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G
ood
practices
for
prone
positioning
at
the
bedside
: C
onstruction
of
a
care
protocol
R
ev
A
ssoc
M
ed
B
ras
2016; 62(3):287-293
289
•
•
oxygen saturation less than 85% in pulse oximetry
or PaO
2
<55 mmHg for more than 5 minutes with
an FiO
2
of 1.0;
•
•
cardiorespiratory arrest;
•
•
heart rate less than 30 beats per minute for more
than 60 seconds;
•
•
drop in systolic blood pressure greater than 60mmHg
for more than 5 minutes;
•
•
or any other life threatening situation.
4,10,30
Complications related to prone positioning
The incidence of complications is low, at 3 per 1,000 pa-
tients/day. Pressure ulcers, pneumonia associated with
mechanical ventilation and obstruction or decannulation
of the endotracheal tube are the most common. Studies
report that accidental extubation is a rare event (0% to
2.4%).
41,42
Complications can be minimized or prevented
with monitoring and proper care.
27,42,46
•
•
Related to positioning: Pressure ulcers of the face, chest
and knee; facial and chest edema; brachial plexus in-
jury; surgical wound dehiscence; dietary intolerance
and lack of flow of the hemodialysis catheter.
•
•
Related to ETT: Accidental extubation; selective intu-
bation; endotracheal tube displacement and obstruc-
tion of the endotracheal tube.
•
•
Related to accesses: Removal of the hemodialysis cath-
eter and other catheters; removal of enteral and vesi-
cal tubes.
27,42,45,47
PEEP titration
There is clear guidance in the literature about PEEP, which
must be maintained during and after prone positioning.
The
Brazilian Mechanical Ventilation Guideline
strongly sug-
gests maintaining standard PEEP prior to position. This
titration can be done using the ARDSnet study’s FiO
2
×
PEEP table,
32
or finding the ideal PEEP through the dec-
remental PEEP maneuver.
Use of neuromuscular blocker
Recent studies and meta-analyses have demonstrated a
reduction in mortality, no increased incidence of poly-
neuropathy in patients with moderate and severe ARDS
(PaO
2
/FiO
2
ratio <120 mmHg) under deep sedation us-
ing cisatracurium in the first 48 hours of ventilatory
support.
33-36
Nutritional care during prone positioning
Review articles,
10
recommendations
38
or consensuses
30
on
positioning of patients in prone do not to cite or are too
summarized to report on how to nourish such individu-
als.
37,39,40
This attests to the lack of uniformity in terms
of the implementation of nutritional therapy among pro-
fessionals, mainly in relation to the schedules of breaks
during nutritional therapy.
41
In a recent study,
39
the use of a protocol based on the
elevation of the patient’s head (reverse Trendelemburg
position), the use of fixed prokinetics and reduced speed
of the diet allowed the application of early enteral nutri-
tion and faster attainment of the planned energy target.
C
onstruction
and
implementation
of
the
protocol
Based on the above review of the literature the authors
have implemented the following protocol in a tertiary
university hospital (Figure 1).
N
utritional
care
Before starting the diet, review the following precautions:
•
•
Document the placement of the nasoenteric tube (NET)
prior to placing the patient in the prone position based
on abdominal x-ray (if possible, the tube should be
postpyloric, however, the gastric position does not con-
traindicate its use).
•
•
Start diet with a semi-elemental formula after the first
hour in prone position, using an infusion pump.
•
•
Keep the head elevated at 25 degrees.
•
•
Prescribe fixed prokinetics (metoclopramide, bromo-
pride and erythromycin in isolation or combination).
•
•
Check for the presence of food in the oral cavity or
vomit every 2 hours.
•
•
Pause the diet for 1 hour before replacing the patient
in the supine position.
In case of complications
•
•
Detection of food remnants in the oral cavity, vomit-
ing or abdominal distension: suspend the diet, open
the NET in a bottle and reassess restarting the diet in
3 hours. Restart the diet if the gastric residue is less
than 250 mL.
Diet
Choose a semi-elemental diet with the following pro-
gression:
•
•
Formula 1 kcal/mL:
•
•
hours 2 to 6 , flow 0.5 mL/kg/h;
•
•
hours 7 to 12, flow 0.75 mL/kg/h;
•
•
hour 13 to the end, flow 1 mL/kg/h;
•
•
Formula 1.2 kcal/mL: