Nursing Management of Prone Positioning in Patients With COVID-19

Prevalence and risk factors of exposure keratopathy among critically ill patients: A systematic review and meta-analysis

AIMS

To identify the incidence, prevalence and risk factors of exposure keratopathy (EK) among critically ill patients.

DESIGN

Systematic review and meta-analysis, in accordance with the PRISMA 2020 Statement.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), Weipu Database (VIP) and WanFang Database were systematically searched from inception to June 2022. Observational studies that reported EK among paediatric and adult critically ill patients were screened and included original articles based on the inclusion criteria. Two reviewers independently completed data extraction and quality assessments. Subgroup analysis investigated potential causes of heterogeneity.

RESULTS

Of the 4508 studies identified, 23 studies involving 3519 subjects were included. The pooled prevalence of EK was 34.0%, and the pooled incidence rate of EK was 23.0%. Risk factors associated with EK in critically ill patients included lagophthalmos, chemosis, eye blinks <5 times per minute, mechanical ventilation, sedation, lower Glasgow Coma Scale (GCS) score and higher Acute Physiology and Chronic Health Evaluation (APACHE) II score.

CONCLUSION

This review shows that EK rates are high in critically ill patients and are influenced by multiple factors. Medical staff should pay more attention to EK in critically ill patients, conduct professional evaluations and implement targeted eye care protocols to reduce its occurrence.

IMPLICATIONS FOR PRACTICE

This study shows the frequency of and multiple risk factors for EK in critically ill patients, which provides evidence-based guidance for nurses to evaluate the risk of EK in critically ill patients and take appropriate precautions to reduce the risk.

PROTOCOL REGISTRATION

The protocol was registered in PROSPERO (https://www.crd.york.ac.uk/prospero/) (CRD42022346964).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Pressure ulcers after prone positioning in patients undergoing extracorporeal membrane oxygenation: A cross-sectional study

BACKGROUND

The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications.

AIM

To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno-venous ECMO.

STUDY DESIGN

This cross-sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno-venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model.

RESULTS

In the study period, 114 patients were treated with veno-venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro-femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%-72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5-3.6, p = .532).

CONCLUSIONS

Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence-based care to prevent such pressure injuries in patients undergoing ECMO.

RELEVANCE TO CLINICAL PRACTICE

The combination of prone positioning and ECMO shows few life-threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff.

Prevalence of adverse events in pronated intubated adult COVID-19 patients: A systematic review with meta-analysis

AIM

To present the pooled estimated prevalence of adverse events in pronated intubated adult COVID-19 patients.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

This study used the Cochrane Library, CINAHL, Embase, LILACS, Livivo, PubMed, Scopus, and Web of Science databases as data sources.

METHODS

The studies were meta-analysed using JAMOVI 1.6.15 software. A random-effects model was used to identify the global prevalence of adverse events, confidence intervals and the heterogeneity data. Risk of bias was assessed using the Joanna Briggs Institute tool, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Of the 7904 studies identified, 169 were included for full reading, and 10 were included in the review. The most prevalent adverse events were pressure injuries (59%), haemodynamic instability (23%), death (17%) and device loss or traction (9%).

CONCLUSION

The most prevalent adverse events in mechanically ventilated pronated patients with COVID-19 are pressure injuries, presence of haemodynamic instability, death and device loss or traction.

IMPLICATIONS FOR THE PATIENT CARE

The evidence identified in this review can help improve the quality and safety of patient care by helping to design care protocols to avoid the development of adverse events that can cause permanent sequelae in these patients.

IMPACT

This systematic review addressed the adverse events related to prone position in intubated adult COVID-19 patients. We identified that the most prevalent adverse events in these patients were pressure injuries, haemodynamic instability, device loss or traction and death. The results of this review may influence the clinical practice of nurses who work in intensive care units and, consequently, the nursing care provided not only to COVID-19 patients but for all intubated patients due to other reasons in intensive care units.

REPORTING METHOD

This systematic review adhered to the PRISMA reporting guideline.

PATIENT OR PUBLIC CONTRIBUTION

As this is a systematic review, we analysed data from primary studies conducted by many researchers. Thus, there was no patient or public contribution in this review.

Were the unfinished nursing care occurrence, reasons, and consequences different between COVID-19 and non-COVID-19 patients? A systematic review

BACKGROUND

Unfinished Nursing Care (UNC) has been documented also during the Coronavirus (COVID-19) pandemic; however, while several secondary studies were conducted before this period to summarise occurrences, reasons, and consequences of UNC and provide a global picture of the phenomenon, no synthesis of the evidence produced during the pandemic has been documented to date. Therefore, the aim of this review is to identify differences, if any, in the UNC occurrence, reasons, and consequences perceived by nurses caring for COVID-19 and non-COVID-19 patients.

METHODS

This study is a systematic review (PROSPERO CRD42023410602). According to the Population, Exposure, Comparator, and Outcomes framework, primary comparative cross-sectional, longitudinal, and cohort studies, randomised/non-randomised controlled trials were included from Medline, CINAHL, and Scopus, collecting perceptions of nurses with tools measuring UNC between COVID-19 and non-COVID-19 patients and published in English, Italian, or Turkish. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and Johanna Briggs Quality Appraisal Tool were used, and findings were summarised narratively.

