Bleeding complications associated with prone positioning in patients with ARDS

Prone positioning is a therapeutic intervention to improve oxygenation in patients with severe acute respiratory distress syndrome (ARDS). [1] Several clinical studies evaluated the safety and efficacy of prone positioning in mechanically ventilated patients; however, a higher frequency of thrombotic and hemorrhagic events has been reported (especially in critically ill patients with severe COVID-19). [2] This study described the prevalence and the characteristics of each hemorrhagic event occurred during prone positioning in critically ill patients with severe ARDS. Patients and methods Observational retrospective analysis of all the patients treated with prone positioning and admitted to the intensive care unit (ICU) of a tertiary level hospital from January 2017 to December 2021. The recorded data included demographics, clinical characteristics, and outcomes (bleeding events, length of stay and mortality). All patients received usual (prophylactic) or full-dose (therapeutic) anticoagulation according to their risk factors for thrombosis. Results Three hundred thirty-nine patients treated with prone positioning were identified in the medical records and bleeding complications occurred in 18.6% (63/339) patients. Demographic and clinical characteristics of patients are summarized in Table 1.A total of 337 prone positioning cycles was recorded in this subgroup of 63 patients and the mean duration of each cycle was 18.8 (5.7) hours. The majority of patients (84.1%, 53/63) experienced bleeding of mouth and nose, 26.9% (17/63) endobronchial bleeding and 23.8% (15/63) vascular bleeding events. Eight patients (12.7%) required the interruption of prone position for bleeding control. Conclusion Upper airways bleeding (mouth and nose) is a frequent complication may require the prone position interruption for bleeding control. Awareness of these bleeding complications, careful management of anticoagulant therapy on the basis of thrombotic risk, and care of the nasal and oral mucosa (avoiding traumatic procedures such as suction or tube placement) may help reduce the prevalence of prone positioning related complications. References 1. Gattinoni L, Busana M, Giosa L, et al. Prone positioning in acute respiratory distress syndrome. Semin Respir Crit Care Med. 2019 Feb;40(1):94–100.2. Godier A, Clausse D, Meslin S, et al. Major bleeding complications in critically ill patients with COVID-19 pneumonia. J Thromb Thrombolysis. 2021 Jul;52(1):18–21.