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2016; 62(3):287-293
FIGURE 1
Protocol in a tertiary university hospital.
ABG: arterial blood gas.
Moderate or severe ADRS with PaO
2
/FiO
2
ratio ≤150 mmHg in patients with
conventional MV (PEEP>10 cmH
2
O with FiO
2
>60%) in the first 48 hours of
the beginning of symptoms and/or impossibility of maintaining protective VM
(Plateau <30 cmH
2
O and alveolar distension pressure <15 cmH
2
O) and/or
presence of right ventricle dysfunction
Nutritional care
Place the post-pyloric enteral tube (check abdominal RX)
Maintain head elevated at 25-30º (reverse Trendelenburg)
Prescribe fixed prokinetics (erythromycin 250 mg IV 6/6h)
Initiate diet after the first hour
30 mL/h from hour 2 to 6
40 mL/h until hour 12
50mL/h from hour 12 until 1 hour before returning
to the supine position
Indication for prone?
Exclusion criteria
Hemodynamic instability (with
progressive increase of vasopressor)
Absolute contraindications
Severe acute arrhythmia
Pelvic fracture
Intracranial hypertension
Instability of the spine
Recent sternotomy/cardiac surgery
Peritoneostomy
Relative contraindications
Tracheostomy within the first 24 hours
Bronchopleural fistula
Hemoptysis/Alveolar hemorrhage
Ophthalmologic surgery/Increased
intraocular pressure
Pregnancy
Face trauma
PIA <20 mmHg
Any complications
occurring during the
maneuver?
Return to supine position
Does patient respond
to prone?
Response to prone position
PaO
2
/FiO
2
>20 mmHg
of baseline
PaO
2
>10 mmHg
of baseline
Return to supine
position and reassess
daily with ABG
Complications of the maneuver
Decrease in SpO
2
<10% of baseline
and/or desaturation <90% maintained
after 10 minutes in prone position
Severe hemodynamic worsening
Acute arrhythmia
PCR
Suspected dislocation of the
respiratory prosthesis
Collect sample for blood
gas test and perform
prone positioning
Maintain prone position for 1 hour and
perform new sample collection for ABG
Maintain prone for up to
17 (16 – 20) hours
Any new complications
during sustained prone
position?
Maintain supine position
Maintain prone for 6
hours and reassess with
new blood gas test
Return to supine position and
reassess in 4 hours with a new
sample for ABG
Re-prone
P/F <150 mmHg
ratio?
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Does patient
respond to
prone?
Offer
alternative
treatment
No