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Journal of Endourology Jan 2024Despite increasing interest in reducing radiation doses during endoscopic stone surgery, there is conflicting evidence as to whether percutaneous nephrolithotomy (PCNL)...
Despite increasing interest in reducing radiation doses during endoscopic stone surgery, there is conflicting evidence as to whether percutaneous nephrolithotomy (PCNL) positioning (prone or supine) impacts radiation. We observed clinically that a patient placed prone on gel rolls had higher than expected radiation with intraoperative CT imaging and that gel rolls were visible on the coaxial imaging. We hypothesized that gel rolls directly increase radiation doses. Anthropomorphic experiments to simulate PCNL positions were performed using a robotic multiplanar fluoroscopy system (Artis Zeego Care+Clear, Siemens) and a 5-second coaxial imaging protocol (5s BODY). A fluoroscopy phantom was placed in various positions, including prone on a gel roll; prone on blankets of equal thickness; prone and supine directly on the table; and modified supine (MS) positions using a thin gel roll or rolled blanket. Impacts of C-arm direction and use of a 1 L saline bag were also evaluated. Measured dose area product (DAP) was compared for the groups. Measured DAP was found to increase by 146 μGy*m2 (287%) when prone on gel rolls compared with only 62.29 (23%) when placed on blankets of equal thickness, although the model likely both overstates the relative impact and understates the absolute impact that would be seen clinically. Measured DAP between experimental groups also varied considerably despite fluoroscopy time being held constant. Our experiments support our hypothesis that gel rolls directly increase radiation dose, which has not been previously reported, using an anthropomorphic model. Surgeons should consider radiolucent materials for positioning to limit radiation exposure to patients and the surgical team.
Topics: Humans; Nephrolithotomy, Percutaneous; Kidney Calculi; Patient Positioning; Prone Position; Supine Position; Radiation Exposure; Nephrostomy, Percutaneous; Treatment Outcome
PubMed: 37917095
DOI: 10.1089/end.2023.0251 -
CHEST Critical Care Sep 2023Prone positioning was widely adopted for use in patients with ARDS from COVID-19. However, proning was also delivered in ways that differed from historical evidence and...
BACKGROUND
Prone positioning was widely adopted for use in patients with ARDS from COVID-19. However, proning was also delivered in ways that differed from historical evidence and practice. In implementation research, these changes are referred to as adaptations, and they occur constantly as evidence-based interventions are used in real-world practice. Adaptations can alter the delivered intervention, impacting patient and implementation outcomes.
RESEARCH QUESTION
How have clinicians adapted prone positioning to COVID-19 ARDS, and what uncertainties remain regarding optimal proning use?
STUDY DESIGN AND METHODS
We conducted a qualitative study using semi-structured interviews with ICU clinicians from two hospitals in Baltimore, MD, from February to July 2021. We interviewed physicians (MDs), registered nurses (RNs), respiratory therapists (RTs), advanced practice providers (APPs), and physical therapists (PTs) involved with proning mechanically ventilated patients with COVID-19 ARDS. We used thematic analysis of interviews to classify proning adaptations and clinician uncertainties about best practice for prone positioning.
RESULTS
Forty ICU clinicians (12 MDs, 4 APPs, 12 RNs, 7 RTs, and 5 PTs) were interviewed. Clinicians described several adaptations to the practice of prone positioning, including earlier proning initiation, extended duration of proning sessions, and less use of concomitant neuromuscular blockade. Clinicians expressed uncertainty regarding the optimal timing of initiation and duration of prone positioning. This uncertainty was viewed as a driver of practice variation. Although prescribers intended to use less deep sedation and paralysis in proned patients compared with historical evidence and practice, this raised concerns regarding patient comfort and safety amongst RNs and RTs.
INTERPRETATION
Prone positioning in patients with COVID-19 ARDS has been adapted from historically described practice. Understanding the impact of these adaptations on patient and implementation outcomes and addressing clinician uncertainties are priority areas for future research to optimize the use of prone positioning.
