Reducing the Risk and Impact of Brachial Plexus Injury Sustained From Prone Positioning—A Clinical Commentary

Abstract

Introduction: Prone positioning is deployed as a critical treatment for improving oxygenation in patients with Acute Respiratory Distress Syndrome. This regimen is currently highly prevalent in the COVID-19 pandemic. The pandemic has brought about increased concern about how best to safely avoid brachial plexus injuries when caring for unconscious proned patients. Methods: A review of the published literature on brachial plexus injuries secondary to proning ventilated patients was performed. This was combined with a review of available international critical care guidelines in order to produce a succinct set of guidelines to aid critical care departments in reducing brachial plexus injuries during these challenging times. Discussion: There is no one manner in which prone positioning an unconscious patient can be made universally safe. This paper provides 6 key steps to reducing the incidence of brachial plexus injuries while proning and suggests a safe and sensible management and referral pathway for the conscious patient in which a brachial plexus injury is identified. Conclusion: There is in truth no completely safe position for every patient and certainly there will be anomalies in anatomy that will predispose certain individuals to nerve injury. Thus the injury rate cannot be reduced to zero but an understanding of the principles of protection will inform those undertaking positioning.

Neurological implications of COVID-19: a review of the science and clinical guidance

“…These guidelines do not completely prevent neuropathies and the main method to prevent injury is frequent, careful and deliberate changing of position; somatosensory evoked potential are not a sensitive method to identify impending insult. 18 Prone positioning may also increase rates of ocular complications, varying from ocular injury, exposure keratopathy, conjunctival chemosis, acute angle closure, ischaemic optic neuropathy, orbital compartment syndrome and vascular occlusions. Neurologists are most likely to be consulted for potential ischaemic optic neuropathy, which may present as a relative afferent pupillary defect.…”

Shoulder Pain in COVID-19 Survivors Following Mechanical Ventilation

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

“…Both patients were in ECMO and intermittently proned. Upper-limb nerve injuries related to brachial plexus neuropathy are also associated with the prone position [ 39 , 40 , 41 , 42 ].…”