Download Turning Patients Into The Prone Position (Adult Critical Care)

August 2015
Title of Guideline:
LOCAL ADULT CRITICAL CARE GUIDELINES FOR TURNING PATIENTS
INTO THE PRONE POSITION.
Date First Issued:
Latest Re-Issue Date:
October 2005
October 2015
Version:
Review Date:
NUH (1)
2018
Author and Job Title:
Local Contact including job title
and Ext. No.
Mary Beckenham, Clinical
Adult Intensive Care Unit
Governance, Practice Development
Queen’s Campus
MAtron
Ext.62758
Document Derivation:
Consultation Process:
See main references
Critical Care Governance Group
Critical Care Directorate
Ratified by:
Distribution:
Tony O’Leary, Head of Service, Adult
Critical Care
Rebecca Selwyn, Matron, Adult
Critical Care
Critical Care Governance Group
AICU, CCD and E12
Evidence base of the guideline:
Guidelines already in place being
updated
Peer reviewed by NUH critical care
cross town guidelines group
5 - Recommended best practice
based on the current literature
available and the clinical experience
of the guideline developer.
Plans for audit of guideline:
Evidence base 1 - 5
Plans for training on/implementing
guideline:
In local areas as required
Will be audited in individual speciality
as appropriate
This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using the guidelines after the review date.
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
NOTTINGHAM UNIVERSITY HOSPITALS
ADULT CRITICAL CARE GUIDELINES
GUIDELINES FOR TURNING THE PATIENT
INTO THE PRONE POSITION
CONTENTS PAGE
GUIDELINES FOR TURNING PATIENTS INTO THE PRONE
POSITION
PAGE
NO.
1

Introduction
Selecting patients for prone positioning
Considerations for turning
Contraindications
Resources and personnel required
1


Preparation and assessment
Turning the patient prone using the “Sandwich
technique”
Patient positioning
Maintenance and evaluation of the patient once prone
Photographic guidance on prone positioning (Stages 2
– 3)
3
9
10
References
Suggested audit points
23
24






Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
ADULT CRITICAL CARE GUIDELINES
FOR TURNING PATIENTS INTO THE PRONE POSITION.
INTRODUCTION
Available evidence suggests that prone positioning must be considered early in
the disease process of acute respiratory distress syndrome (ARDS) / acute lung
injury (MacDonald and Armstrong, 2000). It preferentially expands dorsal alveoli
and is particularly effective in the early oedematous phase of the illness (Marini,
and Hotchkiss 1999). Gattinoni et al (2001) report that only the sickest patients
benefit and therefore prone positioning should be undertaken in the later stages
of ARDS
Evidence also suggests that in addition to improving oxygenation (Ball, 1999),
prone ventilation may also assist in reducing the iatrogenic complications
associated with mechanical ventilation by allowing decrease in peak airway
pressure. (Webster, 1997)
SELECTING PATIENTS FOR PRONE POSITIONING
In order to ensure patients are selected appropriately it is necessary for a set
protocol to be adhered to. There is very little evidence to support specific
optimal parameters in which to institute turning patients prone (MacDonald and
Armstrong, 2000) but the following criteria appear to be common throughout
the literature.
CONSIDERATIONS FOR TURNING: INCLUSION CRITERIA

PaO2 8kPa with SaO2 <90% and FiO2 0.8. (ARDSNET, 2000)

PEEP > 15cm H2O (ARDSNET, 2000)

Radiological evidence of bilateral lung involvement (Gosheron et al, 1998).
Although this may change in the next consensus criteria.

CT demonstration of basal consolidation has also been used to identify
ARDS.
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
It has been suggested that prone positioning should also be considered when:

Patients are receiving prolonged ventilation for acute or acute on chronic
respiratory failure (Marini and Hotchkiss, 1999, Gosheron et al, 1998, Fridrich et
al, 1996)

Patients have evidence of basal collapse/consolidation and require postural
drainage for effective secretion removal (Chatte et al, 1997, Pappert et al, 1994)
CONTRAINDICATIONS: EXCLUSIONS FROM THERAPY
The only contraindications are any factors that may prevent the safe
management of the prone patient. (Mesesole, et al 2002).
Although the decision to utilise the prone position should involve an individual
patient assessment by the multi-professional team the following possible
contraindications have been highlighted throughout the literature:

Patients with a large abdomen (Gosheron et al, 1998), patients in the 2nd/3rd
trimester of pregnancy (Ball et al, 2001, Gosheron et al, 1998). Patients who
weigh > 135kg (Ball et al, 2001)

Head injuries and raised intracranial pressure. Patients experiencing frequent
seizures. Raised intra-ocular pressure (Ball et al, 2001, Gosheron et al, 1998).
Although this is not always considered to be an absolute contraindication.

