oa Practical proning on ECMO

The prone position has been used successfully for many years to improve oxygenation in patients who require mechanical ventilatory support for management of acute respiratory distress syndrome (ARDS). Proning improves oxygenation by optimizing lung recruitment and ventilation–perfusion matching. The following improved outcomes have been shown: when the prone position is used for moderate to severe ARDS; when used in combination with protective lung ventilation; and when the duration of the proning session is >16 h.¹ However, proning is not without contraindications and complications.² There are only two absolute contraindications to proning, which are suspected raised intracranial pressure and spinal instability. Some high-risk relative contraindications that may preclude proning include: recent sternotomy, facial surgery, and severe haemodynamic instability. Other relative contraindications include an open abdomen, pregnancy, and multiple traumas with unstable fractures. Respiratory ECMO is not a contraindication to proning. The risk of proning needs to be weighed against the potential lifesaving benefits of proning. The Extracorporeal Life Support Organisation (ELSO) guidelines for adult respiratory failure recommend the consideration of introducing prone positioning therapy to patients receiving ECMO, if there is posterior consolidation of the lung fields with some lung fields open anteriorly. The guidelines recommend exercising caution to prevent the dislodgement of the ECMO cannulas.³ Expert nursing care can prevent most complications occurring. Complications associated with the mechanics of proning include transient desaturation, haemodynamic instability, accidental extubation, and central lines displacement. Other complications that can occur during proning include the development of pressure ulcers, vomiting, the need for increased sedation ±  paralysis, nerve damage, and bleeding from ECMO cannula sites. To reduce the risk of potential complications, trained critical care staff, strict protocols, and procedures for the implementation of proning, including the mechanics of the proning procedure itself together with the care of the patient and circuit whilst the patient is proned, must be implemented. An experienced team of critical care staff who routinely use this intervention and who are familiar with the procedure are required to facilitate the mechanics of the proning process and the ongoing management of the patient to ensure the safety of both the patient and the ECMO circuit. There is no standard method for moving a patient from supine to the prone position. Most centres that prone adult patients use a “double sheet rolling” technique, whereby the patient is securely wrapped between two sheets and then manually turned from the supine to prone position through careful team coordination.³ Commercially available beds are also available which can initiate, maintain, and facilitate prone positioning. The recommended minimum number of staff required to safely prone an adult patient are five members of staff, six if the patient is on ECMO (four to prone, one to manage the airway, and one to manage the ECMO circuit), although ideally there should be seven members of the team, eight if the patient is on ECMO (six to prone, one to manage the airway, and one to manage the ECMO circuit) (local guidance GSTT).