避免俯卧位通气期间的并发症

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Prone position (PP) is frequently used in patients with acute respiratory distress syndrome (ARDS), during non-invasive ventilation (Longhini et al., 2020), invasive mechanical ventilation for moderate to severe ARDS (Guerin et al., 2013) and even in conjunction with extra-corporeal membrane oxygenation (ECMO) treatment (Giani et al., 2021). PP adjusts pulmonary perfusion diverting flow towards high Va/Q areas allowing a redistribution of aerated and non-aerated areas. If applied early, for prolonged (>16 hours) sessions, PP improves gas exchange in patients with an arterial partial pressure to inspired fraction of oxygen (PaO2/FiO2) < 150 mmHg thereby reducing 28-days mortality (Guerin et al., 2013).

PP requires fluent and smooth movement of the patient by a small group of personnel. There is a positive learning curve relative to accumulating experience. Complications may occur during and after the postural change, including: 1) accidental extubation and/or obstruction of the endotracheal tube; 2) accidental loss of vascular access (including ECMO cannulas), drainage bags and catheters; 3) pressure injuries; 4) facial, palpebral and/or conjunctival oedema; 5) corneal injuries; 6) muscular-skeletal spasm; 7) brachial plexus injury; 8) regurgitation and/or intolerance of enteral nutrition and 9) alterations in haemodynamic and/or respiratory state.

Since the responsibility for PP lies with nursing staff, it is fundamental to avoid or anticipate the occurrence of these potential but rare complications, (Mancebo et al., 2006). To avoid complications, nursing staff should prepare patients appropriately (Jove Ponseti et al., 2017). A checklist for the procedure is identified in Table 1.

Table 1. Checklist for prone positioning.

Firstly, in order to avoid accidental extubation, the endotracheal tube position and fixation must be verified. The endotracheal tube cuff pressure should also be monitored. In the unlikely event of an accidental extubation during the procedure, the patient must be promptly returned to a supine position. All the materials required for an emergency reintubation, such as a resuscitation bag connected to oxygen and suction system must be available at the beside (Jove Ponseti et al., 2017).

Secondarily, it is important to prepare and check all vascular catheters, assuring their fixation and where possible, increasing the available length. Similarly, the urinary catheter, nasogastric feeding tube and all drainage bags must be secured and checked to avert accidental displacement. Whenever possible, lines, tubes and drainage bags should be disconnected.

After proning, it is important to move the electrocardiogram electrodes from the thorax to the shoulders and prepare the monitoring system. During and soon after proning haemodynamic instability and/or desaturations may occur, therefore the invasive arterial blood pressure and peripheral oxygen saturation (SpO2) monitoring should be retained.

Finally, before proning ensure deep sedation and full neuromuscular blockade to avoid coughing, muscular spasm or unplanned extubation. Additionally, the inspired fraction of oxygen should be increased for a period of pre-oxygenation (Jove Ponseti et al., 2017). Which side to turn the patient must be also considered; this depends on vascular access, catheters and drainage bags. During the turn, the patients’ arms must be aligned against the body, with the palms up. The leader co-ordinates the patient’s movement and assures the endotracheal tube. Two operators per side help with turning the patient. All movement must be synchronised according to the leader’s indications. Where the patient is awake and pronation is performed during spontaneous breathing and/or non-invasive ventilation, staff should ask the patient to collaborate (Longhini et al., 2020).

After proning, personnel must: 1) check the endotracheal tube for displacement or obstruction (including auscultation to assure bilateral ventilation); 2) check the monitoring and reconnect all the system; 3) check and/or reconnect all infusion lines, paying attention to possible kinking; 4) check the position of the arms and head, to avoid brachial plexus injury and to assure venous drainage of jugular veins; 5) protect pressure area with dedicated pillows and specific prevention measures to avoid pressures ulcers (include foam, water, gel and air mattresses) (Alshahrani et al., 2021, Jove Ponseti et al., 2017).

The expertise of the nursing staff is fundamental to prevent pressure or corneal ulcers (Alshahrani et al., 2021). Pressure injuries have been reported to occur in about one quarter of patients, often located on the ears, cheeks, chin, the front of the feet, eyelids, chest, abdomen and genitals (mainly stage 1 and 2). Facial and conjunctival oedema are also frequent (in 23% and 15% of the patients, respectively) (Jove Ponseti et al., 2017). Corneal lesions may also occur and they must be prevented by a series of measures such as care using eye drops, ointment or polyethylene film and keeping the patient’s eyelids closed (Werli-Alvarenga et al., 2013, Carneiro e Silva et al., 2021). The patient’s position and pressure areas require frequent monitoring to avoid the occurrence of pressure injuries.

If the patient has been turned in PP while receiving non-invasive ventilation, personnel should check the presence of unintentional air-leaks and the occurrence of patient-ventilator asynchronies (Bruni et al., 2019, Garofalo et al., 2018). Low doses of sedatives such as remifentanil (Costa et al., 2017) or dexmedetomidine (Conti et al., 2016) may be considered to increase the patient’s tolerance.

Finally, enteral nutrition must be also restarted. In prone patients, nurses should frequently monitor, recognize and manage possible complications, such as enteral nutrition intolerance, high gastric residual volume, vomiting or regurgitation, which may require its discontinuation (Bruni et al., 2020). The development of protocols including strategies to increase enteral nutrition tolerance (head-of-bed elevation, use of prokinetic agents, continuous administration over 24 hours) may be effective to reduce complications related to intolerance and to increase the total enteral nutrition volumes (Bruni et al., 2020) which in turn may reduce the risk of pressure injuries (Wenzel and Whitaker, 2021, Tatucu-Babet and Ridley, 2021).

