Prone Positioning High Yield Users Guide

A lot of questions have come up around prone positioning in COVID19 patients. Click the button below for the high yield users guide our team created for Piedmont several years ago. It contains the key information such as when to prone, who to prone (inclusion/exclusion criteria), and when to stop.

Patients with COVID19 we are also occasionally asking them to “self-prone” that is prone while awake and not intubated which has some shown some good results throughout our hospitals thus far.

Background:

Prone position can significantly reduce mortality in Severe ARDS as proven by PROSEVA trial. The main points that they felt lead to their success:

• Strict ARDSnet vent settings

• Long prone sessions (16+ hours)

• Focused on Severe ARDS patients (PF < 150)

• Deep sedation and early paralytics encouraged

• Waiting period from initial ABG to confirm true severe ARDS

• Prone as a step in ARDS care and not done too late as a rescue therapy

Deciding to Prone:

Inclusion Criteria:

1. PF ratio < 150

2. Fio2 0.6 or greater

3. PEEP 5 or greater

4. VT at 6 cc/kg IBW

5. Protocol for initiation

   • Re-test ABG/PF ratio in 6 hours and begin prone position if remains < 150 and above vent settings still relevant

   • Call Rotoprone company at that time (done by RN): allow 2-3 hours for set up time and RN education

Exclusion Criteria

1. Intracranial pressure >30 mm Hg or cerebral perfusion pressure <60 mmHg if monitored

2. Massive hemoptysis requiring an immediate surgical or interventional radiology

3. Tracheal surgery or sternotomy during the previous 15 days

4. Serious facial trauma or facial surgery during the previous 15 days

5. Cardiac pacemaker inserted in the last 2 days

6. Unstable spine, femur, or pelvic fractures

7. Pregnant women

8. Lung transplantation

9. Burns on more than 20 % of the body surface

How to Order through the EPIC Order Set

1. Go to Epic Order Sets and Type in “prone” or “prone position”

2. Nurse and Respiratory Interventions will be prechecked as seen in screen shots below

3. CVL/Arterial line strongly encouraged to be placed if not already done so

Notes:

• This includes a new RASS target of -5 (deep sedation) as opposed to standard RASS 0

  • Nursing will be utilizing their ventilator PAD order set for Propfol and Fentanyl gtt’s

• Prone position for MINIMUM 16 hours prior to return to supine position

• SBT/SAT done during patient’s time in the supine position

  • Will not receive either in prone position

  • May not qualify for SBT due to vent settings (Fio2 or PEEP)

  • Should attempt SAT after discussions with RN if felt patient reasonably able to return to RASS -5 for next prone session and depending on duration of supine position

Respiratory Interventions (All prechecked)

ABG’s will be done mutliple times throughout prone process (arterial line highly encouraged)

Nutrition Consult

• Prechecked Nutrition consult to discuss nutrition plan for prone position

• We are currently working with nutrition to design the best plan for these patients

  • There is no evidence based consensus on Pre vs Post-Pyloric feeding

  • There is no evidence based consensus on full feeds during prone position vs slow feeds vs no feeds (with corresponding increases during supine position)

• Our recommendations:

  • Have nutrition calculate the total caloric daily needs and aim for those rather than a consistent rate

  • Slower feeds during prone position

  • Bolus feeds during supine position

Daily CXR

Paralytics

• Paralytics are available but NEED to be checked if desired

• Once checked they will automically check all 3 boxes below (bolus, infusion, monitoring)

  • Uncheck any that are not desired

• Cisatracurium preferred paralytic in Severe ARDS prone positioning but others available

Important Points

When Utilizing Prone Position

• Prone for minimum CONTINUOUS 16 hours at a time

  • No breaks during that time

• Duration of prone position in days is continues until one of the following guidelines below for stopping has been met (PRECHECKED IN THE ORDER SET)

Criteria for STOPPING prone position (ONE OF THE FOLLOWING)

• Improvement in Oxygenation

  • Defined as PF ratio > 150 WITH FIo2 < 0.6 AND PEEP < 10

  • Criteria must be met in SUPINE position > 4 hours after last prone session

  • RT will notify the provider if these criteria are met

• Clinical Decline

  • Decrease in PF ratio by more than 20% in prone position relative to the ratio in the supine position

    • Needs to be seen in TWO consecutive prone sessions

    • Should not stop prone position due to decreased PF ratio in one session

    • RT will notify provider if these criteria are met

• Complications occurring during a prone session or leading to interruption

  • Nonscheduled extubation

  • ETT Obstruction

  • Hemoptysis

  • O2 sat < 85% for > 5 mins while on 1.0 Fio2

  • PaO2 < 55 for while on 1.0 FIo2

  • Cardiac Arrest

  • Any life threatening event not otherwise defined

  • RN’s or RT’s will notify provider if any of these occur to stop prone positioning

Common Ventilator Adjustments

• Vent settings while prone: think traditional ARDSnet

  • 6 cc/kg IBW

  • PEEP off traditional PEEP/FIo2 table

  • Goal Pplat < 30

  • pH goal 7.25 – 7.45

• If Pplat > 30

  • If breathing spontaneously; sedation increased to RASS -5, paralytic can be started if not already, paralytic bolused if already on

  • If still Pplat> 30; VT decreased by 1 ml/kg every 5 minutes as long a Pplat > 30 until 4 ml/kg.

    • If pH < 7.20 then VT not decreased

• ABG timing

  • Baseline ABG prior to prone position

  • 1 hour after prone position

  • Q6 hours during first prone session

  • Baseline supine ABG at 4 hours after return to supine

Life threatening criteria for IMMEDIATE prone positioning

• PRONE as a true rescue therapy (immediate prone position, no waiting on repeat ABG)

  • PF ratio < 55

  • FIo2 1.0

• Maximal PEEP according to PEEP/FIO2 table

• Call rotoprone company immediately (or manual prone)

• Call ECMO team as well to assess candidacy

Sedation

• Sedation order set from adult ventilator management will be used with change in RASS to -5

  • RN’s will skip Fentanyl PRN boluses and start fentanyl/propofol gtt’s

• Advanced Sedation order set available separately if unable to achieve RASS -5 with standard sedation

• Daily spontaneously awakening and breathing trial ATTEMPTED while in supine position

Paralytics

• Strongly recommended using paralytics within first 48 hours but ultimately up to provider discretion.

• Nimbex preferred agent

PROVIDER NOTIFICATIONS TO BE AWARE OF

• We will need to identify the patients with severe ARDS and assess prone position candidacy

• Once order set written the following notifications will occur:

  • Repeat ABG in 6 hours and initiate the process of securing the prone bed

  • RN notification if unable to get RASS to -5 with currently ordered sedatives

  • Need for daily SAT/SBT

    • Best discussed on rounds with entire team (RN/RT/Intensivist)

  • Line placement if needed

  • Frequent ABG’s and ventilator adjustments

  • Nutrition discussion with RD’s

    • Use our recommendations above

  • RT’s will call if patient meets criteria for stopping prone positioning either due to clinical improvement, decline, or complication