Autor : Carnero Echegaray, JoaquÃn1-2-3, Maldonado, Sabina1, Pellicioni, Mercedes1, Ossemani, Santiago1, Maddonni, Paola1
1 Hospital General de Agudos José MarÃa Penna, CABA, Argentina.
2 Santa Catalina Neurorehabilitación ClÃnica y Cuidados CrÃticos Crónicos, CABA, Argentina.
3Universidad Abierta Interamericana. CABA. Argentina.
https://doi.org/10.56538/ramr.TOUD5897
Correspondencia : Joaqun Carnero Echegaray E-mail: jcarneroechegaray@gmail.com
ABSTRACT
Introduction: Prone positioning (PP) was the most used strategy in patients with
COVID-19 and refractory hypoxemia. Our objective was to describe the clinical
characteristics and evolution of patients with severe Covid-19 who required
this procedure. Also, to evaluate the relationship between
risk factors and mortality.
Materials and methods: Observational retrospective descriptive study. Patients older than 18
years with COVID-19 under mechanical respiratory assistance (MRA) who required
PP were included. Follow-up was carried out for 28 days. Complications
associated with PP were recorded. Factors associated with mortality were
analyzed using Cox regression.
Results: PP was applied in 28 patients. The mean age was 52.43 years, and the
median Charlson Score was 1 [0.00, 2.00]. The median
number of MRA days was 17.00 [IQR, (interquartile range) 13.00, 23.00], and
28.6% of patients managed to be extubated. The median
number of days at the ICU (Intensive Care Unit) was 19.50 [IQR 14.00, 23.50],
with 53.6% mortality. 35.7% of patients needed 2 PP cycles with a predominant
duration of 24-36 hours. 89.4% had pressure ulcers (PUs). Patients who died had
spent fewer days at the ICU (16 vs 28; p = 0.006),
and only one of them had managed to be extubated (1 vs 7, p = 0.011). No factors associated with mortality were
found in the Cox regression.
Conclusion: the study population consisted predominantly of males, average age close
to the fifth decade, with a mortality of approximately 50%. No statistically
significant relationship was found between risk factors and mortality.
Key words: COVID-19, Care units intensive, Prone position,
Coronavirus SARS, Decubitus ulcers
RESUMEN
Introducción: El decúbito prono (DP) fue la estrategia más utilizada en
paciente con COVID-19 e hipoxemia refractaria. Nuestro objetivo fue describir
las características clínicas y evolución de los pacientes
con Covid-19 grave que requirieron este procedimiento. Evaluar la
relación entre factores de riesgo y mortalidad.
Materiales y métodos: Estudio descriptivo retrospectivo observacional. Se incluyeron los
pacientes mayores de 18 años con COVID-19 bajo asistencia respiratoria
mecánica (ARM) que requirieron DP. Se efectuó seguimiento durante
28 días. Se registraron las complicaciones asociadas al DP. Se
analizaron factores asociados a la mortalidad utilizando regresión de
Cox.
Resultados: Se realizó DP en 28 pacientes. La edad promedio fue de 52.43
años y una mediana de Score de Charlson de 1
[0.00, 2.00]. La mediana de días de ARM fue de 17.00 [RIQ 13.00, 23.00]
y un 28,6% logró ser extubado. La mediana de
días en UTI fue de 19.50 [RIQ 14.00, 23.50] con una mortalidad del
53,6%. El 35,7% necesito 2 ciclos de DP con una duración predominante de
24-36 hs. El 89,4% tuvo lesiones de UPP. Los que
fallecieron tuvieron menos días de UTI (16 vs 28; p=0,006) y solo uno de
ellos había logrado ser extubado (1 vs 7, p =
0.011). No se encontraron factores asociados a la mortalidad en la
regresión de Cox.
Conclusión: La población estudiada resultó predominantemente masculina y
de edad promedio cercana a la quinta década de vida, con una mortalidad
aproximada al 50%. No se encontró relación
estadísticamente significativa entre factores de riesgo y mortalidad.
