Center of Proning Excellence C.O.P.E. Training - PowerPoint Presentation

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Center

of Proning Excellence C.O.P.E. Training

Prone Therapy: Positioning the Patient for Improved Outcomes

Angela Rouse RN BSN CCDS

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Arjo products have specific indications, contraindications, safety information and instructions for use. Please consult product labeling and instructions for use.Arjo recommends that clinicians participate in device in-service and training prior to use.Any opinions, findings, and conclusions or recommendations expressed in this presentation are those of the presenter, not necessarily those of Arjo.DisclosureThis speaker is an employee of Arjo, the provider and manufacturer of the only automated prone positioning solution.Unless otherwise noted, all trademarks designated herein are proprietary to Arjo Licensing, Inc., its affiliates and/or licensors. Most Arjo products are subject to patents and/or pending patents.

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Program

objectives

Discuss the impact of immobility in the ICU

Review the prevalence of Acute Respiratory Distress Syndrome (ARDS)

Describe the physiology and pathophysiology of ARDS

Discuss the different treatment modalities for ARDS

Articulate the mechanism of action with prone positioning

Review clinical research related to prone positioning

Incorporate the clinical research into

evidence-based

practice

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Are our patients supposed to be on their backs?

Complications of immobilityDecreased lung volumesExcessive secretions; fluid and cellular debris settle in the dependent regions of the lungMuscle wasting and weaknessAssociated with: Increased length of stay Patient and staff injury Delayed extubation Increased mortality ICU delirium

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ARDS stats170,000 cases/year10 percent of ICU patients diagnosed with ARDS78 percent within 48 hours of admission23 percent of ventilated patients develop ARDSMost develop ARDS within 24 hours of ventilationVentilator stats- 8 day LOS35 percent received >8 ml/kg PBW tidal volumes82 percent received <12 PEEPCost: $115,000 per hospital stay

2016 ARDS epidemiology

Severe ARDS survivorsVentilator LOS 11 daysICU LOS 14 daysHospital LOS 26 days

Bellaini

, et al (2017

).

Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units of 50 countries.

Journal of American Medical Association

, 315 (8

),:

788-800.

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Identification and diagnosis of ARDS is lacking40 percent of all cases never diagnosed with ARDSOnly 34 percent of ARDS cases being identified when criteria is met Opportunity to improve outcomes with early identification and intervention

2016 ARDS epidemiology continued

IDENTIFICATION AND DIAGNOSIS OF ARDS IS LACKING40% of all cases never diagnosed with ARDSOnly 34% of ARDS cases being identified when criteria is met Opportunity to improve outcomes with early identification and intervention

Bellaini

, et al (2017). Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units of 50 countries. Journal of American Medical Association, 315 (8),: 788-800.

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Acute Respiratory Distress Syndrome (ARDS)

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Direct injuryPulmonary contusionPneumoniaAspiration of gastric contentsInhalation of toxinsPulmonary infection (flu/H1N1)Oxygen toxicityIndirect injurySepsis syndromeMultiple transfusionsTrauma PancreatitisCardiopulmonary bypassDIC

Causes of ARDS

Bellaini

, et al (2017

).

Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units of 50 countries.

Journal of American Medical Association

, 315 (8

),:

788-800.

2000

ARDSnet

study- patient population

diagnoses.

The

New England Journal of

Medicine

,

(342) 18

.

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Phases of ARDS

Phase no. 1 – Injury or Exudative1-7 days post-injury, 50 percent of cases within 24 hours of eventPathophysiologyReduced blood flow to lungsInflammatory mediator releaseIncreased capillary permeabilityIntrapulmonary shunting beginsSymptomsRefractory hypoxemiaIncreased respiratory rateDecreased tidal volumeRespiratory alkalosisCXR infiltrates

Levy, B., Shapiro, S., and Choi., A. Acute Respiratory Distress Syndrome. Critical Care Medicine Chapter 268, retrieved from http://media.axon.es/pdf/83592.pdfZompatori, M., Ciccarese, F., and Fasano, L. Overview of current lung imaging in acute respiratory distress syndrome. European Respiratory Review, 2014; 23: 519-530.

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Phase

no. 2

– Reparative or Proliferative 1-2 weeks after initial injury PathophysiologyIncreased capillary permeabilityProtein and fluid leakagePulmonary edemaAlveolar collapseSymptomsDecreased lung complianceWorsened hypoxiaCXR “white out”

Phases of ARDS

Levy, B., Shapiro, S., and Choi., A. Acute Respiratory Distress Syndrome. Critical Care Medicine Chapter 268, retrieved from http://media.axon.es/pdf/83592.pdfZompatori, M., Ciccarese, F., and Fasano, L. Overview of current lung imaging in acute respiratory distress syndrome. European Respiratory Review 2014; 23: 519-530.

