In 2013, the randomized controlled trial “Prone Positioning in Severe Acute Respiratory Distress Syndrome” of the PROSEVA study group, proved the efficacy of prone position in acute respiratory distress syndrome (ARDS) patients with paO2/FiO2 ratio below 150 with an overall improvement of 28-day mortality of 16.8%. During the COVID-19 pandemic, the number of ARDS patients increased dramatically. Those patients required techniques oriented to improve oxygenation among which we may find prone position. Despite the fact that the clinical benefits of proning far outweigh any possible adverse event, healthcare professionals must safeguard against endotracheal tube dislodgement, hemodynamic compromise, line disconnection, eye and pressure injuries, while maintaining access to the chest, central lines, arterial lines and urinary catheters. Prone positioning is accomplished by manual techniques that have been traditionally described to require five to seven care team members, depending on the method and size of the patient.3, 4 However, there is no proof of the optimal number of people required for this procedure. Training of healthcare workers on how to carefully place patients in a prone position while preventing adverse events, is a barrier to implementation. Moreover, gathering trained staff in an intensive care unit (ICU) is challenging and could end in considerable disruption to workflow. In the specific context of COVID-19 pandemic, the previous becomes even more difficult due to staff and personal protective equipment shortages and exposure of the personnel.Only under special circumstances and mainly in limited resource settings with shortages of both material and human resources, this procedure could be done by a reduced number of operators. In the present work we describe a single operator step-by-step description. The amount of invasive devices, the patient's weight and its clinical condition are also factors that should be considered when deciding to carry out this procedure.
Step 1: Preparation
Preparing for a safe prone positioning is the first step, starting with the correct identification of the patient according to international standards and followed by checking for the indication of the procedure with the medical team. After completion, patients should be preoxygenated. General and oral hygiene, aspiration of secretions, and use of eye lubricating ointments should be done at this stage. The endotracheal tube must be correctly fixed, and pressure of the tube cuff should be checked. Enteral feeding should be suspended and temporarily disconnected for easier patient management, and to avoid displacement. For the same purpose, the central line should be placed below the patient's neck, opposite to the side at which the patient will be rotated. Urinary collector bag should be emptied and the catheter clamped to prevent leaks. The collector has to be placed on the same side to which the patient will be turned over. Regarding the respirator, settings must be checked, making sure all parameters are stable, alarms are correct, and that tubes allow proper patient management. All vital signs should be registered prior to patient mobilization, while levels of sedative drugs and neuromuscular blockers must be optimal.
Step 2: Maneuver
For patient rotation, movements must be done in an ordered way. The first one includes placing the patient on one edge of the bed by sequentially moving lower limbs, pelvis, torso, shoulders and head. Afterwards, legs have to be crossed over and the arm opposite to the edge should be placed below the patient's body. Then, a pillow has to be placed on the free border of the bed and below the patient's shoulder and another one below the pelvis. All non-invasive monitoring devices can be temporarily removed. The next movement is to rotate the patient 90° towards the free side of the bed before proceeding to complete rotation by pulling the pillows below, verifying that the arm below the patient's body has now been released. During all the process, the operator must check that tubes and central/arterial lines are not being displaced. Finally, the patient should be adequately placed at the center of the bed, the head facing one side, and the clamp of the urinary catheter, released. Upper limbs should be placed according to the “swimmer position” (when the patient's head looks right, the right arm should be placed beside the head and above the pillow).
Step 3: Post-maneuver care (Fig. 1)
The last step includes repositioning monitoring items and checking vital signs, putting silicone dressings below high pressure zones and below the patient's head to avoid ulcers. Finally, aspiration of secretions and covering the patient in the prone position completes the procedure.Video with a simulated patient showing the single-operator proning procedure.For repositioning the patient back into supine position, the same procedure has to be done following the inverse position.Even though placing patients in a prone position has usually been described as a maneuver requiring between five and seven skilled healthcare workers, the ideal number of people needed to perform this procedure is not clear. The actual pandemic and the lack of trained personnel in critical settings, led to developing the present technique, which could serve as a way to reduce both professional exposure and use of protective equipment. Nevertheless, several considerations have to be taken into account.First, this technique should be applied only when strictly necessary and in settings with limited access to human resources or proper equipment while reducing professional exposure to air transmitted infections. Whenever possible, it should be done with extra personnel to safeguard against adverse events. Secondly, the maneuver must be done with extra people that could care for the endotracheal tube and lines whenever possible. In case it is not possible, it should be performed under the presence of an observer (runner) who must be attentive to any complication and ready to help, guide and supervise the procedure. Thirdly, for overwheighted or obese patients, extra personnel could be needed. All steps should be carefully fulfilled to guarantee safety in this maneuver where the number of operators and their strength are reduced.To date, we have used the proposed prone positioning maneuver in 19 patients, where 14 (74%) were male, with a median age of 54 years old and median body mass index (BMI) of 29. Most patients were placed in a prone position twice or thrice, determining a total of 41 proning procedures. From all prone sessions, only one presented complication (nasogastric tube displacement) and in two cases, more than one operator was needed due to patient weight. No other complications were registered. Further studies are needed to fully understand the safety of the maneuver and its usefulness.
Author's contributions
All authors have significantly contributed to the production of this manuscript. Dr. Las Heras, Dr. Carboni Bisso and Dr. Pina have contributed to the conceptual framework and professional assistance. Dr. Gemelli was in charge of the manuscript production and description. Lic. Sotera and Dr. Barrios provided assistance in the technical description and practical demonstration of the procedure. Dr. Carboni Bisso was also in charge of cropping and editing the video.
Patient consent
The video represents a simulation with models. No real patients were included.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.