Prone sleeping position and sudden infant death.
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Humans↗
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Balloon kyphoplasty is effective in deformity correction of osteoporotic vertebral compression fractures.
STUDY DESIGN: A prospective radiographic analysis of deformity correction during the balloon kyphoplasty procedure. OBJECTIVE: To determine the spontaneous reduction of the deformity in prone position, the subsequent deformity correction by the inflatable bone tamp, and the overall deformity correction after deposition of the cement. SUMMARY OF BACKGROUND DATA: Fracture mobility has been shown to contribute to fracture reduction in vertebroplasty. Spontaneous reduction has not been taken into account in recently published series of balloon kyphoplasty, but it must be considered when performing vertebral augmentation and when reporting and interpreting the significance of vertebral height restoration. METHODS: A consecutive series of 39 osteoporotic vertebral compression fractures were treated in 30 patients. Lateral radiographs were taken and analyzed at six different time points: 1) Preoperative standing. During the kyphoplasty procedure, four consecutive radiographs were obtained: 2) after placing the patient in prone position on the operation table, 3) after inflation of the bone tamp (IBT), 4) after deflation and removal of the IBT, and 5) after deposition of the cement. 6) Standing lateral radiographs were taken after the procedure. All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height), complications, and reduction of pain (VAS). RESULTS: Placement of the patient in prone position displayed a significant spontaneous reduction in deformity of 6.5 degrees +/- 4.1 degrees Cobb angle. Inflation of the IBT demonstrated a further reduction of the fracture and a significant improvement of the Cobb angle of 3.4 degrees compared with baseline prone. After deflation and removal of the IBT and placement of the cement, no significant loss of fracture reduction was seen. Postoperative measurement of the Cobb angle by means of standing radiographs demonstrated a 3.1 degrees significant loss of reduction compared with the intraoperative measurement in prone position after cement application. Cement leaks occurred in 9 of 39 vertebral fractures. All patients subjectively reported immediate relief of their typical fracture pain. The VAS score significantly improved from 8.7 +/- 1.4 before surgery to 2.3 +/- 0.9. CONCLUSION: The restoration of height in kyphoplasty is attributed to dynamic fracture mobility as well as to the expansion of the inserted balloon tamp.
Aged↗
[Infant mortality and sudden infant death in Navarra between 1985 and 1996].
OBJECTIVE: The objective of this study was to obtain an accurate register of the deaths of children less than one year of age in order to discover the real infant mortality (IM) rate in Navara and its trend during the period between 1985 and 1996, a well as to investigate the deaths by sudden infant death (SID) in the same period and their relationship to the prone position during sleep. PATIENTS AND METHODS: Infant mortality was determined by detailed examination of all certified deaths. Research into possible nonregistered deaths was also carried-out. The sources of information included the archives and registers of the pediatric and obstetric wards and pathology departments of all hospitals. Deaths codified as 798.0 (CIE9 infinity R) were included in the study as death by SID. To determine sleeping posture. In the second semester of 1996, a survey was carried out on a sample of 285 children of under 6 months of age. The survey's model is the same as that published previously. RESULTS: In the period of 1985 to 1992, IM was 12.33 per thousand live births. The SID rate was 1.30/1,000 live births. The prevalence of the prone position is unknown. In the period between 1993 and 1996, IM decreased to 5.84/1,000 live births and this decrease was proportional in both the neonatal and postneonatal components. The rate of SIM decreased to 0.44/1,000 live births. At the beginning of 1993, 86% of the children slept in the prone position, in 1994, 38% and in 1996, only 23%. CONCLUSIONS: Trustworthy data in Navarra shows a decrease in IM of more than 50% from 1993 on. The SID rate also decreased by 65%, coinciding with a massive drop in the use of the prone position during sleep.
Humans↗
Ontogeny of immobility reactions elicited by clamping, bandaging, and maternal transports in rats.