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Phase no. 3 – Fibrotic or Chronic 2-3 weeks after injury PathophysiologyFibrous tissue throughout lungDiffuse scarring SymptomsSevere acidosis on ABGOverwhelming hypoxemiaMulti-organ dysfunction (MODS)HypotensionLow urine output

Phases of ARDS

Normal Human Lung Capillaries

Lung Capillaries – 14 day ARDS

Zompatori

, M., Ciccarese, F., and Fasano, L. Overview of current lung imaging in acute respiratory distress syndrome. European Respiratory Review, 2014; 23: 519-530.

Early ARDS

Fibrotic ARDS

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It is important to consider

how much oxygen a patient requires to achieve their PaO2 on an ABG. The P/F ratio is a very useful tool to monitor your patient’s oxygenation status.PaO2 / FiO2= P/F RatioHealthy adult PaO2 = 80-100 mmHgRoom air = 21 percent oxygen100/.21 = P/F ratio 476 for a healthy adult

Calculating PaO2 / FiO2 ratio

European Society of Intensive Care. Medicine, Journal of American Medical Association June 2012: 307 (23).

PaO

2FiO2

= P/F ratio

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2012 Berlin ARDS definition

2012 BERLIN ARDS DEFINITIONMildModerateSevereTiming Acute onset within 1 week of known clinical consult or new/worsening symptomsHypoxemiaPaO2 / FiO2 <300->200 with PEEP ≥ 5PaO2 / FiO2 <200->100 with PEEP ≥ 5PaO2 / FiO2 ≤100 with PEEP ≥ 5Origin of EdemaRespiratory failure not fully explained by cardiac failure or fluid overloadobjective assessment if no risk factors presentRadiologicAbnormalitiesBilateral chest opacitiesBilateral chest opacitiesOpacities involving at least 3 quadrants

Munro

, C.L.

and

Savel, R. H.

A,

Journal

of Critical Care

,

Sept. 2012.

http://ajccjournals.org/content/21/5/305

.

European Society of Intensive Care. Medicine,

Journal of American Medical Association

, June 2012

:

307 (23).

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ARDS mortality rates 2012 to 2016

Bellaini

, et al (2017). Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units of 50 countries.

Journal of American Medical Association

,

315 (8): 788-800.

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Severity of hypoxemiaInfection/sepsisMulti-organ dysfunctionPositive fluid balanceAge Patients with higher plateau pressures have higher risks of death (>20 cm H20)

ARDS predictors of mortality

Bellaini

, et al (2017

).

Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units of 50 countries.

Journal of American Medical Association

, 315 (8

):

788-800

.

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Let’s do a quick analysis of an ICU patient diagnosed with pneumonia and recently intubated:

ABG

pH 7.12 PaO2 80 HCO3 19 CO2 60 FiO2 80%What is their P/F ratio and their stage in ARDS?

P/F ratio calculation

P/F ratio 133Moderate ARDS

PaO

2FiO2

80.6

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Evidence-based

/

standard of care

Treatment

modalities for ARDS

Salvage therapy in ARDS

Physician/facility specific

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The benefits of prone positioning

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Why

does prone positioning work?

Ventilation benefits

Cardiovascular benefits

Figure

1.

Pelosi, et al. Prone position in acute respiratory distress syndrome. European Respiratory Journal, 2002; 20(4): 1017-1028

Oxygenation benefits

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What do you do when you are out of breath?

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Shape of the lungsDependent fluid accumulationAlveolar recruitmentMobilization of secretionsDownward shape of esophagusSecretions!

Oxygenation benefits

Mackenzie, CF. Anatomy, Physiology, and pathology of the prone position and postural drainage. Critical Care Medicine, 2001;29(5): 1084-1085.

~ 75 percent of patients will have an increase in oxygenation in the prone position.

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Ventilation benefits

Pleural Pressure distributed more evenly in the prone positionReduced risk for VILIReduced need for higher ventilatory pressuresReduced stress and strain on the lungRelief of pressure on diaphragm and lungs from abdomen

Figure A – prone lung • Figure B – supine lung

Lung pressure distribution prone vs. supine

Mure

,

M.,

et al. Pulmonary Gas Exchange Improves in the Prone

position with abdominal distension

. American Journal of Respiratory and Critical Care Medicine

,

1998;157(6

):1785–1790.

