Study title: O2 saved by proning patient on mechanical ventilator in ICU

Project done by : Dr. Harsha Makwana, Dr. Sapna Gupta, under guidance of Dr. Bhavesh Jarwani
 Aims: to estimate of O2 that can be saved by proning patient on Mechanical ventilator
in ICU

Objectives:
Primary
1. to estimate of O2 that can be saved by proning patient on Mechanical ventilator
in ICU
2. to see the problems while proning
secondary :
To see the long term effects of prolonged proning (continuous more than 1 day)
on O2 saving
Inclusion critaria:

 Patient with covid pneumonia more than 18 years of age

 Intubation done within last 48 hours

 Moderate to severe ARDS ,on control mode of ventilation with PEEP > 5 and FiO2 > 0.6
Exclusion criteria:
• Recent tracheostomy
• Moribund status
• High dose of vasopressors (map <65 mm hg)
• Clinically unstable with arrhythmias
• Spinal instability
• Less than 24 hours post cardiac surgery
• Massive hemoptysis
• Frequent convulsions
• Pregnancy 2nd and 3rd trimester
• raised iop/icp
• Recent abdominal surgery with intestinal ischemia and raised intra abdominal pressure
 Methodology:
● ⦁ Patients were selected as per inclusion and exclusion criteria
● ⦁ Proning team was activated
● ⦁ Pre-procedure checklist was completed and checked by doctor in team
● ⦁ Additional sedation dose was given if required
● ⦁ Patients were proned by expert proning team as per the SOP
● ⦁ Infusions and monitoring were resumed after proning
● ⦁ Immediate post procedure checklist was filled
● ⦁ patient monitoring was continued continuously (as per SOP)
● ⦁ ABG estimations was done before proning, 4 & 12 hours of proning/ on termination of proning
● ⦁ Rryle’s tube feeding to be started with 50ml for 2 feeds after ensuring negative aspirate and subsequently increased to 7
for two feeds and then 100ml for two feeds. all feeds to be given 2 hourly and each time negative RT aspirate to be confirmed

● ⦁ Patients were supinated after completion of 12 hours by proning team or as and when required
DISCUSSION:
⦁ Results - summary: of 15 cases
⦁ Improvement : 10
⦁ 1 hour and upto 4 hours : 2
⦁ 12 hours : 8
⦁ No improvement in parameters 5
⦁ In 4 hours : 1 (so supinated)
⦁ in 12 hours :4
⦁ Went into hypotension : 1 ---
⦁ Higher PCO2 (after ruling out all possibilities and maneuvering ventilator settings to
optimize): 1---
⦁ Acute gastric dilatation : in 1 patient, inj levosupride given, but did not improve then.
Hence feeding was an issue in that patient.
CONCLUSION: (limitation and road map ahead):
o Out of 15 cases 10 had improvement (could reduce FiO2)
o Out of total 15 cases, 5 had deterioration while proning (5 cases)
o 3 developed hypotension
o 1 penumothorax
o 1 MI (new onset LBBB)
• Proning was terminated due to above mentioned reasons.

 Average oxygen saved in improved (sustained improvement)cases (10 cases): 9144

liters/pt/12 hours of proning

 In two patients (Nahush and khatija), we did proning for 5 days consecutively , in which
beyond third day, no further improvement in oxygenation.
⦁ Large scale study required: Follow required to know the ultimate outcome.
⦁ Sample size is too small, to make it more reliable
⦁ Further staff expertize and training is required.
⦁ Feeding etc should be reevaluated, because gastric distension was noted in one patient

⦁ Unfortunately, in above all case final outcome was all cases died.
⦁ Comorbidities and lung severity score was not taken into account
⦁ Apache II score should be taken into consideration
⦁ Procalcitonin should be done. antibiotic selection should first
⦁ In thrombotic / thromboembolic event should be ruled out first.
Overall impression:

• Proning should be done only after control of sepsis by proper procalcitonin

level and appropriate antibiotics usage
• Fluid status should optimized before proning
• Difficult to know fluid status (one cannot do USG for IVC or measure CVP?
• High level of dedicated team and proper ratio of nurse/doctor per pt is require
• Proper documentation and check list is improvement.
 REFERANCES:
Protocol is adapted from following sources
An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care
Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress
Syndrome
⦁ FICM/ICS Guideline Development Group :
Guidance For: Prone Positioning in Adult Critical Care2019
https://www.ficm.ac.uk/sites/default/files/prone_position_in_adult_critical_care_2019.pdf
⦁ https://www.aacn.org/docs/Photos/Procedure-19-pzjnnuht.pdf
⦁ K. Vollman, S. Dickinson, and J. Powers, “9 Pronation Therapy.”
⦁ M. Jozwiak et al., “Beneficial hemodynamic effects of prone positioning in patients with acute respiratory
distress syndrome,” Am. J. Respir. Crit. Care Med., vol. 188, no. 12, pp. 1428–1433, Dec. 2013, doi:
10.1164/rccm.201303-0593OC.