ASUHAN KEPERAWATAN PADA TN.

U DENGAN PNEUMONIA, FIBROSIS PARU POST

COVI-19 DI INTENSIVE UNIT CARE RS PERKEBUNAN JEMBER
PERIODE 5-10 APRIL 2021

Dosen Pembimbing

Ns. Cipto Susilo, S.Pd., S.Kep., M.Kep

NAMA : DEBIE SAKTYANA IRIAWANDANI

NIM : 2001032012

PROGRAM STUDI NERS

FAKULTAS ILMU
KESEHATAN
UNIVERSITAS MUHAMMADIYAH
JEMBER 2020/2021
 LEMBAR PERSETUJUAN

Laporan Asuhan Keperawatan pada Tn U dengan Pneumonia, Fibrosis Paru post Covid 19 di Ruang ICU
Rumah Sakit Perkebunan Jember

Oleh
Nama : Debie Saktyana Iriawandani
NIM : 2001032012

Jember, 10 April 2021

Mahasiswa

Debie Saktyana I, S.Kep

NIM. 2001032012

PJMK Keperawatan Gadar Pembimbing Akademik

Fikes Unmuh Jember Fikes Unmuh Jember

Ns. Cipto Susilo, SPd., M.Kep Ns. Cipto Susilo, SPd., M.Kep
NPK. 9305832 NPK. 9305832

FIKes UNMUH Jember

 UNIVERSITAS MUHAMMADIYAH JEMBER
FAKULTAS ILMU KESEHATAN
PROGRAM STUDI NERS
Jl. Karimata No. 49 Telp.(0331) 336728 Fax. 337957 Kotak Pos 104 Jember 68121
Website : http://www.unmuhjember.ac.id, E-mail : Kantorpusat@unmuhjember.ac.id

FORMAT PENGKAJIAN KEPERAWATAN KRITIS

MRS Tgl / Jam : 02-04-2021 / 17.33 WIB

Rujukan Dari :-
Pengkajian tgl / Jam : 05-04-2021 / 15.00 WIB No Reg 655540
Diagnosa Medis : Pneumonia, Fibrosis Paru post Covid-19

1. IDENTITAS
Nama : Tn. U Orang yang bertanggung Jawab
Umur : 70 Tahun
Nama : Ny.D
Pekerjaan : Wiraswasta
Hubungan : Anak
Pendidikan : SMA
Umur : 33 tahun
Alamat/ No Telp : Kesilir,
Pekerjaan : Wiraswasta
Banyuwangi
Pendidikan : S1
Suku/Bangsa : Jawa/Indonesia
Suku/Bangsa : Jawa
Agama : Kristen
Agama : Kristen
Status Marietal : Menikah
Alamat/No Telp : Sempusari,
TB / BB : 155 cm / 65kg
Kaliwates
Keluhan Utama : sesak nafas,
badan lemas

2. RIWAYAT KEPERAWATAN
2.1 Riwayat Penyakit Dahulu
pasien tidak memiliki riwayat DM, Hipertensi dan penyakit kronis lainnya
2.2 Riwayat Penyakit Sekarang
Pasien datang ke rumah sakit karena sesak dan badannya lemas. Sebelumnya pernah
menderita Covid-19 dan hasil Lab swab PCR negatif tanggal 1-4-2021.

3. OBSERVASI DAN PEMERIKSAAN FISIK

4.1 Keadaan Umum : lemah

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 FORM KEP KRITIS

4.2 Body Systems

B 1 : (Breathing) Pernafasan
v
Tidak
Ventilator
ya
: Mode : SIMV CPAP BIPAP
IPPV

Memakai High Flow Nasal Canula dg FiO2 100%, flow 20 lpm

RR : 26 x/Menit Teratur v Tidak Teratur SpO2 : 80 %
Suara nafas : Vesikuler
Broncho vesikuler Bronchial Tracheal
Ronchi Fricksion Rub Diameter mm.
Wheezing Rales v
Masker
OTT NTT
v
v
Pola nafas : Cuping Abdomina Thorakal
hidung l
Bentuk dada :simetris
Funnel Pigeon Chest
Barrel Chest chest
Otot bantu nafas : Retraksi interkostal Retraksi sub clavikula
v
Lainnya :
Frekuensi napas berubah ubah, dan SpO2 juga berubah ubah, 6 jam
sebelumnya memakai NRBM 15 lpm saturasi O2 84% dengan posisi
tengkurap, posisi telentang 79%.

B 2 : (Blood) Cardiovascular
TD :140/80 mmHg Nadi : 88 X/Menit Teratur v Tidak teratur
Irama : Teratur C 3 dtk
R
Perfusi :
T:
Hangat <
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Tidak teratur Kering

Merah v Dingin Basah Biru

Suara jantung I & II : Tunggal / abnormal
Suara tambahan : Mur – mur Gallop Thrill
JVP : < 5 Cm > 5 Cm
Lainnya : Warna kulit pucat, MAP : 112 mmHg

B 3 : (Brain) Persyarafan
Kesadaran :CM Apatis
Somnole Soporocomateus Coma
n
Refleks Cahaya + / - Pupil :Isokor
Anisokor
Ǿ : < 3 mm > 3mm
Parese Hemiparese Plegi Hemi para plegi Tetra
Plegi
Refleks Patologis: GCS E4 V5 M6
Plegi

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 FORM KEP KRITIS
Rangsangan Meningeal : Nuchal Brudsinzki’ Neck Sign
Rigidity Brudsinzki’s Contralateral Leg Kernig
Sign Kejang : Klonik Tonik Fokal Umum Grand Mall
Petit Mal
Tremor Twitching Khore Atetosi
a
Cemas Takut
Gelisah
Lainnya
:

B4 : (Bladder) Perkemihan / Eliminasi Uri

BAK : Warna : kuning. Jumlah : 400 cc/ 6 jam. Cateter ya / tidak
Oliguri Anuri Poliuri Gross
hematuri
B 5 : (Bowel) Pencernaan / Eliminasi Alvi
Bentuk abdomen : Simetris / Asimetris
Soepel Distendeed Meteorismus Defend Musculair
BU:12Kpm Peristaltik : Normal Shifting Dullness Undulasi
Hepar : Teraba / Tdk teraba Ginjal : Teraba / Tdk teraba
Limpa : Teraba / Tdk teraba VU : Lunak / Keras / Kosong
Lainnya : makan sehari 3x, lauk dan buah (+). Kadang minum
susu

B 6 : (Bone) Tulang, Otot dan Integumen

Suhu Tubuh : 36,8 o C Axila / Rectal / Oral
Pergerakan : Bebas / Terbatas = Fleksi Ekstensi Endorotasi
Deformitas : ya / Tdk. Otot : Atropi / Hipertropi Kontraktur
Kekuatan otot : 1 2 3 4 5
Vertebra : Lordosis Kiposis Skoliosis Spina Bifida
Turgor Kulit : < 3 detik
Lainnya : Sebagian aktivitas pasien dengan dibantu, kulit teraba hangat. Pasien
bisa miring kanan dan kiri sendiri. Namun saat tengkurap pasien butuh bantuan
perawat.

4.3 Kebutuhan Dasar Manusia

1. Kebutuhan nutrisi selama perawatan dilakukan bantuan sebagian, dengan
pemenuhan nutrisi dipenuhi dengan pasien makan Nasi Tim TKTP dan buah
habis dalam 1 porsi.
2. Kebutuhan perawatan diri dilakukan total care, personal hygiene dengan menyeka
pasien setiap pagi, oral hygiene, pembuangan urine. Semua aktivitas dan
kebutuhan dasar pasien dibantu dengan keluarga dan perawat.

