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Prone Position

 

 

Considerations

 

  • Effects on respiratory

    • ↑ FRC & PaO2 

    • Chest wall & lung compliance unchanged

  • Effects on CVS

    • ↓ stroke volume —> ↓MAP —> reflex tachycardia

    • ↑ pulse pressure (PPV) & stroke volume variation 

      • >14% PPV likely responds to fluid challenge

  • Effects of cerebral blow flow (CBF)

    • possible ↓ CBF from partial occlusion of carotid & vertebral arteries, spinal vessels and from compression of venous drainage

  • Potential complications

    • Direct pressure injuries:

      • skin necrosis, tracheal, breasts, genitals, pinna

    • Indirect pressure injuries:

      • macroglossia & oropharyngeal swelling, mediastinum, liver/pancreas, vessel occlusion

    • Post-operative visual loss

      • Central retinal artery occlusion —> direct pressure on the eye

      • Ischemic optic neuropathy —> no pressure on the eye

      • Risk factors: ↑ duration, ↑ blood loss, diabetes, HTN, male, atherosclerosis

      • Prevention: avoid direct compression of the globe

    • Peripheral nerve injuries

      • Any peripheral nerve is at risk —> often caused by poor positioning

      • Does not usually present in PACU but 90% appear within 7 days

      • 1/2 patients make full recovery at 1 year 

      • Risk factors: male, ↑ hospital stay, ↑BMI, ↓BMI, diabetes, advanced age

      • Prevention:

        • If possible, place arms at side

        • If arms are abducted they should be < 90° at elbow or shoulder

        • Avoid direct pressure in axilla

        • Pad the elbows

    • Prone accidental extubation

      • If possible: immediately call for bed in the room, roll supine and reintubate

      • Consider LMA for airway rescue

        • Can use fibreoptic scope to intubate through LMA

      • Consider use of fibreoptic scope for reintubation

        • only feasible if scope is near by and face is easily accesible

    • Prone cardiac arrest

      • Chest compressions can be performed:

        • with hands over both scapula or;

        • over the thoracic spine or;

        • open cardiac compressions if doing thoracotomy

      • Defibrillation can be done with pads:

        • antero-posterior

        • R axilla & cardiac apex

        • postero-lateral

      • For high risk patients, consider placing defib pads before turning prone

      • Gloved person to support head/neck to prevent C/S injury during shock

 

Management​

  • Six staff members are usually needed to position a patient to prone

  • Unstable C/S may need more staff members for log-rolling

  • Prior to positioning:

    • disconnect monitoring, infusions and breathing circuit

    • note the supine airway pressures to later r/o bronchospasm/endobronchial intubation

    • ensure endotrachial tube is securely fashioned / tied

    • Bed should not leave the room until correct ETT position / ventilation has been confirmed

 

References

Birte Feix, PhD MB BChir FRCA, Jane Sturgess, MBBS MRCP FRCA, Anaesthesia in the prone position, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 6, December 2014, Pages 291–297, https://doi.org/10.1093/bjaceaccp/mku001

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