PubMed: 37810258
DOI: 10.1016/j.chstcc.2023.100008 -
Urolithiasis Apr 2024The purpose of this study was to measure and compare renal pelvic pressure (RPP) between prone and supine percutaneous nephrolithotomy (PCNL) in a benchtop model. Six...
The purpose of this study was to measure and compare renal pelvic pressure (RPP) between prone and supine percutaneous nephrolithotomy (PCNL) in a benchtop model. Six identical silicone kidney models were placed into anatomically correct prone or supine torsos constructed from patient CT scans in the corresponding positions. A 30-Fr renal access sheath was placed in either the upper, middle, or lower pole calyx for both prone and supine positions. Two 9-mm BegoStones were placed in the respective calyx and RPPs were measured at baseline, irrigating with a rigid nephroscope, and irrigating with a flexible nephroscope. Five trials were conducted for each access in both prone and supine positions. The average baseline RPP in the prone position was significantly higher than the supine position (9.1 vs 2.7 mmHg; p < 0.001). Similarly, the average RPP in prone was significantly higher than supine when using both the rigid and flexible nephroscopes. When comparing RPPs for upper, middle, and lower pole access sites, there was no significant difference in pressures in either prone or supine positions (p > 0.05 for all). Overall, when combining all pressures at baseline and with irrigation, with all access sites and types of scopes, the mean RPP was significantly higher in the prone position compared to the supine position (14.0 vs 3.2 mmHg; p < 0.001). RPPs were significantly higher in the prone position compared to the supine position in all conditions tested. These differences in RPPs between prone and supine PCNL could in part explain the different clinical outcomes, including postoperative fever and stone-free rates.
Topics: Humans; Nephrolithotomy, Percutaneous; Kidney Pelvis; Kidney; Kidney Calices; Patient Positioning
PubMed: 38630256
DOI: 10.1007/s00240-024-01555-6 -
Brachial plexopathy as a result of anatomical prone position in COVID-19 patients-Systematic review.Clinical Anatomy (New York, N.Y.) Jan 2024In patients with COVID-19 different methods improving therapy have been used, including one of the anatomical position-prone position, to support ventilation. The aim of... (Review)
Review
In patients with COVID-19 different methods improving therapy have been used, including one of the anatomical position-prone position, to support ventilation. The aim of this review was to summarize the cases of brachial plexopathy as a consequence of the prone position in COVID-19 patients, and thus bring closer the issue of the brachial plexus in the face of clinical aspects of its function, palsy, and consequences. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed, inclusion criteria were created according to Patients, Interventions, Comparisons, Outcomes (PICO). PubMed and Scopus were searched until April 1, 2023 by entering the key term with Boolean terms. The risk of bias was assessed using JBI's critical appraisal tools. Fifteen papers with 30 patients were included in the review. This study showed that brachial plexopathy after the prone position occurs more often among males, who are at least 50 years old with comorbidities like hypertension, overweight, and diabetes mellitus. The most common symptoms were weakness, pain, and motion deficits. Duration of the prone position session and the number of episodes were different as well as the modification of positioning. Brachial plexopathy is a significant problem during prone position, especially when hospitalization is prolonged, patients are males, have comorbidities, and changes in body weight. Attention should be drawn to understand the anatomy of the brachial plexus, correct positioning, avoiding factors worsening the prognosis, and proper nutrition of the patients.
Topics: Female; Humans; Male; Middle Aged; Brachial Plexus; Brachial Plexus Neuropathies; COVID-19; Prone Position
PubMed: 37646090
DOI: 10.1002/ca.24112 -
Enfermeria Clinica (English Edition) 2023To determine the incidence of dependence-related skin lesions (DRSL) in patients in prone position (PP) and to identify the predisposing factors.
OBJECTIVE
To determine the incidence of dependence-related skin lesions (DRSL) in patients in prone position (PP) and to identify the predisposing factors.
