ICU Proning Guidelines June 2016

PROCEDURE

Contraindications:

MAP < 65 despite ≥1 max vasoactive agent support

Unstable fractures of pelvis or spine

Cardiac arrhythmias resulting in hemodynamic instability

Relative Contraindications:

Long bone fractures in traction

Facial fractures

Cervical collar

Elevated ICP

Anterior chest tube with air leak

Pregnancy

Recent tracheal surgery (15 days)

Recent sternotomy (15 days)

Recent major abdominal surgery (15 days)

Temporary abdominal closure

Burns to face or ventral surfaces

Open wounds to ventral surfaces

DVT treated < 2 days

Weight > 150 kg

PREPARATION

**Proning should only occur on Day Shift. If patient needs to be placed supine in PM, Nocturnal Intensivist should be present**

  1. Consider any possible contraindications
  2. Whenever possible, explain the maneuver to patients and / or family
  3. Assign a Team Leader throughout this process (typically be patient’s RN)
  4. Confirm proper endotracheal tube placement
  5. Confirm that endotracheal tube, all peripheral or central venous catheters, chest tubes and arterial lines are well secured
  6. Obtain supplies (see checklist below) and ensure procedure cart is in front of patient room
  7. Consider how the patient’s head, neck and shoulder girdle will be supported after they are turned prone: eg. pillows vs OR foam
  8. Perform four eyes on nursing skin assessment and document
  9. Apply lubricant (Lacrilube) and shut both eyes with 2 x 2 gauze over eyes covered with Tegaderm/appropriate tape in paralyzed patients
  10. Consider Mepilex dressing/padding to high pressure points: eg. shoulders, sternum, knees
  11. Prepare additional pillows to pad arms, knees, ankles once proned
  12. Stop tube feeds, evacuate stomach and clamp feeding or gastric tubes.
  13. Ready endotracheal suctioning in preparation for the possibility of copious airway secretions which may interfere with ventilation.
  14. Make sure mattress is zipped (prevent tugging/wrinkles under patient)
  15. Team Leader decides whether the turn will be rightward or leftward
  16. Prepare all intravenous tubing and other catheters for connection once the patient is in prone position.
  17. Assure sufficient tubing length
  18. Relocate all drainage bags on the opposite side of the bed
  19. Move pleurovac(s) between legs
  20. Move intravenous tubing towards the patient’s head on the opposite side of the bed
  21. Ensure adequate personnel
  22. Attending Physician or Fellow
  23. Respiratory Therapy Supervisor or designee
  24. At least 4RNs
  25. Patient’s RN to act as Team Leader
  26. 2 Additional RN or PCT to act as runner if needed
  27. Team Leader performs a Time Out/Safety Checklist review prior to initiating proning

PRONING

  1. Place 2 (or more) people on either side of the bed to be responsible for turning. Team Leader at head of bed to ensure central lines and endotracheal tube do not become dislodged or kinked
  2. Increase FiO2 to 100% and be sure to note mode, tidal volume, minute ventilation and peak / plateau pressures prior to turning
  3. Disconnect all non-essentialcables and line (e.g, tube feeds, pressure cables, non-essential IVs)
  4. Leave EKG anteriorly, prepare new leads for posterior placement
  5. Leave Arterial Line connected for verification of BP
  6. It may be reasonable to temporarily remove EKG leads for the turn if other hemodynamic monitoring is in place
  7. Place new sheet and wicking pad on top of the patient, roll sheets into patient as tight as possible so patient is wrapped snuggly between the two sheets (burrito)
  8. Pull patient as far as possible to side of bed away the direction they will be turning.
  9. Turn the patient to the lateral decubitus position, with the dependent arm tucked slightly under the thorax. The nondependent arm may be raised in a cocked position over the patient’s head.
  10. Place EKG leads on posterior surface. Move the EKG cables to posterior and remove leads from patient’s anterior surface.
  11. Suction the airway if needed.
  12. Continue turning to prone position and reposition in center of bed using draw sheet.
  13. Turn head toward ventilator and ensure airway is not kinked and has not migrated during the procedure. Suction if needed.
  14. Reconnect all tubing and reassess connections and function.
  15. Support the face and shoulders appropriately, ensure no padding or pressure is put on the eyes or orbits.
  16. Position the arms in a modified “swimmers craw”. Do not maintain arms above shoulder level for risk of nerve damage. May reposition in a “W” shape for comfort
  17. Arm up on side the face is turned
  18. Shoulder dropped and elbow below axilla
  19. Opposite arm at the side of patient with palm up

MAINTENANCE

In addition to the standard ICU care prescribed, patients that are proned should also have the following assessments/procedures done Q2hr

