CACCN Conference: ARDS & Prone Position
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How simulations can be used to train nurses to safely and effectively prone moderate to severe ARDS patients.
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CACCN Conference: ARDS & Prone Position
- 1. PRONE POSITION IN ACUTE RESPIRTAORY DISTRESS SYNDROME D A V I D H E R S E Y B A , B N , R N E L I N O R K E L L Y B A , B N , R N
- 2. ACUTE RESPIRATORY DISTRESS SYNDROME • Acute onset (< 48 hours) • Bilateral infiltrates • PaO2/FiO2 ratio <300mmHg • No evidence of cardiac causes
- 3. PRIMARY & SECONDARY ARDS DIRECT ARDS INDIRECT ARDS Influenza Sepsis Pneumonia Transfusions (TRALI) Aspiration Pancreatitis Inhalation Injuries Fluid Overload* Pulmonary Contusions OD ARDS
- 4. MILD, MODERATE & SEVERE ARDS WE USE RATIO LESS THAN 150 FOR PRONING
- 5. STAGES OF ARDS Recovery Stage Slow restoration of lung function Proliferative Stage 7—21 days Alteration of lung tissue Poor Compliance Decreased Edema Exudative Stage 0-7 days Edema (peaks 048hrs) Inflammation
- 7. CYCLE OF INJURY Barotrauma: too much pressure (>35mmHg) Atelectotrauma: collapse and expansion of the alveoli or excessive driving pressure Volutrauma: too much tidal volume
- 8. PRONE POSITION: WHY DOSE IT WORK NOW?
- 9. Absolute Contraindications SPINAL, PELVIC INSTABILITY AND/OR FRACTURES INCREASED ICP ( SEVERE)
- 10. Does not Exclude the Patient ADVANCED PREGNANCY ABDOMINAL SURGERY RECENT LESS THAN 14 DAYS MORBID OBESITY MULTI TRAUMA SHOCK ABDOMINAL COMPARTMENT SYNDROME
- 11. PRONE POSTIONING OF A PATIENT Management and Checklist This Photo by Unknown Author is licensed under CC BY-SA-NC
- 12. Nursing Management- Pre Family preparation Sedation/paralytics- Rass, BIS, TOF Lubricant/eye drops/pads Assessment of lines Clamp N.G and stop feeds Size of patient –staff required Equipment Team CPR can be in prone
- 13. Checklist- Pre Proning Designate Team Roles Patient has adequate sedation/paralytic Airway management equipment Minimize all non-essential infusions and ensure all lines are secure Place lines midline to head of the bed or feet Airway management physician present for reintubation
- 14. Procedure Checklist Team Assessment Disconnect leads,EKG and NIBP Minimum of 5 staff RT at head Two nurses/staff or more patient size dependent each side Slide patient to edge of bed away from ventilator Tilt the patient and remove pillows Clean tap is placed to roll patient on Patient’s arm is placed underneath his or her hip on the side patient is rolled to Head is placed to side away from lifted arm Pillow under pelvis, upper chest and lower legs
- 15. Post Procedure Reassess patient after movement- vitals, ventilator settings, ABG’s Reconnect monitor Reconnect any infusions Access for pressure injuries-face, breast, genitals, check for abdominal restriction Debriefing prn Checklist every hour Turn head every two hours, arms changed every two hours, eye care, check for pressure injuries
- 17. OPERATION PRONE A PATIENT PRONE PILLOW CHEST PILLOWS HIP PILLOWS
- 18. OPERATION PRONE A PATIENT SOAKER PAD COMFORT GLUDE TAP SYSTEM
- 19. OPERATION PRONE A PATIENT Multiple pillows elevating the chest (A) ensuring head in natural position on the prone pillow (B). Hips elevated with pillows (C) preventing compression on the abdomen (D). A B C D
- 21. OUR IN SITU SIMULATION EXPEREINCE
