1 Upside Down You Turn Me: The When, The Why and the How of Prone Positioning with ARDS PatientsKathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING Northville, MI ©ADVANCING NURSING LLC 2017

2 Disclosures for Kathleen VollmanConsultant-Michigan Hospital Association Keystone Center Consultant/Faculty for CUSP for MVP—AHRQ funded national study Subject matter expert CAUTI, CLABSI, HAPU, Sepsis, Safety culture Consultant and speaker bureau for Sage Products LLC Consultant and speaker bureau for Eloquest Healthcare

3 Objectives Discuss the physiologic rationale for the improvement in oxygenation and reduce lung injury with the prone position in patients with ARDS. Review the evidence to help determine whether to use the position in ARDS as front line therapy Identify evidence based strategies for determining when to turn, how long to remain prone and preventing airway and skin complications. Compare and contrast patient and staff advantages and disadvantages of various methods to position patients prone.

4 Low Tidal Volume VentilationAPPRV HFOV ECMO Neuromuscular Blockade

6 Why Prone Positioning in ARDSTo improve oxigenation during prone positioning and after repositioning supine (Langer, Chest 1988; Gattinoni, NEJM 2001) To improve the response to recruitment maneuvers during prone positioning (Pelosi, AJRCCM 2003, Oczenski, CCM 2005) To improve respiratory mechanics after repositioning supine (Pelosi, AJRCCM 1998) To reduce ventilator associated lung injury “per se” (Broccard, Crit Care Med ; Valenza, Crit Care Med 2005; Papazian, Crit Care Med 2005) To improve drainage of secretions (Pelosi, Eur Respir J 2002; Reignier, Intensive Care Med 2005)

7 Major Factors Influencing Distribution of VentilationGravity/weight of the lung Compliance Heterogeneous lung disease

8 Air Goes To Area of Least Resistance

9 Distribution of Regional VolumesRegional pleural pressures Local lung compliance

10 J. B. West, 1997, Ventilation/blood flow and gas exchange (3rd edJ.B. West, 1997, Ventilation/blood flow and gas exchange (3rd ed.), Oxford: Blackwell, p.28.

11 Lung Weight Theory

12 Supine Position: Distribution becomes more uniform from apex to baseDependent lung ventilation > non-dependent Reduction in FRC Amis et al. Respiratory Physiology ;145 Kaneko et al. J of Applied Physiology ;767

13 Reduction in FRC in the Supine PositionInfluence of the abdominal contents on the diaphragm Position of the heart and relationship of the supporting structures to the lung and its influence on pleural pressure gradients

14 Froese A. and Bryan, A.G Effects of anesthesia and paralysis on diaphragmative mechanics in man. Anesthesiology, 41(3),

15 C,w a C,w ab C,w p = 0 C,w p C,w ab C,w a = 0Pelosi et. al. Am J Respir Crit Care Med 1998;157: (courtesy of Dr. Pelosi)

16 Reduction in FRC Position of the heart and supporting structures alters pleural pressure gradients.

17 SUPINE POSITION Cardiac Structures SpinePressure Lungs Lungs Spine Result: More + Pleural Pressure Collapsed Alveoli

18 PRONE POSITION Sternum Result: More – Pleural Pressure Open AlveoliCardiac Structures Lungs Lungs Sternum Result: More – Pleural Pressure Open Alveoli

19 Malbouisson LM. Et al. Am J Respir Crit Care Med 2000;161:2005-12

20 Major Factors Influencing Distribution of VentilationGravity/weight of the lung Compliance Heterogeneous lung disease

21 Heterogeneous Lung DiseasePelosi P. Am J Respir Crit. Care Med 1994;149:8-13.

22

23 Summary Prone: Supine: Increased FRC & improved complianceShifting of lung water & densities More homogenous aeration of the lung in ARDS from dorsal lung recruitment Increased oxygenation Supine: Marked reduction in lung volumes Alteration in lung mechanics (low compliance/high resistance) Compression atelectasis Hypoxemia