Wistar neonate rats assume a characteristic posture when being transported by the mother. This carrying posture is normally elicited by the pressure given by the mother's teeth on the pup's neck. By clamping or bandaging the neck and head an immobility reflex with flexion of body and limbs resembling the carrying posture is elicited when pups are in a supine position. On the contrary, by bandaging or by lightly clamping the pups in a prone position, a dorsiflexion with extension of forelimbs is elicited. Both clamping or bandaging inhibits contact and air righting. After a period of immobility bursts of activity follow. The characteristics of all the reactions described above depend on the age of the developing pups. It seems that the immobility reflex with ventroflexion of the body is a behavior used initially by pups to facilitate carrying by the mother, and by both pups and adults as a defense against predators. The posture adopted by the pups bandaged in the neck in a prone position is very similar to the posture they adopt while suckling from the mother. It is postulated that the weight of the mother when lying over the pups plus the pressure on the paws caused by their prone position, could be the stimulus that normally produces the suckling posture.
Aging↗
Case report: Endotracheal tube malposition in a patient with a tracheal bronchus.
PURPOSE: A tracheal bronchus is a congenital abnormality of the tracheobronchial tree, in which a displaced or accessory bronchus arises from the trachea superior to its bifurcation. We report a patient with a tracheal bronchus that was found incidentally during surgery in the prone position, and the potential airway management problems which may have ensued. CLINICAL FEATURES: A 70-yr-old female underwent posterior spinal decompression and fusion in the prone position. Intraoperatively, end-tidal CO2 and airway pressure increased. Fibreoptic bronchoscopy revealed that the endotracheal tube (ETT) was kinked at the 16 cm mark, which was corrected by rotating the patient's head and ETT. When the bronchoscope was advanced beyond the tip of the ETT, a tracheal-bronchial tree trifurcation was identified. Endobronchial intubation was suspected. As the ETT was withdrawn, the endoluminal view remained unchanged. During bronchoscopy, the patient's trachea was nearly extubated in the prone position. Subsequent bronchoscopy of the major bronchial divisions showed that the trifurcation represented left main stem bronchus, bronchus intermedius and right upper lobe bronchus. Once the tracheal bronchus was recognized, the tip of the ETT was repositioned 3 cm above the tracheal trifurcation, and the rest of the case was uneventful. CONCLUSION: This case highlights the diagnostic challenge and airway management implications of one variant of a tracheal bronchus when airway problems are encountered intraoperatively. This knowledge should be applied in the differential diagnosis and management of intraoperative hypoxemia; and in the proper positioning of the ETT.
Aged↗
[Arterial oxygen saturation monitoring of sleeping infants by pulse-oximeter--effect of sleeping position on arterial oxygen saturation in infants].
Monitoring of the arterial oxygen saturation (SaO2) in two sleeping infants was reported. They were a couple of female twins and had grown up normally after admission to NICU (Neonatal Intensive Care Unit) for a month. We investigated their SaO2 with the puls-oximeter at the terms between the 2nd and the 10th month. There was no significant difference between SaO2 in prone positions (n = 29) and that in supine positions (n = 30). In the infant with the sniffing conditions, however, SaO2 in prone positions seemed to be slightly lower than that in the healthy conditions. The slightly low SaO2 would give no effects on the healthy infants, but it may cause ALTE (Apparent Life Threatening Event) or death from SIDS (Sudden Infant Death Syndrome) to some infants who are not in good health and/or who are prone to get into ALTEA or SIDS. Especially, in the sniffing condition with hyperthermia, as the oxygen dissociation curve sifts to right and SaO2 degradation appears easily, sudden infant death may be possible to happen in prone position.
Blood Gas Analysis↗
[Surgery of the supratentorial and ventral spine: view-point of the surgeon].
The prone position for posterior fossa and cranio-spinal surgery is becoming the standard posture for neurosurgical teams. We analyze the reasons of such a change and specify indications of this posture. Thereafter, the procedure for optimal positioning is considered and the benefits of the prone position for the neurosurgeon and the anaesthetist are discussed. The selected references originate from Medline search (1991-1997), the Year Book of Neurology and Neurosurgery and the major neurosurgical review articles published between 1980 and 1996.
Humans↗
Provocation and mechanism of angle-closure glaucoma after iridectomy.
Dark room tests and prone-position tests in a lighted room and in a dark room were carried out on 64 eyes in 32 normal patients and 37 eyes of 30 patients that had undergone complicated iridectomy. Among the iridectomized eyes, the dark room tests and the prone-position test in lighted room caused elevation of intraocular pressure of more than 8 mm Hg in only 2.7% and 16.2%, respectively. Nearly 60% of the eyes showed positive results when the prone-position test was performed in a dark room. Our findings may provide experimental support for the theory of direct lens block as an angle-closure mechanism.
