Continuous prolonged prone positioning in COVID-19-related ARDS: a multicenter cohort study from Chile

• Published in: Annals of intensive care 2022-11, Vol.12 (1), p.109-109, Article 109
• Main Authors: Cornejo, Rodrigo A., Montoya, Jorge, Gajardo, Abraham I. J., Graf, Jerónimo, Alegría, Leyla, Baghetti, Romyna, Irarrázaval, Anita, Santis, César, Pavez, Nicolás, Leighton, Sofía, Tomicic, Vinko, Morales, Daniel, Ruiz, Carolina, Navarrete, Pablo, Vargas, Patricio, Gálvez, Roberto, Espinosa, Victoria, Lazo, Marioli, Pérez-Araos, Rodrigo A., Garay, Osvaldo, Sepúlveda, Patrick, Martinez, Edgardo, Bruhn, Alejandro
• Format: Article
• Language: English
• Subjects: Acute respiratory distress syndrome; Anesthesiology; Cohort analysis; Coronavirus disease 2019; Coronaviruses; COVID-19; Critical Care Medicine; Emergency Medicine; Injury prevention; Intensive; Intensive care; Mechanical ventilation; Medicine; Medicine & Public Health; Mortality; Patient positioning; Pressure ulcers; Prone positioning; Severe acute respiratory syndrome coronavirus 2; Ventilation
• ISSN: 2110-5820; 2110-5820
• DOI: 10.1186/s13613-022-01082-w

Background Prone positioning is currently applied in time-limited daily sessions up to 24 h which determines that most patients require several sessions. Although longer prone sessions have been reported, there is scarce evidence about the feasibility and safety of such approach. We analyzed feasibility and safety of a continuous prolonged prone positioning strategy implemented nationwide, in a large cohort of COVID-19 patients in Chile. Methods Retrospective cohort study of mechanically ventilated COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS), conducted in 15 Intensive Care Units, which adhered to a national protocol of continuous prone sessions  ≥ 48 h and until PaO 2 :FiO 2 increased above 200 mm Hg. The number and extension of prone sessions were registered, along with relevant physiologic data and adverse events related to prone positioning. The cohort was stratified according to the first prone session duration: Group A, 2–3 days; Group B, 4–5 days; and Group C, > 5 days. Multivariable regression analyses were performed to assess whether the duration of prone sessions could impact safety. Results We included 417 patients who required a first prone session of 4 (3–5) days, of whom 318 (76.3%) received only one session. During the first prone session the main adverse event was grade 1–2 pressure sores in 97 (23.9%) patients; severe adverse events were infrequent with 17 non-scheduled extubations (4.2%). 90-day mortality was 36.2%. Ninety-eight patients (24%) were classified as group C; they exhibited a more severe ARDS at baseline, as reflected by lower PaO 2 :FiO 2 ratio and higher ventilatory ratio, and had a higher rate of pressure sores (44%) and higher 90-day mortality (48%). However, after adjustment for severity and several relevant confounders, prone session duration was not associated with mortality or pressure sores. Conclusions Nationwide implementation of a continuous prolonged prone positioning strategy for COVID-19 ARDS patients was feasible. Minor pressure sores were frequent but within the ranges previously described, while severe adverse events were infrequent. The duration of prone session did not have an adverse effect on safety.