- 22. PRONE POSITION CASE STUDIES Mr. X is a 60 year- old with a history of HTN, DLP and DM. Mr. X called EHS for SOB and feeling unwell (SpO2 75%) Admitted to a regional ICU Failed and HFNP Bi-Pap (Day4) Intubated (Day4) Progressively difficult to ventilate and oxygenate (Day6) Transfer requested to Halifax Infirmary (Day12) Patient turned prone transport team Transported by ambulance to ECMO centre Required VV- ECMO Died day 40+
- 23. CASE ONE DAY 4 12 13 Pre- Prone Post Prone Arrival at NHI MODE PCV+16 PCV+14 PCV+16 PCV+20 PCV+20 N/A Rate 22 24 30 30 30 N/A FiO2 1.0 .85 1.0 1.0 1.0 N/A PEEP 10 12 14 13 13 N/A Airway 26 26 30 33 33 N/A VT 560 520 310 350 375 N/A Compliance 21.5 20 10.3 11.6 12.5 N/A SpO2% 84% 84% 91% 92% pH 7.53 7.22 7.28 7.27 7.28 PaCO2 28 70.3 67 62 66 PaO2 199 60.1 56 68 65 Ratio 199 60 56 68 65
- 24. CASE TWO Mr. Y is a 55 year-old male with a history of ETOH abuse. Mr. Y presented to ED with CAP and Sepsis Bi-PAP on Day 4 Intubated Day 8 Progressively difficult to ventilate & oxygenate Severe ARDS Transfer to Halifax Infirmary on Day 8 Patient turned prone by transport team Prone for 12-16 hours, turned supine and did very well Slowly improved, extubate and discharged home
- 25. CASE TWO DAY 8 8 8 Pre-Prone Post Prone Arrival at NHI MODE PCV+20 PCV+20 PCV+20 PCV+20 PCV+20 PCV+20 Rate 32 32 32 32 32 32 FiO2 .80 .80 .80 .80 .80 .80 PEEP +12 +12 +12 +12 +12 +12 Airway 32 32 32 32 32 32 VT 273 291 270 270 350 350 Compliance 8.5 9.0 8.4 8.4 10.9 10.9 SpO2% 93% 92% 90% 88% 92% 92% pH 7.22 7.24 N/A 7.11 7.17 7.29 PaCO2 68 63 N/A 90.8 78.7 59 PaO2 106 69 N/A 90.1 79.9 136 Ratio 132 86 112 99.8 73.5
- 26. CASE THREE A 60 year-old male presented to the ED for a puffer renewal Feeling unwell and SOB for a day or so. Heavy smoker Room air SpO2 was 70% Taken to resuscitation Decompensated, intubated and very difficult to ventilate and oxygenate Transferred to ICU Prone position for 12 hours Responded Turned supine Full recover and discharged home
- 27. CASE THREE DAY 0100H 0300H 0700H 1300H PRONE 1530H MODE PCV+22 PCV+22 PCV+22 PCV+22 PCV+22 Rate 32 32 32 32 32 FiO2 1.0 1.0 1.0 .90 .50 PEEP +10 +10 +10 +10 +10 Airway 32 32 32 32 32 VT 351 370 312 508 429 Compliance 10.9 12.3 9.25 15.8 13.40 SpO2% N/A N/A N/A N/A N/A pH N/A N/A 7.21 7.41 7.47 PaCO2 N/A N/A 77 45 36 PaO2 N/A N/A 95 94 128 Ratio N/A N/A 95 104 245
- 28. Four P’s of Proning Practice proning. Prepare equipment Prone early Pressure injury avoidance.
- 30. THANK YOU
Editor's Notes
- Prone positioning has been shown to improve outcomes. We are going to show with a simulation program you can safely bring this therapy to your home units. If it something you are already doing simulations can improve safety and nurses confidence. All that is required is PRACTIVE, CONFIDENCE and PILLOWS.
- Primary, or direct ARDS, results from direct lung injury and tends to be more problematic. Secondary, or indirect, results from a source outside of the lungs.
- ARDS can be stratified as mild, moderate, and severe according to the Pa02/FiO2 ratio. 200-300 / 00-199 / <100 Prone position is indicated for moderate to severe ARDS (<150), early (<36hours) for 12 to 16 hours. Most patients (70-80%) demonstrate improved oxygenation. Even for non-responder prone position represents a lung protective intervention. Our case studies will show how early prone position is more beneficial than late prone positioning.
- ARDS passes through three stages. If the root cause is corrected the patient will recover. If the root cause is not corrected or excessive lung injury occurs the patient will not recover and develop chronic pulmonary dysfunction and a poor quality of life. Moderate to severe cases my die before recover can occour.