Palabras claves: COVID-19, Terapia intensiva, Decúbito prono, Úlceras por
presión
Recibido: 12/31/2022
Aceptado: 02/14/2023
INTRODUCTION
Since the beginning of 2020, the
new disease COVID-19, caused by the SARSCoV-2 virus, has overwhelmed the
Intensive Care Units (ICUs) around the world with large volumes of critically
ill patients. As of October 2021, approximately 238,390,000 cases and 4,859,000
deaths have been reported worldwide.1
COVID-19 infection affects the respiratory system and causes
acute respiratory distress syndrome (ARDS) in 61-81% of patients, with severe
bilateral interstitial pneumonia, which require intensive care.2, 3
Epidemiological information about
patients with severe COVID-19 in low- and middle-income populations has been
scarce, but some Latin American countries with national-level databases have
reported valuable information.4,
5 In
Argentina, the Argentine Society of Intensive Care launched a prospective
multicenter cohort study with the objective of describing epidemiological and
clinical characteristics, treatments received, and outcomes in COVID-19
patients who required invasive mechanical ventilation6
during the first outbreak of the pandemic. This study has been
very helpful to face the second wave in our country.
The marked decrease in mortality
observed in several studies that were carried out in the last 15 years7 supports the
use of prone positioning (PP) along with the strategy of protective lung
ventilation as part of the treatment of refractory hypoxemia in ARDS.8 The response
may differ from one patient to another, but PP results in improvements in
respiratory mechanics, gas exchange, and a reduction in pulmonary heterogeneity,
potentially decreasing the risk of developing mechanical ventilation-induced
lung injury.9
However, prone positioning also
has complications, such as: unplanned extubation,
accidental removal of arterial or venous catheters, hemodynamic instability,
brachial plexus injury, corneal injuries, and pressure ulcers (PUs).10, 11
The ICU is a risk area in terms
of the development of pressure injuries. Patients in the ICU mostly have
altered consciousness due to the effects of analgesic-sedative drugs; they may
have numerous catheters, access routes, and monitoring sensors that can be
poorly positioned; excess moisture in the area that may increase the risk of
developing pressure ulcers by five times.12 Also, tissue oxygenation may be
altered due to failure of the pulmonary ventilation/perfusion ratio, and the
use of vasoactive drugs that can lead to vasoconstriction, reducing peripheral
capillary flow. Moreover, critically ill patients undergo metabolic changes
that can lead to negative nutritional balance and hypoalbuminemia,
resulting in an increase in edema13.
The analysis of Ponsetti et al about PP complications
concludes that there are fewer PUs in patients who have received adequate
nutrition, with a very high percentage of patients in prone position
experiencing malnutrition (82.9%) during their hospitalization at the ICU.10 All of these factors contribute to the formation of PUs and
difficulty in healing.
The primary objective of our
study was to describe the clinical and demographic characteristics as well as
the evolution of a cohort of patients with severe Covid-19 who required PP;
also, to identify the prevalence of complications associated with this
procedure and to evaluate the relationship between risk factors and mortality.
MATERIALS AND METHODS
A descriptive retrospective
observational study was carried out during the period from May 15, 2021, to
July 27, 2021, at the Hospital General de Agudos
José María Penna.
The sample was collected in the
Emergency Department, and Intensive Care Units were organized to meet the
demand during this period.
Patients were followed up for 28
days since their admission to the ICU.
The sample included patients
older than 18 years with COVID-19 who needed mechanical respiratory assistance
(MRA) upon admission to the ICU and required prone positioning as a rescue
maneuver for refractory hypoxemia. Patients who had missing data in the outcome
variables for analysis and homeless patients were excluded; therefore, it was
not possible to collect the necessary information.
Data collection was carried out
through secondary sources such as patients medical records and a form created
specifically for this study by the hospitals Kinesiology Department
specifically for this study. Patients personal data were not included, instead
they were coded using sequential numbers based on their admission date.
