O T H E R F E AT U R E S PROLONGED PRONE POSITIONING FOR PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME The Pennsylvania Patient Safety Authority received a request for events because PA-PSRS does not collect data on the total inci- guidelines and adverse event information about prolonged prone dence and duration of prone positioning. positioning (i.e., 16 or more consecutive hours) for patients with acute respiratory distress syndrome (ARDS). While early applica- Notes tion of prolonged prone positioning for patients with severe ARDS 1. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe has shown a reduction in patient mortality,1,2 no formal evidence- acute respiratory distress syndrome [online]. N Engl J Med 2013 Jun 6 [cited 2015 Sep 3]. http://www.nejm.org/doi/full/10.1056/ based guidelines were found in the literature; however, there are NEJMoa1214103 contraindications associated with this intervention. 2. Park SY, Kim HJ, Yoo KH, et al. The efficacy and safety of prone Before prone positioning is implemented, contraindications to positioning in adults patients with acute respiratory distress syn- consider include increased intracranial pressure, spinal instabil- drome: a meta-analysis of randomized controlled trials. J Thorac ity, severe hemodynamic instability, recent abdominal surgery Dis 2015 Mar;7(3):356-67. or open abdominal wounds, unstable fractures, pregnancy, 3. Chiumello DA, Algieri I, Brioni M, et al. The prone position in the eye trauma or injury, recent pacemaker insertion, maxillofacial treatment of patients with ARDS: problems and real utility. Chapter 1. In: injuries, tracheostomy or tracheal surgery, and extracorporeal Chiumello D, ed. Practical issues updates in anesthesia and inten- membrane oxygenation.3-5 sive care. New York: Springer International Publishing; 2015:1-13. 4. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe Authority analysts queried the Pennsylvania Patient Safety Report- acute respiratory distress syndrome [supplementary appendix [online]. ing System (PA-PSRS) database for event narratives from the most N Engl J Med 2013 Jun 6 [cited 2015 Sep 3]. http://www.nejm. recent 10 calendar years, 2005 through 2014, associated with org/action/showSupplements?doi=10.1056%2FNEJMoa1214103 prone positioning (i.e., keywords “prone” or “proning”) used &viewType=Popup&viewClass=Suppl as an intervention for patients with ARDS, respiratory failure, or 5. London Health Sciences Centre. Critical care trauma centre: proce- pneumonia. The search returned 167 event reports. Pressure dure for turning a ventilated patient prone in CCTC [online]. [cited ulcers accounted for the majority (82.6%, n = 138) of events 2015 Sep 3]. http://www.lhsc.on.ca/Health_Professionals/CCTC/ reported, which is consistent with the literature.1,2,6 procedures/proning.htm Other events related to prone positioning identified in PA-PSRS 6. Powers J. Use of prone positioning in ARDS [online]. Crit Connect 2011 reports or in the literature include unintended extubations; bro- Apr 2 [cited 2015 Sep 3]. http://www.sccm.org/Communications/ ken or displaced teeth; skin tears, lacerations, or abrasions; Critical-Connections/Archives/Pages/Use-of-Prone-Positioning-with- ARDS.aspx edema of the face, eyes, or tongue; disconnected tubes or intra- venous lines; ventilator-associated pneumonia; cardiac events; 7. Ayoubieh H, Alkhalili E, El Kassis Y, et al. Ischemic optic neuropathy pneumothorax; and ischemic optic neuropathy.1,2,6,7 Authority after prone ventilation for ARDS. Crit Care Med 2014 Dec;42(12 analysts were unable to determine the relative risks for these Suppl);A1641-2. Page 158 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 4—December 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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