24 Scholten EL, et al. Chest, 2017;15(1):215-224

25 PERFUSION

26 Factors Influencing Regional Distribution of PerfusionCardiac output Pulmonary vascular resistance Gravity/body position

27 Distribution of PerfusionUpright Position: Blood flow decreases as it moves from base to apex with virtually little or no flow at the apices

28 J.B. West, C.T. Dollery, & A. Naimark, 1964, Journal of Applied Physiology, 19, p.71.3

29 Blood Flow Changes with PositionSupine position: Distribution becomes more uniform. Zone 3 maintained throughout the lung. Greater vertical perfusion gradient. Lateral position: Similar to supine except lung transforms to zone 2 approximately 18 cm above the most dependent part of the chest. Prone position: No major impact on regional distribution of pulmonary blood flow

30 Lung Protection in the Prone PositionAttenuate mechanical lung injury Improves dependent aeration recruiting alveoli Non-dependant regions shows dramatic reduction in hyperinflation Results in more homogenous lung aeration which reduces regional shear strain…less VILI Also decrease barotrauma and atelectrauma by recruiting and reducing over distension that occurs with higher PEEP Potential reduction in infection from drainage Scholten EL, et al. Chest, 2017;151(1):

31 Prone Positioning Clinical Research

32 First Reported Use Of Prone Position to Improve OxygenationPiehl MA, Brown RS. Use of extreme position changes in acute respiratory failure. Crit Care Med, 1976;4:13-14.

33 2000’s Prone Positioning ResearchMethodology Study Period: 304 patients with Acute Lung Injury/Acute Respiratory Distress Syndrome randomized to receive 6 hours of prone positioning q 24 for 10 days or supine position with q 2 hour lateral positioning Entrance criteria: modified ALI/ARDS definitions Measured: Measured: Primary endpoints: mortality at 10 days, hospital D/C & 6 months Secondary endpoints: PaO2/FiO2, ratio reduction, organ failure & incidence of complications Gattinoni L. et. al. N Engl J Med 2001;345:568-73

34 2000’s Prone Positioning ResearchResults 10 day mortality: 21% vs. 25% (RR 0.84 CI 0.56 to 1.27) Hospital d/c mortality: 50.7% vs. 48% ( RR 1.05 CI 0.84 to 1.32) 6 months mortality: 62.5% vs. 58.6% ( RR 1.06 CI 0.88 to 1.28) Significant increase in PaO2/FiO2 ratio in the prone group No difference in organ dysfunction % of patients with new or worsening pressure ulcers per patient was worse in the prone group Gattinoni L. et. al. N Engl J Med 2001;345:568-73

35 Study Concerns Was the study methodology relevant?Testing an intervention using ventilator management TV: 10.3/ml/kg (s) TV: 10.3/ml/kg (p) Average PEEP: <10cm Majority of patients entered into the study were primary respiratory pathology vs. secondary Were the patients in the prone position a sufficient period of time? Average time prone: Was the study powered sufficiently? Stopped early with recruitment problems Deviations from the protocol/41 patients

36 Mortality Benefit in the Most Severely IllMortality rate Quartiles SAPS II Gattinoni L. et. al. N Engl J Med 2001;345:568-73

37 2000’s Prone Positioning ResearchMethodology Study conducted: Dec 791 ARF patients, multicenter trial, unblinded, randomized 413 prone, 378 supine (8 hours per day) Patient in supine group could cross over to prone if P/F ratio < 100 for > 12 hours, or < 60 for 1 hr or on 100% FiO2 P/F ratio <300, hemodynamically stable & no contraindications to the prone position Measured 28 day all cause mortality, duration of mechanical ventilation, incidence of VAP & oxygenation Guerin C. et al JAMA 2004;292:

38 2000’s Prone Positioning ResearchResults No difference in mortality No difference in ventilation days Reduction in VAP in the prone group* Significantly higher P/F ratio for 28 days in the prone group Most patient’s in supine group crossed over Mechanical ventilation was not performed using a pre-determined algorithm (Tidal volume 8 ml/kg & tidal volume in pressure control 11ml/kg) Only in prone position for 8.6 hours for total of 4.6 days Limitations *P < 0.045 Guerin C. et al JAMA 2004;292:

