A Standardized Approach to Safe, Effective Prone Positioning in the SICU

exhaustedcrumMechanics

Oct 24, 2013 (3 years and 1 month ago)

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A Standardized Approach to Safe, Effective Prone
Positioning in the SICU

Sharon Dickinson, Craig Meldrum, Connie Rickelmann and the SICU staff
University of Michigan, Ann Arbor, MI

Purpose

Background

Methods

Results

Discussion

Conclusion

References

To

evaluate

if

a

standardized

approach

to

prone

positioning

for

the

treatment

of

Adult

Respiratory

Distress

Syndrome

(ARDS)

and

Acute

Lung

Injury


(ALI)

prevents

the

following

complications
:


Self

extubations


Line

and

tube

pulls


Employee

injuries


A

retrospective

data

analysis

was

completed

from

May

2010

to

April

2011

to

evaluate

for

complications

of

prone

positioning

utilizing

the

Acute

Physiology

and

Chronic

Health

Evaluation

(APACHE

III)

data

system


All

patients

proned

during

the

study

period

were

included

in

the

analysis


A

comparison

group

of

patients

who

were

not

proned

were

also

analyzed
.

Thi s

group

consi sted

of

all

patients

admitted

to

the

SICU

during

the

study

period


Data

was

analyzed

to

evaluate

for

complications

of

prone

positioning

Prone

positioning

occurred

for

118

days

during

the

study

period
.

One

patient

self
-
extubated

during

the

study

period

but

no

lines

or

trachs

were

pulled
.

Our

overall

incidence

of

notable

complications

is

1
/
118

(
0
.
85
%
)
.

No

employee

injuries

were

noted

secondary

to

proning

a

patient
.

Non
-
prone

positioning

occurred

for

6997

days
.

In

this

comparison

group,

we

experienced

13

self

extubations,

75

line

pulls

and

3

trach

pulls

for

an

overall

incidence

of

91
/
6997

(
1
.
3
%
)
.


In

our

experience,

the

use

of

the

prone

position

is

an

effective

strategy

for

the

treatment

of

severe

hypoxemia

in

patient

with

ARDS
.

To

institute

the

prone

position,

we

favor

a

simple


5

step

technique

that

uses

four

staff

members

and

a

regular

ICU

bed
.

Mor e

recent

st udi es

document

t he

benef i t

of

extended

prone

position

therapy

(>

20

hours

per

day)

in

ARDS
.

A

r e c e n t

r e v i e w

of

all

published

meta
-
analyses

on

the

efficacy

of

prone

position

for

ALI

and

ARDS

concluded

that

prone

positioning

was

associated

with

reduced

mortality

in

the

cohort

of

patients

with

severe

hypoxemia,

defined

as

PaO
2
/FiO
2

ratio

<

100

mm

Hg
.

A d d i t i o n a l l y,

p r o n e

p o s i t i o n i n g

c a n

be

used

as

a

rescue

therapy

for

patients

with

ARDS

and

refractory

life
-
threatening

hypoxemia
.

Based on the evaluation of this intervention,
the following conclusions and
recommendations are made:

1)
Prone positioning of
patient’s with ARDS
using a standardized protocol
can prevent
complications

2)
Prone positioning of patient’s does
not
result in increased injuries to healthcare
workers
.

3)
Prone positioning is a safe and effective
treatment option for severe hypoxemia


1.
Piehl MA, Brown RS. Use of extreme position changes in acute respiratory failure. Crit Care med
1976;4:13
-
4
.

2.

Dickinson S, Park PK, Napolitano LM. Prone
-
Positioning Therapy in ARDS
Crit

Care
Clin
. 2011 Jul;27(3):
511
-
23

3.
Pelosi
P, Tubiolo D, Mascheroni D, Vicardi P, Crotti S, Valenza F, Gattononi L: Effects of the prone position on
respiratory mechanics and gas exchange during acute lung injury. 1997 Am J Respir Crit Care Med. Vol. 157. Pp
387
-
393,
1998

4.
Dirkes S, Dickinson S: Common questions about prone positioning, June 1998. AJN. Vol. 98 No 6

5.
Lamm WJE, Graham MM, Albert RK: 1994. Mechanism by which the prone position improves oxygenation in
acute lung injury. Am J Respir Crit Care Med. Vol. 150. Pp 184
-
193
.

The

prone

position

has

been

used

to

improve

oxygenation

in

patients

with

severe

hypoxemia

and

acute

respiratory

failure

since

1974
.

T h e

p r o n e

p o s i t i o n

h a s

b e e n

s h o wn

to

increase

end
-
expiratory

lung

volume

and

alveolar

recruitment
.

All

studies

with

the

prone

position

document

an

improvement

in

systemic

oxygenation

in

70
%

to

80
%

of

patients

with

ARDS,

and

the

maximal

improvements

are

seen

in

the

most

hypoxemic

patients
.
1
-
3

Prone

positioning

has

associated

risks

to

both

the

patient

and

the

healthcare

worker
.

2

One

challenge

to

use

of

the

prone

position

in

ARDS

patients

has

been

the

difficulty

of

safely

moving

a

patient

with

severe

hypoxemia

due

to

ARDS
.

2

Complications

can

occur

in

the

process

and

include

unplanned

extubation
,

lines

being

pulled,

and

tubes

becoming

kinked
.

A d d i t i o n a l l y,

p r o n i n g

o b e s e

a n d

f l u i d

o v e r l o a d e d

patients

can

be

labor

intensive

and

can

result

in

staff

injuries
.
2


However,

the

technique

can

be

performed

safely

by

trained

and

dedicated

critical

care

staff

aware

of

its

potential

benefits

in

critically

ill

patients

with

ARDS

and

severe

hypoxemia
.
2
-
4


Tuck flat sheet around
pt

arm

In order to protect it and move
pt

With flat sheet, pull
pt

to

one side of the bed.

Tilt the patient over and position
with pillows

Patient fully
proned
, head to

side.

Position
pt

arm up on one side, arm

straight on the other and knee up if
desired.

SICU criteria to initiate prone positioning:


1) Effective compliance (normalized) < 0.5
mL/cmH
2
0/Kg


2) P/F ratio < 200 on Fi0
2

> 0.5

0
1000
2000
3000
4000
5000
6000
7000
8000
Proning
Non-proning
Li ne/tube

pul ls

Days during

study

Sel f
-
extubation

Trachs

pulled

6997

0

13

0

75

0

3

Proning

Data for period 5/1/10
-

4/30/11

% Incidence per non
-
proning

day 1.21%

% Incidence per
proning

day 0.85%