Safety of prone positioning in critically ill patients

Background: During the past two years, 5% of patients admitted to the Medical Intensive Care Unit (MICU) of Hamad General Hospital (HGH) had severe acute respiratory distress syndrome (ARDS) with a PaO(2)/FiO(2) ratio less than 100 mmHg. The risks associated with this condition include ventilator associated lung injury, over distension of lungs, and poor gas exchange which results in increased morbidity and mortality. With quality improvement initiatives like prone positioning, the mortality and morbidity associated with severe acute respiratory syndrome(1) can be reduced by improving hypoxemia(2) with a significant enhancement in PaO(2)/FiO(2) ratios while reducing injurious ventilation. Also, prone positioning can help prevent invasive interventions such as placing patients on extracorporeal membrane oxygenation (ECMO) therapy.(3) Methods: We evaluated the safety of prone positioning for improving hypoxemia in critically ill patients with PaO(2)/FiO(2) ratio < 100 mmHg to PaO(2)/FiO(2) ratio < 200 mmHg from 1(st) January 2017 to 31(st) December 2018, without major complications. Data collected included the PaO(2)/FiO(2) ratios based on arterial blood gases of mechanically ventilated patients before and after prone positioning. We were able to facilitate prone positioning in 72 out of 110 patients with severe ARDS having a total average PaO(2)/FiO(2) ratio of 84.4 ± 30 mmHg. The patients were proned for a maximum of 16 hours in each session where up to three sessions were incorporated. No major complications were encountered during the proning sessions. This was thought to be accomplished through the coordination of a dedicated multidisciplinary team, education and simulation classes for physicians, nurses, and respiratory therapists, following appropriate inclusion and exclusion criteria for prone positioning, and implementing quality measures through Plan-Do-Study-Act (PDSA) cycles as represented in Figure 1. Results: The total average PaO(2)/FiO(2) ratio before proning for 65% of patients (n = 72) with severe acute respiratory distress syndrome(4) was 84.4 ± 30 mmHg and after one hour of 16 hours proning, it improved to 180.3 ± 78 mmHg. The remaining 35% of patients either had traumatic fractures, unstable spinal injury, severe hemodynamic instability, or morbid obesity together with ARDS which made them unfavorable for prone positioning. Out of those who were proned, 11 (12.5%) patients did not have improvement in oxygenation after proning due to non-recruitable lungs and were put on ECMO. The PaO(2)/FiO(2) ratios before and after one hour of implementing the prone position technique in each quarter of 2017 and 2018 are represented in Figure 2. Conclusion: • Sustaining and standardizing the accomplished work of data collection. • Implementing the prone positioning technique across other critical care units of Hamad Medical Corporation. • Keeping a record of minor complications associated with prone positioning and resolving them in further sessions. • Documenting cases with contraindications to prone positioning.