39 Pediatric Prone PositionMethodology Multicenter, randomized controlled clinical trial measuring ventilator free days to day 28 7 Pediatric ICU’s (age 2 weeks to 18 years) Randomized to supine or prone within 48 hrs of ALI criteria Prone position for 20 hours each day during acute phase of illness Both groups tx with lung protective strategy, sedation protocols, extubation readiness and hemodynamic & skin care guidelines Results Stopped for lack of efficacy: no difference in VFD, mortality, OFD, hospital discharge Curley MA, et al. JAMA, 2005;294:

40 Prolonged Prone Ventilation StudyMethodology Multicenter trail: 13 ICU’s accruing 136 ARDS patients randomized within 48hrs of tracheal intubation (Between ) 60 to supine, 76 to prone (20h/d) Guidelines for ventilation & weaning were established Results Mortality: Supine 58% vs. Prone 43% p=0.12 Simplified APACHE II score higher in prone group Independent risk factors for mortality: APACHE score at inclusion, days elapsed prior to inclusion & randomization to supine position Minimal complications and rapidly reversible (prone avg. 17hrs for 10 days) Mancebo J et al. Am J Respir Crit Care Med, 2006;173:

41 Prone Positioning in Patients with Mod & Severe ARDS: RCTMulticenter, unblended RCT, 23 centers in Italy & 2 Spain 324 adults with ARDS (192 mod & 150 severe hypoxemia) Supine or prone 20hrs per day Entrance P/F ratio < 200 with ARDS dx & btwn 5-10 PEEP, <72 hrs Upon enrollment assessed O2 with PEEP 5-10 (potential derecruitment) Ventilation: < 8ml/kg (IBW) Tv & 30 cm H2O PP Did not control weaning or sedation Results No difference in mortality Trend towards a reduced mortality in the subgroup of severe hypoxemia Prone group had higher overall complication rates (3x) higher than shorter prone times Taccone P, et al. JAMA, 2009;302(18):

42 PROSEVA Trail: Proning Severe ARDS PatientsRCT 466 patients with severe ARDS (26 ICU’s in France/1 Spain) Severe ARDS P/F ratio < 150 mm Hg, with Fio2 0.6, PEEP of at least 5 cm of water, & a Vt of 6 ml per kg of PBW Initiation 12-24hrs Prone-positioning 16hrs/or supine position/ (proned within 1hr of randomization) NMB used 5 days Stopping prone treatment After 4hrs in supine meeting oxygenation criteria  in PaO2/FiO2 ratio of 20% (after 2 consecutive prone positions) Complications leading to immediate interruption Applied for 28 days, then clinician discretion Guerin C. et al. N Engl J Med, 2013, 368(23):

43 Results: Guerin C, et. al. Prone StudyBaseline characteristics similar except for, vasopressors (S), sepsis related SOFA score (S) & use of NMB’s (P) Prone 16% mortality, supine 32.8% p< Prone group  ICU LOS (2 days, &  VFD (4 days) (NS) No differences in complications except > cardiac arrest in supine position (31 S vs. 16 P) N=6 Guerin C. et al. N Engl J Med, 2013, 368(23):

44 Prone Positioning in ARDS: A Systematic Review and Meta-analysis11 RCT’s (n=2341) 6 trials used lung protective strategies Difference seen with > 16hrs in the position N=11 Sud S, et al. CMAJ DOI:

45 2014 Meta-Analysis: Sub-GroupsBenefit of lung protective ventilation Benefit of longer time in the prone position Lee JM, et al Crit Care Med, 2014; 42:

46 Impact on Clinical & Safety OutcomesPressure ulcer, dislodgement of the ET tube and thoracotomy tube higher in prone position Sud S, et al. CMAJ DOI:

47 Comparison of the Major Prone Trials* * PROSEVA benefited from limitations of previous trials; limited sample size, sign treatment crossover, unstandardized vent management with higher Vt, mild ARDS, short prone times per 24hrs, stop times arbitrary, enrollment late in Dx Scholten EL, et al. Chest, 2017;151(1):

