Attachment 05 -Prone Therapy for ARDS Patients in the ICU.pdf

VA SAN DIEGO HEALTHCARE SYSTEM INTENSIVE CARE UNIT

SAN DIEGO, CA UNIT BASED POLICY

September 17th 2019

PRONE THERAPY PROCEDURE FOR ACUTE RESPIRATORY DISTRESS

SYNDROME (ARDS) PATIENTS IN THE INTENSIVE CARE UNIT (ICU)

1. PURPOSE:

a. To safely provide prone therapy for patients with severe ARDS (Acute Respiratory Distress Syndrome) in an effort to improve lung function, oxygenation and survival.

2. POLICY:

a. A critical care attending provider orders prone therapy in patients with severe ARDS without contraindications to therapy.

(1) Contraindications for prone therapy include elevated ICP (Intracranial pressure), weight greater than 300 lbs (>136 kg), unable to tolerate the head down position, unstable facial, spine or pelvis fractures, grossly distended abdomen, ischemic bowel, open chest or unstable chest wall.

(2) Patients greater than 300 lbs should be considered for alternative therapy such as RotoProne™ Therapy System. Training is provided with support from ArjoHuntleigh in coordination with the ICU Clinical Nurse Specialist and Nurse Manager.

b. A minimum of two critical care registered nurses (RN) and a respiratory therapist are required to prone the ARDS patient using the manual method.

c. The Respiratory Therapist (RT) manages the patient’s airway during proning and all head position changes.

d. The goal is for the patient to be in the prone position for 16-18 hours a day unless otherwise tolerated.

e. The first time the patient is turned prone will be on the day shift with the provider present. There must be a minimum of 5 staff members to assist with patient management during the turn.

f. Tube feedings are held for one hour prior to proning and restarted when the patient is stable.

3. DEFINITIONS:

a. ARDS (Adult Respiratory Distress Syndrome): is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular

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permeability, increased lung weight, and loss of aerated lung tissue with hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance.

b. Prone Therapy: placing the patient in the prone position has been shown to reduce mortality in ARDS patients when started early and applied for most of the day. Prone therapy improves oxygenation, improves ventilation and perfusion matching, and protects from ventilator induced lung injury.

c. Prone Screen: prior to beginning prone therapy the patient is assessed with a steep lateral turn with the head of bed flat or in a slight Trendelenburg position to determine whether the patient can tolerate prone therapy.

d. RotoProne®: A therapy with an automated bed system that allows caregivers to deliver multiple intervals of prone therapy over an extended time.

4. RESPONSIBILITIES:

a. The Attending ICU Physician:

(1) Orders prone therapy and screens the patient for appropriateness of therapy and any contraindications.

(2) Assesses whether the patient’s hemodynamic status and oxygen demands can tolerate the prone position.

(3) A physician is present for the first prone event.

b. ICU Registered Nurse (RN): provides prone therapy to the patient. Patients in the prone position require one to one nursing care.

c. Respiratory Therapist: maintains the airway and endotracheal tube during all prone maneuvers and with all head position changes.

d. Nurse Manager: ensures a sufficient number of staff are available to safely prone the patient and ensures that staff are trained properly in ergonomics.

5. PROCEDURES:

a. A patient is identified by physician, RN or RT as an ARDS patient that could benefit from prone therapy.

b. Attending physician orders prone therapy including the desired duration in hours of the prone position.

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c. The first prone maneuver is performed on the day shift with the physician present.

d. RN and RT screen the patient using a steep lateral turn:

(1) The RN and Respiratory Therapist screen the patient using a steep lateral turn with the bed in a slight reverse trendelenburg to assess impact on oxygenation and cardiovascular status. Failure of the respiratory rate, respiratory effort, SpO2, heart rate, and blood pressure to return to supine baseline in 5 to 10 minutes after the turn is an indication that the patient may not tolerate the prone position. Notify physician of Prone Screen outcome.

e. The RN and the RT utilize the Prone Therapy Procedure Checklist (Attachment A) to guide patient care needs during the following:

(1) Prior to Proning.

(2) Turning the patient supine to prone.

(3) Turning the patient prone to supine.

(4) Turning the head side to side every two hours.

f. Provider, RN and RT document the patient’s response to prone therapy.

g. If the patient becomes unstable, suffers a cardiac arrest, or experiences an unplanned extubation the patient is returned to the supine position for resuscitation.

