key: cord-0900384-ysibpbmi
authors: Bellinghausen, Amy L.; LaBuzetta, Jamie N.; Chu, Frank; Novelli, Francesca; Rodelo, Anthony R.; Owens, Robert L.
title: Lessons from an ICU recovery clinic: two cases of meralgia paresthetica after prone positioning to treat COVID-19-associated ARDS and modification of unit practices
date: 2020-09-27
journal: Crit Care
DOI: 10.1186/s13054-020-03289-4
sha: 3cd0bf0b9e1b85701cff16e0c6bf65987aaddc2d
doc_id: 900384
cord_uid: ysibpbmi

nan

the bilateral second and third toes, which was also new since discharge, without associated weakness, thought to be potentially due to peroneal nerve compression. As the symptoms were not troublesome to the patient, further electrophysiological testing was deferred.

The second patient was a 57-year-old man, without known past medical history who was intubated, mechanically ventilated, and proned for a total of 42 h, over three sessions. He was extubated after 10 days and discharged home on day 24 of admission. At his ICU recovery clinic visit (7 weeks after discharge), he endorsed left anterior thigh numbness without associated weakness, which was bothersome though not painful. His primary care provider had prescribed capsaicin cream (which depletes substance P, reducing nerve sensitivity to painful stimuli), which had not improved the symptoms. The patient declined referral for electrophysiological examination.

After review of these cases, we altered our unit practice regarding padding of the anterior hips while patients are in the prone position. Previously, we placed 4-in. square, adhesive, foam absorbent dressings over each anterior superior iliac spine, and a pillow under the "up" hip (alternating sides every 2 h). Subsequently, we have changed our practice to more evenly distribute pressure over the hip, with egg-crate style foam padding between the "down" hip and the bed (Fig. 2) .

We present these cases not only to highlight an uncommonly recognized but potentially preventable complication of prone positioning in the ICU, but to show how data gathered in an ICU recovery clinic, staffed by intensivists, can be "fed back" into the ICU where patients were treated, and improve the quality of care that patients receive [6] . "Identifying otherwise unseen targets for ICU quality improvement" has been postulated as one way that ICU recovery clinics might improve care, yet there are few published examples. If these patients returned to their primary care physicians, it is less likely that the cause of the MP would be known, nor would practice change. Lessons like these show the potential value of ICU recovery clinics, not only in treating post-intensive care syndrome, but in changing its underlying causes. Fig. 2 a Absorbent, adhesive, foam dressings (10 cm × 10 cm) and locations used for the initial pressure offloading technique. b Addition of eggcrate foam under the "down hip" in revised pressure offloading technique

Prone positioning in severe acute respiratory distress syndrome

Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure

Meralgia paresthetica: a review of the literature

Case report meralgia paresthetica after prone positioning ventilation in the intensive care unit

Prone position-related meralgia paresthetica after lumbar spinal surgery: a case report and review of the literature

Key mechanisms by which post-ICU activities can improve in-ICU care: results of the international THRIVE collaboratives

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Thank you to Kelsey Desmond, RN, CCRN, for the assistance with the figures and implementing the change in practice.

Abbreviations COVID-19: Coronavirus disease 2019; ARDS: Acute respiratory distress syndrome; ICU: Intensive care unit; MP: Meralgia paresthetica Authors' contributions AB identified the two cases described and was a major contributor in writing the manuscript. FC and RO assisted in the manuscript revision and participated in the ICU recovery clinic visits for these patients. All authors read and approved the final manuscript.

There was no specific funding for this study; research time for author AB is funded by the NHLBI T32 Institutional Training Award (HL134632).

Ethics approval and consent to participate Not applicable Consent for publication Not applicable, no identifiable patient information included

The authors declare that they have no competing interests.Author details 1