Darkness↗
Visual loss in one eye after spinal surgery.
PURPOSE: To report a patient who developed an unusual combination of central retinal artery occlusion with ophthalmoplegia following spinal surgery in the prone position. METHODS: A 60-year-old man underwent a cervical spinal surgery in the prone position. Soon after recovery he could not open his right eye and had ocular pain due to the general anesthesia. Upon examination, we determined that he had a central retinal artery occlusion with total ophthalmoplegia. RESULTS: Despite medical treatment, optic atrophy was still present at the following examination. Ptosis and the afferent pupillary defect disappeared and ocular motility was recovered, but visual loss persisted until the last follow-up. CONCLUSIONS: A prolonged prone position during spinal surgery can cause external compression of the eye, causing serious and irreversible injury to the orbital structures. Therefore, if the patient shows postoperative signs of orbital swelling after spinal surgery the condition should be immediately evaluated and treated.
Blindness↗
Effect of prone and supine positions on functional residual capacity, oxygenation, and respiratory mechanics in ventilated infants and children.
Although numerous reports have described the improvement in PAO2 in patients in the prone position, the underlying mechanism has yet to be determined. Some authors have suggested this phenomenon may be related to an increase in functional residual capacity (FRC); however, no previous studies have described positional changes in FRC in children with severe lung disease or in those under neuromuscular blockade. We measured arterial blood gases, FRC, Rrs, and Crs in supine and prone positions in 30 patients under neuromuscular blockade with lung disorders including moderately severe restrictive (n = 10) and obstructive (n = 10) disease and control subjects without significant lung disease (n = 10). Prone positioning was not associated with a significant increase in FRC in the cohort of 30 patients, nor in any of the subgroups. Although individual patients demonstrated large improvements in oxygenation, a statistically significant (but clinically insignificant) increase in AaPO2 ratio was observed only in the subgroup of patients with obstructive disease (0.35+/-0.03 to 0.38+/-0.04, p = 0.027). There was no correlation between changes in FRC and changes in AaPO2 (r = 0.225, p = 0.23). A significant improvement in Rrs occurred in the prone position compared to supine in patients with obstructive lung disease, decreasing from 0.264+/-0.024 to 0.216+/-0.021 cm H2O/ml/s, p = 0.009. No significant changes in Crs were seen in the prone position. We conclude that prone positioning has no effect on FRC and in this series of 30 patients significantly improved oxygenation only in patients with obstructive airway disease. A significant decrease in Rrs in patients with obstructive lung disease was also observed.
Blood Gas Analysis↗
[Erroneous recommendation results in steep increase of sudden infant deaths. Prone position-induced catastrophy].
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Cause of Death↗
[Electrohydraulic shockwave lithotripsy with ventral shockwave exposure--technic, indications and initial clinical results].
Shockwave lithotripsy of ureteral or calyceal calculi covered by the bony pelvis and of anteriorly located stones, such as calculi in horseshoe kidneys or the common bile duct, requires ventral introduction of the shockwave into the body. Eleven patients underwent ESWL in the prone position for the aforementioned indications. All treatments were performed with the Dornier HM3 lithotripter, which allows prone positioning of the patient without technical modification of the stretcher. ESWL was successful in all patients, one requiring a second session for complete stone disintegration. Thus, the possibility of shockwave lithotripsy with the patient in the prone position allows further extension of the indications for noninvasive treatment of calculi.
Gallstones↗
Sudden infant death syndrome (SIDS) in South Australia 1968-97. Part 2: the epidemiology of non-prone and non-covered SIDS infants.