48 Prone positioning was used in 16.4% of patient with severe ARDSGattinoni L, et al. JAMA, 2016;315(8):

49 What’s the Challenge?

50 Indications for Use

51 Who to Place in Prone Position?Patients with severe ARDS (PaO2/FiO2 < 150 mm Hg) Early in the course (ideally within 48 hr) Best outcomes reported when prone positioning is used in combination with both low tidal volume ventilation (6 cc/kg) and neuromuscular blockade (48 hrs) “Unless otherwise contraindicated prone positioning should be applied as first line therapy to any patient with moderate or severe ARDS and applied as early as possible after identification of hypoxemic ARDS Scholten EL, et al. Chest, 2017;151(1): Bein T, et al. Intensive Care Med,2016;42: )

52 The Berlin ARDS DefinitionTiming Within 1 week of a known clinical insult or new/worsening respiratory symptoms Chest Imaging (X-ray or CAT scan) Bilateral opacities-not fully explained by effusions, lobar/lung collapse or nodules Origin of Edema Respiratory failure not fully explained by cardiac failure or fluid overload; Need objective assessment (e.g. echocardiography) to exclude hydrostatic edema if no risk factors present Mild Moderate Severe Oxygenation < 200 PaO2/FiO2 or < 300 with PEEP/ CPAP > 5 cm H2O < 100 PaO2/FiO2 < 200 with PEEP > 5 cm H2O < 100 PaO2/FiO2 with PEEP Mortality 27% (24% to 30%) 32% (29% to 34%) 45% (42% to 48%) Ferguson ND, et al. Intensive Care Med. 2012;38: Dharia A, et al. ICU Director, 2012;3(6):

53 French Trial Entrance CriteriaSevere ARDS P/F ratio < 150 mm Hg, with Fio2 0.6, PEEP of at least 5 cm of water, and a Tv to 6 ml per kg of PBW Initiation 12-24hrs Berlin ARDS Definition Oxygenation Criteria Mild Moderate Severe Oxygenation < 200 PaO2/FiO2 or < 300 with PEEP/ CPAP > 5 cm H2O < 100 PaO2/FiO2 < 200 with PEEP > 5 cm H2O < 100 PaO2/FiO2 with PEEP

54 Indications for Use Contraindications

55 Who Not to Place in Prone Position?Patients with facial/neck trauma or spinal instability Patients with recent sternotomy or large ventral surface burn Patients with elevated intracranial pressure Patients with massive hemoptysis Patients at high risk of requiring CPR or defibrillation Scholten EL, et al. Chest, 2017;151(1):

56 Decision Making Factors in Positioning Patients ProneTime interval from injury to position change < 48 hrs Hemodynamic status

57 Challenges to Mobilizing Critically Ill PatientsPotentially Modifiable Barriers Patient –related barriers (50%) Hemodynamic instability, ICU devices, physical & neuropysch Structural (18%) Human or Technological Resources ICU culture (18%) Knowledge/Priority/Habits Process related (14%) Service delivery/lack of coordination Clinician function Dubb R, et al,   Ann Am Thorac Soc. 2016 May;13(5): 57

58 How Well Are We Really Doing?Edited JA How Well Are We Really Doing? Every-2-Hour Turning So how well are we doing? There was a study done with 566 hours of observation over an 8-hour period, looking every 15 minutes to see how frequently patients got turned. What percentage of patients do you think got turned every 2 hours?

59 Body Position: Clinical Practice vs. StandardMulticenter study: 74 patients/566 total hours of observation Change in body position recorded every 15 minutes for 8hrs 2.7% had a q 2 hour body position change 49.3% of observed time no body position change Prospectively recorded, 2 days, 40 ICU’s in the UK Analysis on 393 sets of observations Average time between turns 4.85 hrs (3.3 SD) Krishnagopalan S. Crit Care Med 2002;30: Goldhill DR et al. Anaesthesia 2008;63: 59

