Prone position: Contraindications and complications

Contraindications

Acute bleeding (eg, hemorrhagic shock, massive hemoptysis)

Multiple fractures or trauma (eg, unstable fractures of femur, pelvis, face)

Spinal instability

Raised intracranial pressure >30 mmHg or cerebral perfusion pressure <60 mmHg

Tracheal surgery or sternotomy within two weeks

Relative contraindications

Shock (eg, persistent mean arterial pressure <65 mmHg)

Anterior chest tube(s) with air leaks*

Major abdominal surgery

Recent pacemaker*

Clinical conditions limiting life expectancy* (eg, oxygen or ventilator-dependent respiratory failure)

Severe burns*

Recent lung transplant recipient*

Complications

Nerve compression (eg, brachial plexus injury)

Crush injury

Venous stasis (eg, facial edema)

Dislodging endotracheal tube

Diaphragm limitation

Pressure sores (eg, facial)

Dislodging vascular catheters or drainage tubes

Retinal damage

Transient reduction in arterial oxygen saturation

Vomiting

Transient arrhythmias

* Based upon exclusion criteria from the Prone Postioning in Severe ARDS trial (PROSEVA).
¶ Patients in whom benefit is not assured include: patients on inhaled nitric oxide, on almitrine bimesyalte, extracorporeal membrane oxygeneation (ECMO), or noninvasive ventilation (NIV) prior to intubation.

Data from:

Ryan DW, Pelosi P. The prone position in acute respiratory distress syndrome. BMJ 1996; 312:860.
Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368:2159.

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Prone position: Contraindications and complications