This study aimed to determine the prevalence of adverse events in mechanically ventilated adults with COVID-19 who have undergone prone positioning. A total of 100 patients were included retrospectively; 60% were males, the mean age was 64.8 ± 9.1 years, and hospital mortality was 47%. In all, we recorded 118 removals of catheters and tubes in 66 patients; 29.6% were removals of a nasogastric tube, 18.6% of an arterial line, 14.4% of a urinary catheter, and 12.7% of a central venous catheter. Reintubation or repositioning of a tracheotomy tube was required in 19 patients (16.1%), and cardiopulmonary resuscitation in 2 patients (1.7%). We recorded a total of 184 pressure ulcers in 79 patients (on anterior face in 38.5%, anterior thorax in 23.3% and any extremity anteriorly in 15.2%). We observed that body weight (p = 0.021; β = 0.09 (CI95: 0.01-0.17)) and the cumulative duration of prone positioning (p = 0.005; β = 0.06 (CI95: 0.02-0.11)) were independently associated with the occurrence of any adverse event. The use of prone positioning in our setting was associated with a greater number of adverse events than previously reported. Body weight and cumulative duration of prone positioning were associated with the occurrence of adverse events; however, other factors during a COVID-19 surge, such as working conditions, staffing, and staff education, could also have contributed to a high prevalence of adverse events.

Prone positioning of patients is a routine occurrence in procedural suites and operating rooms (ORs). However, the physiological changes that occur with prone positioning are frequently underappreciated by proceduralists, surgeons, and anesthesiologists. This may be related to a sense of the routine or a lack of familiarity with physiological changes that accompany the prone position. The prone position, while aiding visualization and cannulation of the ampulla of Vater during endoscopic retrograde cholangiopancreatography (ERCP), can induce physiological changes such as reduced preload, inferior vena cava filling, and cardiac output; it can also increase intrathoracic pressure and mediastinal compression. Anesthetic agents can further impact cardiopulmonary physiology, decreasing systemic vascular resistance and reducing cardiac contractility. In addition, the transition from negative to positive pressure ventilation following endotracheal intubation can increase pulmonary artery pressures and right ventricular (RV) strain. Therefore, caution is needed with patients who have RV dysfunction, pulmonary hypertension, or preload dependency, as they may not tolerate prone positioning. We describe a case in which a 73-year-old male patient scheduled for an ERCP suffered cardiac arrest after being transitioned to the prone position. The patient was repositioned in the supine position and resuscitated. The case was completed in the supine position.

UNASSIGNED: The prone position has been seen to benefit patients experiencing acute respiratory distress syndrome. However, performing this position in pregnant patients has been difficult and raises safety concerns.
UNASSIGNED: The current study aimed to test the use of a supportive pillow (Prone Pillow for Pregnant Patients or 4P) to address concerns regarding pregnant patients in prone position.
UNASSIGNED: The study prospectively evaluated the use of the prone pillow for patient comfort and usability among healthcare workers with qualitative and quantitative measures.
UNASSIGNED: A total of three patients were recruited alongside 16 healthcare workers assisting pregnant patients to the prone position. Overall, awake pregnant patients found the pillow to be comfortable while healthcare workers perceived the pillow to be useful in improving quality of care among awake and intubated pregnant patients.
CONCLUSIONS: The 4P is a potentially useful and beneficial product in placing pregnant patients in the prone position during episodes of acute respiratory distress. However, due to the limited sample size, more clinical trials are needed to evaluate the impact of this innovation in improving patient and healthcare worker safety.

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.

In the last few years prone positioning has been used increasingly in the treatment of patients with acute respiratory distress syndrome and this maneuver is now considered a simple and safe method to improve oxygenation. Hemodynamic monitoring by echocardiography may be required but prone positioning imposes certain challenges limiting standard examination. The article describes the application of the \"trans-splenic retrocardiac view,\" a little-known echographic window for obtaining Doppler parameters from the back in prone-positioned patients.

