Letter to the Director
Feasibility of prone position with a single operator for low resources ICU: Step-by-step technical description
Viabilidad de la pronación con un único operador para la UCI con bajos recursos: descripción técnica paso a paso
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"apellidos" => "Pina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "I." "apellidos" => "Carboni Bisso" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Las Heras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos para Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos para Adultos, Sanatorio Franchin, Buenos Aires, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Viabilidad de la pronación con un único operador para la UCI con bajos recursos: descripción técnica paso a paso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1291 "Ancho" => 2500 "Tamanyo" => 406954 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Video with a simulated patient showing the single-operator proning procedure.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2013, the randomized controlled trial “<span class="elsevierStyleItalic">Prone Positioning in Severe Acute Respiratory Distress Syndrome</span>” of the <span class="elsevierStyleItalic">PROSEVA</span> study group, proved the efficacy of prone position in acute respiratory distress syndrome (ARDS) patients with paO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> ratio below 150<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> with an overall improvement of 28-day mortality of 16.8%. During the COVID-19 pandemic, the number of ARDS patients increased dramatically. Those patients required techniques oriented to improve oxygenation among which we may find prone position. Despite the fact that the clinical benefits of proning far outweigh any possible adverse event<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, healthcare professionals must safeguard against endotracheal tube dislodgement, hemodynamic compromise, line disconnection, eye and pressure injuries, while maintaining access to the chest, central lines, arterial lines and urinary catheters. Prone positioning is accomplished by manual techniques that have been traditionally described to require five to seven care team members, depending on the method and size of the patient<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>. However, there is no proof of the optimal number of people required for this procedure. Training of healthcare workers on how to carefully place patients in a prone position while preventing adverse events, is a barrier to implementation. Moreover, gathering trained staff in an intensive care unit (ICU) is challenging and could end in considerable disruption to workflow. In the specific context of COVID-19 pandemic, the previous becomes even more difficult due to staff and personal protective equipment shortages and exposure of the personnel<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Only under special circumstances and mainly in limited resource settings with shortages of both material and human resources, this procedure could be done by a reduced number of operators. In the present work we describe a single operator step-by-step description. The amount of invasive devices, the patient’s weight and its clinical condition are also factors that should be considered when deciding to carry out this procedure.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Step 1: preparation</span><p id="par0015" class="elsevierStylePara elsevierViewall">Preparing for a safe prone positioning is the first step, starting with the correct identification of the patient according to international standards and followed by checking for the indication of the procedure with the medical team. After completion, patients should be preoxygenated. General and oral hygiene, aspiration of secretions, and use of eye lubricating ointments should be done at this stage. The endotracheal tube must be correctly fixed, and pressure of the tube cuff should be checked. Enteral feeding should be suspended and temporarily disconnected for easier patient management, and to avoid displacement. For the same purpose, the central line should be placed below the patient’s neck, opposite to the side at which the patient will be rotated. Urinary collector bag should be emptied and the catheter clamped to prevent leaks. The collector has to be placed on the same side to which the patient will be turned over. Regarding the respirator, settings must be checked, making sure all parameters are stable, alarms are correct, and that tubes allow proper patient management. All vital signs should be registered prior to patient mobilization, while levels of sedative drugs and neuromuscular blockers must be optimal.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Step 2: maneuver</span><p id="par0020" class="elsevierStylePara elsevierViewall">For patient rotation, movements must be done in an ordered way. The first one includes placing the patient on one edge of the bed by sequentially moving lower limbs, pelvis, torso, shoulders and head. Afterwards, legs have to be crossed over and the arm opposite to the edge should be placed below the patient's body. Then, a pillow has to be placed on the free border of the bed and below the patient’s shoulder and another one below the pelvis. All non-invasive monitoring devices can be temporarily removed. The next movement is to rotate the patient 90° towards the free side of the bed before proceeding to complete rotation by pulling the pillows below, verifying that the arm below the patient’s body has now been released. During all the process, the operator must check that tubes and central/arterial lines are not being displaced. Finally, the patient should be adequately placed at the center of the bed, the head facing one side, and the clamp of the urinary catheter, released. Upper limbs should be placed according to the “swimmer position” (when the patient’s head looks right, the right arm should be placed beside the head and above the pillow).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Step 3: post-maneuver care (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>)</span><p id="par0025" class="elsevierStylePara elsevierViewall">The last step includes repositioning monitoring items and checking vital signs, putting silicone dressings below high pressure zones and below the patient’s head to avoid ulcers. Finally, aspiration of secretions and covering the patient in the prone position completes the procedure.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">For repositioning the patient back into supine position, the same procedure has to be done following the inverse position.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Even though placing patients in a prone position has usually been described as a maneuver requiring between five and seven skilled healthcare workers, the ideal number of people needed to perform this procedure is not clear. The actual pandemic and the lack of trained personnel in critical settings, led to developing the present technique, which could serve as a way to reduce both professional exposure and use of protective equipment. Nevertheless, several considerations have to be taken into account.</p><p id="par0040" class="elsevierStylePara elsevierViewall">First, this technique should be applied only when strictly necessary and in settings with limited access to human resources or proper equipment while reducing professional exposure to air transmitted infections. Whenever possible, it should be done with extra personnel to safeguard against adverse events. Secondly, the maneuver must be done with extra people that could care for the endotracheal tube and lines whenever possible. In case it is not possible, it should be performed under the presence of an observer (runner) who must be attentive to any complication and ready to help, guide and supervise the procedure. Thirdly, for overwheighted or obese patients, extra personnel could be needed. All steps should be carefully fulfilled to guarantee safety in this maneuver where the number of operators and their strength are reduced.</p><p id="par0045" class="elsevierStylePara elsevierViewall">To date, we have used the proposed prone positioning maneuver in 19 patients, where 14 (74%) were male, with a median age of 54 years old and median body mass index (BMI) of 29. Most patients were placed in a prone position twice or thrice, determining a total of 41 proning procedures. From all prone sessions, only one presented complication (nasogastric tube displacement) and in two cases, more than one operator was needed due to patient weight. No other complications were registered. Further studies are needed to fully understand the safety of the maneuver and its usefulness.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Patient consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The video represents a simulation with models. No real patients were included.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author(s) received no financial support for the research, authorship, and/or publication of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Step 1: preparation" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Step 2: maneuver" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Step 3: post-maneuver care (Fig. 1)" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Patient consent" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 5 => array:2 [ "identificador" => "xack662066" "titulo" => "Acknowledgements" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0080" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1291 "Ancho" => 2500 "Tamanyo" => 406954 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Video with a simulated patient showing the single-operator proning procedure.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.doc" "ficheroTamanyo" => 752640 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PROSEVA Study Group. 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Kumpar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0018720820950532" "Revista" => array:6 [ "tituloSerie" => "Hum Factors" "fecha" => "2020" "volumen" => "62" "paginaInicial" => "1069" "paginaFinal" => "1076" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32845730" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack662066" "titulo" => "Acknowledgements" "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">The research team is especially grateful to Lisandro Ziperovich (AKA Ziperart) for his contribution regarding the graphic design of this work. We would also like to thank Martin Juarez and Soledad Bustos for their assistance providing the necessary material for making the video, Lic. Emilio Steinberg for his contribution in showing the maneuver and Dr. Lucas Bujan for acting as a model.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000380/v1_202304111726/en/main.assets" "Apartado" => array:4 [ "identificador" => "66474" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000007000000003/v1_202304111726/S2341192923000380/v1_202304111726/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000380?idApp=UINPBA00004N" ]
