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Updated: Oct 21, 2026
Structured Motor Rehabilitation After Selective Nerve Transfers
Published on: August 15, 2019
Focal upper limb peripheral nerve injury after prone positioning in patients with ARDS: A prospective
Filippo Binda1, Federica Marelli2, Veronica Rossi2
1Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy; Department of Healthcare Professions, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
Objectives:
To investigate the incidence, timing, and neurophysiological characteristics of focal upper limb peripheral nerve injury (PNI) related to positional brachial plexus involvement after prone positioning in patients with acute respiratory distress syndrome (ARDS).
Methods:
Prospective single-centre observational cohort study conducted in the ICU of an academic tertiary-level hospital in Milan (Italy), between April 2022 and September 2025. All adult patients with ARDS requiring invasive mechanical ventilation and treated with prone positioning were screened. Patients underwent predefined longitudinal neurophysiological assessments at baseline, after each prone positioning cycle and before ICU discharge, whenever feasible. Focal upper limb PNI was defined using specific electrodiagnostic criteria. Cumulative incidence analyses accounted for ICU death as a competing event.
Results:
Overall, 128 prone positioning cycles were performed in 54 patients. Focal upper limb PNI occurred in 11 patients (20.4%; 95% CI 10.6-33.5), after a median of 2 prone positioning cycles (IQR 1-3) and 36 h (IQR 21-50) of cumulative prone exposure. By day 28, the estimated cumulative incidence was 29.1% (95% CI 11.6-46.7), rising to 42.7% (95% CI 17.6-67.9) in patients exposed to at least one uninterrupted prone cycle lasting ≥24 h, compared with 8.6% (95% CI 0-20.4) in patients with shorter exposure (p = 0.047). Among prone positioning-related complications, pressure ulcers were the most frequent, occurring in 40.7% (22/54) of patients and predominantly involving the facial region, whereas no vascular access loss or accidental endotracheal tube displacement were recorded.
Conclusions:
Focal upper limb PNI was a frequent, clinically relevant, and potentially under-recognised complication of prolonged prone positioning in patients with ARDS.
Implications For Clinical Practice:
A prone positioning bundle should include systematic upper limb surveillance, repeated reassessment of limb, head and shoulder alignment, and early detection of focal asymmetric upper limb weakness, particularly during uninterrupted prone cycles lasting 24 h or longer.
