Faculty Bibliography

PURPOSE: The PROSEVA (Proning Severe ARDS patients) trial demonstrated that prone positioning in patients with severe ARDS improves mortality. Patients in this seminal trial, however, were manually proned in a regular ICU bed. Despite this, many hospitals extrapolate the findings of the PROSEVA trial to a kinetic bed (Rotoprone) in the absence of significant evidence supporting its use. We performed a retrospective study to evaluate the hemodynamic and gas exchange alterations in patients with severe ARDS before and after prone position with the Rotoprone bed. METHODS: We completed a retrospective chart review of 9 patients with severe ARDS who underwent prone positioning with the Rotoprone bed in our tertiary care adult ICU. Baseline demographic data, physiologic data (including oxygenation index and dead space fraction) and hemodynamic data (including vasopressor requirement, mean arterial pressure, central venous pressure and urine output) were collected 4 hours before and after prone positioning. For patients in shock, vasopressor dosing was used as an index for degree of hypotension. Complications associated with prone positioning were also collected. A paired 2-tailed t-test was used for statistical analysis RESULTS: There was a trend towards improvement in oxygenation index (supine:23.6 vs. prone: 16.5, p= 0.13) though no significant difference in dead space fraction (supine: 0.33 vs. prone 0.31, p=0.28). There was no change in MAP and vasopressor dosing before and after the initial phase of proning. There were no complications during proning with the use of the Rotoprone bed. CONCLUSIONS: Our retrospective data demonstrates promising trends in improving gas exchange in patients with severe ARDS proned with the Rotoprone bed. While both indices of gas exchange improved, they did not reach statistical significance, possibly due to the small sample size. No complications or hemodynamic changes associated with proning were noted in our cohort. Larger studies to further define changes in hemodynamics and gas exchange in this population are warranted

PURPOSE OF REVIEW: Early identification and appropriate management of sepsis improves outcomes. Despite convincing data showing the benefits of early recognition and treatment of sepsis and septic shock, implementation of such evidence-based therapy is suboptimal. This review describes methods that have been shown to improve bedside application of the evidence-based guidelines. RECENT FINDINGS: The Surviving Sepsis Campaign (SSC) has developed guidelines for the management of severe sepsis and septic shock. The initial SSC guidelines were published in 2004; as evidence continued to evolve, the guidelines were updated, with the most recent iteration published in 2016. Guidelines by themselves can take years to change clinical practice. To affect more rapid change, the SSC guidelines are filtered into bundles to impact behavior change in a simple and uniform way. SUMMARY: Implementation of the SSC bundles revolves around practice improvement measures. Hospitals that have successfully implemented these bundles have consistently shown improved outcomes and reductions in healthcare spending. Finally, the Centers for Medicare and Medicaid Services has approved SSC bundle compliance as a core measure, and hospitals in the United States are mandated to collect and report their data regularly to Centers for Medicare and Medicaid Services.