Latest COVID-19 Research Indicates That Proning Of COVID-19 Ventilator Patients Can Lead To Permanent Peripheral Nerve Damage
studies by researchers from the Regenerative Neurorehabilitation Laboratory (The Shirley Ryan AbilityLab) at Northwestern University Feinberg School of Medicine- Chicago have shown that proning (the technique of placing a patient in a face down position to ease breathing and reduce mortality rates) of severely ill COVID-19 patients on ventilators can cause permanent nerve damage in these vulnerable patients.
The study team believes the nerve damage is the result of reduced blood flow and inflammation. Other non-COVID-19 patients on ventilators in this position rarely experience any nerve damage.
The study team came to this conclusion after studying 85 COVID-19 patients who were placed face down while attached to a ventilator. On recovery, all patients were sent to a post-COVID-19 rehabilitation center at a single health care facility. It was seen that around 13 per cent (11 patients) of them developed a “peripheral nerve injury” in one or more major joints. Most of the injuries were seen in the wrist, hand, foot or shoulder. But researchers say that despite this damage, proning is a potentially lifesaving intervention, which has saved a lot of lives during the pandemic.
The study findings were published on a preprint server and has already been peer-reviewed pending publications in the in the British Journal of Anaesthesia. https://www.medrxiv.org/content/10.1101/2020.07.01.20144436v1
Lead investigator, Dr Colin Franz, a physician-scientist at Shirley Ryan AbilityLab and an assistant professor of physical medicine and rehabilitation and neurology at Northwestern’s Feinberg School of Medicine told Thailand Medical News, “It’s shocking how big a problem it is. This is a much higher percentage of patients with nerve damage than we’ve ever seen in any other critically ill population. Ordinarily, very sick people can tolerate the position that helps their breathing. But COVID patients’ nerves can’t tolerate the forces other people can generally bear.”
From on this study, 12% to 15% percent of the most severely ill COVID-19 patients have permanent nerve damage. Based on the number of COVID patients worldwide, Dr Franz estimated thousands of patients have been impacted.
The experts suspect that the COVID-19 virus may make nerves more vulnerable to damage. This may be due to the increased inflammation, poor blood circulation and blood clotting. Positioning of a patient while proning and the weight it may put on certain nerves for long periods of time are also causes of this damage
He said, “It’s underappreciated, if you take our numbers and extrapolate them.”
To date, he and colleagues have seen 20 patients from seven different hospitals with these injuries.
Often the injury has been missed because individuals who have been critically ill are expected to wake up with some generalized, symmetric weakness because they have been bedridden.
However the pattern of weakness in the COVID-19 patients caught the researchers’
attention during rehabilitation since quite often an important joint such as the wrist, ankle or shoulder would be completely paralyzed on one side of the body.
Because of the results of the study findings, doctors are modifying the prone position protocol for COVID-19 patients at Northwestern Memorial Hospital in order to prevent nerve damage.
Dr Franz further added, “We noticed patients are getting a lot of pressure at the elbow or at the neck, so we’ve made some adjustments to the way we position the joints as well as putting extra padding under the elbow and the knee where there is the most pressure.”
While placing patients face down can cause skin pressure injuries in non-COVID-19 patients, nerve compression injuries are rare if there is regular repositioning and careful padding. It increases end-expiratory lung volume, alveolar recruitment, and oxygenation in patients with severe hypoxemic and acute respiratory failure. This is also an inexpensive therapy for the treatment of severe respiratory distress. It improves systemic oxygenation in 70 per cent to 80 per cent of patients with acute respiratory distress.
It was observed that the most common injuries are wrist drops, foot drops, loss of hand function and frozen shoulder. Some patients had as many as four distinct nerve injury sites. Some individuals who are dragging a foot need assistance with walking such as a wheelchair, brace or cane. Some were irreversible nerve damage.
Dr Franz and colleagues have been doing some therapeutic nerve stimulation, which has shown in other work to help regrow nerves. Dr Franz collaborates on this line of research with Dr John Rogers, biomedical engineer at Northwestern’s McCormick School of Engineering, and Dr Sumanas Jordan, an assistant professor of surgery at Feinberg and a Northwestern Medicine plastic surgeon.
However many patients have pre-existing conditions that interfere with nerve regeneration, such as diabetes mellitus, so they are less likely to recover full function.
Dr Franz warned, “This could mean permanent difficulties with walking or critical hand functions like writing or operating a computer or cell phone.”
The study team says that full recovery for nerve damage may occur in only about 10 per cent of patients and the recovery, if at all it takes place, will take anywhere between 12 to 24 months. This may be the longest-lasting effect of COVID-19 for patients.
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