Guerin, C.,

et al. Effects of Prone Position on Alveolar Recruitment and Oxygenation in Acute Lung Injury

. Intensive Care Medicine

.

1999;25(11):

1222–1230.

Tawhair

, M

.,

et al (1985). Supine and prone

differences in

regional lung density and pleural pressure gradients in the human lung with constant shape.

Journal of Applied Physiology,

2009 Sep; 107 (3): 912-920.

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Relief of pressure of heart on lungsImproved tidal volumeReduced pressure on right ventricleSupine compression of the lungs from the heart is ~20 percentProne compression of the lungs is ~3.5 percentPerfusion preferentially directed to dorsal lung regionsRemoval of abdominal pressure reduces pressure on vena cava to improve venous return

Cardiovascular benefits

Murray

, T

. A. and Patterson, L.A. Prone positioning of trauma patients with acute respiratory distress syndrome and open abdominal incisions. Critical Care Nurse, June 2002; 22 (3): 52-56.From Cardiopulmonary Anatomy & Physiology 4th edition by DESJARDINS. ©2002. Reprinted with permission of Delmar Learning, a division of Thomson Learning: www.thomsonrights.com. Fax 800 730-2215Anzueto, A., and Gattinoni, L. Prone position and acute respiratory distress syndrome. Acute Respiratory Distress Syndrome. 2003. New York: Marcel Dekker, Inc.

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Physiologic effects prone vs. supine

Supine

Prone

Decreased

lung volumes

Increased lung volumes

Accumulation of atelectasis in dependent

regions

Facilitation

of secretion drainage

Refractory

hypoxemia exacerbated by a

ccumulation

of secretions in dependent regions of lungs

Increased oxygenation due to mobilization

of secretions and alveolar recruitment

Regional

and gravitational differences in lungs increase V/Q mismatch and increased stress and strain on the lung

Optimized ventilation due to smaller vertical pleural pressure gradient, increased FRC and more even gas volume

distribution

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Prone positioning

Review research findings

25

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Prone positioning knowledge refined over time

Outcomes

2001

Gattinoni

NEJM

2010 Sud

Intensive Care Medicine

2001 2004 2010 2013 2017

Gattinoni

, L

.,

et al (2001). Effect of prone positioning on the survival of patients with acute respiratory failure. New England Journal of Medicine, 345 (8): 568-573.Guérin, C., Reignier J., Richard, J.-C., et al. New England Journal of Medicine, 2013; 368: 2159-2168. .

2004 ManceboAJRCCM

2013 GuerinNEJM

Improved oxygenation

Improved outcomes with intervention within 48 hours; trend toward statistical significance. Underpowered.

Prone position is appropriate for use with severe ARDS.

Prone position has a statistically significant impact on

mortality.

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PROSEVA: Effect of prone positioning on outcomes in patients with severe ARDS

Guerin 2013

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PROSEVA:

Effect

of prone positioning on outcomes in patients with severe ARDS – methods

Multicenter, prospective, randomized, controlled trial

Enrollment criteria:

Endotracheal intubation and mechanical ventilation for ARDS < 36 hoursPaO2/FiO2 ratio ≤ 150 mmHgFiO2 ≥ 0.6Positive end expiratory pressure (PEEP) of at least 5Tidal volume 6 ml/kg of predicted body weight (PBW)Patients assigned to prone group were placed in the prone position for a minimum of 16 consecutive hoursEndpoints Primary: patient’s death from any cause within 28 days of inclusionSecondary: mortality at 90-days

Guérin, C., Reignier J., Richard, J.-C., et al. New England Journal of Medicine. 2013; 368: 2159-2168.

466 patients, 27 ICUs

Randomization

Data collection on outcome variables

Prone (n=240)

Completed Trial (n=237)

Supine (n=234)

Completed Trial (n=229)

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PROSEVA – Randomization ventilator settings

Guérin, C., Reignier, J., Richard, J.-C., et al. New England Journal of Medicine, 2013; 368: 2159-2168.

At the time of inclusion of the study, patients’ status decreased significantly from the inclusion criteria to average PEEP 10, FiO2 80%, P/F <100.

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Results

Ventilator free days also varied significantly at 28 days:

Supine: 10 days vs. Prone: 14 days (p <0.001)Cardiac arrest incidence higher in supine group (31) vs. prone group (16) (p<.02)

Guérin

,

C.,

Reignier

,

J.,

Richard,

J.-C., et al.

