key: cord-0049571-2zj8jbjt
authors: Malik, George R.; Wolfe, Alexis R.; Soriano, Rachna; Rydberg, Leslie; Wolfe, Lisa F.; Deshmukh, Swati; Ko, Jason H.; Nussbaum, Ryan P.; Dreyer, Sean D.; Jayabalan, Prakash; Walter, James M.; Franz, Colin K.
title: Injury-prone: peripheral nerve injuries associated with prone positioning for COVID-19-related acute respiratory distress syndrome
date: 2020-09-04
journal: Br J Anaesth
DOI: 10.1016/j.bja.2020.08.045
sha: bac4aeb86faf023fc94be91324a7665336f8c716
doc_id: 49571
cord_uid: 2zj8jbjt

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). In total, there 58

were 21 focal peripheral nerve injury sites across these 12 patients as well as one 59 newly acquired distal symmetric polyneuropathy. The majority of these peripheral nerve 60 injuries occurred in the upper limb (76.2%; Figure 1 ). The most frequent sites of injury 61 included the ulnar nerve (6 cases, 28.6%), radial nerve (3 cases, 14.3%), sciatic nerve 62

(3 cases, 14.3%), brachial plexus (2 cases, 9.5%) and median nerve (2 cases, 9.5%). 63 The reasons for the high rate of peripheral nerve injury in this cohort is likely 86 multifactorial. There were high rates of diabetes mellitus, obesity, and older age seen in 87 our cohort which are characteristics of severe COVID-19-related ARDS patients 5 as well 88 as established risk factors for peripheral nerve injury. 6 COVID-19 has been associated 89 with muscle injury, acute inflammatory demyelinating polyneuropathy, and a virus-90 induced state of hyperinflammation and hypercoagulability which increase vulnerability 91 of peripheral nerves. 7 The overlap in COVID-19 mechanisms with type 2 diabetes 92 inflammatory and vascular involvement, may also contribute. 8 94

As the subjects described in this study presented from six different tertiary care 95 facilities, hospital-specific approaches to prone positioning cannot alone account for 96 these peripheral nerve injuries. Since only two patients are believed to have received 97 more than four sessions (Supplemental Table 1 sites. Ultrasound elastography may prove to be a useful quantitative measurement tool 108 for assessment of nerve tension and stiffness. 10 Limitations of this study include missing severe COVID-19-related ARDS patients is surprisingly common. Physicians must be 116 aware of an increased susceptibility to peripheral nerve injury in severe COVID-19 and 117 refine standard protocols in order to reduce the risk. 118 

Surviving Sepsis Campaign: Guidelines on the management 131 of critically ill adults with Coronavirus Disease 2019 (COVID-19)

Prone positioning in COVID-19 acute respiratory failure: just do it? Bairbre McNicholas

Role of Rehabilitation Department for

Adult Individuals With COVID-19: The Experience of the San Raffaele Hospital of

Postoperative peripheral neuropathies

Prone positioning in severe acute respiratory distress syndrome

Clinical characteristics of Covid-19 in New

COVID -19: A Global Threat to the Nervous

Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 155 2018: An Updated Report by the American Society of Anesthesiologists Task

Force on Prevention of Perioperative Peripheral Neuropathies

Influence of limb position on assessment of 159 nerve mechanical properties by using shear wave ultrasound elastography