What is the purpose of posturing in comatose patients?

From the Guidelines

Comatose patients should be positioned in a way that prioritizes their safety, airway patency, and comfort, with the recovery position being a recommended option, as stated in the 2024 American Heart Association and American Red Cross guidelines for first aid 1.

Key Considerations

• The recovery position, also known as semiprone, lateral recumbent, side lying, or three-quarters prone, is recommended for individuals with decreased level of consciousness to maintain an open airway, prevent aspiration, and provide stability and comfort.
• However, this position may not be ideal if there are injuries to the spine, hip, or pelvis; if breathing is abnormal; or if CPR is needed.
• Regular repositioning, every 2 hours, alternating between supine, lateral, and semi-prone positions, can help prevent pressure ulcers.
• Elevating the head of the bed 30-45 degrees can reduce intracranial pressure and prevent aspiration pneumonia, unless contraindicated.
• Limbs should be positioned in functional alignment using pillows or foam wedges, with joints slightly flexed to prevent contractures.
• Range of motion exercises should be performed 3-4 times daily, and splints may be needed for patients showing abnormal posturing.
• Eye care, including lubricating drops every 2-4 hours, and oral care, every 4 hours, are also crucial interventions.

Recent Guidelines

• The 2024 guideline on positioning and early mobilisation in the critically ill by an expert panel recommends elevation of the upper body ≥ 40° in intubated patients, considering possible haemodynamic side effects and an increased risk of pressure ulcers 1.
• Prone positioning is recommended in invasively ventilated patients with ARDS and impaired arterial oxygenation (PaO/FiO2 < 150 mmHg), with a duration of at least 12, preferably 16 hours 1.

Prioritizing Morbidity, Mortality, and Quality of Life

• The primary goal of positioning comatose patients is to prevent complications and promote recovery, while minimizing the risk of morbidity, mortality, and impaired quality of life.
• Interventions should be tailored to the individual patient's needs, taking into account their specific condition, injuries, and medical history.
• Regular monitoring and adjustments to positioning and care are essential to ensure the best possible outcomes for comatose patients.

From the Research

Posturing Comatose Patients

• The prevention of pressure sores by frequent repositioning of patients is a widely accepted practice 2.
• Repositioning is regarded as an important intervention to prevent the development of pressure injuries in patients who are immobile 3.
• However, there is uncertainty as to the optimal regimen in terms of frequency and method of repositioning 3.
• Limited evidence suggests that repositioning every 4 hours, when combined with an appropriate pressure redistribution surface, is just as effective for the prevention of facility-acquired pressure ulcers as a more frequent (every 2 hour) regimen 4.
• There is insufficient evidence to determine whether a 30 degrees lateral position is superior to a 90 degrees lateral position or a semi-Fowler's position 4.
• Results regarding turning and repositioning schedules are inconclusive; however, the topic needs further exploration to improve the outdated guidelines surrounding pressure ulcer prevention 5.

Pressure Ulcer Prevention

• Prolonged exposure to pressure is the primary etiologic factor of a pressure ulcer and effective preventive interventions must avoid or minimize this exposure 4.
• The current regulatory and legal environment has focused increased attention on pressure ulcer prevention, with pressure redistribution methods and the frequency of application being among the first factors scrutinized when a pressure ulcer develops 4.
• Clinical experience validates that regular movement of the immobilized patient is important, but evidence defining the optimal frequency of repositioning or optimal positioning is lacking 4.

Studies on Repositioning

• A systematic review of electronic databases found limited evidence to support the efficacy of repositioning as a pressure ulcer prevention intervention 4.
• A scoping review found that only 2 studies reached a conclusion on the effective frequency of turning and duration for repositioning patients to prevent the development of pressure ulcers, while 8 studies could not reach a conclusion 5.
• A commentary on a Cochrane review summarized and critically appraised the clinical and cost-effectiveness of different repositioning regimens on the prevention of pressure injuries in adults 3.