Multiple trauma; external pelvic fixation, recent pelvic or chest fractures, traction.
Spinal instability. (Ball et al, 2001, Chatte et al, 1997) Facial trauma/ post oral
maxillary facial surgery (Blanch et al, 1997, Fridrich, 1996)

Haemodynamic instability despite fluid resuscitation or inotropes,.
acute
haemorrhage (Fridrich, et al, 1996). Recent cardio thoracic surgery/unstable
mediastinum. New tracheostomy, < 24hrs (Ball et al, 2001)

Patients that have previously demonstrated a poor tolerance of prone positioning
(Ball et al, 2001).
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
RESOURCES AND PERSONNEL REQUIRED:

Total Care sport bed frame & mattress (no pillows required using this)

Or Respistar mattress & Evolution bed frame (if above unavailable)

Sliding sheet

3 pillows
(optional as can increase risk of pressure damage; Chiumello
2006)

2 strong bed sheets (one will already be under the patient)

At least 5 staff, including an airway competent doctor.
Best Practice
IMPORTANT.
Bed environment should be assessed for optimum safety and
comfort. Please refer to local moving and handling policies.
Best Practice
IMPORTANT
If a patient has an “anchor fast” device in place to secure the
endotracheal tube this MUST be removed and replaced with
ET tapes prior to turning to reduce the risk of pressure
damage to the face
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
NOTTINGHAM UNIVERSITY HOSPITALS ADULT CRITICAL CARE GUIDELINES
GUIDELINES FOR TURNING PATIENTS INTO THE PRONE POSITION.
STAGE 1 - PREPARATION AND ASSESSMENT.
The decision to position a patient prone should be made following discussion
with a Consultant and documented in the medical notes.
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
ACTION
1.
2.
3.
4.
5.
6.
Refer to pages 1 and 2 for
suitability
RATIONALE


To
ensure
correct
patient
selection.
To
standardise
assessment,
technique and evaluation of
procedure.
Inform patient and relatives of
intended procedure.
Perform arterial blood gas analysis
and document prior to procedure.

To avoid unnecessary anxiety.


To aid selection.
To
facilitate
evaluation
procedure.
Disconnect
all
non-essential
monitoring
equipment
and
intravenous lines. Ensuring those
remaining are adequately secured
and have the length and flexibility
to accommodate turning the
patient prone.
Disconnect enteral feed and
aspirate nasogastric tube

To reduce the risk of accidental
displacement and removal of lines
during the procedure.
To maintain patient safety.
(Gosheron, et al, 1998, Stocker,
1997, Canter, 1989).
Ensure that the endotracheal/
tracheostomy tube is adequately
secure and free from contact with
supporting surfaces. (Messoral et
al, 2002). If there is an “anchor
fast” device in place, remove
and secure endotracheal tube
with tapes. See Best Practice.
There is no evidence to guide
optimal positioning of the patient
with a tracheostomy.
Check
intubation grading, size of tube and
length at patient lips. Ensure that
this is documented.



of
To minimise risk of regurgitation
and
aspiration
of
stomach
contents
during
procedure
(Gosheron et al, 1998).
To reduce risk of accidental tube
displacement.
 To reduce the risk of pressure
damage to the face.
 To
facilitate
effective
repositioning/re-intubation should
it become necessary.
(Ball, 2001, Ball, 1999, Gosheron et
al, 1998, and Canter, 1989).
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
ACTION
RATIONALE

7.
Perform
endo-tracheal/tracheal
and oro-pharyngeal suctioning
according to local policy. Ensure
closed circuit suctioning catheter is
in situ.

For
effective
removal
of
secretions prior to procedure and
whilst the patient has assumed
the prone position in order to
optimise
ventilation
and
oxygenation. (Ball et al, 2001)
To promote patient comfort.
8.
Perform
endo-tracheal/tracheal
and oro- pharyngeal suctioning
according to local policy. Ensure
closed circuit suctioning catheter is
in situ.


10.
Assess the patient’s sedation
score, according to local policy and
observe
for
any non-verbal
indications of pain. Administer the
necessary boluses as prescribed
and according to local policies.