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 FORM KEP KRITIS
5. DIAGNOSTIK TEST/PEMERIKSAAN PENUNJANG
5.1 Laboratoriun :
1. Pemeriksaan Hematologi Tgl 5-4-2021
Pemeriksaan Nilai Normal
Hemoglobin 12,2 mg/dL 12,0-16,0 gr/dL
Lekosit 10 103/ µl 4,5-11,0 103/ µl
Hematokrit 40 % 36-46 gr/dL
Trombosit 202 109/L 150-450 109/L
CRP 154,96 < 5 mg/L
2. Faal Hati
Pemeriksaan Nilai Normal
Albumin 3,6 gr/dL 3,4-4,8 gr/dL
3. Gula Darah
Pemeriksaan Nilai Normal
GDS 169 <200
4. Elektrolit
Pemeriksaan Nilai Normal
Natrium 133,3 135-155 mmol/L
Kalium 3,5 3,5-5,0 mmol/L
Chlorida 110 90-110 mmol/L
Calsium 2,24 2,15-2,57 mmol/L
5. Hasil BGA

Pemeriksaan Nilai Normal

PH 7,47 7,35-7,45
PCO2 33 35-48
PO2 69 80-100
HCO3 23,6 18,0-23,0
BE 1,9 -2-3,0
Analisa BGA : Alkalosis respiratorik tidak terkompensasi dengan Hipoksemia
5.2 Hasil Rontgen: Pneumonia

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 FORM KEP KRITIS
6. TERAPI
Infus Aminofluid 500cc
RL 500 cc

Obat-obatan
Methylprednison 1x 40mg
Lavit C 2x500 mg
Antrain 2 x1 gr
Resfar 1x 25 mg
Esomeprazol 2 x40 mg
Diviti 1x 5mg
Doripenem 2x 500mg
Cravit 1x 750 mg

Oral: Episan syrup 3x 1 CTH

7. DATA TAMBAHAN
a. Kebutuhan
cairan: 30 cc/kg
BB
30 c x 65 kg = 1950 cc

Intake cairan:
Infus: 300 cc
Minum air putih dan susu 300 cc
Obat-obatan: 50 cc
Total intake = 650 cc
Output:
Urine: 400cc
Total output = 400 cc
Balance cairan / 6 jam = + 250

b. Kebutuhan nutrisi (kalori) = stress ringan = 30 kcal/kgBB/hari

30 kcal x 65/hr
1950 kcal/hari
Intake kalori :
Makan Nasi 1 porsi dan sayur =
3x/hr x 200 kkal = 600 kkal
Aminofluid = 420 kkal
Total intake = 1020 kkal
Balance kalori = 1020 – 1950
= - 930 kkal /hr

Jember, 7 April 2021

Mahasiswa

( Debie Saktyana I)

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 FORM KEP KRITIS
ANALISA DATA

NO DATA ETIOLOGI MASALAH

1 DS : “ nafas berat” Pneumonia dan Gangguan pertukaran
DO : Fibrosis Paru gas
1. RR : 26x/mnt
2. Nafas dengan High flow nasal Infiltrat paru dan
canula (HFNC) 20 lpm, FiO2 100% elastisitas paru <<
3. Pa O2: 69 mmHg
4. pH = 7,47 Ketidakseimbangan
5. Rales di lobus inferior kanan kiri ventilasi-perfusi
(+)
6. SpO2 : 83%
7. CRP = 154, 96 mg/L

2 DS:- Pengobatan post covid Risiko perdarahan

DO:
1. GCS CM Gangguan koagulasi
2. TD :140/80 mmHg
3. Nadi : 88 X/Menit Pemberian LMWH
4. Akral hangat kering merah
5. Gelisah Efek agen
6. Mendapat terapi LMWH (Diviti farmakologis
1x5unit)
7. Trombosit 202 109/L
8. Hb 12,2 mg/dl
9. PCV 40%

3 DS : Pneumonia Defisit perawatan diri

DO: post covid-19 : mandi
1. Badan tampak kotor dan berminyak
2. ADL di bantu sepenuhnya Sesak
3. terpasang HFNC
4. terpasang kateter Kelemahan
5. terpasang NGT
6. badan tampak kotor dan berminyak
7. tonus otot 55555 555555
55555 555555

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 FORM KEP KRITIS
DAFTAR DIAGNOSA KEPERAWATAN
SESUAI PRIORITAS

NO DIAGNOSA KEPERAWATAN

1. Gangguan pertukaran gas berhubungan dengan ketidakseimbangan perfusi-ventilasi d.d

PaO2 69 mmHg, SpO2 83%

2. Resiko perdarahan b.d efek agen farmakologis (heparin)

3. Defisit perawatan diri b.d kelemahan d.d badan tampak kotor dan berminyak, ADL pasien
dibantu sebagian

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 RENCANA TINDAKAN KEPERAWATAN

Tanggal Diagnosis Tujuan dan Kriteria hasil Rencana Tindakan Rasional Paraf
Keperawatan
05-04-2021 / Gangguan Pertukaran gas pasien efektif 1. Lakukan manajemen pernafasan 1. Penatalaksanaan yang baik menjamin keberhasilan Debie
15.00 WIB pertukaran gas dalam waktu 3x24 jam a. Atur posisi kepala head up 300 a. Posisi elevasi kepala bisa berpengaruh terhadap
KH: b. Berikan posisi prone 4 x 2-3 peningkatan tekanan parsial O2
1. RR : 16-20x/mnt jam b. Prone posisi meningkatkan oksigenasi
2. Bunyi nafas tambahan (-) c. Latihan nafas dalam c. Peningkatan tidal volume akan berpengaruh pada
3. Nadi : 80-100x/mnt d. Anjurkan selalu sabar dan ekspansi paru
4. PCO2 35-45 berdo’a e. Aspek spiritual diperlukan untuk mengurangi
5. PO2 80-100 dengan nafas e. Bantu ADL kecemasan
spontan tanpa O2 2. Lakukan monitoring dan evaluasi f. Pelibatan keluarga dalam membantu ADL sangat
6. pH arteri 3,5 - 4,5 a. Respiratory rate penting untuk mengurangi work of breathing
b. Bunyi nafas 2. Perubahan status pola nafas diketahui dengan
c. AGD monitoring yang adekuat :
3. Berikan edukasi tentang penyebab a. Hiperventilasi terjadi akibat anemia, pneumonia,
ketidakefektifan pola nafas penyakit jantung
4. Laksanakan hasil kolaborasi: b Seringkali selain rhonki di lobus yang terinfeksi
a. O2 HFNC juga ditemui suara nafas rhonki halus di lobus
b. Injeksi PPI : pompa proton bawah paru
inhibitor c. Pada pasien COVID-19 sering terjadi gagal nafas
c. Antiemetik baik hipoksemia maupun hiperkapneu atau
d. NSAID keduanya bisa termonitor dari hasil BGA ini
e. Kortikosteroid 3. Pengetahuan yang adekuat menurunkan kecemasan
f. Perlunya intubasi / 4. Profesionalisme lebih tepat
pemasangan ventilator a. O2 aliran tinggi dapat meningkatkan oksigenasi
b. Asam lambung yang meningkat berpengaruh pada
RR
c. Percepatan pengosongan asam lambung
meningkatkan ekspansi paru
e. Antiinflamasi agen dibutuhkan untuk memperbaiki
difusi O2 di paru
f. Pada hipoksemia berat dengan gagal nafas
terindikasi pemasangan ventilator
05-04-2021 / Risiko perdarahan Setelah dilakukan tindakan Observasi : Perubahan status perdarahan dapat dimonitor melalui
15.00 WIB keperawatan, risiko perdarahan 1. Tanda dan gejala 1. Perdarahan dapat dideteksi melalui batuk, urin,
tidak menjadi actual perdarahan (hemoptysis, muntah ataupun perdarahan kulit
KH : hematuria, hematemesis) 2. Hb dan hematocrit yang rendah mengindikasi adanya
1. Kelembaban membrane 2. Nilai hematocrit dan Hb banyak perdarahan
mukosa meningkat sebelum dan setelah 3. Trombosit atau platelet merupakan keeping darah
2. Kelembaban kulit meningkat kehilangan darah yang berfungsi dalam penggumpalan darah
3. Tanda perdarhan (Hemoptisis 3. Koagulasi (trombosit) Penatalaksanaan yang baik menjamin keberhasilan
Hematuria, Hematemesis Terapiutik : 4. Bedrest sangat dianjurkan untuk menghemat banyak
menurun ) 4. Pertahankan bed rest energi dan mencegah komplikasi
4. Hb membaik selama perdarahan 5. Tindakan invasive yang dilakukan saat terjadi
5. Ht membaik 5. Batasi atau tunda tindakan perdarahan berpotensi menciderai pasien
6. Trombosit membaik invasif Pengetahuan yang baik merupakan modal yang baik
HE: untuk perilaku sehat
6. Jelaskan tanda dan gejala 6. Pengetahuan pasien dan keluarga meningkat
peradarahan 7. Deteksi dini agar tidak terjadi perdarahan yang
7. Anjurkan segera melapor banyak
jika ada tanda perdarahan Profesionalisme lebih tepat
Kolaborasi 8. Agen penghenti perdarahan
8. Kolaborasi obat untuk 9. Bila perlu tranfusi untuk koreksi kadar Hb dibawah
mengontrol perdarahan normal
9. Kolaborasi pemberian
produk darah bila perlu
05-04- Defisit perawatan Tujuan: 1. Nursing treatment 1. Nursing treatment: Debie
2021 / diri mandi b.d Defisit perawatan diri dapat a. Lakukan seka di seluruh tubuh a. Menyeka merupakan suatu
15.00 kelemahan d.d teratasi setelah diberikan pasien tindakan yang mampu membantu
WIB ADL pasien intervensi selama perawatan di b. Lakukan oral hygiene klien untuk tetep menjaga
dibantu ICU c. Ganti linen setiap hari atau bila kebersihan diri.
sepenuhnya tampak kotor dan basah b. Oral hygiene dapat
KH: d. Ganti pempers dan underpad setiap membersihkan kotoran ataupun
1. Kesadaran CM hari cairan dari mulut pasien untuk
2. K.u cukup e. Berikan nutrisi dengan gizi menghindari infeksi
3. Badan tampak segar seimbang c. Mengganti linen yang kotor dapat
4. ADL dibantu secara parsial f. Buang urine secara berkala menjadikan pasien tampak lebih
2. Lakukan monitoring dan evaluasi nyaman.
5. Kebersihan diri : mandi
d. Mengganti pempes dan
meningkat terhadap:
vulva hygiene juga dapat
a. Kesadaran pasien
membuat pasien lebih
b. Keadaan umum pasien
nyaman.
c. Kebersihan diri e. Nutrisi wajib diberikan
d. Intake dan Output terutama pada pasien dengan
e. Nutrisi ADL tidak adekuat sehingga
3. Berikan edukasi pada pasien terkait kebutuhan nutrisi pasien tetap
manfaat kebersihan diri terpenuhi.
f. Menghitung intake dan
output cairan menjaga
keseimbangan cairan pasien
2. Melakukan monitoring dan evaluasi
mampu mengidentifikasi
perkembangan pasien:
a. Kesadaran pasien membantu
kebutuhan ADL pasien terpenuhi
walaupun parsial.
b. Keadaan umum yang
adekuat menjadikan
perkembangan pasien lebih
baik.
c. Kebersihan diri pasien
 mengurangi risiko infeksi.
d. Intake output yang bagus mampu
menyeimbangkan kebutuhan
cairan pasien.
e. Nutrisi juga wajib diberikan
agar fungsi metabolik pasien
dapat berfungsi dengan baik.
3. Memberikan edukasi pada pasien
menjadikan pasien paham dan nyaman
bahwa dirinya tetap diperhatikan
kebersihan dirinya
 FORM KEP KRITIS