New England Journal of

Medicine,

2013;

368: 2159-2168.

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Prone positioning reduces mortality from ARDS in the low tidal volume era: A meta-analysis

Beitler

2014

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Prone positioning reduces mortality from ARDS in the low tidal volume era: A meta-analysis

Integrate the findings of the PROSEVA trialTest whether differences in tidal volumes explains previous conflicting results on mortality in prone positioningProne patient analysis:Average P/F ratio: 100-161Prone duration varied greatly: 6 - >20 hours/day

Beittler

, J. R.,

Shaefi

, S.,

and

Montesi

, S. B., et al.

Intensive Care Medicine

online

: January 17, 2014

*National Heart, Lung and Blood

Institute.

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Stratification of data based on two variables:

Beittler

, J. R.,

Shaefi

, S.,

and

Montesi, S. B., et al. Intensive Care Medicine online: January 17, 2014

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This table represents the change over time to favoring prone over supine positioning related to changes in ventilation strategies in ARDS.

Prone positioning is associated with significantly decreased mortality in ARDS with low Vt

Beittler, J. R., Shaefi, S., and Montesi, S. B., et al. Intensive Care Medicine online: January 17, 2014*National Heart, Lung and Blood Institute.

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Prone positioning reduces mortality from ARDS in the low tidal volume era: A meta-analysis

Conclusion: Prone positioning is associated with significantly lower mortality in the low Vt patients at 60 days with ARDS; RR 0.66, 95 percent; p=0.002Longer prone times (>12 hours) associated with significantly lower relative risk for deathThe historical explanation for the inability to consistently show decreased mortality rates with prone positioning can be explained by:Previous stratification of severity of disease, instead of ventilatory management (low vs. high tidal volume)No previous stratification of duration of prone positioning

Belittler

, J. R.,

Shaefi

, S

., and

Montesi

, S. B., et al.

Intensive Care

Mediicine

online

: January 17,

2014.

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2016 surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock

Critical Care Medicine, March 2016.

2013 GUIDELINES2016 GUIDELINESVENTILATORY STRATEGYTarget tidal volumes 6ml/kg predicted body weightTarget tidal volumes 6ml/kg predicted body weightPOSITIONProne position for sepsis induced ARDS for P/F <100Recommend prone over supine position for sepsis induced ARDS for P/F <150 (strong recommendation) NEUROMUSCULAR BLOCKADENo recommendationNeuromuscular blocking agent for <48 hours with P/F <150

This table highlights recommendations for mechanical ventilation management of sepsis

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2017- AJRCCMClinical practice guideline: Mechanical ventilation in adults with ARDS

Official Guidelines of: American Thoracic Society (ATS), European Society of Intensive Care Medicine (ESICM), and Society of Critical Care Medicine (SCCM) for the treatment of ARDSARDS ventilation strategiesLimit tidal volumes (4-8 ml/kg PBW)Inspiratory pressures (<30 cm H2O)Higher PEEPStrong recommendation for prone positioning of patients with severe ARDSProne for > 12 hours/dayUtilize a specific implementation/training program in the ICUStrong recommendation against routine HFOV Cannot provide recommendation for or against ECMO, due to lack of evidence

Fan

et al. (2017) An official American thoracic society/European

Society

of

Intensive Care

M

edicine/Society

of

Critical Care Medicine medical

clinical practice guideline: Mechanical ventilation in adult patients with severe acute respiratory distress syndrome.

American Journal of Respiratory and Critical Care Medicine, (195)

9, 1253-1263.

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Prone positioning

post-PROSEVA

Evidence

Prone

Positioning becomes standard of care

Mortality rates in ARDS are reduced with lung protective ventilation and >12h of prone positioning, with no increased incidence of VAP or cardiac events in prone groups

Prone positioning early (<48 hours after severe ARDS) and long (>16h) improves survival and should be a first-line therapy to treat ARDS

Strong recommendation for prone position to treat severe ARDS with 12h/day sessions – validate

Prone positioning should be done early in ARDS for long periods (>16 hours) with experienced staff – validate

2017

Scholten

CHESTTreatment of ARDS with prone positioning

2017 Fan et

al.