In conclusion, before PP, personnel must appropriately prepare the patient to avoid preventable complications. After proning, the patient must receive a full head to toe check and be monitored for possible complications.

全文翻译（仅供参考）

俯卧位(PP) 常用于急性呼吸窘迫综合征(ARDS)患者、无创通气 ( Longhini et al., 2020 )、中重度 ARDS 有创机械通气( Guerin et al., 2013 ) 和甚至结合体外膜肺氧合 (ECMO) 治疗（ Giani 等人，2021 年）。PP 调整肺灌注分流流向高 Va/Q 区域，允许充气和非充气区域重新分布。如果及早使用，对于长时间（>16 小时）的治疗，PP 可改善动脉分压为吸入氧分数(PaO 2) 的患者的气体交换/FiO 2 ) < 150 mmHg，从而降低 28 天死亡率（Guerin 等人，2013 年）。

PP需要一小群人员流畅、平稳地移动患者。相对于积累经验，有一个积极的学习曲线。体位改变期间和之后可能会出现并发症，包括：1) 意外拔管和/或气管插管阻塞；2) 意外丢失血管通路（包括 ECMO 插管）、引流袋和导管；3) 压力性损伤；4) 面部、眼睑和/或结膜水肿；5)角膜损伤；6) 肌肉骨骼痉挛；7)臂丛神经损伤；8) 反流和/或肠内营养不耐受 和 9) 血液动力学和/或呼吸状态的改变。

由于PP的责任在于护理人员，因此避免或预测这些潜在但罕见的并发症的发生至关重要（Mancebo 等，2006 年）。为避免并发症，护理人员应为患者做好适当的准备（Jove Ponseti et al., 2017）。表 1 中列出了该程序的检查清单。

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首先，为了避免意外拔管，必须验证气管插管的位置和固定。所述气管内管袖带压力也应被监控。万一在手术过程中意外拔管，患者必须立即恢复仰卧位。紧急再插管所需的所有材料，例如连接到氧气和抽吸系统的复苏袋必须在旁边可用（ Jove Ponseti 等，2017）。

其次，重要的是准备和检查所有血管导管，确保它们的固定，并在可能的情况下增加可用长度。同样，导尿管、鼻胃管和所有引流袋都必须固定和检查，以避免意外移位。只要有可能，应断开管线、管道和引流袋。

俯卧后，重要的是将心电图电极从胸部移动到肩部并准备监测系统。在前倾期间和后不久可能会发生血流动力学不稳定和/或饱和度下降，因此应保留有创动脉血压和外周血氧饱和度(SpO 2 ) 监测。

最后，在俯卧前确保深度镇静和充分的神经肌肉阻滞，以避免咳嗽、肌肉痉挛或意外拔管。此外，在预充氧期间应增加吸入的氧气比例（ Jove Ponseti et al., 2017 ）。还必须考虑患者转向哪一侧；这取决于血管通路、导管和引流袋。在转身过程中，患者的手臂必须与身体对齐，手掌朝上。领队协调病人的运动并保证气管插管. 每侧两名操作员帮助转动患者。所有的动作都必须按照领队的指示同步进行。如果患者清醒并在自主呼吸和/或无创通气期间进行旋前，工作人员应要求患者合作（ Longhini 等，2020）。

俯卧位后，人员必须：1) 检查气管插管是否移位或阻塞（包括听诊以确保双侧通气）；2）检查监控并重新连接所有系统；3) 检查和/或重新连接所有输液管线，注意可能的扭结；4）检查手臂和头部的位置，避免臂丛神经损伤，保证颈静脉引流；5）用专用枕头保护受压部位，并采取具体的预防措施，避免压疮（包括泡沫床垫、水床垫、凝胶床垫和充气床垫）（ Alshahrani et al., 2021 , Jove Ponseti et al., 2017）。

护理人员的专业知识是预防压力或角膜溃疡的基础（Alshahrani 等，2021 ）。据报道，大约四分之一的患者发生压力性损伤，通常位于耳朵、脸颊、下巴、脚前部、眼睑、胸部、腹部和生殖器（主要是第 1 和第 2 阶段）。面部和结膜水肿也很常见（分别为 23% 和 15% 的患者）（Jove Ponseti 等，2017 ）。角膜病变也可能发生，必须通过一系列措施来预防，例如使用眼药水、软膏或聚乙烯薄膜进行护理并保持患者的眼睑闭合（ Werli-Alvarenga 等，2013 年，Carneiro e Silva 等人，2021 年）。患者的体位和受压部位需要经常监测，以避免发生压伤。

如果患者在接受无创通气时已转入PP，工作人员应检查是否存在意外漏气和患者呼吸机不同步的发生（Bruni 等人，2019 年，Garofalo 等人，2018 年）。可以考虑使用低剂量镇静剂，如瑞芬太尼( Costa et al., 2017 ) 或右美托咪定( Conti et al., 2016 )，以增加患者的耐受性。

最后，肠内营养也必须重新开始。对于易发患者，护士应经常监测、识别和处理可能出现的并发症，例如肠内营养不耐受、胃残留量高、呕吐或反流，这些可能需要停药（ Bruni 等，2020 ）。包括增加肠内营养耐受性策略（床头抬高、使用促动力剂、连续给药 24 小时以上）在内的方案的制定可能有效减少与不耐受相关的并发症并增加肠内营养总量（Bruni 等al., 2020 ) 反过来可能会降低压力性损伤的风险 ( Wenzel and Whitaker, 2021，Tatucu-Babet 和 Ridley，2021 年）。

总之，在PP之前，工作人员必须为患者做好适当的准备，以避免可预防的并发症。俯卧撑后，患者必须接受从头到脚的全面检查，并监测可能出现的并发症。

原文链接：

https://doi.org/10.1016/j.iccn.2021.103064

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