Prospective study to evaluate the kind of prone position concerning nursing, clinical outcome and material and personnel resources

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Introduction

Acute Respiratory Distress Syndrome (ARDS) is one of the most common, potentially lethal disease processes encountered in critical care with extremely high mortality of about 60%. Researchers have found that a significant improvement in gas exchange often occurs when ARDS patients are turned from the supine to the prone position. Different reasons are discussed for this effect: reduction of oxygen toxicity, recruitment of alveolar space and optimisation of postural drainage. But there are a lot of difficulties in nursing these patients and these depend on the kind of prone position. The dangers of pressure damage and oedema formation increase in the prone position. Also the possibility of suction and observation is decreased. So the major goal is to find out the best kind of prone position.

The available study is designed by physicians and nurses. Besides the question of patients' benefit concerning gas exchange, handling, the acceptance of the nurses, and economic consequences are proved.

Method/material

Patients with ARDS, or those patients identified as requiring to be nursed in the prone position with a Horowitz-Quotient (PaO₂/FiO₂) <250, were turned over into the prone position. In a randomised procedure the patients were placed into a 180° prone position (face down), a 135° prone position (near side position) or they were treated in a Rotation bed (RotorestR). Gas analyses defined the clinical effect of the position on gas exchange. Also changes in skin integrity, skin status and the clinical outcome of proning were documented.

Additionally, the number of nurses/physicians being involved in positioning the patient and the time taken was documented.

The prone position interval is fixed at 4–6 h depending on clinical data and the personnel situation.

End of the positioning-treatment is defined by clinical data and a Horowitz quotient >300.

Results

Twenty-two patients were positioned in the near side prone position. Eight patients were positioned in the 180°-position and five patients were treated in the rotation bed.

The distribution of the patient identified as requiring to be nursed in prone position shows the preferences of the prone position. In handling, nursing and observing, the near side position is the preferred prone position. The clinical outcome is comparable to the other forms of prone-positioning. In comparison with the other kinds of position the risk of complication (skin damages, oedema formation, lost of catheter or tube) is very small. On average you need one physician and two very well-introduced nurses for this positioning. So at every point of time, position changing can occur. For the face down position (180°) on average you need four to five well-introduced persons at minimum for a position changing. Additionally you need sufficient place to range two beds side by side. The possibility of observing, nursing and suctioning is less in the face down position than in the near side position. Our findings show a similar clinical effect concerning the gas exchange in the 180° position as in the 135° position. But for a clear position the number of researched patient is too small.

Also the patients treated in rotation bed shows a similar clinical outcome concerning the gas exchange.

But here also the handling and the economic resources necessary are incomparably high and at every time you need a special introduced nurse.

Conclusion

This study is being continued to get evident data for a clear point of view. The target is to develop evident criteria for the kind of prone position, not only in dependence of the clinical outcome but also concerning the economic and personnel possibilities in an ICU. A clinical treatment is not only orientated in doing the best for the patient but it is also limited by personnel acceptance and economic resources. The kind of treatment is established when the benefit for the patient is recognisable, when the handling is simple, does not need complicated equipment and a lot of personal resources. It must be safe and show a small quantity of complications.

These criteria, as shown by our study, are applicable for the near side position. Our goal is to develop criteria for the different kind of positioning possibilities concerning the clinical problems in gas exchange during the disease process.