IMPLEMENTASI
No Hari/Tanggal/ Dx. Tindakan Keperawatan Paraf
Jam Keperawatan
1. Senin, 1,2, 3 1. Menanyakan keluhan, mengukur tingkat Debie
5-04-2021 kesadaran, mengukur tanda-tanda vital : TD,
( 15.30 WIB) nadi, RR, suhu, suara nafas, SpO2 dan
memonitor analisa gas darah dan pemberian O2
HFNC FiO2 100% 20 lpm
R/ pasien mengatakan nafas sesak, GCS 4 5 6,
TD: 148/84 mmHg, N: 90
x/mnt , RR: 28 x/mnt, S: 36,5 ℃, rales di
paru lobus inferior kanan dan kiri
SPO2: 83%, pH: 7,47, PaO2: 69, PCO2:
33, HCO3: 23,6 (Alkalosis respiratorik tidak
terkompensasi dengan hipoksemia
15.45 WIB 1 2. Mengikuti dokter Fauzanah visite:
R/ advis: terapi injeksi dilanjutkan, observasi
saturasi O2 bila < 90 HFNC ganti terapi O2
NIV dengan PEEP 5 dan PS 6
15.50 WIB 1,2 3. Edukasi tentang pentingnya prone posisi dan
tanda gejala perdarahan
2,3 R/ pasien dan keluarga kooperatif
16.10 WIB
4. Mengobservasi kebersihan kulit, adanya tanda
perdarahan di kulit (hemoptisis, hematuria,
hematemesis, mimisan ) sekaligus menyeka
pasien dan membantu oral higiene
R/ pasien mengatakan badan segar habis seka,
tidak ada tanda perdarahan, badan tampak
bersih dan mulut juga bersih, pasien BAB
lembek banyak sudah dibersihkan
1 5. Memberikan posisi prone/ tengkurap selama 2
jam, mengatur selang HFNC beserta
mengobservasi TTV
R/ Pasien kooperatif, pasien tampak nyaman
pada posisi ini, RR: 22, TD: 125/80mmHg,
nadi 100x/mnt, suhu 36,1, SpO2: 90%
17.00 WIB 1 6. Memberikan injeksi Methilprednison 40 mg,
Vit C 500mg, Antrain 1 gr, Ondancetron 4mg,
Resfar 25 mg, Esomeprazol 40 mg, Diviti 1 x
5mg
R/ Obat injeksi masuk dengan lancar
3 7. Merapikan tempat tidur pasien
18.00 WIB
R/ tempat tidur rapi
8. Mengobservasi TTV dan saturasi O2 beserta
1, 2 observasi tanda perdarahan
18.05 WIB
R/ TD: 130/80mmHg, nadi 92 x/mnt, RR
21x/mnt, SpO2 90%
1 9. Mengubah posisi pasien menjadi semifowler
R/ pasien mandiri dalam mengubah posisinya
18.10 WIB
10. Mengobservasi TTV dan SpO2
R/ TD: 130/70mmHg, N: 95x/mnt, RR: 24,
SpO2 79% dengan posisi terlentang
1 semifowler
11. Menyuapi pasien dan memberikan obat episan
19.00 WIB
syrup 1 sendok obat
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 R/ makan habis 1 porsi, makan buah naga,
minum air putih hangat 200cc,
19.30 WIB 1,2 12. Mengobservasi GCS, TTV dan SpO2
R/ GCS 456, pasien mengatakan nafas berat,
TD: 110/70mmHg, nadi: 90x/mnt, RR: 25
1,2 x/mnt, SpO2 78 %, flow HFNC dinaikkan 30
19.45 WIB lpm,
13. Mengobservasi GCS, TTV dan SpO2
R/ GCS 456, TD: 125/75mmHg, nadi:
99x/mnt, RR: 30 x/mnt, SpO2 82% flow
HFNC dinaikkan 40 lpm
14. Mengobservasi GCS, TTV, suara nafas dan
SpO2
R/ GCS 456, TD: 125/75mmHg, nadi:
99x/mnt, RR: 30 x/mnt, rales di paru lobus
inferior kanan dan kiri.SpO2 92% dengan O2
Non Invasif Ventilation (NIV) FiO2 100%,
PEEP 5, PS 6

