Brachial Plexus Injury After Prone Positioning

Study Overview
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Brief Summary
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The goal of this prospective observational study is to estimate the prevalence of brachial plexus injury after prone positioning in patients with ARDS and to evaluate the safety of swimmer position. The main questions it aims to answer are: Could arm positioning during pronation play a role in the development of any nerve injury at the brachial plexus level? Is swimmer position safe when adopted during prone positioning? Participants will be studied at selective time points using EMG assessment.

Detailed Description
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Prone positioning will be performed according to the current guidelines. Particularly, face and limbs will be placed according to the swimmer position, ensuring the face position in the direction of ventilator and limbs (one arm above head and opposite arm at side) positioned as to prevent abnormal extension or flexion against the shoulders and elbows. Patients will lie on low air loss pressure mattresses, thus avoiding the utilization of any thoraco-pelvic supports, which are not recommended. Electromyography (EMG) will be performed to evaluate the occurrence of brachial plexus injury (BPI).

Official Title
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Brachial Plexus Injury After Prone Positioning in Intensive Care Unit: a Prospective Observational Study

Conditions
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Brachial Plexus Injury, Nerve Compression

Intervention / Treatment
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* Diagnostic Test: Electromyography
* Diagnostic Test: Muscle strength measurement


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥ 18 years old Admission to ICU for severe ARDS Administration of sedation and neuromuscular blocking agents Presence of endotracheal intubation and mechanical ventilation Use of prone positioning to treat hypoxemia Exclusion Criteria: Extracorporeal membrane oxygenation Prone positioning performed in other centers Prone positioning contraindications Neurodegenerative disorders Previous known brachial plexus injury

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Intervention/Treatment |
| --- |
|Diagnostic Test: Electromyography|Electromyography (EMG) monitoring will be performed, using the instrumentation available (Nemus 2, EB Neuro, Italy), to evaluate the occurrence of brachial plexus injury (BPI). EMG will be performed at the end of each pronation cycle. To rule out BPI at ICU admission, an EMG will be performed within two hours from the first pronation maneuver. Particularly, somatosensory evoked potential (SSEP) and sensory action potential (SAP) will be obtained from radial, ulnar, median and sural nerves. In case patients are awake, compound muscle action potential (CMAP) will be obtained as well.|
|Diagnostic Test: Muscle strength measurement|Muscle strength measure willl be assessed at ICU discharge using hand-held dynamometer.|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with signs of brachial plexus injury (BPI) | Signs of BPI are the presence of (almost one of four EMG results): Somatosensory Evoked Potential N20 latency of radial nerve and ulnar nerve > 10% compared to baseline Somatosensory Evoked Potential N20 amplitude of radial nerve and ulnar nerve < 50% compared to baseline Sensory Action Potential amplitude of radial nerve, ulnar nerve and median nerve < 50% compared to baseline Compound Motor Action Potential amplitude of ulnar and median nerve < 50% compared to normative data (assessed before ICU discharge) | EMG will be perform at the end of the every cycle of prone positioning (each cycle is 16 hours on average) and within 24 hours before ICU discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Safety of swimmer position adopted | The safety is defined in terms of: number of patients with adverse events during prone positioning number of patients with pressure ulcers after prone positioning number of patients with ocular damage after prone positioning number of patients with auricle damage after prone positioning | The safety of the swimmer position will be evaluated within 24 hours before ICU discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Prone Position, Brachial Plexus, Respiratory Distress Syndrome, Intensive Care Unit, Swimmer position