The Basics of Prone Positioning for ARDS
Prone positioning is likely to be one of the most intimidating things you’ll encounter in the ICU…the beds are big, they don’t provide instant access to your patient and the risk for complications is higher than in a standard bed. But, with excellent nursing care you can keep your patient safe without biting your fingernails down to the quick!
If you’re not sure what prone positioning is, this article by JAMA is excellent and up to date. Essentially, prone positioning refers to the practice of turning a patient FACE DOWN to improve lung perfusion and oxygenation when there is severe respiratory compromise present (like in ARDS). To effectively turn a patient over into a prone position, we use a specialty bed like this one, which goes by the super-cool name of RotoProne:
What you’re looking at here is the head of the bed. All those blue cushiony things are specially-designed padding intended to keep your patient comfortably cocooned in the bed and free from pressure-related injury as you turn the bed and redistribute their weight significantly. That big round wheel is what turns the bed (and there’s another at the foot)…and through the opening is where your ETT, NGT, IV lines and whatnot are placed. And yes, it is pretty hard-core. And like most hard-core nursing practices…you really have to be on top of your game to take care of these patients. Take your usual level of vigilance and multiply it by 10 as you watch out for all the potential complications of this high-tech and, sometimes, controversial treatment. Please note that this post is NOT in any way meant to usurp your facility’s policies and procedures…when in doubt always, always, always ask!
Enemy #1 when prone positioning: PRESSURE
When you turn your patient face down and then proceed to rotate them gently side-to-side, the risk for pressure-related injury goes way way way up. What is causing all this pressure? First of all, the bed itself. You want to make sure the cushions are tucked in “just so” around the patient so that no part of his/her body comes into contact with the bed frame as you turn. Lucky for you, the cushions are labeled so you know where they go…and you essentially use as many as you need to get the job done.
You’ll want to keep a VERY close eye on all tubings and where they come into contact with the skin. As you tuck your patient into the bed, do so with an eye toward what is lying across the FRONT of their body…as this will soon be the area receiving the greatest amount of pressure. For example, we typically train Foley catheters over the top of the thigh…but doing so with a proned patient is just asking for a pressure ulcer. Try to trail the Foley cath between the legs…and cushion any tube-to-skin areas with something like a Mepilex or possibly even an ABD pad.
Next, look at your IV lines…is tubing touching the patient? If so, it’s gonna leave a mark. Pad it and move it where you can. Hopefully your patient has a nice, juicy central line in the internal jugular where pressure will be minimized…but note they may also have an arterial line in the radial artery (and that tubing is stiff!). Place gauze or a mepilex underneath any areas where the tubing touches the skin.
The next thing to take into consideration are your ECG electrodes. You absolutely DO NOT want them (or the wires) on the chest. So…what is the good nurse to do? Note that your patient will be prescribed a certain amount of time to be placed in a prone position and a supine position. A vigilant nurse will change the ECG electrodes each time position is changed…if your patient is prone, you’ll place the leads on their back. Then, when you go to turn them supine, you’ll remove those leads and place them on the front. The challenging part to this, is that you have your patient off the ECG as they are turning…so if that isn’t acceptable to you, some people make a determination based on which side (front or back) the patient will be on the most. If you’re planning to prone them most of the time, then leave the electrodes on the back with padding between the wires and the patient’s skin.
And, most importantly of all…EVERY TIME you place your patient back in the supine position, check ALL those areas where tubing or monitoring devices could potentially be in contact with the skin. You’ll also want to assess for dependent edema as well…proning a patient can cause pretty severe facial and ocular edema and even corneal ulcerations. Again, vigilance is key.
Enemy #2 when prone positioning: ACCESS
As you can imagine, when your patient is tucked away in their RotoProne bed, your access to him/her is limited. Note that as soon as you turn the patient one way or the other, you’re going to immediately open the hatches across their chest…after all, the whole point of this thing is to improve oxygenation, right? You’ll also open the other hatches across their pelvis, legs and face when it is safe to do so (gotta let the skin breathe and check for pressure-associated injury, right?). But let’s say your patient is proned…and they start having issues…whatcha gonna do? It’s not like you can just run in their and fix it like you do with a standard patient in a standard bed. Let’s say, knock-on-wood, that your arterial line becomes dislodged. Someone let their toddler loose in the unit and they tripped over the art line and pulled it out (okay…far-fetched, but you get the idea).