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FORM KEP KRITIS

2. Selasa, 6-04-2021 1,2 1. Menanyakan keluhan,memonitor keadaan umum, Debie

(15.00 WIB) mengukur tingkat kesadaran, mengukur tanda-
tanda vital dan mengauskultasi dada : TD, nadi,
RR, suhu, SpO2 dan memonitor tanda perdarahan
dan memperbaiki posisi Masker NIV dengan FiO2
100% PEEP 7 PS 8 , rales di lobus inferior paru
kanan dan kiri
R/ pasien mengatakan nafas sesak, GCS 4 5 6,
pasien tampak lemas, tanda perdarahan (-), TD:
150/84 mmHg, N: 80 x/mnt , RR: 26 x/mnt, S:
36,5 ℃
SPO2: 88%, pasien mengatakan bingung dan
khawatir tidak bisa makan
15.20 WIB 2. Memberikan edukasi kepada pasien dan keluarga
perlunya pemasangan NGT untuk kebutuhan
nutrisi pasien
R/ pasien dan keluarga memahami tujuan
pemasangan NGT, pasien bersedia dipasang NGT
3. Memasang NGT
R/ Pasien kooperatif , NGT terapasang, diet pasien
susu entramix 6x 200cc/ hari
15.30 WIB 2 4. Menyeka pasien dan membantu oral higiene
R/ pasien mengatakan badan segar habis seka,
tidak ada tanda perdarahan, badan tampak bersih
dan mulut juga bersih, pasien BAB lembek banyak
sudah dibersihkan
15.45 WIB 3 5. Memberikan posisi prone/ tengkurap selama 2
jam, mengatur selang HFNC beserta
mengobservasi TTV
R/ Pasien kooperatif, pasien tampak nyaman pada
posisi ini, RR: 22, TD: 135/70mmHg, nadi
95x/mnt, suhu 36,7, SpO2: 90%
1 6. Memberikan injeksi Methilprednison 40 mg, Vit C
16.00 WIB 500mg, Antrain 1 gr, Ondancetron 4mg, Resfar 25
mg, Esomeprazol 40 mg, Diviti 1 x 5mg
R/ Obat injeksi masuk dengan lancar
7. Mengurusi rujuk pasien ke surabaya (permintaan
keluarga)
16.30 WIB R/ Calling RS Adi Husada Surabaya, ICU ada
tempat, ACC dapat menerima
1 8. Mengobservasi TTV dan saturasi O2 beserta
16.50 WIB
observasi tanda perdarahan
R/ TD: 150/80mmHg, nadi 92 x/mnt, RR 25x/mnt,
SpO2 92%
1 9. Mengubah posisi pasien menjadi semifowler
18.00 WIB R/ pasien mandiri dalam mengubah posisinya
1 10. Mengobservasi TTV dan SpO2
R/ TD: 120/70mmHg, N: 95x/mnt, RR: 24, SpO2
79% dengan posisi terlentang semifowler
11. Memberikan minum susu via sonde sebanyak
200cc dan memberikan obat episan syrup 1 sendok
obat
R/ tidak ada muntah , retensi cairan lambung (-),
12. Mengobservasi GCS, TTV dan SpO2
19.00 WIB 1,2
R/ GCS 456, pasien mengatakan nafas berat, TD:
FIKes UNMUH Jember
 110/70mmHg, nadi: 90x/mnt, RR: 25 x/mnt, SpO2
78 %, NIV FiO2 100% PEEP 8 PS 9

13. Mengobservasi GCS, TTV dan SpO2 dan

20.00 WIB 1,2
mengobservasi tanda perdarahan, mendengarkan
suara nafas
R/ GCS 456, TD: 125/75mmHg, nadi: 99x/mnt,
RR: 30 x/mnt, SpO2 82 NIV FiO2 100% PEEP 8
PS 9 , tidak ada tanda-tanda perdarahan, terdengar
rales diinferior paru kanan dan kiri
14. Pasien Berangkat rujuk ke Surabaya dengan
Ambulance 118

FIKes UNMUH Jember

 EVALUASI KEPERAWATAN

Dx. Kep Catatan Perkembangan Paraf Catatan Perkembangan Paraf

5-3-2021 6/3/2021
Jam 20.00 WIB Jam 20.00 WIB

Dx. I S : Pasien mengatakan sesak Debie S : Pasien mengatakan masih sesak Debie S.Kep
G3 pertukaran S.Kep
gas O: O:
Pasien tampak gelisah
Pasien tampak gelisah
1. RR : 30x/mnt
1. RR : 30x/mnt 2. Rales di lobus inferior paru kanan dan kiri
2. Rales di lobus inferior paru kanan dan kiri (+) 3. Nadi : 99 x/mnt
3. Nadi : 99 x/mnt 4. SpO2 82 NIV FiO2 100% PEEP 8 PS 9
4. PCO2 33
5. PO2 69 dengan HFNC FiO2 100% flow 20lpm A: Masalah gangguan pertukaran gas masih terjadi
6. pH arteri 7,47
P : Intervensi 1-4 dilanjutkan
SPO2: 83% , HCO3: 23,6 (Alkalosis respiratorik
Keluarga minta pasien dirujuk ke RS. Adi Husada
tidak terkompensasi dengan hipoksemia)
Surabaya
A: Masalah gangguan pertukaran gas belum
teratasi
P : Intervensi 1-4 dilanjutkan
Dx. II S:- Debie S :- Debie S Kep
Risiko perdarahan S.Kep
O: O:
1. Mukosa bibir lembab (+) 1. Mukosa bibir lembab (+)
2. Kulit lembab (+) 2. Kulit lembab (+)
3. Tidak ada Tanda perdarhan (Hemoptisis 3. Tidak ada Tanda perdarhan (Hemoptisis
Hematuria, Hematemesis ) Hematuria, Hematemesis )
4. Hb 12,2 mg/dl 4. Mendapat terapi LMWH (Diviti 1x5unit)
5. Ht 40%
6. Mendapat terapi LMWH (Diviti 1x5unit)
A: Risiko perdarahan belum teratasi
7. Trombosit 202 109/L
A: Risiko perdarahan belum teratasi P : Intervensi dilanjutkan
Rencana konsul luka ke dokter Samsul Sp B
 P : Intervensi dilanjutkan
Dx III S : Pasien mengatakan badannya segar habis Debie SKep S : Pasien mengatakan badan segar setelah mandi Debie S Kep
Defisit perawatan diri
mandi O:
O: Kulit lembab (+)
Kulit lembab (+) Kulit bersih
Kulit bersih Mulut segar
Mulut segar A : Masalah defisit perawatan diri teratasi
A : Masalah defisit perawatan diri teratasi P: Pertahankan intervensi
P: Pertahankan intervensi
 Intensive & Critical Care Nursing xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Intensive & Critical Care Nursing xxx (2018) xxx–xxx

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Research article

Application of prone position in hypoxemic patients supported by

veno-venous ECMO q
⇑
Alberto Lucchini a,d, , Christian De Felippis b, Giulia Pelucchi a, Giacomo Grasselli c, Nicolò Patroniti a,
Luigi Castagna c, Giuseppe Foti a, Antonio Pesenti c, Roberto Fumagalli d,e
a
General Intensive Care Unit, Emergency Department – San Gerardo Hospital, University of Milan-Bicocca, Via Pergolesi 33, Monza (MB), Italy
b
Adult Intensive Care Unit, Glenfield Hospital, University Hospital of Leicester-NHS Trust, Groby Rd, Leicester LE3 9QP, United Kingdom
c
General Intensive Care Unit – Department of Anesthesia and Intensive Care Medicine, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35,
20122 Milan, MI, Italy
d
University of Milan-Bicocca, Milan, Italy
e
Department of Anesthesia and Intensive Care Medicine, Niguarda Ca’ Granda Hospital, Milan, Italy

L E I A B S T R A C T
N
Introduction: Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an advanced respira-
tory care therapy allowing replacement of pulmonary gas exchange. Despite VV-ECMO support, some
patients may remain hypoxaemic. A possible therapeutic procedure for these patients is the application of
F prone positioning.
Objective: The primary aim of the present study was to investigate modification of the PaO2/FiO2 ratio, in
VV-ECMO patients with refractory hypoxaemia. The secondary aim was to evaluate the safety and feasi-
bility of prone positioning for patients with severe Adult Respiratory Distress Syndrome supported by
O ECMO.
Methods: We retrospectively reviewed the electronic records and charts of all patients supported by VV-ECMO
who experienced at least one pronation. Complications related with prone positioning were also recorded. First
PaO2/FiO2 ratio was analysed during four different time steps: before pronation, one hour after pronation, at
Article history: the end of pronation and one hour after returning to supine.
Accepted 4 April 2018 Results: A total of 45 prone positioning manoeuvers were performed in 14 VV-ECMO patients from
Available online xxxx November 2009 to November 2014. The median duration of prone positioning cycles was 8 h (IQR 6–10).
No accidental dislodgement of intravascular lines, endotracheal tubes, chest tubes or a decrease in ECMO blood
Keywords: flow was observed.
ARDS During the first prone positioning for each patient, the median PaO 2/FiO2 ratio recorded was 123 (IQR 82–135),
ECLS 152 (93–185), 149 (90–186) and 113 (74–182), during PRE-supine step, 1 h-prone positioning step, END-prone
ECMO positioning step, and POST-supine step respectively.
Prone position
Conclusions: The application of prone positioning during VV-ECMO has shown to be a safe and reliable
Hypoxaemic patient
technique when performed in a recognised ECMO centre with the appropriately trained staff and standard
procedures.

