Intensive Care Nursing/Prone Position Procedure

Indications

• Severe ARDS

Contraindications

• C-spine precautions
• Haemodynamic instability (although can still perform CPR in prone position)
• Increased or concern with abdominal pressure
• Extreme obesity
• Increased intracranial pressure
• Staff not trained/skilled or not enough personnel to carry out safely

Initial Prone Position Manoeuvre:

Team Discussion	Role designation Team leader (likely airway person) to communicate all steps of the procedure. Clarify terminology on start and stop for safety.
Plan Resources	Anaesthetist or appropriate medical personnel skilled in airway procedure Nursing staff to perform procedure (minimum of 4, assessment of situation will need to be performed) ICU Team on standby
Preparation	Sliding sheets Position ventilator, drains, catheter and medication pumps in preparedness of new position Provide all cares before procedure. Eye protection is required.
Review	Sedation Paralysis Monitoring
Time Out	Pause to prepare team
Safety	Re-Check: Airway IV lines, drains ECG monitoring is no longer on anterior aspect
Start Position	Start with patient in supine position Place patients hands under buttocks Place padding or pillows across ankles, pelvis and chest Place sheet on top and roll together with bottom sheet ('The Cornish Pasty')
Slide Across	Slide across to edge of bed
Side Lie	Slide patient into side lie position
Re-check	Airway Vital signs and ventilator readings IV lines, drains
Side lie to prone position	Process to prone position Turn head and maintain airway as moving into prone position Gel pads can be used to protect head and other at risk areas Reposition 1 arm and head for 'swimming' or 'superman' position
Posture Change	Every 2hrs Anaesthetist or appropriate medical personnel skilled in airway procedure Reposition arms to side of patient Position ventilator, drains, catheter and medication pumps in preparedness of new position Slide up bed so head off the bed with Anaesthetist supporting head and airway throughout Rotate head to face opposite direction as previous position maintaining airway Slide down bed so body fully supported Reposition other arm using 'swimming' or 'superman' position

See Also

1. Airway Adjuncts
2. Mechanical Ventilation

Reference:

Guérin, Reignier, Richard, Beuret, Gacouin, Boulain, . . . Ayzac. (2013). Prone Positioning in Severe Acute Respiratory Distress Syndrome. The New England Journal of Medicine, 368(23), 2159-2168.

Video Resources

• UK 'Cornish Pasty' Critical Care approach from Tutorial WHH
• National teaching institute & critical care symposium demonstration by St. Joseph's Medical Center
• French approach from PROSEVA Trial prone instructional video in NEJMvideo

Note:  this is not a formal guide or competency checklist for performing prone position procedure