• Ashley I Simpson, Kalpesh R Vaghela, Hazel Brown, Kate Adams, Marco Sinisi, Michael Fox, and Tom Quick.
• Peripheral Nerve Injuries Unit, 159096Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, United Kingdom.
• J Intensive Care Med. 2020 Dec 1; 35 (12): 1576-1582.

IntroductionProne positioning is deployed as a critical treatment for improving oxygenation in patients with Acute Respiratory Distress Syndrome. This regimen is currently highly prevalent in the COVID-19 pandemic. The pandemic has brought about increased concern about how best to safely avoid brachial plexus injuries when caring for unconscious proned patients.MethodsA review of the published literature on brachial plexus injuries secondary to proning ventilated patients was performed. This was combined with a review of available international critical care guidelines in order to produce a succinct set of guidelines to aid critical care departments in reducing brachial plexus injuries during these challenging times.DiscussionThere is no one manner in which prone positioning an unconscious patient can be made universally safe. This paper provides 6 key steps to reducing the incidence of brachial plexus injuries while proning and suggests a safe and sensible management and referral pathway for the conscious patient in which a brachial plexus injury is identified.ConclusionThere is in truth no completely safe position for every patient and certainly there will be anomalies in anatomy that will predispose certain individuals to nerve injury. Thus the injury rate cannot be reduced to zero but an understanding of the principles of protection will inform those undertaking positioning.

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