMG). This evaluation was completed with a pain scale, joint range and shoulder muscle strength evaluations. Of the one-hundred-sixteen patients, seventy eight entered the respiratory rehabilitation program. Twenty patients were sent to the multidisciplinary shoulder team for positive Apley scratch tests. Of these twenty patients, one had only an EMG, ten had only ultrasounds, seven had an EMG and ultrasound and two did not need complementary tests. The twenty patients were sent to the physical therapist, with all presenting pain and diminished joint range and muscle strength in the affected shoulder. In this context, shoulder pain could be associated with the prone position in the ICU. We suggest time control and position change for patients on mechanical ventilation in a prone position with COVID-19.

Neuromuscular Disorders in the Intensive Care Unit

PURPOSE OF REVIEW

This article discusses the pathophysiology, presentation, diagnosis, treatment, and prognosis of common neuromuscular disorders seen in the intensive care unit, including Guillain-Barré syndrome, myasthenia gravis, and intensive care unit-acquired weakness.

RECENT FINDINGS

Guillain-Barré syndrome can have an excellent prognosis if patients are diagnosed early, appropriately treated, and monitored for complications, including respiratory failure and dysautonomia. Intensive care unit-acquired weakness increases overall mortality in patients who are critically ill, and distinguishing between critical illness myopathy and critical illness polyneuropathy may have important prognostic implications.

SUMMARY

Neuromuscular disorders are not rare in the intensive care unit setting, and precise identification and treatment of these conditions can greatly impact long-term outcomes.

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

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

Care of the postcoronavirus disease 2019 patient

PURPOSE OF REVIEW

In under a year, coronavirus disease 2019 (COVID-19) has taken the lives of hundreds of thousands of Americans, leaving millions of survivors in its wake. The enormous number of people who survived acute illness but continue to have symptoms has highlighted the need for standardized evaluation of the post-COVID-19 patient. This review, based on the current literature and our experience, aims to guide the care of patients who have survived COVID-19.

RECENT FINDINGS

The literature on this topic is rapidly expanding and covers both pulmonary and nonpulmonary complications of COVID-19. Pulmonary complications include dyspnea with normoxia, organizing pneumonia and pulmonary fibrosis. Nonpulmonary complications include neurologic, cardiac, and thromboembolic disease. Special consideration should be taken for COVID-19 survivors of intensive care.

SUMMARY

The current review outlines the major clinical findings in post-COVID-19 patients and provides a guidelines to the evaluation and management of prolonged symptoms.

Neurological implications of COVID-19: a review of the science and clinical guidance

COVID-19 is a significant global health burden. The pulmonary morbidity and mortality of COVID-19 is well described, however, there is mounting evidence of neurological manifestations of SARS-CoV-2, which may be of prognostic significance. This paper summarises the available evidence in order to provide clinicians with a concise summary of the peripheral and central neurological manifestations of COVID-19, discusses specific issues regarding the management of chronic neurological disease in the context of the pandemic, and provides a summary of the thrombotic implications of the disease for the neurologist.