Complications of prone ventilation in patients with multisystem trauma with fulminant acute respiratory distress syndrome

Introduction: Prone ventilation improves oxygenation in selected patients w ith acute respiratory distress syndrome (ARDS). However, prone positioning of critically ill patients with multiple invasive lines and tubes is potent ially dangerous. Trauma patients, in particular, may require special consid eration because of skeletal fixation devices or prior operative procedures. Our objective was to critically evaluate our experience with prone positio ning in patients with severe postinjury ARDS. Methods: Injured patients admitted to our Level I trauma center who develop ed ARDS mere prospectively identified. Serial lung injury severity and pulm onary mechanical data, as well as complications of prone ventilation were r ecorded. Results: During the 12-month period ending August of 1998, nine patients wi th postinjury ARDS mere treated with prone ventilation because of hypoxemia refractory to other ventilatory strategies. All patients suffered blunt tr auma. Their mean age was 29 +/- 4.5 years; seven patients were men. The ave rage Injury Severity Score n as 26 +/- 5; and, at the time of prone positio ning, the mean Lung Injury Score was 3.5. The mean PaO2/FIO2 ratio increase d from 75 +/- 7 to 147 +/- 27 with prone ventilation (p < 0.85, paired t te st); and in six patients, the FIO2, could be decreased. Four major complica tions occurred (44%). One patient experienced a midline abdominal wound deh iscence. Severe facial or upper chest mail pressure necrosis developed in t wo patients, despite extensive padding and careful attention to skin care, The fourth patient sustained a cardiac arrest immediately after prone posit ioning. Conclusion: Prone ventilation in postinjury patients with ARDS may improve oxygenation but has the potential for significant ant complications. Carefu l consideration is required before prone positioning in this subset of pati ents.