METHOD
Follow-up study in two polyvalent intensive care units. Patients undergoing invasive mechanical ventilation and PP with no skin lesions on admission were included. We recorded the 3 types of DRSL: (pressure ulcers [PU], moisture-associated skin damage [MASD] and friction injuries [FI]), demographic variables, diagnosis, length of stay, PP episodes, postural changes, APACHE II (Acute Physiology and Chronic Health Disease Classification System), prealbumin level on admission, body mass index (BMI), diabetes, hypertension, smoking, peripheral vascular disease (PVD), vasoactive drugs, Braden scale and mortality. Bivariate analysis: chi-square test, t-test or Mann-Whitney U test. Multivariate analysis: logistic regression.
RESULTS
Forty nine patients were included and 170PP were performed.Forty-one DRSL appeared in 22 patients with a cumulative incidence of 44.9% (95%CI: 31.6-58.7). PU accounted for 63.4% (73.1% facial; 76.9% stage II), 12.2% were MASD (60% inguinal; 60% stage II) and 24.4% were FI (50% thoracic; 70% stage III). The median age of the lesion group (LG) was 66.5 [61.8-71.3] vs. 64 [43-71] years old in the non-lesion group (NLG), p=0.04. Eighty percent of the LG had PVD vs. 20% of the NLG, p=0.03. The median total hours on PP of the LG was 96.9 [56.1-149.4] vs. 38.2 [18.8-57] of the NIG, p<0.001. Multivariate analysis selected total PP hours (OR=1.03; 95%CI:1.01-1.05) and PVD (OR=8.9; 95%CI:1.3-58.9) as predisposing factors for developing DRSL.
CONCLUSIONS
There is a high incidence of skin lesions related to prone decubitus dependence, mostly pressure lesions, although of low severity.The accumulated hours in probe position and peripheral vascular disease favor their development.
Topics: Humans; Adult; Middle Aged; Aged; Follow-Up Studies; Cohort Studies; Pressure Ulcer; Intensive Care Units; Peripheral Vascular Diseases
PubMed: 37898167
DOI: 10.1016/j.enfcle.2023.10.005 -
Heliyon Sep 2023We investigated the effect of awake prone positioning on endotracheal intubation rates in spontaneously breathing patients with COVID-19 not undergoing endotracheal... (Review)
Review
PURPOSE
We investigated the effect of awake prone positioning on endotracheal intubation rates in spontaneously breathing patients with COVID-19 not undergoing endotracheal intubation.
METHODS
We searched the CINAHL, Cochrane Library, PUBMED, MEDLINE, and Web of Science databases until December 31, 2022. Prospective randomized controlled, cohort, and case-control studies were included. A meta-analysis was performed on the primary outcome measure, tracheal intubation rates, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
RESULTS
Ten studies with a total of 2641 patients were included. The tracheal intubation rate in the awake prone position was 34% (95%CI: 0.59-1.10; = 0.18; = 55%), showing a non-significant benefit. Mortality was lower in prone-positioned than in supine-positioned patients (odds ratio: 0.75; 95% CI: 0.61-0.93; = 0.007; = 46%), prone positioning significantly improved the PaO2/FiO2 ratio (mean difference -29.17; 95%CI: -50.91 to -7.43; = 0.009; = 44%).
CONCLUSIONS
Prone positioning can improve the PaO2/FIO2 ratio in patients with COVID-19 but we found no significant effect on tracheal intubation rates. Awake prone positioning seems to be associated with lower mortality, however, and may thus be a beneficial and effective intervention for patients with COVID-19. The optimal timing, duration, and target population need to be determined in future studies.