60 Hemodynamic Instability Is it a Barrier to Positioning?

61 The Role of Hemodynamic Instability in Positioning1,2Lateral turn results in a 3%-9% decrease in SVO2, which takes 5-10 minutes to return to baseline Appears the act of turning has the greatest impact on any instability seen Minimize factors that contribute to imbalances in oxygen supply and demand Factors that put patients at risk for intolerance to positioning:3 Elderly Diabetes with neuropathy Prolonged bed rest Low hemoglobin and cardiovascular reserve Prolonged gravitational equilibrium One of the big concerns that we have is when a hemodynamically unstable patient is turned or early mobilization is used. A couple of practices that we routinely do that are not supported by science. One of them is that when we turn patients, we’re looking at all of the data on the monitor (the saturation and the blood pressure) and if we see that change, we immediately return the patient to the supine position. That isn’t supported by science. When we are laterally turning these patients, their hemodynamic variables do drop; it is expected. These patients require about 5 to 10 minutes of equilibration before they return to baseline. We shouldn’t be making our assessment until 5 to 10 minutes into the position turn or sitting up (because this also applies to dangling patients). We’re preventing progression to mobility because we’re not allowing this adaptation to occur. The other intervention that we can do to help is to minimize the factors that contribute to the oxygen supply-and-demand imbalance, because turning takes a fair amount of demand for the patient and that patient may not have the supply. By breaking up our care practices so the pateints have rest period in between they are more likely to tolerate activity. Winslow EH, et al. Heart Lung. 1990;19: Price P. Dynamics. 2006;17:12-19. Vollman KM. Crit Care Nurs Q. 2013;36:17-27

62 Has the manual position turn or HOB elevation been performed slowly?Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement1,2 Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Is the patient hemodynamically unstable with manual turning? O2 saturation < 90% New onset cardiac arrhythmias or ischemia HR < 60 <120 MAP < 55 >140 SPB < 90 >180 New or increasing vasopressor infusion No Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Yes No Is the patient still hemodynamically unstable after allowing minutes’ adaption post-position change before determining tolerance? Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Yes No Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance Here’s an algorithm that was recently published. If a patient is hemodynamically unstable with manual turning, this algorithm can help you determine what to do. You can start by waiting 5 to 10 minutes for the patient to equilibrate. If the patient is still experiencing issues, you can look at the mobility readiness. You can try manually turning, slowly, to see if the patient tolerates it. If not, the patient can be moved to rotational therapy. This algorithm is designed to ensure that no patient will remain hemodynamically unstable with manual turning or remain in a supine position for extended periods of time. Yes No Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change Has the manual position turn or HOB elevation been performed slowly? Yes Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure. Vollman KM. Crit Care Nurse. 2012;32:70-75. Vollman KM. Crit Care Nurs Q. 2013;36:17-27.

63 Decision Making Factors in Positioning Patients ProneTime interval from injury to position change Hemodynamic status Mentation-PAD guidelines Vollman KM, Dickenson S, Powers J. AACN Procedural Manual, Chapter 19;2016: Scholten EL, et al. Chest, 2017;151(1):

64 Neuromuscular Blockade in Early ARDS: Not Ready For Front Line TherapyMulticenter, double blind trial 340 patients with ARDS within 48hrs of admitted to ICU ARDS defined as P/F ratio of < 150 > PEEP 5cm & Vt of 6-8 ml/kg PBW Randomized to receive 48hrs of cisatracurium or placebo Study did not use train of 4 Results: After risk adjustment NMB group showed improved mortality at 90 days (31.6% vs. 40.7%) Also significant at 28 days time off vent No difference in muscle weakness NNT 10-11 SCCM guideline revisions in the works Papazian L, et al. N Engl J Med. 2010;363(12):

65 Neuromuscular Blocking Agents in ARDS: Systematic Review and Meta-analysis3 trials (431 patients; 20 centers; all from the same research group in France) All trials assessed 48-hour infusions of cisatracurium besylate. Lower risk of barotrauma No increase in vents days or risk of ICU acquired weakness Consider use in patients with Severe ARDS and patient ventilator asynchrony Gattinoni L, Marini JJ. ICM, 2015;41: Alhazzani W, et al. Critical Care, 2013;17:R43