In most cases of arterial line dislodgment, you’d hustle into the room with some gauze pads and grab that wrist and hold pressure until the bleeding stops. But your patient is tucked away in his bed and you can’t access his wrist quickly. Oh no! Whatcha gonna do? You’re going to supine the patient as quickly (and safely) as possible. This applies to ANY urgent situation…ETT dislodgement, CPR, etc. Here’s how you do it:
Step 1: Call for help…you’ll need at least one other RN (preferably two or three if needed) and your respiratory therapist.
Step 2: Stay calm…vigilance and safety are key!
Step 3: Position your team and assign roles. RT will manage the ETT. Assign one nurse to watching the IV lines coming from the head of the bed. If there’s anything coming from the foot of the bed, have another RN watch those lines (femoral lines, for example). Assign another RN to taking care of the gushing arterial line puncture. And assign another nurse to the task of operating the bed and opening the hatches when it is safe to do so. Your job, is to monitor the whole enterprise AND the patient while the turn is taking place.
Step 4: You have a couple of options for turning your patient…if you have the time to go step-by-step do it that way as there are built-in safety checks along the way. If it’s a CRISIS, then there are about three different ways to rotate the bed quickly…you can see one of them here on the bottom right of the screen labeled “CPR.” Hitting the CPR button on the screen or on the bed will cause the bed to immediately start turning and it’s the fastest way to get your patient supine when seconds count.
Step 5: Once the patient is turned, open the hatch across the chest, then any others that you can or need to.
Step 6: Thank your team and get on about the business of taking awesome care of your patient!
Enemy # 3 when prone positioning: LACK OF EXPEPERIENCE
Thankfully, we don’t prone patients all that often…which is also its downside. While I’m glad we don’t have patients that are this sick on a regular basis…using a specialty bed that only makes an appearance once in a while means you have to find other ways to stay on top of your skills. I’m lucky to work at a hospital that provides high-quality skills fairs where we can get our hands on the RotoProne bed and even get inside (pretty comfy!). The takeaway from this is that if you see a RotoProne on your unit…get in there and get familiar with the bed…be one of the “helpers” when the RN turns the patient, ask questions of the reps when they come by and flag down your clinical educator to seek out additional learning opportunities.
If you are assigned a patient on a RotoProne and you have ANY QUESTIONS, do not hesitate to ask. Ask your charge nurse, ask the other nurses and call the 800# any time you are even 0.00000001% unsure of something. Getting comfortable with any kind of critical care equipment is simply a matter of using it, touching it, troubleshooting it and seeing how your patients respond to it.
Enemy # 4 when prone positioning: HEMODYNAMIC COMPROMISE
There’s no doubt that turning your patient into the prone position changes hemodynamics, namely in the face of two components: venous return and cardiac function itself. While there are some instances when hemodynamics will be IMPROVED when proning, you need to be aware of the fact that they can also be COMPROMISED, so that’s what we’ll look at here.
When proning, venous return is likely to be reduced, thanks to increased intra-abdominal and intra-thoracic pressure. However, note that the RotoProne bed is designed to allow for abdominal expansion, but note that decreased venous return can still occur…especially AS you turn. Again, vigilance is key!
Now think about your vented patient (and every patient on a RotoProne is going to be vented)…positive-pressure ventilation is also going to increase intra-thoracic pressure, which can be even further evident in the prone position. I’m sure you remember from your physiology class that the result of increased intra-thoracic pressure is reduced cardiac output. Note that in SOME cases, cardiac output could actually be improved, but the physics of that is really fancy…if you want to read about it, then be my guest 🙂 The short version is this: know that your patient’s hemodynamics are likely going to change as you prone them…this is why you’d LOVE to have an arterial line at the very least (but if you can get a CVP or SWANN, you’ll have even more data to utilize. You’ll also have even more “things” to keep track of every time you turn your patient…it’s a toss-up).
So there you have it! While there are MANY other considerations to take into account when proning your patient…I hope this serves as a basic introduction to the exciting (and sometimes terrifying) world of prone positioning!
Be safe out there 🙂
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