Post updated 20-6-2022

Minimum staff and resources listed below, more can be utilised based on availability or need. Consider this as a streamlined technique and supplement to the existing SVHM ICU ‘Prone positioning in ARDS 2018’ protocol rather than a replacement.

Quick links: Proning: 1:48 (click time to move to this part of video on YouTube) De-proning: 6:33 (click time to move to this part of video on YouTube)

Considerations

Patient selection:

• Indication – as per Intensivist
• Contraindications – >120kg, unstable fracture (spine, pelvis, face), recent sternotomy, pregnancy (2nd trimester onwards)
• Exceptions to above to be considered by Intensivist (higher weight patients can be proned with more staff and planning)

Staff: 

• Proning team (4+) 
  • Airway by senior ICU Nurse or doctor
  • 3 other members to turn the patient (made up of nurses and SSAs)
• Optional additional staff in complex patients (e.g. obesity, CRRT, ECMO) to watch lines, ensure safe manual handling or manage instability

Equipment: 

• 3 pillows
• Slide sheets X 2
• Eye lubricant (chlorsig or equivalent)
• Gauze to cover eyes
• 2 small or 1 large tegaderm – cut into 2 to cover eyes over gauze
• 5 new ECG dots
• Tubing clamp to clamp ETT in case of emergency disconnection
• Leukoplast tape
• PPE as per unit guidelines

Process

Preparation (by bedside nurse):

• Ensure the ICU Senior Registrar or Consultant is aware proning is about to occur
• Pre-oxygenate to 100% for 5 minutes before the proning procedure
• Ensure ETT is at appropriate depth as per last CXR, secured with Leukoplast tape (not AnchorFast – can cause pressure injury when proned) and circuit connections are reinforced with sleek tape
• Remove patient’s gown (if applicable) and lubricate (chlorsig), apply gauze and tape eyes
• Disconnect nasogastric feeds and aspirate, ensure IDC is not taped to anterior leg
• Ensure lines (CVC and arterial lines) are well secured (sutured and dressed) and long enough 
• Rationalise infusions (cease non essential infusions until after proning) and prepare for potential haemodynamic instability on turning
• Ensure ventilator and infusion pumps are appropriately positioned
• Remove ECG dots (with new dots ready to go)
• Essential monitoring to remain is capnography and arterial pressure monitoring

Proning procedure:

• Align the 2 slide sheets and roll them up tightly together. Place the slide sheets under the patient and linen sheet. Unroll the combined slide sheets from head to toe with one person on either side of the bed.
• Place 2 pillows (one for pelvis, one for shoulders) over the patient
• Place sheet over top of patient, roll up sides firmly into cocoon ensuring patient arms are tucked by their side
• Slide patient to the edge of the bed to the side furthest away from the ventilator
• Turn patient 90 degrees onto their side, facing the ventilator
• Pull slide sheet from opposite side to turn patient into prone position in middle of bed
• Ensure that patient is ventilating adequately, reattach all monitoring and check that pillows are well positioned over the pressure areas

De-proning procedure:

Bedside nurse will once again prepare the patient for turning by notifying a senior doctor, preoxygenating, ceasing NG feeds and preparing lines/ETT to ensure that there is no accidental dis-logdement or disconnection during the turn. 

• Align 2 slide sheets and roll them together as in the proning setup. Place the slide sheets under the patient and sheet. Unroll the combined slide sheets from head to toe with one person on either side of the bed to coordinate this.
• Place bed sheet over top of patient, roll up sides firmly into cocoon ensuring patient arms are tucked by their side
• Slide patient to the edge of the bed towards the ventilator
• Turn patient 90 degrees onto their side, facing the ventilator
• Pull slide sheet from opposite side to turn patient into supine position in middle of bed
• Ensure that patient is ventilating adequately, reattach all monitoring 
• Bedside nurse will then check pressure areas, restart infusions and feeds and resume usual patient care.

Pictorial demonstration

Thanks to all those who contributed to this very quickly produced educational content!