66 Challenges to Mobilizing Critically Ill PatientsPotentially Modifiable Barriers Patient –related barriers (50%) Hemodynamic instability, ICU devices, physical & neuropysch Structural (18%) Human or Technological Resources ICU culture (18%) Knowledge/Priority/Habits Process related (14%) Service delivery/lack of coordination Clinician function Dubb R, et al,   Ann Am Thorac Soc. 2016 May;13(5): 66

67

68 Lee JM, et al. Crit Care Med, 2014;42(5):1252-1262

69 Decision Making Factors in Positioning Patients ProneTime interval from injury to position change Hemodynamic status Mentation-PAD guidelines/NMB Patient Size Vollman KM, Dickenson S, Powers J. AACN Procedural Manual, Chapter 19;2016:

70 Indications for Use Contraindications Pre-Proning Prep The How

71 Pre-Prone Position Requirements for Safe Prone Positioning Checklist Pre-oxygenate the patient with FiO2 1.0 Secure the endotracheal tube and lines Tubes inserted above the waist/Top of the Bed Tubes inserted below the waist/Foot of the Bed (Except Chest Tubes) Correct number of staff to assist in the turn, and monitor the turn Adequate number supplies to turn (pads for bed, sheet, protection for the patient or specialty bed) Experienced staff with working knowledge of how to perform the turn and how to supine the patient in the event of an emergency Scholten EL, et al. Chest, 2017;151(1): Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3): Dickenson S, et al. Crit Care Clin 27 (2011) 511–523 Vollman KM, Dickenson S, Powers J. AACN Procedural Manual, Chapter 19;2016:

72 Pre-Prone Position Requirements for Safe Prone Positioning Checklist Requires 3-5 people, close attention to endotracheal tube (ETT) and central lines Preparation: preoxygenation, empty stomach, suction ETT/oral cavity, remove ECG leads and reattach to back, repeated zeroing of hemodynamic transducers Consider placement of 5 layer silicone dressings in high pressure/shear risk areas (forehead, chest, knee’s) Ensure the tongue is inside patients mouth Empty ileostomy/colostomy bags before the turn Scholten EL, et al. Chest, 2017;151(1): Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3): Dickenson S, et al. Crit Care Clin 27 (2011) 511–523 Vollman KM, Dickenson S, Powers J. AACN Procedural Manual, Chapter 19;2016:

73 The How

74

75 Prone Positioning: The HowStep 2: Place the flat sheet around the arm that will pull through, (side you are turning toward). Turn towards the ventilator Step 1: With a flat sheet, pull the patient to side of bed opposite the ventilator using 4 staff.

76 Prone Positioning: The HowStep 4: Using the sheet turn the patient over toward the ventilator and position them prone. The arm and sheet will pull across the bed. Step 3: A second flat sheet is placed on the bed and tucked under the patient. This sheet will pull through as you are turning the patient.

77 Prone Positioning: The HowStep 5: Pull and center the patient. Discard the sheet that was used to supine patient. Straighten lines and tubes. Chest and/or pelvic support can be done by placing a pillow at the abdomen before completing the turn.

78 Returning to Supine: The HowStep 1: Using a flat sheet, pull the patient to one side of the bed. Step 2: Place the flat sheet around the arm that will pull through, (side you are turning toward). Step 3: A second flat sheet is placed on the bed and tucked under the patient. This sheet will pull through as you are turning the patient.

79 Returning to Supine: The HowStep 4: Using the sheet turn the patient over and position them supine. The arm and sheet will pull across the bed. Step 5: Discard the sheet that was used to supine patient (A). Straighten lines and tubes (B).

