If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Continuously rising numbers of obese critical care patients pose many challenges to the healthcare workers, especially during the COVID-19 pandemic. Among them, proning may be one of the most labour-intensive tasks. Prone positioning is performed manually in hospitals where mechanical lifting aids are unavailable; however, the exact method of manual proning is not explicitly described in the literature.
Here, we present a case of a morbidly obese patient with COVID-19 pneumonitis in the intensive care unit with a step-by-step guide of the manual proning technique. Our approach is simple and feasible, as only readily available tools, such as bed sheets and friction-reducing sheets, are used.
However, with the clash of the two pandemics, we are faced with even more challenging situation: according to the most recent UK Intensive Care National Audit and Research Centre Report on COVID-19 in critical care, the prevalence of obesity in the ICU reached 49.6%.
Among many diagnostic, therapeutic, and logistic challenges in caring of obese patients, proning may be one of the most labour-intensive tasks. Despite that, it has been demonstrated to be a feasible and safe intervention for this population and also likely even more beneficial than for nonobese individuals.
Here, we present a case of a morbidly obese patient with COVID-19 pneumonitis in the ICU with a step-by-step guide of the manual proning technique. Our approach is simple and feasible, as only readily available tools, such as bed sheets and friction-reducing sheets, are used.
A written informed consent was obtained from a legally authorised representative of the patient before the publication.
2. Case report
A 50-year-old man was admitted to a hospital with COVID-19 pneumonitis in December 2020. He had a past medical history of asthma, obstructive sleep apnoea, and morbid obesity (height, 193 cm; weight, 190 kg; body mass index, 51). He received continuous positive airway pressure (CPAP) ventilation on a respiratory ward for 5 days; however, owing to a sudden deterioration, he was admitted to the ICU and intubated.
During intubation, the patient sustained a cardiac arrest. After one cycle of chest compressions, return of spontaneous circulation was achieved; however, the patient remained unstable and developed multiple-organ failure (acute respiratory distress syndrome, shock, and acute kidney injury), requiring high level of organ support (FiO2 of 1.0, noradrenaline infusion of 0.9 mcg/kg/min, and renal replacement therapy). Chest X-ray demonstrated worsening bilateral infiltrations. Bedside cardiac ultrasound revealed a right ventricular strain, and given a high risk of pulmonary embolism (risk factors: morbid obesity, immobility, and COVID-19) and haemodynamic instability, thrombolysis was administered. Several hours later, the SpO2 of the patient remained 75–85% with FiO2 of 1.0 (PF ratio 60 mmHg); therefore, it was decided to place the patient into a prone position.
The usual proning method in our hospital was a “burrito” technique, which has been demonstrated elsewhere.
It was performed by a proning team assembled during the COVID-19 pandemic. The team consisted of one anaesthetist or critical care doctor and a combination of redeployed anaesthetic nurses and other theatre staff. The “burrito” technique applied for nonobese patients included lifting a patient after proning to adjust the thoracopelvic support (pillows) and positioning a patient straight. The application of this technique for proning of our morbidly obese patient was deemed too dangerous for the staff owing to the weight of the patient and the personnel body mechanics when reaching over a wide bariatric bed. Therefore, a new manual proning technique was proposed with the following goals:
to completely avoid lifting.
to straighten out the body of the patient and avoid a semiprone position with the panniculus lying sideways to make head turns possible both ways.
to use pillows as thoracopelvic support. Whilst we did not expect to achieve a full abdominal suspension, our hope was that the elevation of the chest and pelvis would relieve some of the abdominal pressure and improve the lung ventilation.
The schematic sequence of the used proning technique can be seen in Fig. 1. After a 16-h proning session, a significant improvement in the gas exchange was observed: SpO2 91% and PaO2 67 mmHg on FiO2 of 0.6. Over the following days, the patient was successfully proned two more times with the same methodology. The time needed to achieve prone position for this patient shortened from approximately 1 h to 30 min with subsequent proning sessions. The proning team did not report any injuries.
Despite the initial improvement of the patient's condition, 1 week later, respiratory failure worsened again and, sadly, after 9 days of ICU stay, the patient passed away.
To our knowledge, this is the first published detailed description of manual proning of a morbidly obese patient.
Despite a widespread use of the prone position for patients with acute respiratory distress syndrome during the COVID-19 pandemic, the practical aspects of the technique did not receive a wide scientific interest. The most common methods have recently been summarised by Wiggerman et al.;
described a similar manual proning approach in morbidly obese patients. However, important practical aspects were not mentioned in the publication. It is unclear whether the patient was straightened or kept semiprone with the panniculus lying sideways and how the thoracopelvic supports were positioned underneath the patient.
Skin integrity damage in prone position is one of the most common complications; therefore, 2-hourly head turns are recommended to prevent facial injuries.
For this to be feasible, the patient needs to be positioned straight with a neutral spine. However, in morbidly obese patients, obtaining such a position may be difficult owing to patient's panniculus, and thus, only a semiprone position can be typically achieved, as can be seen in the publication by De Jong et al.
However, positioning of the pillows is usually achieved by lifting the patient, which, in the case of a morbidly obese individual, poses an unacceptable risk to the staff's health.
Our case report and the illustrated proning technique aim to address these practical questions of prone position of obese patients. We have successfully used simple tools to place a morbidly obese patient in a straight prone position as well as adjust thoracopelvic supports while completely avoiding lifting.
This technique may be used as an alternative to mechanical lifting aids in low-resource settings.
CRediT authorship contribution statement
The author wrote the manuscript and prepared the illustrations.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The author is grateful to the Queen's Hospital Proning Team members: operating department practitioners, anaesthetists, and other theatre staff members, who have been invaluable in our critical care units during the COVID-19 pandemic, and Dr Tomas Jovaisa for the relevant discussions.
GBD 2015 Obesity Collaborators
Health effects of overweight and obesity in 195 countries over 25 years.