Proning patients, face and neck positioning

[Wildplaces]

Hello everyone, I've been working on a specialty COVID-19 positive ICU since the pandemic started. I typically work in the MICU and while we proned patients once in a while, every intubated patient on the specialty unit is now being proned. Most of our patients are currently on a schedule including 16 hours in prone position. We are having difficulty trying to find the best positioning for the patient's head and neck, (particularly if they lack much of a neck). Everyone has tried something, from the OR prone pillows (not having much success, oddly. They are awkwardly large and seem poorly made), to pillow positioning to 1L sale bags on foreheads, to towels rolled into different shapes, and yet nearly everyone's face remains smashed into the wrong position. Arm placement has been usually at 90 degrees by the face but we have tried tucking them by the patient's side as well on some patients as well in attempt to find the most comfortable spot. I understand everyone is different and some patients will be calm in particular positions while others may get irritated (I have some that absolutely HATE being prone, their vital signs showing distress until they are flipped back to supine), but I'm looking for tips and suggestions of you have any to offer. Thank you!

[dianah, ASN]

I found these helpful articles on the web:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496747/

and

[murseman24, MSN, CRNA]

This would be a great contribution the OR nurses could make in the units.

[Rose_Queen, BSN, MSN, RN]

Actually, my facility is using our surgical technologists for a proning team. The RNs are being floated to other units to work as nurses. Those prone pillows used in the OR are typically utilized with positioning devices that lift the torso higher, which is likely why they aren’t working for you in the ICU. I do know that my facility has kits with all sorts of wedges and padding and sandbags, but since I’m not a member of the proning team I’m not sure what all gets used for which purpose. While the OR has experience placing patients in prone position, it’s going to be very different than what the ICU is doing- we use speciality devices that if used for extended periods of time are going to cause pressure issues. Google Pro-Axis table to see what we use and how miserable it would be for an extended time.

[SquatsNScrubs, BSN, RN]

For our COVID pts that are prone, we use foam pillows that resemble a donut and rotate the head/neck q2h between left, right, and center.

For arm placement, we do one arm at a 90 degree angle by pt's face, and other arm extended at side with palm facing up (we call it the "swimmer" position). Arms also get rotated q2h

Agreed that every patient's face looks smashed and uncomfortable regardless of position :(

[KR]

On 4/19/2020 at 7:30 PM, dianah said:

I found these helpful articles on the web:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496747/

and

Thank you for sharing!

[asoundchoice]

Place chuck under the patient's head area on the bed.  Place a folded pillow across their upper chest.  Place something soft under their forehead that would elevate it around 3 inches.  This way you can manage secretions effectively, do oral care, rotate ET tube, and avoid skin breakdown under ET holder.  Turn their head towards the vent.  Place pumps behind the bed.  

Back in April, we had to prone 50% of the vented Covid patients.  It was very frustrating at first, because none of the prone foam, or gel pads worked.  People were still getting skin breakdown, and they were drowning in secretion.  Eventually we became very good at proning.  The above method proved to be the best.

We usually give some paralytics before we prone.  Most patients oxygenate better after proning, but some do worse.  We usually grab an ABG and supine the ones that don't benefit from or tolerate proning. 

Good luck, and stay strong.

[LadyStark, MSN, RN]

Same situation for me here, I worked in a COVID MICU from the beginning of the pandemic until the end of august. What we did was pull the patient all the way up the bed where their head was hanging off essentially. Then we would wedge a pillow under their chest/head. Yeah it was still awkward and their face was in the pillow, but much easier to get to the ETT and to do oral care.

[amoLucia]

Don't know if this might help, but try looking on Amazon for ideas! I know, sounds silly, but I was looking for a personal pillow to specially prop my  shoulder/torn rotator cuff in a slightly elevated position where my lower arm would just be in a lower position than my shoulder. (I sleep in a elec recliner, so I needed chest/shoulder expansion, but lower arm.)

 Amazon has all kinds of pillows & wedges to think about.

I found a folding bed pillow for my Craftmatic bed where the pillow wedges into the gap as the HOB rises.

[pmath_RRT]

Your friendly RT should be taping the tubes as well. Using AnchorFasts cause soo much breakdown due to the hard plastic on them.  

I normally place a saline bag under their forehead and one on their chest and it seems to help.  I don't think there truly is a foolproof way of doing it in my experience. Rotate head and arms q2. Stuff a pillow under them abdomen on whatever side they are facing