Prone to injury

SESSION TITLE: Critical Care Case Report Posters 24 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Acute respiratory distress syndrome (ARDS) is a common and frequently life-threatening condition encountered in the intensive care unit (ICU). Only supportive care measures such as low volume ventilation and positive end expiratory pressure have been shown to improve outcomes. Recently, prone positioning has been shown to reduce the mortality of severe ARDS. However, prone positioning is logistically challenging and can result in adverse events including hypotension, barotrauma, ventilator associated pneumonia, facial edema, pressure sores, and peripheral nerve injuries.(1) Here, we report a rare complication of prone positioning for severe ARDS. CASE PRESENTATION: A 40-year-old female with history of diabetes, hypertension, asthma, and keratoconus previously treated with right eye corneal transplant presented to the local community hospital with hypoxemic respiratory failure. She tested positive for COVID-19 pneumonia and was started on treatment with dexamethasone and remdesivir. She declined on hospital day 2 requiring ICU transfer and was intubated on day 3. Prone positioning was initiated on day 4 and upon return to the supine position, the nursing staff noted "right eye collapse" (Image 1). She was transferred to the main hospital campus for Ophthalmology evaluation and underwent urgent repair of the ruptured right globe injury secondary to corneal graft dehiscence (Image 2). Her respiratory failure improved, and she was extubated three days later and discharged on day 8 with antibiotic and steroid eye drops with Ophthalmology follow-up appointments. She had an unremarkable post-operative course with survival of the original graft and achieved 20/20 visual acuity with a scleral contact lens within three months. DISCUSSION: Prone positioning is one of the few supportive measures that reduces mortality in severe ARDS and has been increasingly utilized in the context of the COVID-19 pandemic. Given this, it is critical that clinicians are familiar with both common and uncommon adverse events associated with prone positioning, as well as their risk factors and strategies to mitigate them. Here we present a case of globe rupture in the context of prone positioning. To our knowledge, there is only one other case report that occurred in a patient with a remote history of large-incision extracapsular cataract surgery.(2) Similarly, the patient presented here was at increased risk due to a history of corneal transplant for keratoconus five months earlier. The mechanism of rupture is related to a significant increase in intraocular pressure during prone positioning.(3) CONCLUSIONS: Prone positioning is associated with common and uncommon adverse events that each have unique risks. Severe ocular complications such as globe rupture are rare but are possible in patients with prior eye surgeries. Prompt recognition of and intervention for such events can result in remarkable regain of function. REFERENCE #1: González-Seguel F, Pinto-Concha JJ, Aranis N, Leppe J. Adverse events of prone positioning in mechanically ventilated adults with ARDS. Respiratory Care. 2021; 66 (12): 1898-1911. REFERENCE #2: Van Wicklin SA. Systematic review and meta-analysis of prone position on intraocular pressure in adults undergoing surgery. International Journal of Spine Surgery. 2020; 14(2):195-208. REFERENCE #3: Leuzinger-Dias M, Lima-Fontes M, Oliveira-Ferreira C, Camisa E, Sousa C, Rocha-Sousa A, Falcão-Reis F, Freitas-da-Costa P. Ophthalmology and Therapy. 2021; 10 (3): 691-697. DISCLOSURES: No relevant relationships by Nitin Bhatt No disclosure on file for John Christman No relevant relationships by Kyle Cotten No relevant relationships by Tyler Haddad No relevant relationships by Rebecca Kuennen No relevant relationships by Patrick Sylvester