Postoperative hypoxemia after aortic dissection surgery presents a considerable clinical challenge, and acute respiratory distress syndrome (ARDS) is a common etiology. Prone positioning treatment has emerged as a potential intervention for improving respiratory function in this context. We report the case of a 27-year-old male who developed severe hypoxemia complicated by pulmonary embolism after aortic dissection surgery. He was diagnosed with postoperative hypoxemia combined with pulmonary embolism following aortic dissection. His respiratory status continued to deteriorate despite receiving standard postoperative care, thereby necessitating an alternative approach. Implementation of prone positioning treatment led to a substantial amelioration in his oxygenation and overall respiratory health, with a consistent hemodynamic state observed throughout the treatment. This technique resulted in significant relief in symptoms and improvement in respiratory parameters, facilitating successful extubation and, ultimately, discharge. This case underlines the possible efficacy of prone positioning therapy in managing severe hypoxia complicated by pulmonary embolism following aortic dissection surgery, warranting more thorough research to explore the potential of this treatment modality.

BACKGROUND: We present a case with abnormal findings of initial motor-evoked potential (MEP) in the left upper limb after prone positioning during lumbar spine surgery.
METHODS: A 71-year-old man with bilateral lower extremity numbness without a history of preexisting motor weakness underwent L3-5 spinal fenestration. Initial MEP monitoring after prone positioning revealed markedly prolonged latency and lower amplitude in the left abductor pollicis brevis (APB). Because the left upper limb somatosensory-evoked potentials had normal values, a position-related impending peripheral nerve injury located between the neck and the forearm was excluded. Postoperative examination revealed that MEP abnormality in the left APB was caused by carpal tunnel syndrome.
CONCLUSIONS: Abnormal initial MEP from the upper limb was unexpectedly detected after prone positioning during lumbar spine surgery. The condition was caused by preexisting carpal tunnel syndrome.

UNASSIGNED: Understanding the complications arising from prone positioning following mechanical ventilation during management of acute respiratory distress from COVID-19.
UNASSIGNED: Acute respiratory distress syndrome (ARDS) resulting from coronavirus disease 2019 (COVID-19) has been one of the well-known complications of the disease since it was first reported in 2020. Mechanical ventilation for severe ARDS has been widely utilized for the management of such patients. Prone positioning (PP) is associated with improved oxygenation and overall outcomes in both intubated and non-intubated patients. However, there are several complications associated with this procedure, including compressive neuropathies. In this article, we report a case of unilateral foot drop following mechanical ventilation and PP during the management of ARDS from COVID-19.

Pregnancy is associated with immunological changes that could render an individual vulnerable to the severe coronavirus disease 2019 (COVID-19) disease. Even as we witnessed the third and most widespread pandemic wave, a conclusively advantageous treatment option still remained elusive. Remdesivir was one of the front-running therapeutic options that received emergency use authorization (EUA) and subsequent approval for the management of moderate to severe COVID-19 infections. Here, we report a series of moderate to severe COVID-19-infected pregnancies and the experience of remdesivir use on a compassionate basis. Four cases of pregnancy complicated with moderate to severe COVID-19 infections where remdesivir was administered were recruited into the study, and their outcome was assessed objectively. Of these cases, three women received remdesivir in addition to standard SARS-CoV-2 treatment in the antenatal period. One woman received remdesivir after delivery. One woman received tocilizumab in addition to remdesivir and standard SARS-CoV-2 care. Two women survived and were subsequently discharged to home care. Two succumbed to the disease. One baby who was exposed to remdesivir in utero is doing well at six months post-delivery. Remdesivir had been granted EUA for the treatment of suspected or laboratory-confirmed COVID-19 infection in adults and children who were hospitalized with severe disease or requiring supplemental oxygen and mechanical ventilation or extracorporeal membrane oxygenation (ECMO) in May 2020. This issuance allowed the use of the same dosing regimen in pregnant and parturient women as in the general adult population. Thus, this series of cases tried to assess the outcome of this drug among COVID-19-infected pregnant women. Early initiation of remdesivir in pregnancy in the viremic phase seems to provide some advantages in the survival outcome. Its use may be associated with transient elevation in hepatic transaminases in some cases. No detrimental effects on the ongoing pregnancies, fetuses, or neonates have been observed. Further large-scale studies may provide more conclusive evidence.