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 © 2018 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice:

- Prone position during ECMO was not associated with major adverse events.
- In hypoxaemic patients, prone positioning can improve patient’s oxygenation supported by
VV-ECMO.

q
The present study was performed at the General Intensive care Unit, Emergency Department and Intensive Care, San Gerardo Hospital – ASST Monza, Via Pergolesi 33, Monza
(MB), Milan-Bicocca University, Italy.
* Corresponding author at: General Intensive Care Unit – San Gerardo Hospital – ASST Monza, Via Pergolesi 33, Monza (MB), Italy.
E-mail addresses: alberto.lucchini@unimib.it, a.lucchini@asst-monza.it (A. Lucchini).

https://doi.org/10.1016/j.iccn.2018.04.002
0964-3397/© 2018 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
3
Introduction

According to the Berlin Definition of 2012, Acute Respiratory Distress Syndrome (ARDS) has
been classified into three categories by means of PaO2/FiO2 ratio (P/F) during the application of a
posi- tive end expiratory pressure (PEEP) at least of 5 cmH2O. Mild ARDS was characterised by a
P/F between 300 and 200 mmHg, moderate ARDS by a P/F between 200 and 100 mmHg and severe
ARDS by a P/F < 100 mmHg (ARDS Definition Task Force et al., 2012). Despite therapeutic and
supportive treatments, mortality in ARDS remains high: above 27%, 32% and 45% in mild,
moderate and severe ARDS, respectively (Rubenfeld et al., 2005; Villar et al., 2011).
In the past, with the purpose of reducing mortality and improv- ing the survivors’ quality of life,
many guidelines and therapeutic strategies were developed (Nemmilla and Napolitano, 2006). In
the early 2000s, the ARDS Network Clinical Trials demonstrated how a protective mechanical
ventilation strategy, based on low tidal volumes was able to reduce the mortality of ARDS (The
Acute Respiratory Distress Syndrome Network, 2000; Villar et al., 2006). If oxygenation levels
remain low despite lung protective strategy and high levels of PEEP, other advanced procedures can
be carried out, such as prone positioning (PP) and Veno-Venous Extracorpo- real Membrane
Oxygenation (V-V ECMO) support (Taccone et al., 2009; Bellani et al., 2016).
PP is a postural therapy able to influence the patient’s oxygena- tion by improving the balance
between lung ventilation and perfu- sion, recruiting dependent lung tissue, and promoting drainage
of pulmonary secretions (Abroug et al., 2008; Sud et al., 2010; Gattinoni et al., 2013). Despite the
recognised benefits of PP, this treatment is not commonly implemented since the manoeuvre
requires an experienced team (Gattinoni et al., 2013). Moreover, PP was related to the
development of pressure sores and oedema of the anterior body regions, including the face.
Furthermore, pronation is not recommended for haemodynamically unstable patients, despite this,
absolute contraindication for PP do not exist (Patroniti et al., 2011and Bellani et al., 2016).
Regarding VV-ECMO support, this extracorporeal blood treat-
ment essentially acts by replacing pulmonary gas exchange via an external artificial oxygenator
(Pesenti et al., 2009; Paden et al., 2013; Bellani et al., 2016). Despite its efficacy, the VV-
ECMO treatment is not free from potential risks due to the percutaneous placement of large size
cannula, the systemic antico- agulation and possible haemorrhagic-thrombotic events associated
with the extracorporeal treatment of the blood (Pesenti et al., 1988; Terragni et al., 2014; Murphy et
al., 2015). Advisably, patients eligible for ECMO support should be referred to recognised ECMO
centres because the clinical and technical complexity related with this advanced technique (Peek et
al., 2009).
Sometimes, in severe ARDS patients, tissue oxygenation cannot
be maintained despite the ECMO support. This may occur when the patient’s oxygenation demand
exceeds the ECMO’s oxygenation performance. During VV-ECMO, the extracorporeal carbon
dioxide removal usually does not represent an issue, since its complete removal is feasible with only
1 L/min of extracorporeal blood flow (Pesenti et al., 2009). On the other hand, a total replacement of
patient’s oxygen consumption or a large part of it, could be chal- lenging, since it requires high rates
of extracorporeal blood flow (Montisci et al., 2015).
Recently Levy et al. suggested the application of prone position also during ECMO support, as a
useful strategy to improve oxy- genation, especially for enduring hypoxia (Levy et al., 2015).
Using ultra-protective ventilation with low plateau pressures during VV-ECMO, can lead to a
creation of poorly ventilated areas in dependent lung regions and also in the alteration’s process of
ventilation/perfusion ratio. The prone position, thanks to its ability

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
4
in recruiting the dorsal regions of the lungs, could exert beneficial effects during VV-ECMO
therapy (Culbreth and Goodfellow, 2016). Lately Culbreth and Goodfellow have recently
published a liter- ature’s review about complications related with PP and ECMO in the adult
population. Seven studies are matching the inclusion’s criteria for the study (Culbreth and
Goodfellow, 2016). Dislodg- ment of ECMO cannulas has been recognised (as potentially) the
most serious complication resulting from prone positioning during ECMO (Haefner et al., 2003;
Masuda et al., 2014). All the studies included in the above-mentioned review, reported no
occurrence of ECMO cannula dislodgement. Only one (Kipping et al., 2013)
has reported vascular lines’ complications.
No dislodgement of central venous or arterial lines was reported among all studies. Pressure
sores are considered a poten- tial complication of prone positioning and/or ECMO, but none of
the analysed studies reported cutaneous pressure ulcers. Concern- ing the haemodynamic
instability during the PP manoeuvres, very few adverse haemodynamic episodes were reported
by Kipping et al. (2013) and Guervilly et al. (2014).
The authors, who reported adverse effects, have stated that the episodes were quickly and
successfully reversible.
Oxygenation measures before and after prone positioning manoeuvres were reported in four
studies (Kipping et al., 2013; Masuda et al., 2014; Guervilly et al., 2014; Kredel et al., 2014).
Three of them found a significant difference between the PaO 2/ FiO2 ratio before and after prone
positioning (Kipping et al., 2013; Masuda et al., 2014; Guervilly et al., 2014).
In this paper, we have reported our experience regarding the effects of VV-ECMO and PP in
patients with ARDS plus enduring hypoxaemia.
For these particular ECMO patients, we used PP as a first-line treatment before adding anextra
drainage cannula as an adjunct to increase the ECMO blood flow (Montisci et al., 2015). To
improve the safety of PP manoeuvre, we standardised our procedure of pronation for patients
supported by ECMO (Culbreth and Goodfellow, 2016).

Objective

The primary aim of the present study was to investigate modi- fication of the PaO2/FiO2 ratio, in
VV-ECMO patients with enduring hypoxaemia. Measures were performed before PP, 1 h after
com- mencing the PP, at the end of PP cycle and 1 h after turning the patients into supine
position.
The secondary aim of this study was to evaluate the safety and feasibility of prone positioning
for patients with severe ARDS dur- ing ECMO therapy inside our intensive care unit (ICU) by
recording the occurrence of known complications related to PP (Gattinoni et al., 2001).