6. REFERENCES:

a. Abroung, F., Ouaned-Besbes, L., Elatrous, S., et al. (2008) The effect of prone positioning in acute respiratory distress syndrome or acute lung injury A meta-analysis. Areas of uncertainty and recommendation fo research.

Intensive Care Medicine; 34: 1002-1011. https://doi.org/10.1007/s00134-008- 1062-3

b. Guerin, C., Reignier, J., Richard, J.C., Beuret, P. (2013). Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine; 368:2159-2168.

c. Wiegand, D.J. (2017). AACN Procedure manual for Critical Care, 7th ed. St.

Louis, MO: Elsevier/Saunders.

7. REVIEW DATE:

a. September 2022 https://doi.org/10.1007/s00134-008-1062-3 https://doi.org/10.1007/s00134-008-1062-3

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8. FOLLOW-UP RESPONSIBILITY:

a. Critical Care Multidisciplinary Committee

b. Nursing Practice Council

9. RESCISSION:

a. ICU Unit based policy, titled, “Prone Therapy for ARDS Patients in the ICU,” dated June 2015.

10. SIGNATURE:

X Christmas Gonzales, MSN, RN Nurse Manager for Critical Care

X Heather Fojas, MSN, RN, ACNS-BC Critical Care Clinical Nurse Specialist

Attachments: A Distribution: SharePoint

VA SAN DIEGO HEALTHCARE SYSTEM NURSING SERVICE

SAN DIEGO, CA CLINICAL POLICY

Attachment A Date

Prone Therapy Procedure Checklist

Prior to Proning

□ Obtain Attending Provider order for prone therapy.

□ Identify any contraindications for prone therapy and notify the Provider.

a. Elevated ICP (Increased Intracranial Pressure)

b. Weight greater than 300 lbs. (>136 Kg)

c. Unable to tolerate the head down position

d. Unstable spine or pelvis fractures

e. Grossly distended abdomen

f. Ischemic bowel

g. Open chest or unstable chest wall

□ Place patient on a low air loss mattress on a standard bed frame.

□ Address any skin care needs prior to proning.

□ Ensure prior to proning that a minimum of 5 nurses and one RT assist with patient management during the turn.

□ Provider is present for the initial pronation and at subsequent times per RN discretion.

□ Use of a repositioning sheet allows the nurse to make small changes in the patient’s position while prone to prevent skin breakdown and assess the need for pillows to support the abdomen, chest and head.

□ The RN and Respiratory Therapist screen the patient for prone therapy with a steep lateral turn with the bed in a slight reverse Trendelenburg to assess impact on oxygenation and cardiovascular status. Failure of the respiratory rate, respiratory effort, SpO2, heart rate, and blood pressure to return to supine baseline in 5 to 10 minutes after the turn is an indication that the patient may not tolerate the prone position. Notify providerof Prone Screen outcome.

□ Administer anxiolytics and analgesia as ordered to the target RASS (Richmond

Agitation Sedation Score) and pain score that facilitates prone therapy. It may be necessary to use neuromuscular blockade in some patients.

□ Turn off the tube feeding one hour prior to proning. Tube feeding is restarted once patient is stabilized in the prone position.

□ Perform eye care, including lubrication and tape eyelids closed in a horizontal fashion.

□ Ensure the tongue is inside the mouth. A bite-block can be used if tongue is swollen or protruding.

□ Ensure the endotracheal tube is secure with twill tape or cloth tape. Do not use commercial ET tube device.

□ Capnography monitoring will be initiated to help ensure proper positioning of the endotracheal tube during the procedure and in the prone position.

□ Complete all care requiring access to the front of the body (e.g. dressing changes).

□ Ensure all essential emergency equipment is available (BVM with peep valve and mask must be present if unplanned extubation were to occur).

Prone the Patient:

□ Once all staff are gathered to perform the prone maneuver, address good staff ergonomics before turning.

□ Place SAGE® TAP blue/white glide sheet or a repositioning sheet/sling under the patient. No bottom sheet required on clean low air loss mattress cover.

□ Remove the headboard and tuck the steering handles down. Place low air-loss mattress on maximum inflate. Remove any IV poles from bed frame.

□ Remove ECG electrodes from anterior chest wall.