PubMed: 37809914
DOI: 10.1016/j.heliyon.2023.e19633 -
The Journal of Vascular Access May 2024The unprecedented challenges posed by the global COVID-19 pandemic have magnified the significance of managing intensive care patients in prone positions, particularly... (Review)
Review
The unprecedented challenges posed by the global COVID-19 pandemic have magnified the significance of managing intensive care patients in prone positions, particularly those requiring mechanical ventilation. Central venous access is crucial for delivering essential therapies to patients, particularly in intensive care settings. However, the shift in patient management during the pandemic, necessitating prone positioning for improved oxygenation, presented unique hurdles in maintaining and establishing central venous access. Before the pandemic, scant literature detailed the insertion of vascular access devices in prone or unconventional positions. Limited case reports and letters highlighted the feasibility of procedures like ultrasound-guided central catheter placement in patients undergoing surgery or with specific clinical needs. During the pandemic, a surge in case reports and series illuminated the complexities faced by clinicians in maintaining vascular access during pronation procedures. These reports delineated critical scenarios, ranging from rapid clinical deterioration necessitating immediate interventions to challenges with vascular access device (VAD) malfunctions or misplacements during prone maneuvers. Patient selection and device types emerged as critical considerations. Various scenarios, including patients transitioning to prone position from non-invasive ventilation and those requiring additional access for therapies like dialysis, posed challenges in device selection and placement. Successful VAD insertion techniques in prone patients encompassed multiple anatomical sites, including the internal jugular, brachial, femoral, and popliteal veins. However, challenges persisted, particularly with respect to anatomical variations and technical complexities in cannulation. Further research, standardized protocols, and randomized studies are needed to refine and validate the proposed strategies in both pandemic and non-pandemic settings.
PubMed: 38770685
DOI: 10.1177/11297298241254410 -
Enfermeria Intensiva 2023The appearance of pressure ulcers (PU) is one of the frequent complications of prone position (PP), due to prolonged pressure and shear forces. (Observational Study)
Observational Study
UNLABELLED
The appearance of pressure ulcers (PU) is one of the frequent complications of prone position (PP), due to prolonged pressure and shear forces.
OBJECTIVES
To compare the incidence of pressure ulcers secondary to prone position and describe their location among four Intensive Care Units (ICU) of public hospitals.
METHODS
Multicenter descriptive and retrospective observational study. The population consisted of patients admitted to the ICU between February 2020 and May 2021, diagnosed with Covid-19 who required prone decubitus. The variables studied were sociodemographic, days of admission to the ICU, total hours on PP, PU prevention, location, stage, frequency of postural changes, nutrition and protein intake. Data collection was carried out through the clinical history of the different computerized databases of each hospital. Descriptive analysis and association between variables were performed using SPSS vs.20.0.
RESULTS
A total of 574 patients were admitted for Covid-19, 43.03% were pronated. 69.6% were men, median age was 66 (IQR 55-74) and BMI 30.7 (RIC 27-34.2). Median ICU stay was 28 days (IQR 17-44.2), median hours on PD per patient 48 h (IQR 24-96). The incidence of PU occurrence was 56.3%, 76.2% of patients presented a PU, the most frequent location was the forehead (74.9%). There were significant differences between hospitals in terms of PU incidence (P = .002), location (P = .000) and median duration of hours per PD episode (P = .001).
CONCLUSIONS
The incidence of pressure ulcers due to the prone position was very high. There is great variability in the incidence of pressure ulcers between hospitals, location and average duration of hours per episode of prone position.
Topics: Aged; Female; Humans; Male; COVID-19; Incidence; Intensive Care Units; Pressure Ulcer; Prone Position; Middle Aged
PubMed: 37248133
DOI: 10.1016/j.enfie.2022.12.001 -
Journal of Sport Rehabilitation Aug 2023Posterior shoulder tightness evaluated as limited glenohumeral internal rotation and horizontal adduction is a risk factor for throwing-related shoulder and elbow...
CONTEXT
Posterior shoulder tightness evaluated as limited glenohumeral internal rotation and horizontal adduction is a risk factor for throwing-related shoulder and elbow injuries. Given that the throwing motion uses the entire body kinematics, limited lower-limb flexibility might be associated with posterior shoulder tightness. Therefore, we aimed to investigate the relationships between posterior shoulder tightness and lower-limb flexibility in college baseball players.
DESIGN
Cross-sectional study.