Materials and methods

The study protocol was evaluated by the local Ethics Committee (Comitato etico della
Provincia di Monza e Brianza – session: 19/03/2015) which waived written informed consent due
to both reasons: the retrospective study design and also because PP and VV-ECMO, represent an
integral part of cares provided to patients with ARDS. The local Ethics Committee approved the
study on 22/04/2015 (approval progressive number: 363).
All the patients enroled or their relative, were informed that data from their ICU’s experience
could be collected for clinical research purpose.
We retrospectively analysed data from patients admitted November 2009 to November 2014 in
Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
5
the general ICU of a major

teaching hospital (ECMO referral centre), pronation (1 h-PP step), at the end of prona- tion
supported by VV-ECMO that experienced at (END-PP step) and one hour after supination
least one period of PP. All eligible patients, (POST-supine step). Moreover at each time step
were connected to the PLS System (Maquet, other arterial blood gas parame- ters (i.e. pH,
Getinge Group, Gote- borg, Sweden), PaCO2), ventilator parameters (i.e. tidal volume,
composed by a centrifugal pump (Rotaflow respi- ratory rate, PEEP, plateau pressure),
Cen- trifugal Pump, Maquet) and an external ECMO parameters (i.e. bloodflow: BF),
oxygenator (PLS-i, Maquet). Demographic revolution per minute of centrifugal pump
data (i.e. gender, age), ICU length of stay (RPM), sweep gas flow (GF), FiO2 of GF and
(LOS), outcomes at discharge, severity score haemodynamic parameters (heart rate, arterial
(i.e. Simplified Acute Physiology Score II – blood pressure, pulmonary blood pressure,
SAPS II), number of PP circles per-patient, wedge pressure, cardiac output and mixed
duration of pronation as well as incidence of venous oxygen saturation from optical
complication related to PP were recorded. The pulmonary artery catheter) were collected.
bore size of the ECMO cannula, total days of Every prone positioning manoeuvre was
ECMO support and numbers of days from performed in adherence to our ICU protocol and
ECMO institution to the first PP application policy as follows (Gattinoni et al., 2001;
were also recorded. Taccone et al., 2009; Lucchini et al., 2010):
Occurrence of known complications related
- Pronation of patients involves a complex and coordinated effort,
to PP applications (i.e. displacement of involving physicians and nurses. A total of six staff involved: four
indwelling catheters, facial oedema, second- operators performing the turning of patient, one looking after the
ECMO circuit and one for the management and protec- tion of the
degree pressure sores or higher, pressure endotracheal tube. While two physicians ensure sta- bility and
neuropathies, compres- sion of nerves and patency of the endotracheal tube and ECMO cannula, a nurse
looks after the intravenous lines and at least two mem- bers of staff
retinal vessels, vomiting and intolerance to roll the patient. It is advisable, a senior physician should be always
the manoeuvre) were reported as record in the available at the bedside in case of an emer- gency re-intubation.
- Application of thin hydrocolloid dressing for pressure ulcer pre-
medical and nurs- ing charts (Gattinoni et al., vention (Huang et al., 2015).
2001). - Meticulous securing of every ECMO cannula, using a self-
adhesive bandage at the medial side of inferior limbs for the
The in-hospital protocol for PP requires the femoral cannula or forehead anchorage for the jugular cannula.
following: manda- tory completion of a - Placement of the head over the upper edge of patient’s bed, using
customised facial padding for patients with a tracheostomy.
dedicated electronic chart where types of - Positioning of transverse rolls placed under the pelvis and the chest.
potential complications PP related has to be They are particularly useful for patient with poor neck flexibility
(in those patients rolls improve a better facial reposi- tioning)
recorded (e.g. vascular catheter’s and/or with tracheostomy (Fig. 1).
dislodgement, respiratory compromise, - Utilisation of double sheets for turning. Using the bottom sheet,
two nurses pull the patient towards them on the edge of bed. If
haemodynamic instability, development of rolling is performed on the right side, the right arm of patient
pressure ulcers).
Also, the monitoring of patient’s skin status
is recorded before and after every cycle of PP
manoeuvre, focusing on detection of early
stage of oedema or pressure sores.
In order to calculate the P/F ratio for each
patient, at their first application of PP, PaO2
and ventilator FiO2 values were collected
during four different time steps: before
pronation (PRE-supine step), one hour after
Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
6

Fig. 1. Patient in Prone Position with oral intubation.

Fig. 2. Devices and pillows used in the study. Legend: 1 – Transversal rolls – CEA SpA,
should be placed under his right side Italy. 2 – Pillow for hands and arms – CEA SpA, Italy. 3 – Face cushion – CEA SpA,

otherwise vice versa for left sided rolls. Only Italy. 4 – Face cushion with polystyrene microspheres – Askle medical, France.
5 – Disposa-View (Disposable Prone Position Head Cushion with Mirror) – GE Healthcare,
when the endotracheal tube and vascular USA (for patients with tracheostomy).

lines are secured, the team can gently roll Statistical analysis
the patient into PP.
- Placing the head of patient on a C-letter shaped pad to prevent Statistical analysis was performed using
pressure ulcers. Limbs are positioned in order to prevent abnor-
mal extension or flexion against shoulders and elbows. Pillows can
Statistical Package for the Social Sciences,
be added to provide additional support to hip, shoulders and face version 22.0, (SPSS Inc., Chicago, IL, USA).
(Fig. 2).
- The standard monitoring during the entire procedure is: pulse
Continuous variables were expressed as mean
oximetry, continuous mixed venous oxygen saturation, end tidal ± SD or median (interquartile range). Unpaired
carbon dioxide and invasive arterial blood pressure.
Student’s t-test and One-way repeated
measures analysis of variance (rmANOVA)
was used to evaluate the differences at the
different timepoints of the PaO2, FiO2,
respiratory rate (RR), Tidal Volume (TV),
plateau pressure, PEEP, respiratory system
compliance (Cpl), ECMO Blood Flow (BF),
ECMO Gas Flow (GF) and pO2/FiO2 (PF)
values. A P-value
< 0.05 was considered statistically significant.

Results

A total of 14 patients were enroled (3 female

and 11 male). The median age was 55 years
Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
7
(44–54). In 10 patients only one PP days (3–9) from the ECMO’s institution. At
manoeuvre was performed, whereas for 3 the first prone positioning, the median tidal
patients the PP was applied twice. Just one volume was 3.2 ml/kg (2.3–4.1), the median
patient received 21 pronation procedures plateau pressure was 28.0 (28.0–29.8), the
(median 1 – IQR 1–1.5). During the study’s median blood flow was 3.4 l/min (3.1–
period, a total of 45 PP were performed. The 3.9), while the gas-flow (sweep) was 5.8 l/min
(4.1–6.6).
median duration of PP lasted 8 h (IQR: 6.0– During all PP manoeuvres, the inspired
10/range 3–24). Nine patients were discharged fraction of oxygen for the ECMO gas flow was
from hospital, while five patients did not constantly at 100%. The median tidal vol- ume
survive (survival rate 64%). The median ICU at first prone positioning was 224 ml (164–
LOS of patients was 33 days (28–74). The 331), the mean respiratory rate was 10.0 (10–
median of ECMO days was 27 days (21– 15) bpm and PEEP value was 15 (13–17)
59). Patients were proned a median of 7 cmH2O.
Patients’ values are shown in Table 1.

Table 1
Population’s features.

Pt. Nr. Sex Age TV ml/kg. Plateau SAPS II Outcome LOS Duration of PP Cycles Pressure PP Comp. ECMO
first PP Cycle Sores
ECMO Days Dr. Cann Fr. Re. Cann. Fr.
1 M 73 2.26 40 39 D 31 13 1 no no 31 25 19
2 F 52 2.53 28 43 D 72 4 1 no no 71 23 21
3 M 4 3.92 30 – D 77 13 21 no no 77 15 15
4 M 49 4.55 33 39 A 43 6 1 no no 23 25 23
5 M 55 3.27 30 37 A 36 11 1 no no 16 23 21
6 M 65 4.03 34 42 D 24 6 1 no no 24 25 21
7 F 39 4.76 44 – A 21 4 1 no no 21 23 21
8 M 64 2.65 30 37 A 84 13 2 no no 65 25 21
9 M 19 2.00 31 – A 24 7 1 no no 5 25 25
10 F 77 2.11 30 62 D 27 8 1 no no 27 23 23
11 M 50 4.21 30 24 A 120 9 5 no no 53 23 23
12 M 56 2.92 32 58 A 110 7 7 no no 80 25 23
13 M 16 4.12 25 37 A 30 8 1 no no 21 23 21
14 M 60 4.09 29 – A 35 10 1 no no 12 23 23

Pt. Nr.: Patient number.

