Prone position saves lives, but nerve pressure injuries affect arms and legs.
Seriously ill COVID-19 Ventilator patients are placed on the prone position because they can breathe more easily and mortality is reduced. However, this life-saving position can cause permanent nerve damage even in these vulnerable patients, reports a newly accepted study by Shirley Ryan AbilityLab and Northwestern University Feinberg School of Medicine.
Scientists believe the nerve damage is the result of decreased blood flow and inflammation. Nerve damage rarely occurs in other non-COVID-19 patients with ventilators in this position.
The study was sponsored by the British Journal of Anesthesia. It can be viewed as a preprint.
“It’s shocking how big the problem is,” said lead investigator Dr. Colin Franz, Physician Scientist at Shirley Ryan AbilityLab and Assistant Professor of Physical Medicine, Rehabilitation and Neurology at the Feinberg School of Medicine in the Northwest. “This is a much higher percentage of patients with nerve damage than ever before in any other seriously ill population. Usually very sick people can tolerate the position that helps their breathing. But the nerves of COVID patients cannot tolerate the forces that other people in general can carry. “
Based on this and another study that came out after Franz, 12 to 15% of the most seriously ill COVID-19 patients have permanent nerve damage. Based on the number of COVID patients worldwide, Franz estimated that thousands of patients were affected.
“It is underestimated if you take our numbers and extrapolate them,” said Franz. So far, he and his colleagues have seen 20 patients from seven different hospitals with these injuries.
The injury was overlooked because people who were critically ill are expected to wake up with general, symmetrical weakness from being bedridden, Franz said. However, the weakening pattern in the COVID-19 patients caught the researchers’ attention during rehabilitation, as an important joint such as the wrist, ankle or shoulder on one side of the body was often completely paralyzed.
Based on the results, doctors are modifying the prone position protocol for COVID-19 patients at Northwestern Memorial Hospital to prevent nerve damage.
“We found that patients put a lot of pressure on their elbows or neck. So we made some adjustments to the position of the joints and put extra padding under the elbow and knee where the greatest pressure is, “said Franz.
The most common injuries are wrist drops, foot drops, loss of hand function, and frozen shoulder. Some patients had up to four different nerve injury sites. Some people pulling a foot need walking assistance, such as walking. B. a wheelchair, a support or a stick.
Franz and colleagues carried out a therapeutic nerve stimulation, which in other work has proven to be helpful for nerve regrowth. Franz is working on this line of research with John Rogers, a biomedical engineer at the McCormick School of Engineering in the Northwest, and Dr. Sumanas Jordan, assistant professor of surgery in Feinberg and plastic surgeon in northwest medicine.
However, many patients have pre-existing conditions that affect nerve regeneration, such as: B. diabetes mellitus, making them less likely to regain full function.
“This could mean permanent difficulty walking or critical hand functions such as typing or operating a computer or cell phone,” said Franz.
Reference: “Prone to Injury: Peripheral Nerve Injuries Associated with the Prone Position for COVID-19-Related Acute Respiratory Distress Syndrome” by George R. Malik, Alexis R. Wolfe, Rachna Soriano, Leslie Rydberg, Lisa F. Wolfe, Swati Deshmukh, Jason H. Ko, Ryan P. Nussbaum, Prakash Jayabalan, James M. Walter and Colin K. Franz, accepted, British Journal of Anesthesia.
The multidisciplinary team of scientists from Northwestern and Shirley Ryan AbilityLab is working on a printed map of nerve sensitivity hot spots, radiographic imaging to document the injury, and skin sensors to identify better prone strategies.