- The lungs are heavier at the base and lighter at the top. This means apex requires less effort to expand than the bases. Conversely, perfusion favors the bases. More blood reaches the bases than the apex. With ARDS lung edema makes the lungs heavier. Hydrostatic pressure and gravity pulls this edema to the bases. The heavy bases collapse under their own weigh while receiving utilized perfusion.
- Frequently, ARDS patient require intubation and mechanical ventilation. Unfortunately, with moderate to severe ARDS, ventilation exacerbates lung injury with barotrauma, atelectotrauma and volumetrauma. Prone position can break this cycle of injury while improving oxygenation.
- Prone positioning in ARDS has been extensively studied over the past 20 years. Implementation of prone position has been on and off over the years. Several RCT and meta-analysis showed improved oxygenation but no significant survival benefits until PROSEVA in 2013. Supportive care has caught up to prone positioning. N=466 / N=229 Supine /N=237 prone / Early <36 / Duration 12 to 16 hours / Can be prone multiple times / Expected outcome +20% in PaO2 / Lung protective It was a large European study with 466 that demonstrated survival benefits with prone positioning
- Policy really only has a few. We really only follow pretty much these two main ones. I
- All of these conditions require assessment. Patients with trachs can also be proned. We proned this winter a patient who was more than 80 percent burned . Obesity is not a barrier. We have proned or thought of proning patients with these conditions. It can be done although carefully. It is easier for us to say this with the central resources at our doisposal but I think it is worth trying even for these patients because they are going to die anyway and it is an option that is cheap and possible to offer families.
- If only proning was this simple
- Very upsetting to the patient’s family. The patient is acutely unwell, RASS -4, -5 BIS less than 40 and TOF less than 2/4 . Who do you need to prone? R.T Doc skilled in intubation nursing comfortable doing this. Designate leaders in your unit with this procedure. We now can do it with an intensivist on the unit. R.T skilled in this . Proning pillow patients with short necks may need pillow cut. Three pillows taped . This is one everyone forgets to remove the jonnyshirt. Airway management close by. Respiratory equipment. Tube has been xrayed and verified it is in a good position.
- Head and tube R.T leader at foot of bed. Nurse responsible for patient and vitals, Make sure the ETT tube is marked and aware of the position before proning. Check liens. We have intensivist present .
- Reminder to remove electrodes. Consider applying defib pads if patient having dysthrmias’s
- ABG’s thirty minutes after proning. Need to see a 10-20 percent increase in PAO2. patient might need an increase in inatrope support or fluid. If sats and PAO2 do not improve assessment of changing back to supine. Every two hours it is a lift with the head to the side. The R.T is responsible for this.
- Option A: In Situ Simulations: On the unit with people who work together with the actual equipment. You can start simple and advance to more complex situations (lost tube, code, ect..). The disadvantage is it take a large investment of time and requires facilitators. Option B: Simulation for Key Stakeholders: Put key staff trough simulations so they can take a leadership role. This can be RN or RT. This may be easier to adapt in smaller centres. Option C: Rehearsals by the Ad Hoc Team: Practice a few times before you prone a patient. For example, have a nurse lay in bed and prone them a few times just to pull the team together. Life Flight was able to train a teamwith simulations, with some who have never proned a patient, to be able to prone patients and transport them. Now, we will look at our case studies. One was late, intermediate and ealry and you can see the variance in results.
- Core group of leaders charge nurses, staff educators, R.T’s and physician leads. Cut your pillow if necessary to fit neck size. Pillows can be the same depending on patient size. It might take some maneuverers to get the neck in position. If the patient improves and no further intervention great if not they can be transferred for possible ECMO. At least we have given them a chance. Many patients comorbidities might preclude them from ECMO but proning might save their life. Life flight can transport proned. We have received patients with significant pressure injuries to the face. Checklist of skin to be followed and check before proning things s such as ETT tab. Use the deep breath approach and check pre and post proning
- N=11 N=2 N=0 N=9 Simulations were used to train staff who never proned and now they prone and transport.
- Simulations are an effective method, either option A, B or C, to help prepare critical care nurse for these high acuity low occurrence competencies. Good outcomes, of course, a good for the patient but also for nurses’ well being. We can all recall being thrust into unpleasant situations in which our performance may have not been the best. More importantly, we all can recall nurses who left critical care or nurses after an adverse event. Let’s change this. Thank you.