Pronation and pressure sores.

Hi,
We regularly prone our patients. It works well for the most part however we are finding more and more that these patients end up with terrible presure sores over the fore head and chin especially where the ET tape lies.
I have sourced a type of "frame" for the patients head that acts as a pressure relieving device.
However, I wondered if any of you have any experience with products for this as the market seems to be limited to this device only.
I have googled various descriptions of the proning word and have not found any match so far.
I notice that the majority of this website is for American based nurses so i am not sure if i have put this in the right section, could any one advise about talking to UK based nurses please.
Thanks
dissle

as an ICU RN I have to say that OR has us beat on all prone products. WHen I circulated OR nurses use a variety of products to prevent this type of break down. Talk to the OR nurses and /or manager in your facility. Their are multiple products to protect airways, eyes, etc for the prone patient.

Thanks for your reply......could you translate please, what is "OR"? Is this Operating room or a company of some description?
( i watch "ER" occasionally and the Americans use this terminology alot i think)
If it is "operating room" then within the NHS in the UK unfortunatly there is little or no money and so the only products that they use are GEL like products which are cheap and are wholly unsuitable for patients proned for longer than 24 hours. These items are used in patients who are proned for surgery over a short period of time.
Thanks for taking the time to reply.

Why are these patients being left in one position for so long anyway?

It has been a while since I have worked in ICU but when we did nurse our patients prone we used it as another position change. We made sure the head was turned reguarly and used pillows to tilt and turn the patient to relieve pressure to areas such as the breasts / chest.

The pateint was not left prone indefinately we alternated the position with other positioning as well.

That was how I hoped it was used, but the OP makes reference to "patients proned for more than 24 hours."

Yes, in severe ARDS we prone for 12 hours and assess then leave them for as long as 24 hours.
every 4 hours however, we turn the head and alternate the arms as described above.
Despite this the pressure sores are a problem.
We dont use this as an alternative pressure area relieving position though, we only use it in certain situations for severe respiratory distress.
thanks for replies.

I am still new in the ICU...I have not seen a patient proned. Hmmm that is interesting, is this still a very common occurance?? Maybe just not at my hospital?

Relatively uncommon actually.
We are using this manouvre more and more and have a protocol in place which tells us when to prone.
Have to say that this is a hot topic and in favour at the moment, where as last year it was nitric oxide therapy, the year before that it was oscillation!

Any way, we are trialling the head frame device and i have sourced another company which also manufacture something similar, so we will have 2 products to compare.
Im having to put together the "trial package" at the moment, which includes risk assessment which is a mine-field in its self!
wish me luck.

I have to be honest with you I would only use prone along with the other positions, so turn them prone for a few hours with some head turns in there, then tilt from side to side whilst prone and then back onto the back.

I understood it should be used as alternative position rather than turning prone for an extended period

Our unit policy states that patients can remain proned for up to 24 hours with head and arm position changes every 4 hours IF stable enough to do so.
This may seem prolonged but it works, the gasses are miles better a very short time after pronation.
We only prone when the pateint gasses are poor on 80%fio2 or above. so established lung injury. Pesonally i think it should be used a bit earlier than this.
Its usually the sickest of patients who we dont know what else to do with! Its a last ditch attempt to save them.
Interesting that you use pronation as an alternative position, i dont know why we dont use it for this more often, i suspect that it has allot to do with the inconvenience of all the bits ans bobs that have to be rearranged!

bear in mind it has been over 6 years since I left ICU, things will have changed greatly since then and having read through some of the literature today there was very little about how often or for how long prone should be used.

If it works for your patients then it works and as you say your using it on the very sickest who will have very poor skin integrity anyway therefore will be at greater risk of pressure injuries.

What type of face pillow is being used when the tapeing is resulting in a pressure wound in the prone position and how long is the patient left in the prone position?

Hi,
We regularly prone our patients. It works well for the most part however we are finding more and more that these patients end up with terrible presure sores over the fore head and chin especially where the ET tape lies.
I have sourced a type of "frame" for the patients head that acts as a pressure relieving device.
However, I wondered if any of you have any experience with products for this as the market seems to be limited to this device only.
I have googled various descriptions of the proning word and have not found any match so far.
I notice that the majority of this website is for American based nurses so i am not sure if i have put this in the right section, could any one advise about talking to UK based nurses please.
Thanks
dissle

Im curious, are you proning the patients mostly for surgical reasons or for ventilation reasons such as ARDS patients with poor oxygenation? Hillrom makes a bet that is pretty amazing and is made specifically for proning a ventilated surgical patient, however Im sure the cost of it is insane. As far as proning patients for ventilation reasons (if you are doing that), research has shown that simply putting a patient into a steep bed rotation on a bed equipped to do rotation is very similar to prone ventilation.

"research has shown that simply putting a patient into a steep bed rotation on a bed equipped to do rotation is very similar to prone ventilation."

Do you remember the source in which you found this? If steep rotation works just as well, I'd like to implement it at our hospital. I'm always afraid the ETT will become dislodged when turning an already very compromised patient. Also, as many of you have probably witnessed, the patient's O2 sat often takes a long time to recover with any activity.

Whenever pronation is ordered in either of our ICUs, we rent a specialty bed from KCI called the "Rotoprone". Before that, we used a brace called the "Vollman Pronator". It required multiple staff in order to use the straps and "flip" the patient from supine to prone. The head was stabilized in-line with the torso. The intensivist who was fond of ordering the treatment would stand at the bedside and maintain the airway. I think the Vollman Pronator actually padded the face and kept it elevated off the bed, keeping the endotrachial tube from being compressed beneath the head. The advantage of the bed from KCI is that continuous lateral rotation is used. Also, doors under the patient's backside can be opened to aerate the surfaces, relieve pressure, do dressing changes, etc.

http://www.kci1.com/317.asp

http://www.vollman.com/prone_positioner.cfm

"research has shown that simply putting a patient into a steep bed rotation on a bed equipped to do rotation is very similar to prone ventilation."

Do you remember the source in which you found this? If steep rotation works just as well, I'd like to implement it at our hospital. I'm always afraid the ETT will become dislodged when turning an already very compromised patient. Also, as many of you have probably witnessed, the patient's O2 sat often takes a long time to recover with any activity.


Yes, a critical care intesivist/pulmonologist that I worked for had it a few years back. I will ask him next time I work where he got it. Basically, with prone ventilation you are trying to change the V/Q match/mismatch to areas that are not being ventilated as efficiently. I dont recall the exact angle of rotation that was mentioned, however it was pretty steep but could be accomplished via a rotation bed. The rotation that Im talking about isnt the standard air bed. In our ICUs we have Hilrom beds that you can place a turn module in and specify the % or angle of turn. That type of rotation is what Im referring to.

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