80

81 When to Stop Prone Positioning?In PROSEVA, prone positioning was stopped when PaO2/FiO2 remained > 150 mm Hg 4 h after supinating (with PEEP < 10 cm H2O and FiO2 < 0.6) Optimal strategy is unclear: consider continuing prone positioning until clear improvement in gas exchange, mechanics, and overall clinical course. Scholten EL, et al. Chest, 2017;151(1):

82 Positioning Schedule & Maintenance CareConsider every 16hrs uninterrupted (more freq turn back may cause decruitment) Maintain gain, laterally rotated/q2 turning until gas exchange decreases or no more than 2 hrs Loose gain, provide necessary care and return to the prone position Move head slightly every hour or q 2 If hemodynamic monitoring, level the zero reference point at the right atrium Vollman KM, Dickenson S, Powers J. AACN Procedural Manual, Chapter 19;2016:

83 Positioning Schedule & Maintenance CareROM of arms every 2 hours/change position of the arms Support feet in correct anatomical alignment Double secure endotracheal tube Eye care-if taping preform horizontal Turn off tube feeding 1hr prior to position change Consider time periods in reverse trendelenburg to address facial edema and reduce risk of vomiting Vollman KM, Dickenson S, Powers J. AACN Procedural Manual, Chapter 19;2016:

84 Potential ComplicationsTemporary increase in oral and tracheal secretions occluding airway ETT migration or kinking Vascular catheter kinking Elevated intraabdominal pressure Increased gastric residuals Facial pressure ulcers, facial edema, lip trauma from ETT, Brachial plexus injury (arm extension) Scholten EL, et al. Chest, 2017;151(1):

85 Care Concerns Hemodynamic monitoring: Feeding:In studies that communicated landmarks for zero reference, no difference in HR, SBP or CI Feeding: The patient is at most risk for aspiration during the turning process If reverse trendelenburg position is used to reduce facial edema, must weigh risk-benefit of micro aspiration Tubes placed past the pyloric valve may also reduce the risk of aspiration Patients have been placed in the prone position successfully; open abdomens, intra-cranial pressure monitoring, hemodynamic instability, pelvic fractures, external fixators, multiple traumatic injuries, use of extracorporeal membrane oxygenation (ECMO), and continuous renal replacement therapy (CRRT) Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3): Schiller HJ, Reilly PM, Anderson HL, et alChest 1996;110:142S.29. Goettler CE. Et al Critical Care 2002,6: .

86 Questions That Remain Optimal PEEP management in prone positionDoes effective prone positioning necessitate neuromuscular blockades for several days? What impact does that have on ICU acquired weakness? What is the learning curve and associated risk for inexperience centers adopting the practice Scholten EL, et al. Chest, 2017;151(1):

87 Definition of Progressive MobilityEarly Progressive Mobility definition: Planned movement in a sequential manner beginning at a patient’s current mobility status and returning the patient to baseline Early mobility includes: Head elevation Manual turning Passive and active range of motion Continuous lateral rotation therapy/prone positioning Movement against gravity Physiologic adaptation to an upright/leg down position (Tilt Table, bed egress) Chair position Dangling Ambulation The definition of early mobility is “planned movement in a sequential manner beginning at a patient’s current mobility status and returning the patient to baseline.” This definition includes all types of mobility, from head-of-bed (HOB) elevation (which can not only prevent aspiration, but can also begin to help the patient physiologically adapt to an upright position), to manual turning in the bed, to passive and active range of motion (ROM), rotational therapy (if needed), using the bed as a Tilt Table for that physiological adaptation, in-bed and out-of-bed chair position, dangling, and ambulation. It covers a full spectrum of mobilization. Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

88 Outcomes of Early Mobility Program incidence of skin injury  time on the ventilator  incidence of VAP  days of sedation  delirium  ambulatory distance Improved function Bassett RD, et al. Intensive Crit Care Nurs. 2012;28:88-97. Staudinger t, et al. Crit Care Med, 2010;38. Abroung F, et al. Critical Care, 2011;15:R6 Morris PE, et al. Crit Care Med, 2008;36: Pohlman MC, et al. Crit Care Med, 2010;38: Schweickert WD, et al. Lancet, 373(9678): Thomsen GE, et al. CCM 2008;36; Winkelman C et al, CCN,2010;30:36-60 Dickinson S et al. Crit Care Nurs Q, 2013;36:

89 Base Your Decision on Research & Clinical ExperienceTo Prone or Not to Prone? Base Your Decision on Research & Clinical Experience

90