What are the contraindications of proning?

Contraindications of Proning

Prone positioning should not be performed in patients with open abdomen, spinal instability, increased intracranial pressure (ICP), cardiac arrhythmias with hemodynamic consequences, or shock, except in individual cases after careful interdisciplinary risk-benefit assessment. 1

Absolute Contraindications

• Hemodynamic instability: Patients who are hemodynamically unstable should not undergo prone positioning 1
• Open abdomen: Surgical wounds may be compromised and intra-abdominal pressure may increase 1
• Unstable spine/spinal fractures: Risk of further neurological injury 1
• Unstable chest wall: May worsen respiratory mechanics and increase risk of complications

Relative Contraindications (Requiring Careful Assessment)

Neurological Conditions

• Increased intracranial pressure (ICP): Requires continuous monitoring if proning is attempted 1
  • Head should be positioned centrally
  • Lateral rotation should be avoided
  • Consider risks vs. benefits in an interdisciplinary discussion

Cardiovascular Issues

• Cardiac arrhythmias with hemodynamic consequences: May worsen during position change 1
• Shock: Requires hemodynamic stabilization and volume status optimization before attempting prone positioning 1
  • Note: Use of catecholamines alone is not a contraindication 1

Abdominal Conditions

• Recent abdominal surgery: Not an absolute contraindication but requires careful consideration 1, 2
• Abdominal pathologies: Requires individual assessment of benefits vs. risks 1
• Abdominal obesity: May increase intra-abdominal pressure with risk of:
  • Surgical complications
  • Acute renal failure
  • Hypoxic hepatitis 1

Other Considerations

• Pregnancy: Requires special positioning techniques to accommodate the gravid uterus 3
• Empyema or prior chest radiation: Should be assessed on an individual basis 1
• Advanced age: Not an absolute contraindication but requires careful assessment 1
• Significant cardiopulmonary comorbidities: Requires individual assessment 1
• Anticoagulation use/uncorrected coagulopathy: Increases risk of bleeding complications 1
• Active malignancy or terminal illness: Requires careful risk-benefit assessment 1

Risk Mitigation Strategies

Before Proning

• Stabilize patient hemodynamically and optimize volume status 1
• Consider interdisciplinary consultation for high-risk patients
• Ensure proper education and training of proning team 4

During Proning

• Monitor ICP continuously in at-risk patients 1
• Maintain proper head positioning (centered) in patients with ICP concerns 1
• Carefully examine areas at risk for pressure ulcers 1, 5
  • Prone positioning significantly increases pressure ulcer risk
  • Higher risk in patients >60 years, BMI >28.4 kg/m², and higher illness severity 5

Special Considerations

• Complete vs. Incomplete Proning: Complete (180°) prone positioning has stronger effects on oxygenation than incomplete proning 1
• Duration: Maintain prone position for at least 12 hours, preferably 16 hours 1, 6
• Ventilator Management: Maintain lung-protective ventilation strategies with tidal volume limitation and appropriate PEEP 6

When to Terminate Proning

• Improvement in supine oxygenation persists (4 hours after repositioning: PaO₂/FiO₂ ≥150 with PEEP ≤10 cm H₂O and FiO₂ ≤0.6) 1
• After at least two unsuccessful positioning attempts with no improvement in oxygenation 1

By carefully assessing these contraindications and implementing appropriate risk mitigation strategies, prone positioning can be safely performed in most patients with severe ARDS requiring improved oxygenation.