For
effective
removal
of
secretions prior to procedure and
whilst the patient has assumed
the prone position in order to
optimise
ventilation
and
oxygenation. (Ball et al, 2001)
To promote patient comfort.
To reduce the risk of patient
discomfort, pain, and/or agitation
during the procedure (Pelosi,
1998, Blanch, 1997),
To ensure ventilator compliance
and optimal ventilation (Jolliet,
1998, Canter, 1989).
N.B: Consider the use of an intravenous muscle relaxant at this stage. Assess
effectiveness prior to procedure with a peripheral nerve stimulator. Please refer
to appropriate local guidelines, policies and procedures (Jolliet et al, 1998).
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
STAGE 2: TURNING THE PATIENT PRONE USING THE “SANDWICH
TECHNIQUE” - (Please refer to photographs in appendix 2).
The patient should ideally be rolled towards the ventilator unless you need to
consider other attachments such as CVVH lines, and the person responsible
for the patient’s head and airway should co-ordinate the procedure.
ACTION
RATIONALE
1.
Position doctor at the head of the
bed and two people at either side
of the bed.

To ensure equitable distribution
of weight.
2.
Insert sliding sheet under the
bottom bed sheet and position
patient’s arms close to their sides
with palms facing thighs.(Fig. 1)

To conform to local manual
handling policy.
To ease turning and to reduce
likelihood of limb injury.
Position pillows: (Fig. 2)

3.

A) across the patient’s chest

B) across the patient’s pelvic area

C) across the patient’s knees





To reduce the risk of over
distension (by allowing the
patient’s shoulders to fall slightly
forwards) of the anterior capsule
of the shoulder joint and injury to
the brachial plexus (Butler, 1991).
To enhance a negative pleural
pressure, thus optimising the
patient’s
functional
residual
capacity, and improving basal
expansion of the lungs (Gibson
and Rutherford, 1999).
To
enhance
haemodynamic
stability.
To ensure the abdomen is free.
To minimise pressure exerted on
the patient’s knees (Ball et al,
2001).
To
minimise
the
risk
of
overstretch on the soft tissues
over the anterior aspect of the
ankle joints (Ball et al, 2001).
To reduce the risk of shortening
the Achilles tendon (Ball et al,
2001, MacDonald and Armstrong,
2000).
To reduce pressure over the
head of the fibula, which may
predispose to injury of the
common perennial nerve (Ball et
al, 2001, Pelosi et al, 1998)
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
ACTION
RATIONALE
4.
Pull bottom sheet straight and taut.
Then place the second sheet over
the top of the patient, matching all
four corners. (Fig. 3)

To aid safe and effective turning.
5.
Uncover the patient’s head and
face. All personnel on either side
of the bed then roll the long edges
of both (top and bottom) sheets
tightly together. (Fig. 4)

To ensure the roll is equally
distributed and is as tight as
possible.
To effectively cocoon the patient
within the two sheets.
6.
Once the person responsible for
the head and airway is satisfied
with the patient’s safety, slide the
cocooned patient across the bed
AWAY from the ventilator to as
close to the opposite edge of the
bed as possible. (Fig. 5) The
patient is supported by the
personnel on the opposite side of
the bed to the ventilator.
All
personnel should maintain a
TIGHT grip on the rolled sheets.

To ensure clear coordination and
facilitate safe and effective turning
of the patient.
7.
Turn the patient to a lateral
position,
maintaining
sheet
integrity and security, TOWARDS
the ventilator and then lower into
the prone position, onto the
original top sheet and arranged
pillows. This should be performed
slowly allowing personnel on either
side of the bed to swap over
supporting hands. (Figs. 6 & 7.)

To ensure safe handling of the
patient and effective use of the
sandwich technique.
8.
All personnel, on the count of the
person responsible for the patient’s
head and airway, slides the patient
into a more central position of the
bed. (Fig. 7.)


For patient safety.
For effective multi-professional
management of the patient.

Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
STAGE 3: PATIENT POSITIONING
ACTION
RATIONALE
The patient must be maintained in
the swimmers position, ensure that
the arms are alternated. (Ball et al,
2001).
The shoulder of the
prominent
arm
should
be
positioned at 80 abduction and
the elbow at 90. Placing a rolled
pillowcase in the palm of the
prominent hand. (Fig.8.)

Alternate swimmers position
2-4 hourly (Ball et al, 2001),
supporting upper arm
between shoulder and elbow
and lower arm between elbow
and wrist. Avoid pulling on
the patient’s wrist. (Fig.9)
Modify the prone position to ¾
facing right and left with pillows
supporting the side to be lifted.
Liaise with unit physiotherapist for
regular
passive
movement
exercises within the normal range.