The purpose of the study is to examine presentation, injury patterns, and clinical course, for COVID-19-related peripheral nerve injury following mechanical ventilation.
A multicenter retrospective study of patients with COVID-19 complicated by acute respiratory distress syndrome (ARDS) that required mechanical ventilation was undertaken. Patient records were reviewed for intensive care unit and intubation characteristics, prone or lateral decubitus positioning, and the onset of neuropathy diagnosis.
Between September 2020 and January 2022, 11 patients were diagnosed with peripheral neuropathy, including 9 with brachial plexopathy following COVID-19 infection. Each patient developed ARDS requiring mechanical ventilation for a median of 39 days. Six patients (54.5%) underwent prone positioning and 1 lateral decubitus. Neuropathies involved 5 brachial pan-plexopathies, 2 incomplete brachial plexopathies, 2 lower trunk plexopathies, 1 radial neuropathy, and 1 bilateral ulnar neuropathy. At a mean follow-up of 10.2 months, patients with brachial pan-plexopathies demonstrated signs of reinnervation proximally, and 1 resolved to a radial mononeuropathy; however, the majority have demonstrated minimal clinical improvements.
Our series demonstrates that peripheral neuropathies and especially brachial plexopathies have occurred following mechanical ventilation for ARDS-related COVID-19 infections. Contrary to prior COVID-19 studies, only 54.5% of these patients underwent prone positioning. Aside from a traumatic disturbance of prone positioning, the increased incidence of neuropathy may involve an atraumatic effect of COVID-19 via direct invasion of nerves, autoantibody targeting of nervous tissue, or hypercoagulation-induced microthrombotic angiopathy.

The prone position can lead to anatomical compression of the thoracic cavity resulting in reduced cardiac output, especially in the context of chest wall deformities commonly present in patients with scoliosis. There are no protocols for using transesophageal echocardiography (TEE) to optimize prone positioning and for safe use of TEE during cases requiring neuromonitoring.
We present a case of a 23-yr-old male with Cornelia de Lange syndrome undergoing elective posterior spinal fusion for syndromic scoliosis who developed severe refractory hypotension and cardiac arrest in the prone position. After hemodynamic stabilization in the intensive care unit, the patient returned to the operating room on postoperative day 2 for completion of his spinal fusion. Transesophageal echocardiography determined the optimal position of longitudinal bolster placements associated with minimal left ventricular compression in the supine position. The patient was then proned and intraoperative hemodynamics during the second surgery remained stable. Owing to the special considerations of using TEE in the prone position with neuromonitoring, we describe technical aspects to consider to protect the equipment and patient.
Patients with compliant chest walls or thoracic deformities are at risk of hemodynamic instability in the prone position. Intraoperative TEE can be used in the supine patient prior to proning to determine optimal longitudinal bolster positioning to minimize cardiac compression. Transesophageal echocardiography used during spine surgery in the prone position with neuromonitoring and motor-evoked potentials requires special considerations for patient safety.
RéSUMé: OBJECTIF: La position ventrale peut entraîner une compression anatomique de la cavité thoracique provoquant une réduction du débit cardiaque, en particulier dans le contexte de déformations de la paroi thoracique, fréquentes chez les patients atteints de scoliose. Il n’existe aucun protocole guidant l’utilisation de l’échocardiographie transœsophagienne (ETO) pour optimiser le positionnement ventral et pour favoriser l’utilisation sécuritaire de l’ETO dans les cas nécessitant un neuro-monitorage. CARACTéRISTIQUES CLINIQUES: Nous présentons le cas d’un homme de 23 ans atteint d’un syndrome de Cornelia de Lange bénéficiant d’une fusion spinale postérieure non urgente pour traiter une scoliose syndromique; le patient a manifesté une hypotension réfractaire sévère et un arrêt cardiaque en position ventrale. Après stabilisation hémodynamique à l’unité de soins intensifs, le patient est retourné en salle d’opération au jour postopératoire 2 pour terminer sa fusion spinale. L’échocardiographie transœsophagienne a permis de déterminer la position optimale des traversins longitudinaux qui était associée à une compression ventriculaire gauche minimale en décubitus dorsal. Le patient a ensuite été positionné sur le ventre, et les valeurs hémodynamiques peropératoires sont restées stables au cours de la deuxième chirurgie. En raison des considérations particulières de l’utilisation de l’ETO en position ventrale avec neuro-monitorage, nous décrivons les aspects techniques à prendre en compte pour protéger l’équipement et le patient. CONCLUSION: Les patients présentant des parois thoraciques compliantes ou des déformations thoraciques sont à risque d’instabilité hémodynamique en position ventrale. L’ETO peropératoire peut être utilisée chez le patient en décubitus dorsal avant le positionnement ventral pour déterminer le positionnement optimal des traversins longitudinaux afin de minimiser la compression cardiaque. L’utilisation de l’échocardiographie transœsophagienne lors d’une chirurgie du rachis en position ventrale avec neuro-monitorage et potentiels évoqués moteurs nécessite des considérations particulières en ce qui a trait à la sécurité des patients.

