SESSION TITLE: Medical Student/Resident Critical Care Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: It is described in the literature, prone positioning showed improvement of gas exchange by ameliorating the ventral-dorsal transpulmonary pressure difference, reducing dorsal lung compression and improving lung perfusion and oxygenation. Prone positioning has a reduction in 28-day mortality in patients with severe acute respiratory syndrome on mechanical ventilation. The duration per session was 17±3 hours, with the average number of session of 4±4 per patient.
CASE PRESENTATION: A 60-year-old female with a significant past medical history of morbid obesity (BMI: 51), stroke, atrial fibrillation, hypertension, and pacemaker placement who presented to the ED with nausea, vomiting, and diarrhea for the last 2 days. She also reported 2 weeks of general weakness, moderate dyspnea on exertion, fever, and chills. The patient was admitted due to respiratory distress requiring oxygen supplementation. Her chest x-ray showed bilateral opacities and COVID-19 test was positive. On the second day of admission, patient's respiratory status deteriorated requiring intubation and transfer to the ICU. Her course was complicated by septic shock requiring vasopressor, superimposed MRSA pneumonia which was treated with 8 days of vancomycin, mild acute kidney injury, and mild transaminitis. Inflammatory markers were remarkable for D-Dimer 2.63, ferritin 931, lactate dehydrogenase 894. Initially, the patient was placed on pressure-control ventilation then switched to volume control but continued to have high oxygen requirements and PEEP. Proning protocol was initiated and she was placed on 16 hours prone position, followed with 8 hours supine. Due to her refractory hypoxemia, it was decided to proceed with multiple prone positioning, total of 6 times to be weaned off the ventilator. She was successfully extubated after 18 days, and discharged home without any complications.
DISCUSSION: We present a case of a patient with multiple comorbidities as hypertension, atrial fibrillation, morbid obesity with BMI 51, and age ≥60 years, associated to severe COVID-19 infection and high mortality, who underwent to multiple prone positions, with successful extubation. A recent study assessed prone positioning outcome in mechanically ventilated patients with COVID19 showing improvement in oxygenation and lung compliance with a median of two sessions (range, 1–3), and 18 hours per session. Also, a recent study showed earlier prone positioning was feasible and effective in improving oxygenation in non-intubated, awake and spontaneously breathing COVID19 patients with oxygen supplementation.
CONCLUSIONS: Prone positioning in mechanical ventilated COVID19 patients improve oxygenation. The optimal number of sessions of prone positioning is unknown, and it needs further studies to create a prone protocol for severe COVID-19 disease, with the potential outcome of decreasing mortality.
Reference #1: Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al.; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159–2168.
Reference #2: Ziehr D, Alladina J, Petri C, et al. Respiratory pathophysiology of mechanically ventilated patient with COVID-19: A cohort study. American journal of respiratory and critical care medicine. 2020, 201(12). https://doi.org/10.1164/rccm.202004-1163LE
Reference #3: Coppo A, Bellani G, Winterton D, Di Pietro M, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respiratory Medicine 2020. https://doi.org/10.1016/S2213-2600(2030268-X)
DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response
No relevant relationships by Anastasia Maltseva, source=Web Response
No relevant relationships by Lady Sanchez Fernandez, source=Web Response