What are the key considerations when preparing a patient for the prone position in surgery?

Preparing a Patient for Prone Position in Surgery

Before placing any patient prone for surgery, you must stabilize hemodynamics, optimize volume status, secure all tubes and lines, protect pressure points with prophylactic dressings, ensure proper head positioning to avoid eye compression, and verify absence of absolute contraindications including open abdomen, spinal instability, severe increased intracranial pressure, hemodynamically significant arrhythmias, and shock. 1

Pre-Positioning Assessment and Stabilization

Hemodynamic Optimization

• Stabilize the patient hemodynamically and optimize volume status before prone positioning 1
• Ongoing vasopressor therapy is NOT a contraindication to prone positioning, as the intervention is generally well tolerated hemodynamically 1
• Patients may experience improved right ventricular load in prone position 1

Absolute Contraindications to Screen For

Prone positioning should only proceed after interdisciplinary risk-benefit assessment if any of these exist: 1

• Open abdomen
• Spinal instability
• Increased intracranial pressure (ICP)
• Cardiac arrhythmias with hemodynamic consequences
• Shock

Special Population Considerations

• Patients with abdominal surgery, abdominal pathologies, or abdominal obesity require individual consideration of benefits (improved oxygenation) versus risks (increased intraabdominal pressure leading to surgical complications, acute renal failure, or hypoxic hepatitis) 1
• Patients at risk of increased ICP must have continuous or close monitoring during positioning, with head positioned centrally and lateral rotation avoided 1

Equipment and Positioning Preparation

Airway and Tube Management

• Secure all endotracheal tubes, lines, and catheters before positioning to prevent dislodgement during the turn 2, 3
• Reexamine all tubing after positioning to ensure they are free of kinks, twists, and functioning properly 4
• Ensure adequate tube length and mobility to accommodate the position change 5

Pressure Point Protection

• Apply prophylactic foam dressings to vulnerable areas BEFORE positioning to minimize pressure ulcer risk 1, 2
• Key pressure points requiring protection include: face (especially eyes and nose), chest, anterior iliac crests, knees, and toes 2, 3
• Plan for careful examination of all at-risk areas during and after prone positioning 1

Head and Eye Protection

• Ensure absolutely no ocular compression - this is a critical safety priority 6
• Position head centrally with proper support to avoid lateral rotation 1
• Use appropriate head support devices (foam headrests, mirror systems, or specialized prone positioning frames) 5, 3

Abdominal Decompression

• Ensure the abdominal wall is not under pressure to allow adequate ventilation and prevent increased intraabdominal pressure 6
• Use chest rolls or specialized prone positioning frames that allow the abdomen to hang freely 5, 3
• This is particularly important as intraabdominal pressure typically increases from 12±4 mmHg to 14±5 mmHg in prone position 1

Positioning Technique

Complete vs Incomplete Prone Position

• Use complete (180°) prone positioning rather than incomplete prone positioning 1
• Complete prone position has stronger effects on oxygenation and is the only position with evidence for improved clinical outcomes 1

Limb Positioning

• Position arms carefully to avoid brachial plexus injury - typically tucked at sides or positioned on arm boards with shoulders abducted less than 90° 5, 2
• Ensure proper padding of all bony prominences 2, 3
• Verify neutral spine alignment throughout 2, 3

Monitoring During Prone Position

Continuous Assessment Requirements

• Monitor hemodynamics continuously during and after positioning 1
• For patients with ICP risk, maintain continuous or close ICP monitoring 1
• Assess respiratory mechanics and oxygenation after positioning 5
• Regularly inspect pressure points throughout the procedure to detect early signs of pressure injury 1

Ventilation Management (if applicable)

• Apply optimized ventilation principles including limitation of tidal volumes, prevention of derecruitment, and integration of spontaneous breathing components when appropriate 1
• Prone positioning and PEEP have additive effects on improving oxygenation 1

Common Pitfalls to Avoid

• Never proceed with prone positioning without first securing all tubes and lines - dislodgement during turning is a preventable catastrophe 2, 4
• Never allow any pressure on the eyes - postoperative vision loss from ocular compression is devastating and preventable 6
• Do not assume vasopressor use is a contraindication - optimize volume status but proceed with positioning if hemodynamically appropriate 1
• Do not use incomplete prone positioning thinking it's "safer" - there is no evidence for clinical benefit and complete positioning has superior oxygenation effects 1
• Do not neglect pressure point protection - prone positioning significantly increases pressure ulcer risk and prophylactic measures must be taken before positioning 1, 2