UNASSIGNED: The use of extracorporeal membrane oxygenation (ECMO) technology has significantly decreased mortality rates associated with neonatal pulmonary hypertension and respiratory failure. Prone positioning ventilation (PPV) is a commonly used technique in critically ill infants, designed to improve thoracic pressure gradients, re-expand dorsal lung segments, and increase oxygenation in approximately 70-80% of patients suffering from acute respiratory distress syndrome. This study aimed to evaluate the effects of PPV on pulmonary function in neonates undergoing venous-arterial extracorporeal membrane oxygenation (VA-ECMO).
UNASSIGNED: We conducted a retrospective analysis of clinical data from 17 neonates who received ECMO support in our institution, divided into two groups based on ventilation strategy: ECMO with PPV (ECMO-PPV, n=8) and ECMO with supine positioning ventilation (ECMO-SPV, n=9). Parameters such as the P/F ratio [arterial oxygen partial pressure (PaO2)/fraction of inspired oxygen (FiO2)], oxygenation index (OI), respiratory system compliance (Crs), and airway resistance (RAW) were collected and analyzed at baseline, and at 1, 2, and 3 days post-ECMO initiation. In the ECMO-PPV group, these parameters were also assessed 3 days pre-treatment and 2 hours post-treatment initiation.
UNASSIGNED: Initial comparisons between ECMO-PPV and ECMO-SPV groups showed no significant difference in PaO2/FiO2, OI, Crs, or RAW. Throughout the ECMO treatment, both groups demonstrated gradual improvements in PaO2/FiO2 and Crs, and reductions in OI and RAW. Notably, by day 3, the ECMO-PPV group exhibited significant improvements in Crs and RAW compared to the ECMO-SPV group (P<0.05). Specifically, in the ECMO-PPV group, Crs significantly increased and RAW decreased after 2 hours of initiating PPV, with these changes becoming statistically significant by day 3 (Crs P=0.03, RAW P=0.03). No severe PPV-related complications were noted.
UNASSIGNED: PPV during neonatal ECMO may improve respiratory compliance and reduce RAW, potentially aiding lung recovery. Our findings suggest PPV as a viable strategy for neonates under ECMO support.

BACKGROUND: Pneumocystis pneumonia is an uncommon precipitant of acute respiratory distress syndrome and is associated with high mortality. Prone positioning ventilation has been proven to reduce mortality in patients with moderate-severe acute respiratory distress syndrome. We investigated the effect of prone positioning on oxygenation and mortality in intubated patients with pneumocystis pneumonia comorbid with moderate-severe acute respiratory distress syndrome.
METHODS: In this single-center, retrospective, observational, cohort study, eligible patients were enrolled at West China Hospital of Sichuan University from January 1, 2017, to December 31, 2021. Data on demographics, clinical features, ventilation parameters, arterial blood gas, and outcomes were collected. Patients were assigned to the prone cohort or supine cohort according to whether they received prone positioning ventilation. The main outcome was 28-day mortality.
RESULTS: A total of 79 patients were included in the study. Sixty-three patients were enrolled in the prone cohort, and 16 patients were enrolled in the supine cohort. The 28-day mortality was 61.9% in the prone cohort and 68.8% in the supine cohort (P = 0.26), and 90-day mortality was 66.7% in the prone cohort and 68.8% in the supine cohort (P = 0.55). Patients in the supine cohort had fewer invasive mechanical ventilation days and more ventilator-free days. The incidence of complications was higher in the prone cohort than in the supine cohort.
CONCLUSIONS: In patients with pneumocystis pneumonia and moderate-severe acute respiratory distress syndrome, prone positioning did not decrease 28-day or 90-day mortality. Trial registration ClinicalTrials.gov number, ChiCTR2200063889. Registered on 20 September 2022, https://www.chictr.org.cn/showproj.html?proj=174886 .

