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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