Upside Down You Turn Me: Impacting SaO with Prone ... Kathleen M. Vollman MSN, RN, CCNS, FCCM Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING Northville, Mi [email protected]

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Kathleen M. Vollman MSN, RN, CCNS, FCCMKathleen M. Vollman MSN, RN, CCNS, FCCMClinical Nurse Specialist/Educator/ConsultantClinical Nurse Specialist/Educator/Consultant

ADVANCING NURSINGADVANCING NURSINGNorthville, MiNorthville, Mi

[email protected]

Upside Down You Upside Down You Turn Me: Impacting Turn Me: Impacting

SaOSaO22 with Prone with Prone PositioningPositioning

© Vollman 2007

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What factors contribute to What factors contribute to the improvement in the improvement in oxygenation with the prone oxygenation with the prone position?position?

WHY PRONE POSITION IN ACUTE RESPIRATORY FAILURE ?

To improve oxigenation during prone positioning and after repositioning supine (Langer, Chest 1988; Gattinoni, NEJM 2001)

To improve the response to recruitment maneuversduring prone positioning (Pelosi, AJRCCM 2003, Oczenski, CCM 2005)

To improve respiratory mechanics after repositioningsupine (Pelosi, AJRCCM 1998)

To reduce ventilator associated lung injury “per se”(Broccard, Crit Care Med 1997-2000; Valenza, Crit Care Med 2005; Papazian, Crit Care Med 2005)

To improve drainage of secretions(Pelosi, Eur Respir J 2002; Reignier, Intensive Care Med 2005)

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Major Factors Influencing Distribution of Ventilation

Gravity/weight of the lung

Compliance

Heterogeneous lung disease

Air Goes To Area of Air Goes To Area of Least ResistanceLeast Resistance

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Distribution of Regional Volumes

Regional pleural pressures

Local lung compliance

J.B. West, 1997, Ventilation/blood flow and gas exchange(3rd ed.), Oxford: Blackwell, p.28.

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Lung Weight Theory

Supine Position:

Distribution becomes more uniform from apex to base

Dependent lung ventilation > non-dependent

Reduction in FRC

Amis et al. Respiratory Physiology 1984 56;145Kaneko et al. J of Applied Physiology 1966 21;767

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Reduction in FRC in the Supine Position

Influence of the abdominal contents on the diaphragm

Position of the heart and relationship of the supporting structures to the lung and its influence on pleural pressure gradients

Impact of the Abdomen




























































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Froese A. and Bryan, A.G. 1974. Effects of anesthesia and paralysis on diaphragmative mechanics in man. Anesthesiology, 41(3), 242-255.

Differences in FRC Based on Position

Sitting to Supine Position: FRC declines: 30%(mean decrease: 800 ml)

Sitting to Lateral Position: FRC declines 15-20%(mean decrease: 450 ml)

Sitting to Prone Position: FRC declines: 15-20%(mean decrease: 450 ml)

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Reduction in FRC

Position of the heart and supporting structures alters pleural pressure gradients.

Cardiac Structures

Pressure

Spine

Lungs Lungs

Result: More + Pleural PressureCollapsed Alveoli

SUPINE POSITION

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Cardiac Structures

SternumLungs Lungs

Result: More – Pleural PressureOpen Alveoli

PRONE POSITION

Position Affects Mechanics After Volume Infusion

Mutoh et al. Am Rev Resp Dis, 1998;146:300

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Results:

Supine position:– Increase in pleural pressures in the

dependent region– Increase in A-a gradient

Prone position:– Less negative pleural pressures– Decrease in A-a gradient

Mutoh et al. Am Rev Respir Dis 1992;146:300

Malbouisson LM. Et al. Am J Respir Crit Care Med 2000;161:2005-12

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Supine Position Impacts Local Lung Compliance

Shifting of blood volume into the pulmonary vascular bed

Effects of gravity and pressures on chest wall shape

Changes related to the effect of gravity/pressures on chest wall shape

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Compliance in the Prone Position with Normal Weight Patients

Methodology:17 patients undergoing elective surgery

Mechanically ventilated

Measured respiratory system (Cst, rs), Lung (Cst, L), Chest wall (Cst, w), compliance, respiratory resistance, FRC and PaO2 in supine & prone positions