OBJECTIVE: To investigate the association between the duration of the first prone positioning maneuver (PPM) and 90-day mortality in patients with C-ARDS.
METHODS: Retrospective, observational, and analytical study.
METHODS: COVID-19 ICU of a tertiary hospital.
METHODS: Adults over 18 years old, with a confirmed diagnosis of SARS-CoV-2 disease requiring PPM.
METHODS: Multivariable analysis of 90-day survival.
METHODS: Duration of the first PPM, number of PPM sessions, 90-day mortality.
RESULTS: 271 patients undergoing PPM were analyzed: first tertile (n = 111), second tertile (n = 95) and third tertile (n = 65). The results indicated that the median duration of PDP was 14 h (95% CI: 10-16 h) in the first tertile, 19 h (95% CI: 18-20 h) in the second tertile and 22 h (95% CI: 21-24 h) in the third tertile. Comparison of survival curves using the Logrank test did not reach statistical significance (p = 0.11). Cox Regression analysis showed an association between the number of pronation sessions (patients receiving between 2 and 5 sessions (HR = 2.19; 95% CI: 1.07-4.49); and those receiving more than 5 sessions (HR = 6.05; 95% CI: 2.78-13.16) and 90-day mortality.
CONCLUSIONS: while the duration of PDP does not appear to significantly influence 90-day mortality, the number of pronation sessions is identified as a significant factor associated with an increased risk of mortality.