OBJECTIVE: To identify the risk factors for infants who die suddenly and unexpectedly, but whose deaths are not related to prone position, or having the head covered. METHODOLOGY: A case-control study was designed in which the cases were infants who had died of sudden infant death syndrome (SIDS) in South Australia between January 1974 and December 1997, who were found not prone, not bed sharing and with the head not covered. The controls were two infants for each case, born in the same year and found in the prone position (again not bed sharing and with the head not covered). RESULTS: Sudden unexpected death infancy is rare in non-prone infants with the head not covered. occurring on average twice a year in South Australia, where there are 18,000-21,000 births per year. In this group there was a higher percentage of infants with features associated with low socio-economic groups (teenage pregnancies and maternal smoking), sibling SIDS, suspicion of non-accidental injury and the presence of minor congenital anomalies, especially cardiac anomalies. CONCLUSIONS: The majority of unexpected deaths in infancy can be prevented by not allowing infants to be unobserved in prone position, and by preventing them from getting their faces covered. For the few infants not found in these positions, a careful investigation should be made for malformations or non-accidental injury.
Bedding and Linens↗
Arm-down Concorde position: a technical note.
BACKGROUND: When the surgeon's approach is from behind the patient's shoulder via the infratentorial supracerebellar approach in the prone position (Concorde position), the patient's shoulder nearest the surgeon occasionally interferes with the visual route and surgical manipulation. To avoid this difficulty the author developed a modified Concorde position. METHODS: In the prone position, the patient's arm at the surgeon's side hangs down over the head end of the operating table, with elbow flexion supported by an arm-holder. CONCLUSIONS: This arm-down Concorde position provides good access for the surgeon in muscular- or broad-shouldered, short-necked, or obese patients.
Arm↗
Anterior ischemic optic neuropathy: a complication after systemic inflammatory response syndrome.
BACKGROUND: Patients are surviving previously fatal injuries. Unique morbidities are occurring in these survivors. Anterior ischemic optic neuropathy represents a previously unrecognized cause of blindness in the trauma victim. We hypothesize that this phenomenon is caused by unique characteristics of optic edema/ pressure or decreased blood flow associated with massive resuscitation. METHODS: Between November of 1991 and August of 1998, there were 18,199 admissions to our trauma center. Of this group, 350 patients required massive volume resuscitation (>20 liters infused over first 24 hours). Patients having closed head injuries, facial fractures or direct orbital trauma were excluded from study. The following variables were studied: demographics, injury severity (Injury Severity Score, highest lactate, worst base deficit, and lowest pH) crystalloid and transfusion requirements, ventilator requirements (PEEP) RESULTS: Of the 350 patients with massive resuscitation, 9 patients were diagnosed with anterior ischemic optic neuropathy (2.6%). Of these, seven patients required celiotomy (78%). Six of the seven celiotomy patients had damage control celiotomies and abdominal compartment syndrome (86%). One patient had a repair of a subclavian artery; one had a complex acetabular repair. Blindness was unilateral in five patients and bilateral in four. All nine patients had evidence of global hypoperfusion, systemic inflammatory response, massive resuscitation, and high ventilatory support; one patient required cardiopulmonary resuscitation. CONCLUSION: Prone positioning is known to be associated with an increased intraocular pressure. We postulate that the combination of massive resuscitation and prone positioning will increase the incidence of anterior ischemic optic neuropathy. As such, we recommend that prone positioning for adult respiratory distress syndrome be reserved for only those patients at risk of death.
Adolescent↗
Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient.