TV ml/kg.: Tidal Volume ml/kg.
Plateau: Plateau Pressure cmH2O.
SAPS II: Simplified Acute Physiology Score II.
Outcome: D = dead A = Alive.
LOS: Length of Hospital Stay.
Duration of the first PP Cycle during ECMO: time in Prone Position (first cycle) in hours. Pp
Cycles: numbers of Prone position manoeuvers for each patient.
Pressure Sores: development of pressure sores caused by PP.
PP Comp.: Major complication (cannulae dysfunction, tubing rupture, circuit disruption, decrease of the ECMO flow, endotracheal tube obstruction, chest tube, arterial or central
venous catheter displacement).
BF: Blood Flow Lt/min (first PP).
GF: Membrane Lung Gas Flow (sweep gas flow) Lt/min (first PP). Dr.
Cannula Fr.: Drainage ECMO Cannula diameter.
Re. Cannula Fr.: Reintroduction ECMO cannula diameter.

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
8
During the first PP application, the median During the procedures of PP, we did not
P/F recorded was 123 mmHg (IQR 82–135), observe significant haemodynamic variations
152 mmHg (93–185), 149 mmHg (90– in the values of heart rate, systolic arterial
186) and 113 mmHg (74–182), during PRE- pressure, mean arterial pulmonary pressure,
supine step, 1 h-PP step, END-PP step, and cardiac out- put, wedge pressure and SvO2.
POST-supine step, respectively. The lowest On the other hand, we observed a slight
pO2 value observed in PRE-supine step was increase, albeit statis- tically significant, in the
44. values of systolic and mean arterial pres- sure;
Table 2 highlights P/F values at different mean diastolic pulmonary arterial pressure and
stages of the investi- gation. The median P/F CVP.
in every step of the study is shown in Fig. 3. Haemodynamic parameters before, during
The difference between the PRE-supine step and after PP, are showed in Table 3.
and END-PP step (113 vs. 147) was found No displacement of vascular lines, ECMO
to be statistically significant (p = 0.034). cannula, endotracheal tube and chest tubes was
None of the patients required an extra drainage observed during and at the end of all PP cycles.
can- nula placement on the ECMO circuit to No stage two pressure ulcers were reported in
improve their oxygenation levels. any patients.

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
9
Table 2
Oxygenation levels before, during and after Prone Position.

PRE-supine step Median (Q1-Q3) 1 h-PP step END-PP step POST-supine step p. value
pO2 mmHg 71.0 (62.1–78.1) 76.3 (61.0–91.4) 83.9 (83.9–99.0) 75.1(67.4–79.9) 0.903
FiO2% 0.7 (0.5–0.8) 0.7 (0.5–0.1) 0.7 (0.5–0.9) 0.6 (0.5–1) 0.903
RR b/min 10.0 (10.0–14.6) 10.0 (10.0–14.8) 10.0 (8.0–12.2) 10.0 (9.0–10.8) 0.964
TV ml 224 (164–331) 240 (169–324) 226 (167–343) 194 (166–341) 0.982
Plateau cmH2O 28.0 (28.0–29.0) 29.5 (27.3–31.0) 29.5 (27.3–31.0) 30.0 (27.0–31.0) 0.822
PEEP cmH2O 15.0 (13.3–17.5) 15.0 (14.3–18.0) 15.0 (13.3–17.5) 14.5 (12.6–17.5) 0.887
Cpl 16.1 (12.1–24.2) 16.8 (10.7–25.8) 15.8 (10.7–24.0) 13.5 (10.1–22.7) 0.423
BF l/min 3.4 (3.1–3.9) 3.4 (3.1–3.9) 3.4 (3.1–3.9) 3.4 (3.2–3.9) 0.982
GF l/min 5.8 (4.1–6.6) 5.8 (4.1–6.6) 5.8 (4.1–6.6) 5.8 (4.3–6.7) 0.982

PRE-supine step: before pronation.

1 h – PP step: one hour after pronation.
END-PP Step: at the end of pronation.
POST-supine step: one hour after resupination. RR:
respiratory rate.
TV: tidal volume.
Plateau: plateau pressure.
BF: blood flow.
GF: membrane lung gas flow (sweep gas flow).

Fig. 3. P/F ratio pre, during and post Prone Position. Legend: 1 h – PP step: one hour after pronation. END-PP Step: at the end of pronation. POST-supine step: one hour after
resupination. rmANOVA p. value: 0.284.

Table 3
Hemodynamic parameters before, during and after Prone Position.

PRE-supine step Median (Q1-Q3) 1 h-PP step END-PP step POST-supine step p. value

HR 104 (95–110) 105 (97–108) 108 (101–118) 100 (83–109) 0.112

sBP 118 (107–134) 127 (116–146) 131 (125–148) 117 (98–135) 0.792
mBP 79 (70–86) 83 (79–91) 89 (80–97) 74 (57–91) 0.044
dBP 60 (53–68) 64 (59–67) 68 (63–74) 53 (44–68) 0.039
sAP 45 (39–53) 49 (35–54) 53 (38–60) 41 (37–48) 0.456
mAP 31 (28–35) 36 (28–41) 37 (29–45) 29 (26–33) 0.123
dAP 21 (19–24) 24 (18–30) 25 (22–33) 21 (17–22) 0.056
CVP 10 (11–16) 12 (11–16) 14 (11–19) 11 (8–14) 0.029
WP 13 (11–16) 15 (12–19) 20 (12–25) 13 (10–17) 0.082
CO 7.5 (6.2–8.2) 9.2 (7.6–9.5) 8.4 (7.0–10.2) 7.9 (6.5–9.2) 0.524
SvO2 84 (80–88) 84 (82–88) 85 (83–89) 86 (84–88) 0.830

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
PRE-supine step: before pronation. 1
1 h – PP step: one hour after pronation.
END-PP Step: at the end of pronation.
POST-supine step: one hour after resupination. HR:
heart rate bpm.
sBP, mBP and dBP: systolic, mean and diastolic Arterial Blood Pressure (mmHg).
sAP, mAP and dAP: systolic, mean and diastolic Pulmonary Arterial Blood Pressure (mmHg). CVP:
central venous pressure (mmHg).
WP: wedge pressure.
CO: cardiac output (l/min).
SvO2: mixed venous oxygen saturation (%).

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
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 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
1
Initially for all the patients enroled, an oral intubation (OT) was performed. However, for 3 of
them (21%), during the ECMO support period, in order to obtain a better airway management plus
avoid- ing OT-related complications; a percutaneous tracheostomy tube was placed according to
Fantoni translaryngeal retrograde tech- nique known as TLT (Fantoni and Ripamonti, 1997; Bellani
et al., 2013; Camporota et al., 2015).
It is helpful to remind readers that TLT uses a non-flexible can- nula and it usually protrudes for
nearly 5 cm. from the tracheal stoma. The presence of a closed-circuit suction system makes the
patient’s positioning very difficult unless specific supporting devices are available at bedside.
The main issues are the possible kinking of the cannula, increas- ing the skin’s contact pressure
plus the inability to perform endo- tracheal suctioning of bronchial secretions. Contrary to patients
managed with orotracheal tube, for patients enroled and treated with PP, the patients managed with a
tracheostomy had their head positioned over the edge of the bed, supported by a specific device.
This strategy of airway’s management, has allowed nurses to easily perform suctioning of
secretions, monitor the tracheal cannula site plus reducing contact pressure on the stoma.