SETTING
University laboratory.
PARTICIPANTS
Twenty-two college baseball players (20 right-handed and 2 left-handed).
METHODS
To investigate the relationships between glenohumeral range of motion and lower-limb flexibility using simple linear regression analysis, we measured passive range of motion of glenohumeral internal rotation and horizontal adduction, hip internal/external rotation in the prone/sitting position, ankle dorsiflexion, and quadriceps and hamstrings flexibility from both shoulders and legs.
RESULTS
Our analysis indicated that decreases in the lead leg hip external rotation in the prone position were moderately associated with limitations in glenohumeral internal rotation (R2 = .250, β [95% confidence interval, CI] = 0.500 [0.149 to 1.392], P = .018) and horizontal adduction (R2 = .200, β [95% CI] = 0.447 [0.051 to 1.499], P = .019) on the throwing shoulder. Furthermore, there were significant moderate relationships between decreases in glenohumeral internal rotation and limited lead leg quadriceps flexibility (R2 = .189, β [95% CI] = 0.435 [0.019 to 1.137], P = .022), and between decreases in glenohumeral horizontal adduction and limited stance leg ankle dorsiflexion (R2 = .243, β [95% CI] = 0.493 [0.139 to 1.438], P = .010).
CONCLUSION
College baseball players with limited lower-limb flexibilities including the lead leg hip external rotation in the prone position, the lead leg quadriceps flexibility, and the stance leg ankle dorsiflexion showed excessive posterior shoulder tightness. The current results support the hypothesis that lower-limb flexibility is associated with posterior shoulder tightness in college baseball players.
Topics: Humans; Baseball; Cross-Sectional Studies; Universities; Shoulder Joint; Regression Analysis; Range of Motion, Articular; Shoulder Injuries
PubMed: 37146986
DOI: 10.1123/jsr.2022-0205 -
World Neurosurgery Aug 2023The aim of this study was to investigate the changes in spine-pelvis sagittal parameters from the standing position to the prone position and to study the relationship...
Sagittal Spinopelvic Alignment in the Standing and Prone Positions of Patients with Old Traumatic Thoracolumbar Kyphosis: Relationship with Immediately Postoperative Parameters.
OBJECTIVE
The aim of this study was to investigate the changes in spine-pelvis sagittal parameters from the standing position to the prone position and to study the relationship between sagittal parameters and immediately postoperative parameters.
METHODS
Thirty-six patients with old traumatic spinal fracture combined with kyphosis were enrolled. The preoperative standing position, prone position, and postoperative sagittal parameters of the spine and pelvis, including the local kyphosis Cobb angle (LKCA), thoracic kyphosis angle (TKA), lumbar lordosis angle (LLA), sacral slope (SS), pelvic tilt (PT), pelvic incidence minus lumbar lordosis angle (PI-LLA), and sagittal vertebral axis (SVA), were measured. The data of kyphotic flexibility and correction rate werecollected and analyzed. The parameters of the preoperative standing position, prone position and postoperative sagittal position were analyzed statistically. Correlation analysis and regression analysis of the preoperative standing and prone sagittal parameters and postoperative parameters were conducted.
RESULTS
There were significant differences in the preoperative standing position, prone position, and postoperative LKCA and TK. Correlation analysis showed that preoperative sagittal parameters of the standing position and prone position were all correlated with postoperative homogeneity. Flexibility was not related to the correction rate. Regression analysis showed preoperative standing, prone LKCA, and TK were linear with postoperative standing.
CONCLUSIONS
The LKCA and TK of old traumatic kyphosis obviously changed from the standing position to the prone position, which were linear with postoperative LKCA and TK and can be used to predict postoperative sagittal parameters. This change should be taken into account in the surgical strategy.
Topics: Humans; Lordosis; Standing Position; Prone Position; Thoracic Vertebrae; Kyphosis; Fractures, Bone; Lumbar Vertebrae; Retrospective Studies
PubMed: 37295468
DOI: 10.1016/j.wneu.2023.05.121