OBJECTIVE: To assess how the level of positive end-expiratory pressure (PEEP) (antiderecruitment strategy), etiological category of diffuse lung injury, and body position of the patient modify the effect of the alveolar recruitment maneuver (ARM) in acute respiratory distress syndrome (ARDS). DESIGN: Prospective clinical trial. SETTING: Medical intensive care unit at a tertiary hospital. PATIENTS: Forty-seven patients with early ARDS, including 19 patients from our preliminary study. INTERVENTION: From baseline ventilation at a tidal volume of 8 mL/kg and PEEP of 10 cm H2O, the ARM (a stepwise increase in the level of PEEP up to 30 cm H2O with a concomitant decrease in the magnitude of tidal volume down to 2 mL/kg) was given with (ARM + PEEP, n = 20) or without (ARM only, n = 19) subsequent increase of PEEP to 15 cm H2O. In eight other patients, PEEP was increased to 15 cm H2O without a preceding ARM (PEEP only). MEASUREMENTS AND RESULTS: In all three groups, Pao2 was increased by the respective intervention (all p<.05). In the ARM-only group, Pao2 at 15 mins after intervention was lower than Pao2 immediate after intervention (p =.046). In the ARM + PEEP group, no such decrease in Pao2 was observed, and Pao2 at 15, 30, 45, and 60 mins after intervention was higher than in the ARM-only group (all p<.05). Compared with the PEEP-only group, Pao2 of the ARM + PEEP group was higher immediately after intervention and at the later time points (all p <.05). Compared with patients with ARDS associated with direct lung injury (pulmonary ARDS), patients with ARDS associated with indirect lung injury (extrapulmonary ARDS) showed a greater increase in Pao2 (27 +/- 21% vs. 130 +/- 112%; p=.002) and a greater decrease in radiologic scores (1.0 +/- 2.4 vs. 3.4 +/- 1.5; p=.005) after the ARM. The increase in Pao2 induced by the ARM was greater for patients in the supine position than for patients in the prone position (61 +/- 82% vs. 21 +/- 14%; p=.028). Consequently, Pao immediately after the ARM was similar in the two groups of patients in different positions. CONCLUSIONS: After the ARM, a sufficient level of PEEP is required as an antiderecruitment strategy. Pulmonary ARDS and extrapulmonary ARDS may be different pathophysiologic entities. An effective ARM may obviate the need for the prone position in ARDS at least in terms of oxygenation.
Female↗
Head position dependency of induced nystagmus to ice-water irrigation in peripheral vestibulopathy.
OBJECTIVE: Evaluation of head-position dependency during the ice-water test is essential when the test is indicated. Because ice-water irrigation (IWI) in the prone position is frequently skipped in many laboratories, we investigated the importance of evaluating position dependency in an ice-water test. DESIGN AND SETTING: Twenty-five unilateral peripheral vestibulopathy patients showing no nystagmus during warm irrigation were included. IWI was performed in supine and prone positions, and maximum slow-phase velocity and direction of nystagmus were assessed by using video nystagmography. RESULTS: Eleven cases showed head-position dependency and were interpreted as hypofunctional. Fourteen cases showed no dependency, suggesting the absence of end organ function. In the latter group, 6 patients showing definite nystagmus in supine position could have been misinterpreted as hypofunctional, had it not been for prone-position results. CONCLUSIONS: Evaluation of head position dependency by using IWI is important in the determination of lateral semicircular canal function.
Adult↗
Effects of supine, prone, and lateral positions on cardiovascular and renal variables in humans.
The hypothesis was tested that changing the direction of the transverse gravitational stress in horizontal humans modulates cardiovascular and renal variables. On different study days, 14 healthy males were placed for 6 h in either the horizontal supine or prone position following 3 h of being supine. Eight of the subjects were in addition investigated in the horizontal left lateral position. Compared with supine, the prone position slightly increased free water clearance (349 +/- 38 vs. 447 +/- 39 ml/6 h, P = 0.05) and urine output (1,387 +/- 55 vs. 1,533 +/- 52 ml/6 h, P = 0.06) with no statistically significant effect on renal sodium excretion (69 +/- 3 vs. 76 +/- 5 mmol/6 h, P = 0.21). Mean arterial pressure and left atrial diameter were similar comparing effects of supine with prone. The prone position induced an increase in heart rate (54 +/- 2 to 58 +/- 2 beats/min, P < 0.05), total peripheral vascular resistance (13 +/- 1 to 16 +/- 1 mmHg. min(-1). l(-1), P < 0.05), forearm venous plasma concentration of norepinephrine (97 +/- 9 to 123 +/- 16 pg/ml, P < 0.05), and atrial natriuretic peptide (49 +/- 4 to 79 +/- 12 pg/ml, P < 0.05), whereas stroke volume decreased (122 +/- 5 to 102 +/- 3 ml, P < 0.05, n = 6). The left lateral position had no effect on renal variables, whereas left atrial diameter increased (32 +/- 1 to 35 +/- 1 mm, P < 0.05) and mean arterial pressure decreased (90 +/- 2 to mean value of 85 +/- 2 mmHg, P < 0.05). In conclusion, the prone position reduced stroke volume and increased sympathetic nervous activity, possibly because of mechanical compression of the thorax with slight impediment of arterial filling. The mechanisms of the slightly augmented urine output in prone position require further experimentation.
Adult↗