Recorded variables
Demographic data and clinical characteristics
of patients were recorded, including the date of intubation, age, sex, obesity
(body mass index > 30), and Charlson Comorbidity
Index (CCI).
The following variables related
to PP complications were gathered:
Those associated with the rotation
maneuver (caused during the procedure): accidental extubation,
loss of lines.
Those associated with the
period of time spent in such position: PUs, location, corneal injuries, facial
edema, shoulder injury (injuries developed by prolonged PP care), and difficult
venous access (a complication that requires patients to be returned to the
dorsal decubitus position in order to gain better access for line placement).
Those associated with hemodynamia: hemodynamic instability (developed in
response to the maneuver).
Recording of PUs was divided into
chest, knee, fronto-orbicular, foot, chin, tibia, humerus, and nose.
The other variables related to
the prone positioning were: number of PP cycles (recorded up to a maximum of
six cycles) and duration of each cycle (divided into four groups according to
the time spent in PP: 6 hr-8 hr, 12 hr-16 hr, 24 hr-36 hr, 48 hr-72 hr).
In addition, data related to
hospital stay were collected: days of MRA, days of ICU stay, weaning from MRA, extubation, tracheostomy, decannulation,
and ICU discharge status (alive/dead).
Then, the sample was divided into
surviving and deceased patients, and the same variables mentioned above were
compared between these two groups.
We evaluated potential risk
factors explaining mortality in our patient cohort. Some of them were: age,
sex, CCI, obesity, number of prone cycles, extubation,
and tracheostomy.
Procedure
In order to standardize care, a
PP protocol was applied to COVID-19 patients that covered clinical criteria for
installing the decubitus, performing the procedure, and ending it.
Before considering PP, each
patient was ventilated with a protective ventilation strategy (tidal volume 6-8
ml/kg of predicted body weight, titrated PEEP [positive end-expiratory pressure],
plateau pressure <30 cmH2O,
working pressure <16 cmH2O,
and FiO2 with a target SpO2
of 88-92%).9 If despite this ventilatory
strategy, the PaO2/
FiO2 was <150
with FiO2> 0.6, the patient was subjected to the prone
positioning.
Considering the critical
conditions of patients with COVID-19, at least four healthcare professionals
and an experienced team leader (physicians, kinesiologists,
and nurses) were required during the maneuver to coordinate each step, so as to
minimize all possible risks.
Statistical analysis
Continuous variables were
described as mean and standard deviation or median (Mn)
and interquartile range (IQR 25:75), as appropriate, based on the Lilliefors normality test. Categorical variables were
reported as frequency and percentage. The comparison between the different
groups was carried out using the Students t-test, Wilcoxon test, or Fishers
exact test. A Cox regression was conducted to search for risk factors
associated with mortality.
RESULTS
Between May 15, 2021, and July
27, 2021, 50 patients diagnosed with COVID-19 were admitted to the ICU, of
whom 45 (90%) required MRA, and 28 patients required prone positioning for the
treatment of refractory hypoxemia, forming the final sample (Figure 1).
The cohort of patients who
required prone positioning had a mean age of 52.43 ( 9.54) years, with a
majority of male patients (75%), a mean Charlson
Score of 1 [0.00, 2.00]; and 50% (14) had obesity. The median number of MRA
days was 17.00 [IQR 13.00, 23.00] and 28.6% (8) managed to be weaned and extubated at the ICU. 14.8% (4) had to be tracheostomized due to prolonged mechanical ventilation.
The median number of days at the ICU was 19.50 [IQR 14.00, 23.50], with 53.6%
mortality (15). 35.7% (10) of the patients required 2 cycles of PP due to a
poor response to the maneuver, with a predominant time interval of 24-36 hours
in all cycles (table 1.1). The more common complications were PUs, with 89.4%
(25). The most frequent PUs were: facial edema in
67.9% (19) of patients, knee lesions in 57.1% (16), and fronto-orbicular
lesions in 60.7% (17). Regarding the complications produced during the
procedure, none of the patients presented accidental extubation
and/or accidental removal of lines. (Table 1.2).