Pelosi et al. Anesth Analg 1995;80:955

Respiratory System, Lung, Chest Wall Compliance, FRC and PaO2 in the Supine

and Prone Position in Normal Weight Surgical Patients

Supine Prone PCst,rs (mL/cmH2O) 80.9+16.6 75.9+13.2 NSCst,w (mL/cmH2O) 203.2+72.4 184.3+77.1 NSCst,L (mL/cmH2O) 150.0+52.3 142.5+36.7 NSRmax/rs( cmH2O.L-1.s) 4.8+2.5 5.4+2.7 <0.05Rmax/w( cmH2O.L-1.s) 1.3+0.6 1.9+0.8 <0.05FRC 1.9+0.6 L 2.9+0.7 L <0.01PaO2 160+37 mmHg

199+16mmHg <0.01


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Compliance in the Prone Position with Obese Patients

Methodology:10 obese patients undergoing surgery

Mechanically ventilated

Measured respiratory system (Cst,rs), Lung (Cst,L), Chest wall (Cst,ws), compliance, respiratory resistance, FRC and PaO2 in supine & prone positions


Respiratory System, Lung, Chest Wall Compliance, FRC and PaO2 in the Supine

and Prone Position in Obese Surgical Patients

Supine Prone P

Cst,rs (mL/cmH2O) 55.4+9.6 59.6+12.1 NS

Cst,w (mL/cmH2O) 199.5+58.7 160.5+45.4 <0.01

Cst,L (mL/cmH2O) 91.4+55.2 109.6+52.4 <0.01Rmax/rs( cmH2O.L-1.s) 9.6+5.2 9.0+5.5 NS

FRC 0.894+0.327L 1.980+0.856L <0.01

PaO2 130+31mmHg 181+28 mmHg <0.01


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Increased Lung Compliance(Obese Group)

Supine:Tidal volume change occurred at extremely low FRC (flatter portion of PV curve)

Prone:

Tidal volume change occurred at higher FRC (steeper portion of the PV curve)

Major Factors Influencing Distribution of Ventilation

Gravity/weight of the lung

Compliance

Heterogeneous lung disease

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SummarySupine:

Marked reduction in lung volumes

Alteration in lung mechanics (low compliance/high resistance)

Compression atelectasis

Moderate hypoxemia

Prone:Increased FRC & improved complianceShifting of lung water & densitiesIncreased oxygenation

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Prone Positioning Effects on Lung Mechanics & Oxygenation

16 Acute Lung Injury patients (11/16 met ARDS criteria)Volume control ventilationMeasured relationship between gas exchange and respiratory mechanics before, during & 2 hours post prone position with the abdomen unrestricted

Pelosi et. Al. Am J Respir Crit Care Med 1998;157:387-393

Methodology:

Compared gas exchange difference to changes in EELV, total respiratory system compliance (Cst,rs), lung compliance (Cst,L) & throacoabdominal cage compliance (Cst,w)

Prone Positioning Effects on Lung Mechanics & Oxygenation

PaO2 increased 103.2+23.8 to 129 + 32.9 (p <.05)No significant change in EELV, Cst,rs or Cst,L.Decrease in Cst,w from 204.8 + 97.4 L to 135.9 + 52.5 L (p < .01)Decrease in Cst,w correlated with increase in PaO2Higher baseline Cst,w, greater the decrease in the prone positionAble to predict oxygen change from baseline r=.80 (p<.01)Prone position improves respiratory system and lung compliance when supine position resumed

Pelosi et. al. Am J Respir Crit Care Med 1998;157:387-393

Results

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C,w p

C,w a = 0

C,w ab

C,w a

C,w ab

C,w p = 0

Pelosi et. al. Am J Respir Crit Care Med 1998;157:387-393 (courtesy of Dr. Pelosi)

Evaluated position influence on extent & distribution of lung injury in animal model of oleic acid lung injury ventilated with high tidal volumes & PEEPAnimals ventilated with high tidal volume & PEEP had less histologic change in the prone versus the supine position

Broccard Crit Care Med 1997; 35:16-27

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PERFUSION

Factors Influencing Regional Distribution of Perfusion

Cardiac output

Pulmonary vascular resistance

Gravity/body position

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Distribution of Perfusion

Upright Position:Blood flow decreases as it moves from base to apex with virtually little or no flow at the apices

J.B. West, C.T. Dollery, & A. Naimark, 1964, Journal of Applied Physiology, 19, p.71.3

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Blood Flow Changes with Position

Supine position:Distribution becomes more uniform. Zone 3 maintained throughout the lung. Greater vertical perfusion gradient.

Lateral position: Similar to supine except lung transforms to zone 2 approximately 18 cm above the most dependent part of the chest.

Prone position: Zone 3 maintain throughout the lung.Reduced gravitational flow noted

Effect of Position on PaO2, PaCO2 and QT Before and After OA

QT, PaO2 PaCO2n l/min Torr Torr

Before OA 8Supine 3.9 + 0.4 539 + 14 30 + 2Prone 4.4 + 0.5 566 + 11* 33 + 1

After OAOA injected supine 4

Supine 3.6 + 0.7 156 + 19 37 + 1Prone 3.9 + 0.8 280 + 49* 38 + 3

OA injected prone 4Supine 3.5 + 0.3 95 + 11 36 + 2Prone 3.8 + 0.6 162 + 39* 34 + 3

Weiner et al. J of Appl. Physiol 1990;68:1386* P < 0.01

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Systemic Review of Prone Research

297 patients turned prone17 studies15 studies noted position of the abdomen

47% abdomen suspended20% fully restrained33% partially suspended

RESULTS: 70% reported a response ( in PaO2) within 30-60 minutesEarly intervention resulted in better response Initial response failed to predict subsequent response

Curley M. AJCC, 1999;8:397-405

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Systemic Review of Prone Research…Research up to 2000

454 patients turned prone– 29 studies– 80% abdomen free– 93% volume ventilation– > 80% predominance primary ARDS

RESULTS: 73% reported a response >20% change in P/F ratio within 1 hour% response greater in patients with extra-pulmonary ARDS

Pelosi P. et al Eur Respir J, 2002;20:1017-1028

Review of Prone Research Research up to 2004• 651 patients turned prone (1105 total)

– 17 studies (46 total)– 58% abdomen free (versus 80%)– 50% volume ventilation (versus 93%)– 50% pressure controlled

RESULTS: 71% reported a response >20% change in P/F ratio or 10mmHg increase in PaO2 within 1 to 2 hoursTime in prone position 30 minutes to 20 hoursTrend of complications associated with > time spent in the prone position

Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3):319-336.

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1970’s Prone Positioning ResearchMethodology:

5 ARDS patientsProne position via CircoElectric® bed with the abdomen restrictedMechanically ventilated/varying PEEP levels ABG’s at baseline, 30 minutes and 120 minutes

Results:Average increase in PaO2 of 47 mmHgDecline in PaO2 4-8 hours in the prone position.

Piehl & Brown. Crit Care Med 1976;4:13

Methodology:6 ARDS patientsProne position via CircoElectric ® bed with abdomen unrestrictedABG’s measured 2 hours per & post turn

Douglas et. al, Am Rev Respir Dis, 1977;115:559

1970’s Prone Positioning Research

Results:Average increase PaO2 69 mmHg (range 2-178)Subsequent turns average increase 35 mmHg (range 4-110)No change in PaCO2, RR, compliance

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Methodology13 ARDS patients (mechanically ventilated, sedated and paralyzed)

Prone positioned manually with abdomen partially unrestricted

Examined ABG’s before, during and after 2 hours in the prone position

Langer et. al. Chest, 1988;91:103.


Langer et. al. Chest, 1988;91:103

PaO

2mm

Hg

120

80

40

0supine

1/2 hprone

2 hprone

4 hsupine

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1980’s Prone Positioning ResearchResults:

Responders increased PaO2 70 + 8 to 90 + 8 mmHg*Non-responders decreased PaO2 81 + 22 to 67 + 13 mmHgNo differences in PaCO2, Qs/Qt, CI or PAPCat scan revealed shifts in lung densities

opening of previous atelectatic areas/ventilation redistribution redistribution of fluid

Langer et. al. Chest, 1988;91:103* p < 0.01

PurposesIdentify a safe, maneuverable and effective technique to position patients prone

Determine if the suspended prone position improves oxygenation in the adult patient with acute respiratory failure

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PHASE I

PRODUCT EVALUATION STUDY

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1980’s Prone Positioning Research…

Methodology15 critically ill ARDS patientsServed as their own controlRandomly assigned positionABG’s at baseline & 20 minsRespiratory & hemodynamicsmeasuredManual turning performed with a frame using 3 individual/abdomen unrestricted

Vollman & Bander Inten Care Med 1996: 22(10):1105

Ventilator Settings

Tidal Volume:Oxygen:A / C rate:PEEP:

600 to 900cc40% to 100%10 to 25 / min5 to 20 cm of H2O

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Results:

Responders (9): PaO2 89.1+14.1 to 122.0+27.4*Shunt 32.2+ 5.3 to 27.1+ 5.3**

Non-Responders (6) PaO2 82.8+15.3 to72.6+10.3Shunt 31.7+11.3 to34.7+12.0

No difference in hemodynamics seen between positions

Vollman & Bander et al. Vollman & Bander et al. IntenInten Care Med 1996: 22(10):1105Care Med 1996: 22(10):1105*p<0.001

**P<0.01

R NR PPIP (cmH2O)

Supine 45.8 +10.4 61.0 + 11.6 0.02Prone 47.6 + 8.7 65.0 + 14.8 0.02

PPlat (cmH2O)Supine 37.4 + 10.2 52.6 + 15.0 0.04Prone 37.4 + 9.5 55.0 + 17.5 0.03

PaCO2 (mmHg)Supine 31.5 + 3.9 41.8 + 4.3 0.0001Prone 32.0 + 4.1 44.0 + 3.4 0.0001

MPAP (mmHg)Supine 27.0 + 7.1 36.4 + 5.5 0.02Prone 25.4 + 6.0 34.9 + 6.1 0.01

Differences in Pulmonary & Hemodynamic Variables between R& NR

Vollman & Bander. Inten Care Med 1996;22(16):1105

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Demographic Differences of Non-Responders

Additional lung pathologies

Trend toward longer stay in ICU & time on vent

Vollman & Bander. Inten Care Med 1996;22(16):1105


32 patients with severe Acute Respiratory Failure

PaO2/FiO2 measured 1 hr pre prone, 1 & 4 hrs prone, & 1 hr post prone

manual positioning with 4 individuals

fold sheets used to support the shoulders and face

Chatte et. al. Am J Respir Crit Care Med, 1997;155:393-394

Methodology

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25 (78%) Responders: PaO2/FiO2 ratio 108-144-174-136*

7 (22%) Non-responders: PaO2/FiO2 ratio 83-77-83-81

Responders:43% returned to baseline PaO2/FiO2 ratio when repositioned supine

57% improvement persisted when repositioned supine

Results

Chatte et. al. Am J Respir Crit Care Med, 1997;155:393-394* p < 0.001

2000’s Prone PositioningResearch

Study Period: 1996-1999304 patients with Acute Lung Injury/Acute Respiratory Distress Syndrome randomized to receive 6 hours of prone positioning q 24 for 10 days or supine position with q 2 hour lateral positioningEntrance criteria: modified ALI/ARDS definitions

Methodology

GattinoniGattinoni L. et. al. N L. et. al. N EnglEngl J Med 2001;345:568J Med 2001;345:568--7373

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Measured: Primary endpoints: mortality at 10 days, hospital D/C & 6 months Secondary endpoints: PaO2/FiO2, ratio reduction, organ failure & incidence of complications

MethodologyMethodology



10 day mortality: 21% vs. 25% (RR 0.84 CI 0.56 to 1.27)

Hospital d/c mortality: 50.7% vs. 48% ( RR 1.05 CI 0.84 to 1.32)

6 months mortality: 62.5% vs. 58.6% ( RR 1.06 CI 0.88 to 1.28)

Significant increase in PaO2/FiO2 ratio in the prone groupNo difference in organ dysfunction% of patients with new or worsening pressure ulcers per patient was worse in the prone group

Results


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Study ConcernsWas the study methodology relevant?– Testing an intervention using 1996-

1999 ventilator management• TV: 10.3/ml/kg + 2.9 (s)• TV: 10.3/ml/kg + 2.7 (p)• Average PEEP: <10cm

– Majority of patients entered into the study were primary respiratory pathology vs. secondary

Were the patients in the prone position a sufficient period of time?– Average time prone: 7.0 + 1.8

Study ConcernsWas the study powered sufficiently?– Stopped early with recruitment

problems– Less than half of the targeted number

of subjects for whom the study was powered were enrolled

– Deviations from the protocol/41 patients non-compliant with the study protocol

Were the most appropriate patients study?– Altered ALI/ARDS criteria– Post-hoc analysis showed sicker

patients had a significant improvement in mortality

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Mortality Benefit in the Most Severely Ill

>49 40-49 31-40 0-31

SupineProne

Mor

talit

y ra

te

Quartiles SAPS II


• Study conducted: Dec 1998-2002 • 791 ARF patients, multicenter trial, unblended,

randomized• 413 prone, 378 supine (8 hours per day)• Patient in supine group could cross over to prone if P/F

ratio < 100 for > 12 hours, or < 60 for 1 hr or on 100% FiO2

• P/F ratio <300, hemodynamically stable & no contraindications to the prone position

• Measured 28 day all cause mortality, duration of mechanical ventilation, incidence of VAP & oxygenation

Methodology

Guerin C. et al JAMA 2004;292:2379-2387

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• No difference in mortality• No difference in ventilation days• Reduction in VAP in the prone group*• Significantly higher P/F ratio for 28 days in the prone group

• Most patient’s in supine group crossed over• Mechanical ventilation was not performed using a pre-

determined algorithm (Tidal volume 8 ml/kg & tidal volume in pressure control 11ml/kg)

• Only in prone position for 8.6 hours for total of 4.6 days

Results

Guerin C. et al JAMA 2004;292:2379-2387*P < 0.045

Limitations

Days100806040200

Surv

ival

(%)

1009080706050403020100

GROUPS

PP

SP

P=0,84

Gattinoni NEJM 2001

Guerin, JAMA 2004

Decreased Incidence of

VAP in prone !

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Prolonged Prone Ventilation Study

• Multicenter trail: 13 ICU’s accruing 136 ARDS patients randomized within 48hrs of tracheal intubation (Between 1998-2002)

• 60 to supine, 76 to prone (20h/d) • Guidelines for ventilation & weaning were established

• Mortality: Supine 58% vs. Prone 43% p=0.12• Simplified APACHE II score higher in prone group• Independent risk factors for mortality: APACHE score at

inclusion, days elapsed prior to inclusion & randomization to supine position

• Minimal complications and rapidly reversible (prone avg. 17hrs for 10 days)

Mancebo J et al. Am J Respir Crit Care Med, 2006;173:1233-1236

Results

Methodology

SP / PP

PP hours / day

Patients

Italy Spain France

152 / 152 60 / 76 378 / 413

≥ 6 ≥ 8= 20

ALI ARDS ARF P/F < 300

Primary end-point

MortalityDay-10

MortalityICU

Mortality Day-28

Hypothesis 50% ↓ 30% 40% ↓ 30%40% ↓ 30%

Prone Positioning3 Multicenter RCTs Completed

Courtesy of P Pelosi

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Limitations Of The Clinical Prospective Randomized Prone-supine Trials Power of the study

Criteria for pronation

Duration and frequency of pronations

Ventilation tidal volumes high

Ventilatory setting unmodified during pronation

Mixed cathegories of patients

Differences between centres

Treatment of the etiologic agent uncertain !!

Prone-Supine II:The Effects of

Prone Positioning for Patients

Affected by ARDS

Phase III Trial in Progress

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Pediatric Prone Position

Multicenter, randomized controlled clinical trial measuring ventilator free days to day 287 Pediatric ICU’s (age 2 weeks to 18 years)Randomized to supine or prone within 48 hrs of ALI criteriaProne position for 20 hours each day during acute phase of illnessBoth groups tx with lung protective strategy, sedation protocols, extubation readiness and hemodynamic & skin care guidelines

Curley MA, et al. JAMA, 2005;294:229-237

Methodology

ResultsStopped for lack of efficacy: no difference in VFD, mortality, OFD, hospital discharge

What’s the Challenge?

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Decision Making Factors in Positioning Patients Prone

Time interval from injury to position change

Decision Making Factors in Positioning Patients ProneTime interval from injury to position change Hemodynamic status

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HemodynamicInstability

Is it a Barrier toPositioning?

Hemodynamic StatusNo differences noted in hemodyanmicvariables between supine & positionsLateral turn results in a 3-9% decrease in SVO2 which takes 5-10 minutes to return to baselineAppears the act of turning has the greatest impact on any instability seenMinimize factors which contribute to imbalances in oxygen supply & demand

Winslow, E.H. Heart and Lung, 1990 Volume 19, 557Winslow, E.H. Heart and Lung, 1990 Volume 19, 557--561.561.Price P. CACCN, 2006, 17(1):12Price P. CACCN, 2006, 17(1):12--19.19.

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Patients at Risk for Intolerance to Positioning

Elderly Diabetes with neuropathyProlonged bedrestLow Hb an cardiovascular reserveProlonged gravitational equilibrium

Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3):319-336

Decision Making Factors in Positioning Patients ProneTime interval from injury to position change Hemodynamic statusMentation

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Decision Making Factors in Positioning Patients Prone

Time interval from injury to position change Hemodynamic statusMentationPatient size

Positioning Schedule &Maintenance Care

Every 6 hoursMaintain gain, laterally rotated until gas exchange decreases or 6 hours is reachedLoose gain, laterally rotate for 1 hour to provide care and return to the prone positionTubes inserted above the waist/Top of the Bed Tubes inserted below the waist/Foot of the Bed(Except Chest Tubes)

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Positioning Schedule & Maintenance Care (contd.)

Move head slightly every hourROM of arms every 2 hoursSupport feet in correct anatomical alignmentPad bony prominence areas if not on a low air loss surfaceDouble secure endotracheal tubeTurn off tube feeding 45 minutes prior to position change

Care Practices to Reduce Complications

Vollman KM. CritCare Nurs Clin of North Amer, 2004;16(3):319-336

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Care Concerns• Hemodynamic monitoring:

– In studies that communicated landmarks for zero reference, no difference in HR, SBP or CI

• Feeding:– The patient is at most risk for aspiration during the turning

process– If trendelenburg position is used to reduce facial edema, must

weigh risk-benefit of aspiration– Tubes placed past the pyloric valve may also reduce the risk of

aspiration• Patients have been placed in the prone position

successfully;– open abdomens, increased intra-cranial pressure

monitoring/increased intracranial pressure, hemodynamicinstability, pelvic fractures, external fixators, multiple traumatic injuries, use of extracorporeal membrane oxygenation (ECMO), and continuous renal replacement therapy (CRRT)

Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3):319-336

Barriers to Positioning

Hemodynamic instabilityHuman or Technological ResourcesKnowledge/Priority

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Reported Complications for 746 Prone Turn Cycles

12 studies noted critical events> 12 hours in the prone position associated with more complicationsOne-half of the studies reported cutaneous & structural problems

dependant edemapressure ulcers : chin & chestcontractures (9 days prone, 56 days prone)

Curley M. AJCC, 1999;8:397-405

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Reported Complications for 746 Prone Turn Cycles (cont’d.)

8 episodes of hemodynamic instability (1.1)3 episodes of extubation (.4%)2 episodes of in SaO2 (.3%)2 atypical atelectasis (.3%)1 obstructed ET tube (.1%), 1 kinked ETT (.1%), 1 CVC dislodgment (.1%), 1 femoral hemodialysis catheter dislodgment (.1%), 1 SVT (.1%)

Curley M. AJCC, 1999;8:397-405

Maneuver Related Complications

Added sedation 55.2398

Airway obstruction 39.3283

Facial edema 29.8215

Added curarization 27.6199

Fighting ventilator 19.4140

Transient desaturation 18.6134

Complication %(of maneuvers)

n

Gattinoni ,NEJM 2001

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Effect on Cannula Position

Retrospective chart review– 10 patients with ECMO– 42 patients with CRRT

Examined cannula location, displacement &/or malfunction for a total of 68 turning eventsAll had venous cannulation: IJ & femoral sites

MethodologyMethodology

ResultsResultsNo inadvertent No inadvertent cannulacannula removal during turningremoval during turning2 patients demonstrated poor flow: 1 supine, 2 patients demonstrated poor flow: 1 supine, 1Prone1Prone

GoettlerGoettler CE. Et al Critical Care 2002,6:452CE. Et al Critical Care 2002,6:452--455455

Prone

Positioning

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Diagram of the pancake method (top and bottom sheet) to turn a critically ill patient prone. (From Balas M.C. Crit Care Nurse, 2000;20(1):35.

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Vollman Prone Positioner

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Barriers to Positioning

Hemodynamic instabilityHuman or Technological ResourcesKnowledge/Priority

Fear of the Prone Position

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To Prone or Not to Prone?

Base Your Decision on Research & Clinical

Experience

Beneficial effects on gas-exchange and respiratory mechanics in ALI/ARDS patients

Should be performed as early as possible (within 1 week)

The reduction in PaCO2 (and NOT the improvementin PaO2) seems to be associated with better outcome

Prone Position In Critically Ill Patients:

The reduction in mortality is unclear (more effective in more severe patients ? more effective if applied as much of the day as possible ? )

Ventilatory setting (FiO2 & RM & PEEP) should be modified during prone position

Pelosi 2006 Paris

Documents

Upside Down You Turn Me: Impacting SaO with Prone ... Kathleen M. Vollman MSN, RN, CCNS, FCCM Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING Northville, Mi [email protected]