Discussion

This retrospective study shows as the prone positioning can improve oxygenation for enduring
hypoxaemia during VV-ECMO and could be performed safely with the application of a standard-
ize protocol.
The addition of prone positioning therapy in synergy with VV- ECMO, can further aid and
optimise alveolar recruitment, when ultra-protective ventilation is used for reducing ventilator-
induced lung injury (Taccone et al., 2009). This combination of strategies (VV-ECMO and PP)
improved the overall survival rate (Culbreth and Goodfellow, 2016).
Adding prone positioning therapy can also help to reduce the risk of memory loss and other
cognitive impairments associated with hypoxaemia (Gattinoni et al., 2010; Charron et al., 2011).
However, severe complications can potentially result from prone positioning in ECMO patients
(Gattinoni et al., 2010; Guérin et al., 2013). PP alone can generate serious risks. In addition to
unplanned extubations, complications from prone positioning itself include accidental removal of
lines, kinking of infusion lines. and drainage sets and the development of pressure sores. Despite
this, an overwhelming literature supports prone positioning as a treatment option for patients with
severe respiratory failure trea- ted with VV-ECMO (Culbreth and Goodfellow, 2016).
It is crucial to remember, the improvement of the P/F ratio value on its own, does not represent
a reliable parameter to evaluate pos- sible benefits of PP. Guérin et al. (2013) have shown how PP
com- pared with supine positioning markedly reduces the overinflated lung areas while promoting
alveolar recruitment (Galiatsou et al., 2006). These effects may contribute to prevent the
ventilator- induced lung injury by homogenising the distribution of stress and strain within the
lung.
In patients with severe ARDS, early application of prolonged prone-positioning sessions
significantly decreased 28-day and 90-day mortality (Guérin et al., 2013).
In all PP manoeuvres analysed in this study, no adverse or life- threatening events related to
position changing were recorded. Arguably, this could be explained by the expertise and
confidence of operators managing the ECMO support and prone-position pro- tocols. Data from
the present study and others previously pub- lished, suggest that PP during VV-ECMO is safe
when performed by an experienced team (Culbreth and Goodfellow, 2016).
To succeed in the prevention of complications during pronation, the availability of padded limb
Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 A. Lucchini et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
1
supports and customised facial sup- ports is crucial, as pressure ulcers are common complications
reported by the literature (Taccone et al., 2009; Gattinoni et al., 2013). None of the patients
experienced grade two pressure ulcers.
According to our experience, this achievement is strictly related to three different factors: the
availability of pressure-relieving air mattress, the application of skin protection with an extra thin
hydrocolloid dressing (Gattinoni et al., 2001; Huang et al., 2015) and the use of special
cushions-pads during PP for limbs, chest and abdominal regions (Chiumello et al., 2006).
Chiumello and colleagues (2006) found that the prone position with thoraco-pelvic supports,
when compared with the prone posi- tion without supports, did not affect gas exchange and lung
vol- ume; but decreased the chest wall compliance, increased pleural pressure and slightly
modified the haemodynamic pattern.
The implementation of thoracic and pelvic padded support was mandatory because, one of the
most serious issue detected in the positioning of patients with tracheostomy tube, was the
inability to maintain a minimum rotation of patient’s face. Unfortunately,

Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002
 the presence of TLT during PP does not allow a safe positioning of the face without the roll
implementation. Despite the use of these rolls represent a major risk factor for the development of
pressure sores, as reported by Chiumello and colleagues (2006); this circum- stance did not occur in
the population investigated.
In order to avoid the occurrence of skin ulcers, it is essential to use devices able to alternate and
relieve pressure from cutaneous points, as shown in Fig. 1. Furthermore, the medial anchorage of the
ECMO cannulas could help in reducing the amount of skin sur- face affected by the pressure related
to the circuit and tubes.
Nevertheless, ECMO patients exhibit considerable risks of bleeding due to the required systemic
anticoagulant therapy. Bleeding may occur from the cannula or catheter site when patients’ position
is changed.
In our experience, major bleeding that required specific man- agement did not occur from
catheters or cannula site (Pesenti et al., 2009; Grasselli et al., 2010).
The second consideration regards the duration of prone posi- tion. Recently, the Proseva trial has
demonstrated how an early application of prolonged prone positioning sessions (at least 16 h)
significantly decreased the 28-day and 90-day mortality rates (Albert et al., 2014).
In this study, the application of prone positioning has been used for a median of 8 (IQR: 6–10)
hours as a rescue therapy for severe hypoxic patients, not responding to conventional treatments
already in place.
However, it should be noted that several studies have found a higher frequency of pressure ulcers
in patients kept for long ses- sions of PP, a finding confirmed in a meta-analysis by Sud et al. (2014).
Pressure ulcers remain a complication of major concern in the intensive care unit (ICU) because
they are associated with pain, infections, prolonged length of stays and increased costs.
We suggest considering prone positioning as an integral part of therapy during VV-ECMO support,
especially for enduring hypox- aemia. In these cases, another alternative approach could be the
implementation of ECMO circuit by a second drainage cannula (Montisci et al., 2015). However, we
may argue that this practice could be challenging and not free of complications also for skilled team
working in specialised ECMO centre.
Despite the availability of dedicated beds in our unit; (Roto- prone – Arjo Huntleigh) all prone
positioning was performed using a manual technique in order to have a direct control of the ECMO
circuit all the time. Other papers suggest no less than five trained and skilled operators to perform
the PP manoeuvre (Gattinoni et al., 2001; Taccone et al., 2009; Girard et al., 2014).
Finally, it is important to highlight the fact that the PP was car- ried out by nurses and physicians
experienced with placement of ARDS patients in prone position plus the management of patients on
ECMO support (Culbreth and Goodfellow, 2016; Van Kiersbilck et al., 2016).
Our experience suggests that PP during VV-ECMO has more beneficial effects beyond improving
oxygenations and this therapy may be useful for ECMO patients. Prospective and randomised con-
trol trials are necessary to assess the long-term impact of prone positioning and ECMO on survival,
as well as the effects on ICU stay and complications.

Limitations

This is a retrospective single-centre study so our conclusions have some bias related to the
individual centre. In fact the physi- cian was free to decide whether to implement the PP, to select
only patients suitable to improve their oxygenation and able to tolerate the positioning therapy.
Furthermore, in several patients the set- up of ventilation (PEEP, TV) was modified during the PP
andcitemore-
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over, the small sample size does not allow a rigorous evaluation of the effect of PP on clinical
outcomes. According to Guérin et al. (2013), prone positioning, as compared with supine
positioning, markedly reduces the overinflated lung areas while promoting alveolar recruitment.
These effects may help, even in ECMO patients, to prevent the ventilator-induced lung injury by
 homogenising the distribution of stress and strain within the lungs. Patients with ARDS, with or
without ECMO and with severe hypox- aemia (as confirmed by a PaO 2/FiO2 ratio of <150 mmHg,
with a FiO2 of 0.6 and a PEEP of 5 cm of water)≥can benefit from PP treatment when it is
commenced early and for long sessions (Guérin et al., 2013).

Conclusions

For patients requiring ECMO support, prone positioning can be performed safely when is carried
out by an experienced and skilled team. The present study is too small to offer a statistical signifi-
cance about the beneficial effects on P/F ratio by PP. Further studies involving more patients;
different centres, are needed and desirable.

Conflict of interest

None of the authors discloses potential conflicts of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial,
or not-for-profit sectors.
All authors have approved the final article and acknowledge that all those entitled to authorship
are listed as authors.

Disclosure

The authors have disclosed that they have no significant rela- tionships with, or financial interest
in any commercial companies that may have an interest in the subject matter of this study.

Authors contributions

AL, GP, CDF, GG, LG designed the study, coordinated and drafted the manuscript with AP, GF,
NP and RB. AL, GP and CDF completed data extraction. AL and GP wrote the prone-positioning
procedure. Data analysis was conducted by AL, LG and GG. AP, GF, NP and RF gave expert
content to the manuscript. All authors read and approved the final manuscript.

Ethical statement

The study protocol was evaluated by the local Ethics Committee (Comitato Etico della Provincia
di Monza e Brianza, Italy) which waived written informed consent due to both the retrospective
study design and because PP and VV-ECMO are an integral part of care provided to patients with
ARDS. All patients or their rela- tives were informed that some data could be used for clinical
research.

Acknowledgement

We would like to thank the reviewers for their insightful com- ments on the paper, as these
comments led us to an improvement of the work.Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at
https://doi.org/10.1016/j.iccn.2018.04.002.
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Please cite this article in press as: Lucchini, A., et al. Application of prone position in hypoxemic patients supported by veno-venous ECMO. Intensive &
Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.04.002