COVID-19 ventilator patients can have permanent nerve damage
Prone positioning saves lives, but nerve pressure injuries impair arms
and legs

Date:
September 11, 2020
Source:
Northwestern University
Summary:
Severely ill COVID-19 patients on ventilators are placed in a prone
(face down) position because it's easier for them to breathe and
reduces mortality. But that life-saving position can also cause
permanent nerve damage in these vulnerable patients, reports a
new study. Scientists believe 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.



FULL STORY ========================================================================== Severely ill COVID-19 patients on ventilators are placed in a prone
(face down) position because it's easier for them to breathe and reduces mortality. But that life-saving position can also cause permanent nerve
damage in these vulnerable patients, reports a newly accepted study
from Shirley Ryan AbilityLab and Northwestern University Feinberg School
of Medicine.


========================================================================== Scientists believe 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 has been accepted by the British Journal of Anaesthesia. It
can be viewed as a preprint.

"It's shocking how big a problem it is," said 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. "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."
Based on this study and another that came out after Franz's, 12% to 15%
percent of the most severely ill COVID-19 patients have permanent nerve
damage. Based on the number of COVID patients worldwide, Franz estimated thousands of patients have been impacted.

"It's underappreciated, if you take our numbers and extrapolate them,"
Franz said. So far, he and colleagues have seen 20 patients from seven different hospitals with these injuries.



==========================================================================
The injury has been missed because people who have been critically ill
are expected to wake up with some generalized, symmetric weakness because
they have been bedridden, Franz said. But 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.

As a result of the findings, physicians are modifying the prone position protocol for COVID-19 patients at Northwestern Memorial Hospital in
order to prevent nerve damage.

"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," Franz said.

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 people who are dragging a foot need assistance with walking such
as a wheelchair, brace or cane.

Franz and colleagues have been doing some therapeutic nerve stimulation,
which has shown in other work to help regrow nerves. Franz collaborates
on this line of research with 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.

But many patients have pre-existing conditions that interfere with
nerve regeneration, such as diabetes mellitus, so they are less likely
to recover full function.

"This could mean permanent difficulties with walking or critical hand
functions like writing or operating a computer or cell phone," Franz said.

The multidisciplinary team of scientists at Northwestern and Shirley
Ryan AbilityLab are working on a pressure map of hot spots for nerve sensitivity, radiology imaging to document the injury and skin sensors
to help identify better "prone" position strategies.


========================================================================== Story Source: Materials provided by Northwestern_University. Original
written by Marla Paul.

Note: Content may be edited for style and length.


========================================================================== Journal Reference:
1. George R. Malik, Alexis R. Wolfe, Rachna Soriano, Leslie Rydberg,
Lisa F.

Wolfe, Swati Deshmukh, Jason H. Ko, Ryan P. Nussbaum, Prakash
Jayabalan, James M. Walter, Colin K. Franz. Injury-Prone:
Peripheral nerve injuries associated with prone positioning for
COVID-19-related acute respiratory distress syndrome. medRxiv,
2020; DOI: 10.1101/2020.07.01.20144436 ==========================================================================

Link to news story: https://www.sciencedaily.com/releases/2020/09/200911141648.htm

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