ATS/SCCM ARDS Treatment Guidelines

2016

Bein

Standard of Care for Treatment of ARDS

2015 Park

PP Efficacy and Safety

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Prone position best practices

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Contraindications

Patient conditions for which the application of prone therapy is contraindicated include: Unstable cervical, thoracic, lumbar, pelvic, skull or facial fracturesCervical and/or skeletal tractionUncontrolled intracranial pressure (ICP)Automated only:Patient weight below 40 kg (88 lbs.)Patient weight above 159 kg (350 lbs.)Patient height in excess of 6 feet 6 inches

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Prone positioning – risks and precautions

RISKSPRECAUTIONSReported risk of the following in relation to prone positioning therapy:Skin breakdown and/or pressure necrosisWound dehiscenceCardiac arrestLoss of invasive line or tubes or extubation (endotracheal and oral)Edema and/or swellingSplenic ruptureBlindness and other consequences of damage to the ocular nerveCorneal abrasionMyositis ossificationVenous air embolismIncreased intraorbital pressureCentral retinal artery occlusionPain and discomfortDifficulty performing cardiopulmonary arrest (CPR)Precautions may also need to be taken when prone positioning patients with certain conditions, including but not limited to:Hemodynamic instabilitySevere agitationUncontrollable claustrophobia or fear of confinementUncontrollable diarrheaIntolerance to the facedown positionWounds at risk of dehiscence while in prone positionPatient in the prone position with open sternal wound or thoracic post-surgical incisionPatient in the prone position with open abdomenAny implant that potentially increases the risk of skin breakdown, including but not limited to breast implants or penile prosthesisPregnancyExtensive facial traumaAny other unstable fracture not listed as a contraindicationICP monitoring or intracranial drainage devices

Caregivers should make sure to discuss risks and precautions with the patient (or the patient’s legal guardian) and the patient’s family.

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Manual proning

Typically involves 5-7 nurses or caregiversUnsafe in emergency situationsSuboptimal with obese patientsHigher complications

Powers

, J. (2012) Use of prone positioning with ARDS. http://www.sccm.org/communications/critical-connections/archives/pages/use-of-prone-positining-with-ARDS.aspx.

The American Nurses Association (2013) Safe Patient Handling and Mobility-interprofessional National Standards. http://anasphm.org.

Slide43

Healthcare workers at increased risk for injury

(Injuries per 100 full-time workers)

Data source: Bureau of Labor Statistics

Slide44

National law being proposedHR2480 (Nurse and Healthcare Worker Protection Act of 2013)Safe patient handling laws have been in effect for 20 years in Europe, Canada and Australia!

Laws for safe patient handling

http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios

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Automated prone positioning

Typically involves 1-2 nurses or caregivers once patient is transferredEmergency cardiopulmonary resuscitation (CPR) mode availableOptimal for patients up to 350 lbs.More secure tube and line management

Powers

, J. (2012) Use of prone positioning with ARDS. http://www.sccm.org/communications/critical-connections/archives/pages/use-of-prone-positining-with-ARDS.aspx.The American Nurses Association (2013) Safe Patient Handling and Mobility-interprofessional National Standards. http://anasphm.org.

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Proning

devices over time

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Prone position evidence based practice

Low tidal volume ventilation is essential Early intervention of prone positioning can significantly impact mortalityP/F ratio <150FiO2 >60 percentPEEP >5Intubation for ARDS for <36 hours Extended periods of prone positioningAverage 17 hours in prone position – PROSEVA Discontinuation of therapyP/F ratio >150 AND PEEP <10 AND FiO2 <60 percent for at least four hours in supine

Guérin

,

C.,

Reignier

J., Richard J.-C., et al.

New England Journal of

Medicine,

2013;

368: 2159-2168.

Slide48

At enrollment

ARDS lung and effect of proning

After 2 days of proning

Images courtesy of Frank Sebat, M.D.

Slide49

Program summary

Immobility in the ICU poses significant risks to patientsProne positioning provides positive physiologic effects, such as improving oxygenation and ventilation and promoting alveolar recruitment Evidence-based clinical research supports the implementation of prone positioning for patients with:P/F <150; PEEP >5; FiO2 >60 percentBoth mortality and ventilator days can be reduced with prone positioningSeveral major journals have published support and recommendations for prone positioning as first line therapy for ARDSNurses are at increased risk for injuryTrend toward decreased risk of injury with use of devices to mitigate risk

Guérin

,

C.,

Reignier

,

J., Richard J.-C., et al.

New England Journal of Medicine, 2013;

368: 2159-2168.

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Q & A

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Evaluations

Please

complete

C.O.P.E.

course evaluation and

turn into the

Arjo

representative before you leave the program today.

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Arjo Inc. 2349 W. Lake StreetAddison, IL 60101

Phone: 1-800-323-1245

www.Arjo.us