Prone To Problems

The risk of complications of a transfer is naturally higher in the prone position. These can be broadly divided into environment, patient and equipment causes…

Environment

• Being in a moving ambulance with limited space makes even the simplest interventions challenging. Limited access to IV lines, the ETT and the anterior of the chest increases the risk of adverse events being managed inadequately.

Due to the limited access to the chest when prone it is difficult to perform cardiopulmonary resuscitation – which is why a likely need for CPR needs to be considered when proning

Patient

• The patient can be haemodynamically unstable, requiring fluid resuscitation en route and adjustment of vasoactive drugs.
• The prone position promotes secretion drainage which may require frequent endotracheal suction. Secretion pooling – especially of acidic stomach contents – can damage the eyes and skin. There are also cases where the end-tidal sensor has required frequent changing from failure due to secretions.

Equipment

• Proning increases incidents such as accidental extubation, loss of central venous catheters or other intravenous access and ETT obstruction or kinking.
• These events may also not be identified as quickly when they are not directly visible en route.

Be Prone To Plan Ahead

• Planning should include what should happen in the event of complications and roles for team members. This should take place prior to the patient being transferred to the stretcher. Ensure sufficient staff are available for the transfer, including:
  • an intensivist
  • a critical care nurse
  • 1 to 2 paramedics

Critical care transfer in the prone position is a high-risk event – but good planning and critical thinking can minimise complications and make it a safe option

• Several case reports suggest increasing normal staffing by two, but others have operated successfully without a physician on board. Reports imply the benefit of a checklist specific for prone transport to improve safety compliance.
• Simulation and ongoing education of transfer staff can prepare them to undertake challenging prone transfers to minimise complications.

Share your thoughts and experiences on CPR in proned patients in the comments below. Have you had to make a decision to prone in the likelihood of cardiac arrest? Would you choose to do CPR prone or return the patient to supine before commencing?

• See more on some CPR guidelines referencing emergency re-positioning in proned cohorts from the Resuscitation Council UK

References