The same variables described were
compared between alive and deceased groups of patients at 28 days of follow-up.
It was found that those who died had spent fewer days at the ICU (16 vs 28; p = 0.006) and only one of them had managed to be extubated (1 vs 7, p = 0.011). (Table 2)
No risk factors associated with
mortality were found in the Cox regression of patients who required prone
positioning. (Table 3)
DISCUSSION
The new outbreak of COVID-19 in
the year 2021 in Argentina brought about some differences in the clinical and
demographic characteristics presented by patients, compared to the first period
of the pandemic in our country.
The percentage of patients who
required MRA and subsequently PP as a maneuver against refractory hypoxemia is
consistent with what has been published so far.6, 14-17
Males were predominant in our
cohort, just like in the literature18,
but age and the presence of CCI differ from other studies. Our median age (52,
43 years) is moderately lower than what has been shown in both our country and
Europe.6, 15, 19 This is
possibly due to the delay in the vaccination program, which may have primarily
exposed younger people during this second wave while protecting the elderly.
This could also explain why our CCI value is low compared to what has been
described so far. In the sole multicenter study developed in Argentina on
COVID-19 patients, Estensoro et al found that CCI is
an independent predictor of mortality. It should be noted that although only
25% of their sample had the same age range as ours, and a large percentage of
analyzed patients adopted the prone positioning, the analysis was performed on
the entire patient population6.
A meta-analysis conducted in the
United States by Popkin et al found that obesity was
a predictor of mortality in COVID-19 patients.20
Although half of our patients had a BMI (body mass index) >
30, that characteristic wasnt related to this outcome, with no differences
between the group of those who survived and those who died after 28 days.
Over the years, very diverse data
have been reported regarding complications related to prone positioning in
patients with ARDS. The study of Curley et al21 didnt report
any critical incidents in more than 200 PP procedures, while in the study by Mancebo et al, a high incidence of complications was
described, and 7.9% of unplanned extubations were
reported. No deaths were reported in any of them.22
However, in their scoping review, Araújo
et al found that 67% of the studies revealed complications in the use of prone
positioning. The most common complications included accidental extubation (78%), pressure injury (50%), and facial edema
(50%)23.
Patients in prone position may have a higher risk of displacement and twisting
of the orotracheal tube due to the spatial
configuration of the position with respect to the airways, which causes a
dilation of the airways due to gravitational action on local anatomical
structures, thus leading to extubation.24 Compared to the relatively
high incidence (13.3%) observed in the study by Guérin
et al7, no accidental extubations were
reported in our cohort. The detailed knowledge of the procedure and its
execution by a multidisciplinary team may have contributed to this result.
The substantially higher
prevalence of PUs in our sample compared to other studies could be explained by
a multicausal situation.25, 26, 27, 28 The
severity of the condition, the presence of several
factors (inadequate nutrition, tissue hypoxia, skin moisture, use of inotropic
agents, hours of proning, etc.) that these patients
suffer during their stay in the ICU, the high workload/physical and
psychological exhaustion of healthcare personnel ratio may have negatively
affected the quality of care, to some extent, thus explaining the high percentage
of PUs. This shows that better prevention and care measures can have an impact
on or reduce complication rates.29 The presence of PUs was
identified as an independent predictor of mortality in patients with MRA.30
They increase the length of hospital stay, burden the healthcare system budget,
and constitute an indicator of quality of care.31 This highlights
the importance of standardizing records, care, and prevention strategies.
The frequency of
pressure ulcers found in our study is higher than that reported by two systematic
reviews where pressure ulcers occurred in 34% and 43% of cases, respectively.32,
33, 34 From a clinical standpoint, we believe it would have been
important to differentiate pressure ulcers basing on severity and extension,
taking into account the different impacts they have in terms of treatment and
patient morbidity. In addition, in our study, pressure ulcers caused by proning developed in patients who underwent multiple PP
maneuvers and remained in that position for more than 24 consecutive hours. It
is important to highlight that all pressure ulcers were grade I and II, and no
high-grade ulcers (III and IV) were detected. Low-grade pressure ulcers have
less serious consequences, and none of our patients required special care or
treatment. Once their condition improved and PP was no longer performed, the
skin fully recovered in all patients. It should be noted that although there
was no statistical significance between the occurrence of PUs and hours of proning, a trend was observed. Facial edema was present in
a high percentage of patients, but it quickly improved upon returning to the
supine position.
With regard to risk
factors, preexisting conditions, age, and the CCI, along with physiological
alterations (changes in oxygenation, presence of hypotension, acidosis, acute
kidney injury, and activation of coagulation) and mechanical ventilation
variables were independent predictors of hospital mortality in the Argentine
SATICOVID study.6 Vences et al found that
also in Peru mortality was associated with age (patients aged 60 or older),
inflammatory markers, and lung involvement.35 However, in our
analysis we didnt find any risk factors associated with mortality. We believe
that this may be due to the age range of admitted patients that was discussed
earlier, as well as the small size of the analyzed cohort.
While this is the
first record and analysis carried out in our Hospital on critically ill
COVID-19 patients, this study presents among its main limitations the sample
size and the single-center nature of it, as well as the bias that is typical of
a retrospective analysis, depending on the quality of the information
collected.
During the pandemic,
the extensive use of the prone position in a large number of critically ill
patients represented the greatest challenge for the health team of the
Intensive Care Unit11 and offered a unique opportunity to refine
clinical protocols, establish more precisely the prevalence of adverse effects and
complications, and identify possible areas for improvement in the implementation
of this important intervention.14
CONCLUSION
The study population
consisted predominantly of males with an average age close to the fifth decade,
and an mortality of approximately 50%. In order to
improve the management of critically ill COVID-19 patients in the ICU in this
pandemic context, the presence of an experienced and dedicated multidisciplinary
team would imply an improvement in the procedure, resulting in a possible
decrease in serious complications induced by proning.
On the other hand, the prevalence of minor complications (pressure injuries)
could be related to the severity of COVID-19, without a clear association with
proning, thus suggesting a combination of multiple
pathogenic mechanisms.
Conflict of interest
Authors have no
conflict of interest to declare.
REFERENCES
1.
Hopkins University and Medicine John.> John Hopkins Coronavirus Resour.
Cent; 2020. COVID-19 Map (October 2021). Johns Hopkins Coronavirus Resource Center. Disponible en: https://coronavirus.jhu.edu/map.html.
2. Wu C, Chen X, Cai Y, et al. Risk Factors Associated With Acute Respiratory
Distress Syndrome and Death in Patients With Coronavirus Disease 2019
Pneumonia in Wuhan, China. JAMA Intern Med. 2020;180:934-43.
https://doi.org/10.1001/jamainternmed.2020.0994
3. Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on
the Management of Critically Ill Adults with Coronavirus Disease 2019
(COVID-19). Crit Care Med.
2020;48:e440-e69.
4. Ñamendys-Silva
SA, Gutiérrez-Villaseñor A, Romero- González JP.
Mortalidad hospitalaria en pacientes COVID-19 ventilados mecánicamente
en México. Intensive Care
Medicine. 2020;46:2086-88.
https://doi.org/10.1007/s00134-020-06256-3
5. Ranzani OT,
Bastos LSL, Gelli JGM. Caracterización de los
primeros 250 000 ingresos hospitalarios por COVID-19 en Brasil: un
análisis retrospectivo de datos a nivel nacional. Lancet
Respir Med. 2021:407-18.
6. Estenssoro E, Loudet
CI, Ríos FG, et al. Clinical
characteristics and outcomes of invasively ventilated patients with COVID-19
in Argentina (SATICOVID): a prospective, multicentre
cohort study. Lancet Respir Med. 2021;9:989- 98. https://doi.org/10.1016/S2213-2600(21)00229-0
7. Guérin C, Reignier J,
Richard JC, et al. Prone positioning in severe acute respiratory distress
syndrome. N Engl J Med. 2013;368:2159-68.
https://doi.org/10.1056/NEJMoa1214103
8. Gattinoni L, Taccone P, Carlesso E, Marini JJ.
Posición prona en el síndrome de dificultad respiratoria aguda.