RESULTS

Five hospital-based cross-sectional studies using the self-administered MISSCARE and UNC Survey comparing data collected (a) before the pandemic vs. in the first wave; (b) before, in the second and in the third wave; and (c) simultaneously among COVID-19 and non-COVID-19 patients in the second wave. Three main patterns emerged suggesting a higher UNC occurrence among COVID-19 patients in the first wave, less occurrence among them compared to non-COVID-19 patients in the second wave, and contrasting findings with some in favour and others in contrast to COVID-19 patients. Similar patterns emerged regarding UNC reasons while no studies investigated the UNC consequences.

CONCLUSIONS

In the first wave, COVID-19 patients were likely to be at increased risk of UNC, while in later waves non-COVID-19 patients were at increased risk of UNC. Reasons also were different across waves. Findings documented during the COVID-19 pandemic may help to prevent UNC in future disasters.

Person-centred critical care for a person with learning disability and COVID-19: case study of positive risk taking

People with learning disabilities are known to experience a wide range of health inequalities and have a lower life expectancy than the general population. During the COVID-19 pandemic this extended to higher mortality rates following infection with the novel coronavirus. This case study presents an example of a positive outcome for Jade, a 21-year-old woman with learning disabilities and autism who required a long period in intensive care following COVID-19 infection. It demonstrates the impact of effective multidisciplinary collaboration involving the acute hospital learning disability liaison nurse and Jade's family, leading to a wide range of reasonable and achievable adjustments to her care.

Thematic analysis of intensive care unit diaries kept by staff: insights for caring

OBJECTIVE

To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

Qualitative study.

SETTING

Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021.

METHODS

ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed.

FINDINGS

Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations).

CONCLUSION

The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them.

IMPLICATIONS FOR CLINICAL PRACTICE

The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.

Nursing Care of an Older Patient With Severe COVID-19 Receiving Prolonged Prone Ventilation: A Case Report

Introduction

Prone positioning has been shown to improve ventilation status for patients with severe COVID-19 who are receiving mechanical ventilation. This case report describes the nursing care of a patient with severe COVID-19 who underwent prone ventilation for 72 hours. Relevant nursing management and operational considerations are also discussed.

Clinical Findings

An 83-year-old woman was admitted to the hospital with fatigue, dizziness, and positive tests for SARS-CoV-2 on nasopharyngeal swab specimens. The patient was intubated.

Diagnosis

The patient’s positive tests for SARS-CoV-2, chest computed tomography findings, and clinical symptoms were consistent with a diagnosis of severe COVID-19.

Interventions

When the patient’s condition did not improve with mechanical ventilation and intermittent prone positioning, she was placed in the prone position for 72 hours. She received sedation, analgesics, anti-infective medications, and enteral nutrition support in the intensive care unit. Nurses performed dynamic monitoring based on blood gas analysis results to guide lung rehabilitation.

Outcomes

The patient was weaned from the ventilator on day 20 and successfully discharged home on day 28 of hospitalization.

Conclusion

During prolonged prone ventilation of a patient with severe COVID-19, nursing strategies included airway management, early lung rehabilitation training guided by pulmonary ultrasonography, skin care, hierarchical management of nurses, hemodynamic support, and enteral nutrition. This report may assist critical care nurses caring for similar patients.

Pressure Injury Prevention in Patients in Prone Position With Acute Respiratory Distress Syndrome and COVID-19

Introduction

In patients with acute respiratory distress syndrome, prone positioning improves oxygenation and reduces mortality. Pressure injuries occur frequently because of prolonged prone positioning in high-risk patients, and preventive measures are limited. This article describes 2 patients who developed minimal pressure injuries despite several prone positionings. Prevention strategies are also described.

Clinical Findings

A 64-year-old man and a 76-year-old woman were admitted to the hospital with respiratory insufficiency. Due to acute respiratory distress syndrome, both patients were intubated and received mechanical ventilation and prone positioning.

Diagnosis

Both patients had positive test results for SARS-CoV-2 and a diagnosis of acute respiratory distress syndrome.

Interventions

Patient 1 was in prone position for 137 hours during 9 rounds of prone positioning; patient 2, for 99 hours during 6 rounds of prone positioning. The standardized pressure injury prevention bundle for prone positioning consisted of skin care, nipple protection with a multilayer foam dressing, a 2-part prone positioning set, and micropositioning maneuvers. For both patients, 2-cm-thick mixed-porosity polyurethane foam was added between skin and positioning set in the thoracic and pelvic areas and a polyurethane foam cushion was added under the head.

Outcomes

Patient 1 developed no pressure injuries. Patient 2 developed category 2 pressure injuries on the chin and above the right eye during deviations from the protocol.

Conclusion

For both patients, the additional application of polyurethane foam was effective for preventing pressure injuries. These case reports support the addition of polyurethane foam to prevent pressure injuries in patients placed in the prone position.