BACKGROUND: Pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk of severe disease progression. Comorbidities, such as chronic arterial hypertension, diabetes mellitus, advanced maternal age and high body mass index, may predispose to severe disease. The management of pregnant COVID-19 patients on the intensive care unit (ICU) is challenging and requires careful consideration of maternal, fetal and ethical issues.
OBJECTIVE: Description and discussion of intensive care treatment strategies and perinatal anesthesiological management in patients with COVID-19 acute respiratory distress syndrome (CARDS).
METHODS: We analyzed the demographic data, maternal medical history, clinical intensive care management, complications, indications and management of extracorporeal membrane oxygenation (ECMO) and infant survival of all pregnant patients treated for severe CARDS in the anesthesiological ICU of a German university hospital between March and November 2021.
RESULTS: The cohort included 9 patients with a mean age of 30.3 years (range 26-40 years). The gestational age ranged from 21 + 3 weeks to 37 + 2 weeks. None of the patients had been vaccinated against SARS-CoV‑2. Of the nine patients seven were immigrants and communication was hampered by inadequate Central European language skills. Of the patients five had a PaO2/FiO2 index < 150 mm Hg despite escalated invasive ventilation (FiO2 > 0.9 and a positive end-expiratory pressure [PEEP] of 14 mbar) and were therefore treated with repeated prolonged prone positioning maneuvers (5-14 prone positions for 16 h each, a total of 47 prone positioning treatments) and 2 required treatment with inhaled nitric oxide and venovenous ECMO. The most common complications were bacterial superinfection of the lungs, urinary tract infection and delirium. All the women and five neonates survived. All newborns were delivered by cesarean section, two patients were discharged home with an intact pregnancy and two intrauterine fetal deaths were observed. None of the newborns tested positive for SARS-CoV‑2 at birth.
CONCLUSIONS: High survival rates are possible in pregnant patients with CARDS. The peripartum management of pregnant women with CARDS requires close interdisciplinary collaboration and should prioritize maternal survival in early pregnancy. In our experience, prolonged prone positioning, an essential evidence-based cornerstone in the treatment of ARDS, can also be safely used in advanced stages of pregnancy. Inhaled nitric oxide (iNO) and ECMO should be considered as life-saving treatment options for carefully selected patients. For cesarean section, neuraxial anesthesia can be safely performed in patients with mild CARDS if well planned but the therapeutic anticoagulation recommended for COVID-19 may increase the risk of bleeding complications, making general anesthesia a more viable alternative, especially in severe disease.
UNASSIGNED: HINTERGRUND: Schwangere mit einer SARS-CoV-2-Infektion (COVID-19) haben ein erhöhtes Risiko für einen schweren Verlauf der COVID-19. Die medizinische und ethische Abwägung maternaler und fetaler Risiken und die Priorisierung von Therapieoptionen stellen eine große Herausforderung auf der Intensivstation dar. Eine enge interdisziplinäre Abstimmung ist unabdingbar.
UNASSIGNED: Beschreibung und Diskussion intensivmedizinischer Behandlungsstrategien und des perinatalen anästhesiologischen Managements bei Patientinnen mit COVID-19-ARDS (CARDS).
METHODS: Analyse von demografischen Daten, Anamnese, klinischem Management, Komplikationen, Indikationen und Management der extrakorporalen Membranoxygenierung (ECMO) sowie des kindlichen Überlebens aller schwangeren Patientinnen, die zwischen März und November 2021 auf der anästhesiologischen Intensivstation eines deutschen Universitätsklinikums wegen eines schweren CARDS behandelt wurden.
UNASSIGNED: Kohorte von 9 konsekutiven Patientinnen mit einem Durchschnittsalter von 30,3 Jahren (Min–Max: 26 bis 40 Jahre) und einem Schwangerschaftsalter von 21 + 3 bis 37 + 2 Wochen. Keine der Patientinnen war gegen SARS-CoV‑2 geimpft. Zwei Patientinnen mussten mit inhalativem Stickstoffmonoxid und venovenöser ECMO behandelt werden. Alle Frauen und 5 Neugeborene haben überlebt. Zwei Patientinnen wurden mit intakter Schwangerschaft nach Hause entlassen. Alle Kinder wurden durch einen Kaiserschnitt entbunden. Es wurden 2 intrauterine fetale Todesfälle beobachtet. Keines der Neugeborenen wurde bei der Geburt positiv auf SARS-CoV‑2 getestet.
CONCLUSIONS: Das peripartale Management erfordert eine enge interdisziplinäre Zusammenarbeit und sollte in der Frühschwangerschaft vorrangig auf das mütterliche Überleben ausgerichtet sein. Die Bauchlagerung, ein wesentlicher, evidenzbasierter Eckpfeiler in der Therapie des akuten Atemnotsyndroms (ARDS), kann auch in fortgeschrittenen Schwangerschaftsstadien sicher angewendet werden. Inhalatives Stickstoffmonoxid (iNO) und extrakorporale Membranoxygenierung (ECMO) sollten als lebensrettende Behandlungsoptionen für sorgfältig ausgewählte Patientinnen in Betracht gezogen werden.

UNASSIGNED: Previous studies suggest that prone positioning can increase PaO2/FiO2 and reduce mortality in moderate to severe acute respiratory distress syndrome. Effect of prone positioning and high flow nasal oxygen has been studied individually in COVID-19 patients but their combined effect on patient\'s outcome is yet to be reported.
UNASSIGNED: In this study 120 severe COVID-19 positive patients were included and placed in awake prone positioning with high flow nasal oxygen. The efficacy in improving oxygenation with prone positioning and high flow nasal oxygen were evaluated by blood gas analysis. The primary outcome was a proportion of patients requiring non-invasive ventilation or invasive ventilation. The secondary outcomes were a comparison of arterial blood gas parameters and biochemical inflammatory parameters pre proning, end of first proning and end of last prone position in these patients.
UNASSIGNED: We found only 35 patients (34.3%) required the need for non-invasive or invasive mechanical ventilation support whereas 67 patients (65.7%) were managed successfully on high flow nasal oxygen along with awake prone positioning (p = 0.001). We found there were statistically significant improvements in arterial blood gas parameters and biochemical inflammatory markers after the end of last prone positioning with high flow nasal oxygen.
UNASSIGNED: Early application of prone positioning in combination with high flow nasal oxygen may help in avoiding mechanical ventilation by improving oxygenation and biochemical inflammatory markers.