3.
Once in the prone position place
the bed in the reverse Trendleberg
position (30-40 foot down). Gel
doughnuts are not considered
effective. (Messerole, 2002)

To minimise the development of
facial oedema (Ball et al, 2001,
MacDonald and Armstrong, 2000,
Gosheron et al, 1998).
4.
Maintain eye care according to
local AICU policy.

To minimise risk of corneal
drying/abrasion/ulceration
(MacDonald
and
Armstrong,
2000).
1.
2.




To minimise the risk of damage
and to prevent over extension
and
development
of
limb
contractors (Ball, 1999, Gosheron
et al, 1998).
To avoid subluxation of the glenohumeral joint.
To avoid pressure sores to the
ears,
cheeks
and
neck
(MacDonald
and
Armstrong,
2000, Gosheron et al, 1998)
To extend the wrist and allow
flexion of joints.
To promote effective sputum
drainage (Ball et al, 2001,
MacDonald
and
Armstrong,
2000).
To maintain soft tissue length and
mobility (Ball et al, 2001).
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
STAGE 4: MAINTENANCE AND EVALUATION OF THE PATIENT ONCE
PRONE
ACTION
RATIONALE
1.
Reattach all monitoring that was
 To re-establish safe monitoring
removed for turning. Resume
and
allow
continuation
of
enteral feeding.
therapies.
2.
Perform oral and tracheal
suctioning immediately following
the procedure.

To
clear
oral/pulmonary
secretions mobilised as a result of
prone positioning (Chatte et al,
1997, Wayne et al, 1994).
3.
Observe patients SaO2 levels

Perform arterial blood gases 20
minutes following assuming the
patient’s
prone
position.
Looking for at least a 20%
increase in the PaO2 .

Initial assessment of effectiveness
of treatment rise in Sao2
If the patient’s PaO2 has
increased by 1.3Kpa the patient
can be classed as a responder
(Gattinoni et al, 1997, Pappert et
al, 1994).
To monitor the effectiveness of
prone positioning.

4.
Maintain the patient in the prone
position for as long as they
continue to demonstrate a
positive response, or up to 20
hours a day providing no
deterioration or discomfort is
observed
(Fridrich,
Krafft,
Hochleuthner, and Maurirz,
1996)

To ensure optimal response from
prone therapy.
5.
Monitor, and document the
patient’s arterial blood gases as
individual condition requires and
prior to any changes in position,
e.g. from supine to prone and
vice versa. Report significant
deviations
immediately.
Compare SaO2 to that obtained
prior to the procedure (whilst
supine) if lower than that value
consider returning the patient to
supine position (Ball et al, 2001)

To identify those patients that will
or will not benefit from prone
positioning.
To optimise patient oxygenation
and minimise risks associated
with hypoxia.

Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
Placing additional absorbent protection under the patient’s head will
minimise the risk of tissue excoriation due to possible copious oral
secretions).
N.B. Although most patients respond quickly to prone positioning there are
those who will benefit but show a more gradual positive response. Therefore
in the absence of an immediate improvement, and assuming there is no
prolonged or unacceptable deterioration in the patient’s oxygenation status,
maintain them in the prone position for an additional 3-6 hours in order to illicit
a positive response.
HOWEVER, if a patient’s oxygenation status deteriorates and continues to do
so for 30 minutes, the patient MUST be returned to the supine position. This
does not automatically preclude them from subsequent attempts at prone
positioning.
IN A CARDIAC ARREST SITUATION, CPR CAN BE EFFECTIVELY
PERFORMED IN THE PRONE POSITION.
Hands placed directly under the patient can increase the efficiency of
cardiac compressions. (Dequin et al, 1996) If the decision has been
made to return the patient to the supine position all staff must be
efficient at performing the manoeuvre (MacDonald and Armstrong,
2000).
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
REFERENCES
Ball, C., Adams, J., Boyce, S., and Robinson, P. (2001) Clinical guidelines
for the use of the prone position in acute respiratory distress syndrome.
Intensive and Critical Care Nursing. 17. pp. 94- 104.
Ball, C. (1999) Use of the prone position in the management of acute
respiratory distress syndrome. Intensive and Critical Care Nursing. 15.
pp192- 203.
Blanch, L., Mancebo, J., Perez, M., Martinez, M., Betbese, Mas, M., Betbese,
A. J., Joseph, D., Ballus, J., Lucangngelo, U., and Bak, E. (1997) Short tem
effects of prone position in critically ill patients with acute respiratory distress
syndrome. Intensive Care Medicine. 23. pp. 1033-1039.
Butler, D. S. (1991) Mobilisation of the nervous system. Harcourt Publishers,
Edinburgh.
Canter, C. (1989) Nursing mechanically ventilated patients in the prone
position. Care of the Critically Ill. May. 3 (3).
Chatte, G., Sab, J. B., Dubois, J. M,. Sirodot, M., Gaussorgues, P., and
Robert, D. (1997) Prone position in mechanically ventilated patients with
severe acute respiratory failure. American Journal of Respiratory and Critical
Care Medicine. 155. pp. 473-478.
Chiumello, D., Cressoni, M., Landi, L., Li Bassi, G., Polli, F., Carlesso, E., and
Gattinoni, L. (2006) Effects of thoraco-pelvic supports during prone position in
patients with acute lung injury/acute respiratory distress syndrome: a
physiological study. Critical Care. 10 (3) http://ccforum.com/content/10/3/R87
Dequin, P. F., Hazouard, E., Legras, A., Lanotte, R., and Perrotin, D. ((1996)
Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
Intensive Care Medicine. 22. pp. 1272-1282.
Fridrich, P., Krafft, P., Hochleuthner, H., and Maurirz, W. (1996) The effects of
long term prone positioning in patients with trauma induced adult respiratory
distress syndrome. Anaesthesia and Analgesia. 83. pp. 1206-1211.
Gattinoni, L., Tognoni, G., Brazzi, L., and Latini, R. (1997) Ventilation in the
prone position. Lancet. 350 (9080) pp 815.
Gosheron, M., Leaver, G., Forester, A., and Harmsworth, A. (1998) Prone
lying – a nursing perspective. Care of the Critically Ill. April. 14 (3).
Gibson, V., and Rutherford, I. (1999) Artificial Ventilation in the Prone
Position. Australian Critical Care. 12. pp 18-22. Cited in: Ball, C., Adams,
J., Boyce, S., and Robinson, P. (2001) Clinical guidelines for the use of the
prone position in acute respiratory distress syndrome. Intensive and Critical
Care Nursing. 17. pp. 94- 104.
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
Jolliet, P., Bulpe, P., and Chevrolet, J. C. (1998) Effects of the prone position
on gas exchange and haemodynamics in severe respiratory distress
syndrome. Critical Care Medicine. 26 (12) pp. 1977-1985.
Macdonald, C., and Armstrong, D. (2000) The prone position – a nursing
perspective. Nursing in Critical Care. 5 (5) pp. 215-219.
Pelosi, P., Tubiolo, D., Vicardi, P., Crotti, S., Valenza, F., and Gattinoni, L.
(1998) Effects of the prone position on respiratory mechanics and gas
exchange during acute lung injury. American Journal of Respiratory Critical
Care Medicine. 157. pp. 387-393.
Marini, J., and Hotchkiss, J. (1999) Peep in the prone position: Reversing the
perfusion imbalance. Critical Care Medicine. 27 (1) pp. 1-2.
Messerole, E., Peine, P., Wittkopp, S., Marini, J. and Albert, R. (2002) The
Pragmatics of Prone Positioning. American Journal of Respiatory Critical
Care Medicine. Vol. 165, pp1359 – 1363.
Pappert, D., Rossaint, R., Slama, K., Grunning, T., and Falke. (1994)
Influence of positioning on ventilation- perfusion relationships in severe adult
respiratory distress syndrome. Chest. 106 (5) pp. 1511-1516.
Stocker, R., Neff, T., Ecknauer, E., Trent, O., and Russi, E. (1997). Prone
positioning and low- volume pressure-limited ventilation improve survival in
patients with severe ARDS. Clinical Investigations in Critical Care. Pp.
1008-1017.
Wayne, J., Lamm. M., and Richard, A. (1994) Mechanism by which the prone
position improves oxygenation in acute lung injury. American Journal of
Respiratory Critical Care Medicine. 150. pp 184-193.
Webster, N. (1997) Ventilation in the prone position. Lancet. 349 (9066) pp
1638-1639.
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
APPENDIX 2
PHOTOGRAPHIC GUIDANCE ON PRONE POSITIONING (STAGES 2-3)
Fig. 1
Fig 3
Fig. 2
Fig.4
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015
August 2015
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Local Adult Critical Care Guidelines for turning patients into the prone position. August
2015