Prone position plexopathy: an avoidable complication of prone positioning for COVID-19 pneumonitis?

Abstract

Prone positioning is a mainstay of management for those presenting to the intensive care unit with moderate-to-severe acute respiratory distress syndrome due to COVID-19. While this is a necessary and life-saving intervention in selected patients, careful positioning and meticulous care are required to prevent compression and traction of the brachial plexus, and resultant brachial plexopathy. We describe two patients who developed a brachial plexus injury while undergoing prone positioning for management of COVID-19 pneumonitis. Both patients were diabetic and underwent prolonged periods in the prone position during which the plexopathy affected arm was abducted for 19 and 55 hours, respectively. We discuss strategies to reduce the risk of this rare but potentially disabling complication of prone positioning.

Keywords: COVID-19; adult intensive care; neurological injury; peripheral nerve disease.

Figure 1

Traction on the brachial plexus. Traction is placed on the brachial plexus by abducting the arm, particularly beyond 90°, where it results in tension across the humeral head. This is further exacerbated by turning the head away from the abducted arm. Figure drawn by Josh King-Robson.

Figure 2

Analysis of prone positioning. Patient 1 spent 22 hours and patient 2 101 hours in the prone position, including extended periods with the plexopathy-affected arm continuously abducted. Patient 2 was often positioned with the head facing away from the abducted arm. time is indicated, in hours (h), for each period in prone position. BMI, body mass index; I&V, intubated and ventilated; ITU, intensive therapy unit. Figure drawn by Josh King-Robson.