Justificación, indicaciones y límites. Am J Respir
Crit Care Med .
2013; 188:1286‐93. https://doi.org/10.1164/ rccm.201308-1532CI
9. Guérin C, Albert RK, Beitler
J, et al. Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med.
2020;46:2385-96.
https://doi.org/10.1007/s00134-020-06306-w
10. Jové Ponseti E., Villarrasa
Millán A., Ortiz Chinchilla D. Análisis de las complicaciones de
la posición prona en el síndrome de dificultad respiratoria
aguda: estándar de calidad, incidencia y factores relacionados. Enferm Intensiva. 2017;28:125-34.
https://doi.org/10.1016/j.enfi.2016.12.003
11. Binda F, Galazzi A, Marelli F, et al. Complications of prone positioning in patients with
COVID-19: A cross-sectional study. Intensive Crit Care Nurs. 2021;67:103088. https://doi.org/10.1016/j.iccn.2021.103088
12. Reuler JB, Cooney TG.> The pressure sore: pathophysiology and principles of
management. Ann Intern Med. 1981;94:661-6.
https://doi.org/10.7326/0003-4819-94-5-661
13. Salgado M, García G, Cardozo R,
Gaona M, Gimenez C. Guía para la
prevención y el tratamiento de lesiones por presión en pacientes
críticos en decúbito prono. Pandemia COVID-19. Asociación
Interdisciplinaria de Cicatrización de Heridas AIACH. Primera
Edición. Buenos Aires. 2020.
14. Carsetti A., Damia Paciarini A., Marini B., Pantanetti
S., Adrario E., Donati A.
Prolonged prone position ventilation for SARS-CoV-2 patients is feasible and
effective. Crit. Care. 2020;24:225.
https://doi.org/10.1186/s13054-020-02956-w
15. Grasselli G, Zangrillo A, Zanella A, et al. Baseline characteristics and outcomes of
1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region,
Italy. JAMA 2020; 323: 1574-81. https://doi.org/10.1001/ jama.2020.5394
16. Richardson S,
Hirsch JS, Narasimhan M, et al. Presenting
characteristics, comorbidities, and outcomes among 5700 patients hospitalized
with COVID-19 in the New York City area. JAMA
2020; 323:2052-59. https://doi.org/10.1001/ jama.2020.6775
17. Ferrando-Vivas P, Doidge
J, Thomas K, et al. Prognostic factors
for 30-day mortality in critically ill patients with coronavirus disease 2019:
an observational cohort study. Crit Care Med. 2021;49:102-11. https://doi.org/10.1097/CCM.0000000000004740
18. Mathews KS, Soh H, Shaefi S, et al. Prone
Positioning and Survival in Mechanically Ventilated Patients With 24
Coronavirus Disease
2019-Related Respiratory Failure. Crit Care Med. 2021;49:1026-37. https://doi.org/10.1097/ CCM.0000000000004938
19. Karagiannidis C, Mostert C, Hentschker C, et al. Case characteristics, resource use,
and outcomes of 10 021 patients with COVID-19 admitted to 920 German
hospitals: an observational study. Lancet Respir Med.
