Adverse Events of Prone Positioning in Mechanically Ventilated Adults with Acute Respiratory Distress Syndrome.

González-Seguel, Felipe; Pinto-Concha, Juan José; Aranis, Nadine; Leppe, Jaime

INTRODUCTION Prone positioning is a therapy utilized globally to improve gas exchange, minimize ventilator-induced lung injury, and reduce mortality in acute respiratory distress syndrome (ARDS), particularly during the ongoing coronavirus disease 2019 (COVID-19) pandemic. While the respiratory benefits of prone positioning in ARDS have been accepted, the concurrent complications could be undervalued. Therefore, this study aimed to identify the adverse events related to prone positioning in ARDS, and secondarily, to collect strategies and recommendations to mitigate these adverse events. METHODS In this scoping review, we searched recommendation documents and original studies published between June 2013 and November 2020 from six relevant electronic databases and the websites of intensive care societies. RESULTS We selected 41 documents from 121 eligible documents, comprising 13 recommendation documents and 28 original studies (involving 1,578 patients and 994 prone maneuvers). We identified more than 40 individual adverse events, and the highest pooled occurrence rates were that of severe desaturation (37.9%), barotrauma (30.5%), pressure sores (29.7%), ventilation-associated pneumonia (28.2%), facial edema (16.7%), arrhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%). The reported mitigation strategies during prone positioning include alternate face rotation (18 [43.9%]), repositioning every 2 hours (17 [41.5%]), and the use of pillows under the chest and pelvis (14 [34.1%]). The reported mitigation strategies for performing the prone maneuver comprise one person being at the headboard (23 [56.1%]), the use of a pre-maneuver safety checklist (18 [43.9%]), vital sign monitoring (15 [36.6%]), and ensuring appropriate ventilator settings (12 [29.3%]). CONCLUSIONS We identified >40 adverse events reported in prone positioning ARDS studies, involving additional AEs not yet reported by previous systematic reviews. The pooled adverse event proportions collected in this review could guide research and clinical practice decisions, and the strategies to mitigate adverse events could promote future consensus-based recommendations.