Prone positioning has been used for decades to improve oxygenation in patients with acute respiratory distress syndrome. With the COVID-19 pandemic there has been a growing emphasis on the utilization of prone positioning for non-intubated patients as a means of preventing invasive ventilation and improving outcomes. In this case report, a patient is presented with acute hypoxemic respiratory failure in late pregnancy who experienced significant improvements in oxygenation with prone positioning. Additionally, the physiology of prone positioning is reviewed, as well as its mechanism and safety in pregnancy.

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus causing the coronavirus disease 2019 (COVID-19) pandemic is known to lead to the complicated sequelae of severe acute respiratory distress syndrome. Proning has been used as an adjunctive treatment to improve oxygenation in both ventilated and non-ventilated patients. Although patients respond well to this strategy, complications from this arise as well. It is hypothesized that COVID-19 intensive care unit (ICU) proned ventilation is associated with new cases of foot drops or compressive unilateral ankle dorsiflexion weakness during the early 2020 COVID-19 pandemic. Five patients presented to an acute rehabilitation facility with unilateral ankle dorsiflexion weakness after ICU proned ventilation during the COVID-19 pandemic. Three patients were found to have primarily subacute left sensory-motor dysmyelinating common peroneal neuropathies located around the fibular head. Two patients were found to have primarily subacute sensory-motor dysmyelinating right-sided common peroneal neuropathies above the fibular head and distal to biceps femoris muscle. Compressive unilateral common peroneal neuropathies during the pandemic are possibly related to the impromptu, unconventional, and unfamiliar use of proned ventilation.

If noninvasive ventilation (NIV or high-flow CPAP) fails in severe cases of COVID-19, escalation of treatment with orotracheal intubation and intermitted prone positioning is provided as standard care. The present case reports show two COVID-19 patients with severe refractory hypoxemia despite NIV treatment during the first wave (first half year 2020) and the resulting influence on the treatment regimen during the second wave (since October 2020) of the pandemic. Both patients (aged 63 years and 77 years) voluntarily positioned themselves on the side or in a prone position without prior sedation and oral intubation. Positional treatment promptly improved the arterial oxygenation level. The oxygenation index improved in the following days with continued NIV and intermittent prone and side position. The recovered patients were transferred from the intensive care unit at days 5 and 14, respectively after admission. The case reports, along with other reports, show that prone or lateral positioning may be important in the treatment of SARS-CoV‑2 pneumonia in awake and not yet intubated patients.
UNASSIGNED: Schwere Verläufe von COVID-19 führen bei Versagen einer unterstützenden nichtinvasiven Beatmung („high flow“, CPAP bzw. NIV) zur Eskalation der Therapie mit orotrachealer Intubation und anschließender Bauchlagerung. In dem vorliegenden Fallbericht werden zwei COVID-19-Patienten mit schwerer refraktärer Hypoxämie unter eskalierter nichtinvasiver Beatmungstherapie aus der ersten Pandemiewelle (erstes Halbjahr 2020) sowie das dadurch beeinflusste Vorgehen in der zweiten Pandemiewelle (seit 10/2020) vorgestellt. Beide Patienten (Alter: 63 und 77 Jahre) lagerten sich bereits vor Indikationsstellung einer Intubation selbstständig auf die Seite bzw. auf dem Bauch, was zu einer prompten Verbesserung der Oxygenierung führte. Die Oxygenierungsstörung verbesserte sich unter regelmäßiger Lagerungstherapie und NIV in den folgenden Tagen, sodass die Patienten nach 5 bzw. 14 Tagen von der Intensivstation verlegt werden konnten. Der Fallbericht zeigt zusammen mit anderen Berichten, dass eine Bauch- oder Seitenlagerung bei wachen, noch nicht intubierten Patienten einen wichtigen Stellenwert bei der Behandlung einer SARS-CoV-2-Pneumonie haben könnte.

COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery.