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
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
Background
The prone position has been used to improve
oxygenation in patients with severe hypoxemia
and acute respiratory failure since 1974. The
prone position has been shown to increase endexpiratory
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.
Additionally,
proning obese and fluid overloaded 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
Methods
• 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. This group consisted of all patients
admitted to the SICU during the study period
• Data was analyzed to evaluate for complications of prone
positioning
Discussion
With flat sheet, pull pt to
one side of the bed.
Tuck flat sheet around pt arm
In order to protect it and move pt
Position pt arm up on one side, arm
straight on the other and knee up if
desired.
Patient fully proned, head to
side.
Results
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. Nonprone 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%).
References
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.
Tilt the patient over and position
with pillows
SICU criteria to initiate prone positioning:
1) Effective compliance (normalized) < 0.5
mL/cmH20/Kg
2) P/F ratio < 200 on Fi02 > 0.5
Proning Data for period 5/1/10 - 4/30/11
8000
7000
6997
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. More
recent studies document the benefit of
extended prone position therapy (> 20 hours
per day) in ARDS. A recent review 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 PaO2/FiO2
ratio < 100 mm Hg.
Additionally, prone
positioning can be used as a rescue therapy
for patients with ARDS and refractory lifethreatening hypoxemia.
6000
5000
4000
Proning
3000
Non-proning
2000
1000
0
0
Days during
study
13
Self-extubation
75
0
3
0
Line/tube
pulls
Trachs pulled
% Incidence per proning day 0.85%
% Incidence per non-proning day 1.21%
Conclusion
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