Vloga izvajalcev zdravstvene nege pri pronaciji in supinaciji intubiranega pacienta s hudim akutnim respiratornim sindromom koronavirus-2

Uvod: Hud akutni respiratorni sindrom koronavirus-2 je s svojo intenzivnostjo močno vplival na razmere in delo v enotah intenzivne terapije. Pri vse več intubiranih pacientih z akutnim respiratornim distresnim sindromom se je pokazala potreba po pronaciji (obrat na trebuh). Namen raziskave je bil preučiti vlogo izvajalcev zdravstvene nege pri pronaciji in supinaciji (obrat na hrbet) pacienta ter ugotoviti najpogostejše zaplete, ki se ob tem lahko pojavijo.Metode: Uporabljen je bil pregled znanstvene in strokovne literature. Iskanje literature je potekalo v podatkovnih bazah PubMed, Sage in ScienceDirect ter Google Scholar. Vključene so bile raziskave od januarja 2020 do decembra 2021. Izvedena je bila vsebinska analiza raziskav.Rezultati: Skupno je bilo identificiranih 993 člankov. Dodanih je bilo še deset člankov, najdenih s prostoročnim iskanjem v Google Scholar. Izmed 1.003 identificiranih zadetkov je bilo v končno analizo vključenih osem člankov. Izpostavljena so bila tri glavna vsebinska področja: (1) vloga izvajalcev zdravstvene nege pred pronacijo intubiranega pacienta; (2) vloga izvajalcev zdravstvene nege med pronacijo intubiranega pacienta in (3) vloga izvajalcev zdravstvene nege pri supinaciji intubiranega pacienta.Diskusija in zaključek: Pronacija in supinacija intubiranega pacienta predstavljata velik izziv za celoten zdravstveni tim, ki je v času epidemije okrnjen tako številčno kot tudi glede na stopnjo usposobljenosti. Izvajalec zdravstvene nege mora ob teh intervencijah zagotoviti hemodinamsko stabilnost, pravilno pozicioniranje pacienta, preprečiti ekstubacijo in izpade različnih katetrov, zaščititi kožo in vseskozi izvajati potrebne aktivnosti zdravstvene nege.

Cuidados de enfermería ante la necesidad de oxigenación en adultos con enfermedad por COVID-19:

Introducción: la enfermedad por COVID-19 genera el síndrome de distrés respiratorio agudo, afecta la necesidad de oxigenación y demanda cuidados de enfermería para mantener la estabilidad hemodinámica y prevenir complicaciones respiratorias. Objetivo: analizar la evidencia científica sobre los cuidados de enfermería ante la necesidad de oxigenación en adultos hospitalizados con enfermedad por COVID-19. Métodos: revisión integrativa con un universo de 518 artículos científicos de 2020 y 2021 de las bases de datos: PubMed, Ebsco, Cuiden y ScienceDirect. Se analizaron seis (n= 6) estudios que abordan: ¿cuáles son los cuidados de enfermería ante la necesidad de oxigenación en adultos con enfermedad por COVID-19? Resultados: los cuidados de enfermería incluyen estrategias de oxigenoterapia, recomendaciones sobre el cuidado en la primera línea de atención, uso de oxígeno de alto flujo, posicionamiento prono despierto temprano, y control de saturación y de signos vitales mediante un proceso de atención en enfermería. Conclusión: los cuidados de enfermería satisfacen la necesidad de oxigenación mediante intervenciones de oxigenoterapia, control de comorbilidades y prevención de riesgos hospitalarios.

Effectiveness of prone position in acute respiratory distress syndrome and moderating factors of obesity class and treatment durations for COVID-19 patients: A Meta-Analysis

Objectives

To examine the effectiveness of prone positioning on COVID-19 patients with acute respiratory distress syndrome with moderating factors in both traditional prone positioning (invasive mechanical ventilation) and awake self-prone positioning patients (non-invasive ventilation).

Research methodology

A comprehensive search was conducted in CINAHL, Cochrane library, Embase, Medline-OVID, NCBI SARS-CoV-2 Resources, ProQuest, Scopus, and Web of Science without language restrictions. All studies with prospective and experimental designs evaluating the effect of prone position patients with COVID-19 related to acute respiratory distress syndrome were included. Pooled standardised mean differences were calculated after prone position for primary (PaO₂/FiO₂) and secondary outcomes (SpO₂ and PaO₂)

Results

A total of 15 articles were eligible and included in the final analysis. Prone position had a statistically significant effect in improving PaO₂/FiO₂ with standardised mean difference of 1.10 (95%CI 0.60–1.59), SpO₂ with standardised mean difference of 3.39 (95% CI 1.30–5.48), and PaO₂ with standardised mean difference of 0.77 (95% CI 0.19–1.35). Patients with higher body mass index and longer duration/day are associated with larger standardised mean difference effect sizes for prone positioning.

Conclusions

Our findings demonstrate that prone position significantly improved oxygen saturation in COVID-19 patients with acute respiratory distress syndrome in both traditional prone positioning and awake self-prone positioning patients. Prone position should be recommended for patients with higher body mass index and longer durations to obtain the maximum effect.

Cuidados de enfermagem e posição prona: revisão integrativa

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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