Pan Brachial Plexopathy After Intermittent Prone Positioning During Ventilation in a Patient With Coronavirus Disease 2019 (Covid-19) Induced Acute Respiratory Distress Syndrome: A Case Report.
PM & R
Case Diagnosis: Pan brachial plexopathy after intermittent prone positioning during ventilation in a patient with coronavirus disease 2019
Case Description: The patient was admitted to the intensive care unit due to respiratory distress after positive Covid-19 testing. Due to acute adult respiratory distress syndrome (ARDS), he was subsequently intubated. He was in the intermittent prone position (PP) during the first few days of intubation using paralytics but this was stopped due to decreased oxygen saturations while PP. Right upper extremity (RUE) weakness was noted 20 days after extubation. MRI Brachial Plexus showed no acute abnormalities. He continued to have RUE weakness which slowly improved during inpatient rehabilitation; NCS/EMG performed 3 months after extubation.
Setting: Inpatient rehabilitation hospitalization with outpatient follow-up.Assessment/
Results: Nerve conduction studies showed the absence of sensory nerve action potential of the right median, ulnar, medial, and lateral antebrachial cutaneous nerves. Electromyography revealed fibrillation potentials and positive sharp waves in the right supraspinatus, deltoid, biceps brachii, pronator teres, triceps brachii, abductor policis brevis, and extensor indicis proprius. Normal EMG findings in the paraspinal muscles and rhomboids. These findings were supportive of a right-sided pan brachial plexopathy with ongoing denervation.
Discussion: PP has been used since the 1970s to improve oxygenation in ARDS. Neuropathies after invasive ventilation with PP are considered rare conditions. The major risk factors include mispositioning, decreased muscle tone after sedation, prolonged PP, male sex, obesity, weight loss due to malnutrition, and diabetes. This patient has multiple risk factors which highly increased his risk for brachial plexus injury.
Conclusion: PP in high-risk patients during Covid-19 ventilation might increase the risk of brachial plexus injury due to malpositioning and stretch injury.
Level of Evidence: Level IV
Zhang D, Mafiah M. Pan brachial plexopathy after intermittent prone positioning during ventilation in a patient with coronavirus disease 2019 (covid-19) induced acute respiratory distress syndrome: a case report. PM & R. 2021;13(suppl. 1):s197.