□ Tuck both hands under buttock. Run intravenous, central and arterial lines off the head of the bed. Ensure foley stat lock is attached to medial aspect of thigh.

Ensure all lines and tubes have adequate line clearance.

□ Place a flat sheet and a repositioning sheet/sling on top of patient. Ensure that repositioning sheet/sling is across the chest, including the shoulders, but below the neck.

□ RTispositioned at head of bed to guide and maintain ET tube in secure position.

RN is positioned at the head of the bed to support and turn patient’s head. Two RNs at each side of bed to rotate patient to prone position.

□ Primary RN managing the patient’s head, and the RT managing the airway, will determine when it is safe to move the patient.

□ The two nurses at each side of the bed will take both the bottom and the top sheets and roll them tightly together toward the patient placing the patient in a cocoon.

□ Slide the patient as far to the side of the bed as possible away from the ventilator with railings down while maintaining safety.

□ Turn patient in the direction of the ventilator to the side lying position while Primary RN supports the head and RT manages the ET tube and ventilator tubing. If using a repositioning sheet/sling under the patient, the ceiling lift can be used to turn the patient to the side.

□ Stabilize in the lateral position and ensure the airway is secured, and the vital signs and SaO2 are stable before completing the turn to prone. Place Chux under head to absorb secretions. Place ECG electrodes to patient’s back for monitoring.

□ Complete the turn to prone when safe.

□ If necessary attach the ceiling lift to the repositioning sheet/sling to adjust the patient’s position, and add additional pillows to the pelvis and chest to allow the head and neck to lie freely on the bed. A pillow at the pelvis can allow the abdomen to expand if necessary.

□ Position patient’s arms for comfort. They can be left in a side-lying position, aligned with the body, or positioned one up and one down, similar to a swimmer.

Support the patient’s arms and legs with pillows as necessary.

□ The patient should be micro shifted and arms repositioned at least every two hours. An alternating swimmers position can be done utilizing two RNs and RT.

□ May apply a slight reverse Trendelenburg to the bed for patient comfort.

□ Take mattress out of max inflate mode. Leave repositioning sheet/sling under patient.

□ Restart the tube feeding when patient is stabilized.

From Prone to Supine:

□ Place SAGE® TAP blue/white glide sheet or repositioning sheet/sling on top of patient and tuck the patient’s hands under hips.

□ Ensure all lines and tubing are running up to the head of the bed with enough slack.

□ Primary RN managing the patient’s head and the RT managing the patient’s airway will determine when it is safe to move the patient.

□ The two nurses at each side of the bed will take both the bottom and the top sheets and roll them tightly together toward the patient placing the patient in a cocoon.

□ RT is positioned at head of bed to guide and maintain ET tube in secure position.

RN is positioned at the head of the bed to support and turn patient’s head. Two RNs at each side of bed to rotate patient to prone position.

□ Move the patient as far to the side of the bed as possible away from the ventilator with the rails down while maintaining safety.

□ Supporting the head and ET tube, turn patient torward the ventilator to a side lying position, remove posterior ECG leads and place new anterior ECG patches and leads. Allow the patient to stabilize.

□ Tuck the repositioning sheet/sling under the patient.

□ Supporting the head and ET tube, complete the turn to the supine position when safe.

□ Remove the top repositioning sheet/sling and adjust the patient in the bed using the repositioning sheet.

Turning the head side to side while prone:

□ Every two hours patient’s head is to be turned side to side.

□ One RN managing the head and one RT managing the ET tube are positioned at the head of the bed.

□ Support the head; secure the airway, ventilator tubing and all lines before turning the head.

□ Position two nurses on each side of the bed and one RT and one nurse at the top of the bed prior to turning the head. Slide the patient until his head is off the end of the bed, far enough to turn his head to the other side. The repositioning sheet/sling and the ceiling lift can be used as an alternative method for turning the patient’s head. Ensure that the repositioning sheet/sling is across the upper chest away from the neck prior to lifting the patient. Once the patient is lifted his head can be turned to the opposite side. Either method will allow his head to move freely for turning.

□ When the patient’s head is turned to the opposite side inspect the skin for breakdown and position patient’s head and neck for comfort. A hydrocolloid dressing may be applied to any areas exhibiting pressure, shearing or friction.

The head may also be turned more frequently than every 2 hours as needed.