Brachial plexus injury and facial breakdown as a consequence of proning during COVID-19 treatment

Abstract

By early 2020, the novel SARS-CoV-2 virus (COVID-19) was spreading rapidly worldwide, and its effects proved devastating. In many critically ill patients afflicted with COVID-19, treatment often involves prolonged periods of proning that, along with other interventions, can lead to improved oxygenation. However, sustaining this position predisposed patients to increased complications. We present a case of an older patient with respiratory failure secondary to COVID-19 who developed rapidly forming facial and knee wounds and a brachial plexus injury from proning. The pressure injuries were unresponsive to standard wound care treatments and resulted in full-thickness wounds. During outpatient posthospital follow-up, a facial eschar was debrided, and weakness of the left shoulder and arm secondary to a brachial plexus injury was identified. This case highlights various complications associated with prolonged proning and the importance of close attention to follow-up by both inpatient and outpatient providers.

Facial Pressure Sores in COVID-19 Patients during Prone Positioning: A Case Series and Literature Review

“…Out of seven publications, 10,13,16,17,20,24,25 the prevalence of chin injuries varied from 7% 16 to 16% 17 of cases. Ramondetta 24 and Ayala 20 reported uncomplicated PP-related chin lesions that benefited from local care. Ibarra et al 17 reported a single case of bedside surgical drainage.…”

“…12 According to Ayala et al, 20 PP-related facial ulcers mainly affect the cheeks, and the diagnosis may be delayed by the presence of a tape securing the endotracheal tube. 20 Occasionally, diagnosis cannot be made until the endotracheal tube is removed and replaced with a tracheotomy. 14 Ibarra et al 17 reported 70% of anterior pressure sores affecting the face and 18% on the cheeks.…”

“…Facial wounds due to PP can affect up to 70% of patients, 19 and some may require surgical debridement and reconstruction 11 even though most are limited and graded I or II. 12 According to Ayala et al, 20 PP-related facial ulcers mainly affect the cheeks, and the diagnosis may be delayed by the presence of a tape securing the endotracheal tube. 20 Occasionally, diagnosis cannot be made until the endotracheal tube is removed and replaced with a tracheotomy.…”

“…Ten articles reported cheek pressure ulcers. [10][11][12][13][14][16][17][18][19][20] Of those, three were case reports, 14,18,20 and others were systematic reviews, reviews of the literature, 12 and series of cases.…”

“…17 Shearer et al 13 found a similar rate of nasal damage (17.6% of cases). Other authors 20,24 described cases of non-surgical PP-related nasal lesions, some of which occurred after less than 48 hours.…”