  1. Auscultate the chest to check for movement of the endotracheal tube during procedure. Reassess minute ventilation and tidal volume.
  2. Monitor Head and Face
  3. Ears not kinked
  4. Eyes remain closed/well lubricated
  5. ETT secure and at appropriate placement
  6. Pressure points assessed
  7. Nasal/oral/ETT suction
  8. Maintain patient in 20° reverse Trendelenburg position. Lateral turning (20° - 30°) should be used, changing position every 2 hours.
  9. Rotate head and neck from left to right every 2 hours.
  10. Ensure ETT is secure
  11. Gather min of 2 RNs or RT
  12. Place both arms at side of patient with palms facing up
  13. Remove pillows and ensure patient’s head fully supported by RN/RT
  14. RT/RN repositions head and tubing to alternate side
  15. RN/RTpositions head to remain on pillow
  16. RN/RT to assess the face and ensure ETT is accessible/face is properly positioned
  17. Inspect skin for breakdown, specifically in weight bearing areas (iliac crest, shoulders, knees) and consider skin barrier application or wound care consultation.
  18. The recommended goal duration of prone positioning is 16 hours / day but may vary at the discretion of the attending physician.
  19. Team Nurse initiates a Time Out/Safety check prior to patient returning to supine to evaluate appropriate staff and supplies are present
  20. Surveillance CXR should be planned for time when patient is in supine position.

TERMINATION

  1. Emergent termination in setting of dislodgement of endotracheal tube, occlusion of endotracheal tube, severe hemoptysis, life threatening arrhythmias, cardiac arrest, hemodynamic instability not responding to medical therapies, worsening oxygenation with SpO2 < 85% or PaO2 < 55 mmHg for > 5 minutes with FiO2 100%, or any other life-threatening condition at the provider’s discretion.
  2. Once oxygenation improves as exhibited by PaO2/FiO2 > 150 with PEEP ≤ 10 and FiO2 ≤ 60% while in supine position, or at provider discretion.

Appendix: ICU Prone Positioning Checklist

Pre-Prone Checklist
Prior to Proning:
  • Identify MD (Attending or Fellow)
  • Contraindications reviewed
  • Review guideline
  • Emergency procedures reviewed
  • Explain procedure/risks/benefits to patient and family
  • Any future lines placed (eg: vas caths)
  • Team Leader identified
  • Procedure cart in front of room
Gather Equipment:
  • Pillows (minimum of 4)
  • Appropriate head support (OR Foam or pillows)
  • Ocular lubricant (Lacrilube)
  • Two 2x2s and 2 Tegaderms
  • Flat sheet
  • Wicking pads (chux)
  • 2 additional sat probes
  • Additional electrodes
  • Minimum of 4 Mepilex (knees, elbows)
  • Consider additional medications for hypotension, sedation, etc. (Phenylephrine/Push-Dose Epinephrine)
Assessment:
  • Hold Tube Feeds/Evacuate Stomach if indicated
  • ETT & Oral suction
  • ETT secured
  • Cap off and remove unnecessary lines & tubes (consider extension tubing if needed)
  • Apply protective dressings (Mepilex) to boney prominences
  • Eyes lubricated, 2x2’s applied and taped secure
  • Gastric tube secure (not taped to face)
  • Chest tubes/drains/foley midline
  • Ensure adequate analgesia/sedation/NMB
  • Reposition equipment to allow access to HOB
  • Prepare anticipated medications
  • Gather adequate and appropriate staff (MD, RT, 4 RNs, additional turning personnel)

Proning Checklist
**Each move must be done solely on the direction of the RT who is managing airway to ensure synchronous and safe movement
  • MD at HOB
  • RT at ventilator/to assist with airway management
  • RT Pre-oxygenate
  • RN/PCT minimum 2-3 per side of patient
  • Time Out performed: Team Leader to communicate plan and review emergency procedures. Choose which side patient will turn towards. RT will count out turns (airway)
  • Remove additional connections from patient
  • Place flat sheet on top of patient (with chux)
  • Roll top sheet together with bottom sheet (burrito)
  • Pull patient to opposite side of bed to prepare
  • Turn pt to lateral decubitus position, adjust EKG leads at this point if needed
  • Slowly complete proning and position patient to center of bed
  • Assess lines/ETT tube/drains for kink/dislodging
  • Reattach disconnected lines/cables
  • Position arms in modified “swimmers crawl”
  • Ensure pillows under shins. Knees/toes off bed
  • Place bed in reverse Trendelenburg
  • Reassess ETT cuff pressures/tidal volumes

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Title: Adult Inpatient Proning Guideline

Owner: Adult Inpatient ICU’s

Effective Date:

Doc. #

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