2020;8:853-62. https://doi.org/10.1016/S2213-2600(20)30316-7
20. Popkin BM, Du S, Green WD, et al. Individuals with obesity
and COVID-19: a global perspective on the epidemiology and biological
relationships. Obes Rev. 2020;21:e13128.
https://doi.org/10.1111/obr.13128
21. Curley MA,
Thompson JE, Arnold JH. The effects of early and repeated prone positioning in
pediatric patients with acute lung injury.> Chest. 2000 Jul;118:156-63. https://doi.org/10.1378/chest.118.1.156
22. Mancebo J, Fernández R, Blanch
L, et al. A multicenter trial of prolonged prone ventilation
in severe acute respiratory distress syndrome. Am J Respir
Crit Care Med. 2006;173:1233-
39. https://doi.org/10.1164/rccm.200503-353OC
23. Araújo
MS, Santos MMPD, Silva CJA, Menezes RMP, Feijão AR, Medeiros SM. Prone positioning as an emerging tool in the care
provided to patients infected with COVID-19: a scoping review. Rev Lat Am Enfermagem. 2021;29:e3397. Published 2021 Jan 8.
https://doi.org/10.1590/1518-8345.4732.3397
24. Yamamoto N, Ishii
A, Miyashita T, Goto T. Airway management strategy
for accidental tracheal extubation in the prone
position: A simulation study. J Clin Anesth. 2020;63:109786. https://doi.org/10.1016/j.jclinane.2020.109786
25. Lucchini A., Bambi S., Mattiussi E.
Posición prona en pacientes con síndrome de dificultad
respiratoria aguda: un análisis retrospectivo de las complicaciones.
Enfermeras de cuidados críticos de Dimens.
2020;39:39-46.
26. Gattinoni LG, Tognoni G., Pesenti A. Efecto del
decúbito prono en la supervivencia de pacientes con insuficiencia
respiratoria aguda. N Engl
J Med. 2001;345:568-73. https://
doi.org/10.1056/NEJMoa010043
27. Sud S., Friedrich JO, Adhikari
NKJ. Efecto de la posición en
decúbito prono durante la ventilación mecánica sobre la
mortalidad entre los pacientes con síndrome de dificultad respiratoria
aguda: una revisión sistemática y un metanálisis.
Cmaj.> 2014;186:381-90.
https://doi.org/10.1503/cmaj.140081
28. Girard R, Baboi L, Ayzac L, Richard JC, Guérin C. The impact of patient positioning on
pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled
trial on prone positioning. Intensive Care Medicine. 2014;40:397-403.
29. Bloomfield R., Dw
N., Sudlow A. Posición en decúbito
prono para la insuficiencia respiratoria aguda en adultos (Revisión)
resumen de los resultados de la comparación principal. Cochrane Database Syst Rev. 2015:1-92
30. Manzano F, Pérez-Pérez AM,
Martínez-Ruiz S, et al. Hospital-acquired
pressure ulcers and risk of hospital mortality in intensive care patients on
mechanical ventilation. J Eval Clin Pract. 2014;20:362-8. https://doi.org/10.1111/jep.12137
31. Demarré L, Van Lancker A,
Van Hecke A, et al. The cost of prevention and
treatment of pressure ulcers: A systematic review. Int J Nurs Stud. 2015;52:1754-74.
https://doi.org/10.1016/j.ijnurstu.2015.06.006
32. Mora-Arteaga JA, Bernal-Ramírez
OJ, Rodríguez SJ. >The effects of prone position ventilation in patients
with acute respiratory distress syndrome.> A systematic review and metaanalysis. Med Intensiva. 2015;39:352-65.
https://doi.org/10.1016/j.medin.2014.11.003
33. Munshi L, Del
Sorbo L, Adhikari NKJ, et al. Prone Position for Acute Respiratory
Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2017;14:S280- S8.
https://doi.org/10.1513/AnnalsATS.201704-343OT
34. Gattinoni L, Carlesso E, Taccone P, Polli F, Guérin C, Mancebo J. Prone
positioning improves survival in severe ARDS: a pathophysiologic review and
individual patient meta-analysis. Minerva Anestesiol. 2010;76:448-54.
35. Vences MA, Pareja-Ramos JJ, Otero P, Veramendi-Espinoza LE, Vega-Villafana
M, Mogollón-Lavi J, et. al. Factors associated with mortality in patients
hospitalized with COVID-19: A prospective cohort in a Peruvian national
referral hospital. Medwave 2021;21:e8321.
https://doi.org/10.5867/medwave.2021.06.8231