ICU peeps: who are you proning, and when?

[Idiopathic]

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how long do you give a patient on HFOV/VDR before going prone? or do you ever consider it?

 

[BobBarker]

At our ICU, if we have much oxygenation problems the go on the Rotabed. They never use the oscillator.

 

[jdh71]

how long do you give a patient on HFOV/VDR before going prone? or do you ever consider it?

Obvious disclaimer: Never been shown to improve outcomes. We should all know that.

Neither has HFOV/VDR for that matter.

We try an get all fancy, but the bottom line is that many of these patients are probably dead for all intents and purposes when we finally decide to try these "salvage" interventions, anecdotes notwithstanding. This is where the future of ECMO lies IMHO, but those details are still being ironed out.

I'll consider prone positioning in a patient if they still have low sats despite high PEEP and inhaled vasodilators after paralysis, and if they tolerate it, I'll keep them prone for 12-18 hours before turning back around. If that is not enough to recruit when turned back over, it's time to have a tough talk with family.

 

[jdh71]

At our ICU, if we have much oxygenation problems the go on the Rotabed. They never use the oscillator.

If you really want to improve oxygenation prone them with the oscillator.

I never use a rotabed, much to angst of the local reps.

 

[Idiopathic]

Obvious disclaimer: Never been shown to improve outcomes. We should all know that.

Neither has HFOV/VDR for that matter.

We try an get all fancy, but the bottom line is that many of these patients are probably dead for all intents and purposes when we finally decide to try these "salvage" interventions, anecdotes notwithstanding. This is where the future of ECMO lies IMHO, but those details are still being ironed out.

I'll consider prone positioning in a patient if they still have low sats despite high PEEP and inhaled vasodilators after paralysis, and if they tolerate it, I'll keep them prone for 12-18 hours before turning back around. If that is not enough to recruit when turned back over, it's time to have a tough talk with family.

failing to prove a positive does not necessarily prove the negative. if you have a patient who cannot oxygenate supine, and you flip them prone, and you can oxygenate them, then youve bought time for source control and resolution. ive become really skeptical of looking at extreme measures in the context of mortality. why do you decide 12-18 hours is enough? do you have that much practical experience with it? ive decided ill go three days and reevaluate, but Im still not sure what my endpoints are, although certainly weaning FiO2 has to be the major one. Also, I dont think Ill prone anyone who Im not also oscillating.

 

[jdh71]

failing to prove a positive does not necessarily prove the negative. if you have a patient who cannot oxygenate supine, and you flip them prone, and you can oxygenate them, then youve bought time for source control and resolution. ive become really skeptical of looking at extreme measures in the context of mortality. why do you decide 12-18 hours is enough? do you have that much practical experience with it? ive decided ill go three days and reevaluate, but Im still not sure what my endpoints are, although certainly weaning FiO2 has to be the major one. Also, I dont think Ill prone anyone who Im not also oscillating.

We can do all sorts of things that improve oxygenation. If randomized scientific trials don't convince you that proning, ocillation, and inhaled vasoldilators show no survival benefits when compared to control, then I don't know what else to say. If your point is that it's nuanced and it may help SOME people survive, I might buy that, but who and why have clearly not been worked out.

Furthermore, simply because you've improved your oxygen saturation or buffed your ABG, why would you think that is actually buying you any time at all?

I've actually had quite a bit of experience with proning as a pulmonary and critical care fellow. And I like 12-18 hours because that about as long as the tissue can handle the edema before it starts breaking down, especially in the face and breasts in women. Plus they are either going to recruit with it or they won't. You'll either pop open the atelectatic areas. Or the lungs are so crumped it doesn't matter. The blood flow is the essentially the same regardless.

 

[seinfeld]

Too much risk of instant mortality with proning someone in a unit which does it infrequently. I feel if someone is not responding to the capabilities of a conventional ventilator then go to ECMO.

 

[jdh71]

Too much risk of instant mortality with proning someone in a unit which does it infrequently. I feel if someone is not responding to the capabilities of a conventional ventilator then go to ECMO.

amen

but then . . . ECMO isn't always widely available currently