5/30/2014 Yielding Positions Prone positioning improves VQ To - - PDF document

5/30/2014 1

To Prone or Not to Prone?

John H. Turnbull, MD Assistant Professor of Anesthesia and Perioperative Medicine

Yielding Positions

Prone positioning improves VQ mismatch Prone positioning improves arterial

• xygenation

Prone position may be helpful for some patients

The Clinical Question

Does the current data support the ROUTINE use

• f extended prone positioning in moderate to

severe ARDS?

5/30/2014 2

Enrollment

3449 Patients Identified with ARDS 1434 Screened 576 Eligible

Exclusion Criteria

• Contraindication for Prone Positioning

– ICP > 30, massive hemoptysis, sternotomy within 5 days, unstable spine, femur or hip fractures, MAP < 65 mm Hg

• Use of iNO or ECLS prior to enrollment
• Burns > 20% BSA
• Life expectancy < 1 year
• NIPPV for > 24hrs prior to inclusion
• Chronic respiratory failure

5/30/2014 3

Baseline Characteristics Baseline Characteristics

Characteristic Supine Group (N = 229) Prone Group (N = 237) SOFA score 10.4 + 3.4 9.6 + 3.2 Use of vasopressors 83% 72.6% Use of NM blockade 82.3% 91%

Baseline Characteristics

Characteristic Supine Group (N = 229) Prone Group (N = 237) Body-mass index 29 + 7 28 + 6

https://www.youtube.com/watch?v=E_6jT9R7WJs

5/30/2014 4

Study Center Requirement

All participating centers must have had 5 years of experience prior to participation

• Non-blinded

– Use of fluids not reported – Causes of death not reported

Increased GOC Transitions

5/30/2014 5

Kaplan Meier Curves Prone Complications

Complication Prone Supine Events During Positional Change Increased sedation/NM blockade 80.4 56.3 27 Vomiting 29.1 12.6 35.1 Loss of venous access 16.1 4 36.6 Extubation 10.7 4.6 40 Airway obstruction 50.6 34 20.4 Hypotension, arrhythmias, vasopressors 72 54.6 22

5/30/2014 6

Conclusion To ensure we first do no harm, further studies are required prior to the initiation of wide-spread, routine proning of patients with moderate- to-severe ARDS