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PubMed1979

The effect of posture on ventilation and lung mechanics in preterm and light-for-date infants.

The effect of right lateral, supine, and prone postures on ventilation and lung mechanics was studied in 23 healthy newborn infants, ten preterm and 13 term, "light-for-date," In the preterm group, tidal volume, minute volume, elastic work, inspiratory viscous work, total viscous work, and the total work of breathing were significantly greater in the prone position than in the supine position. Results obtained in the lateral position did not differ significantly from those in the prone or supine positions. Posture did not significantly affect tidal volume or lung mechanics in the light-for-date infants. The prone position is suggested to be the optimum nursing posture for healthy preterm infants.

Female↗

PubMed1998

Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community.

BACKGROUND: Some people in states of excited delirium die while in police custody. Emerging evidence suggests that physical restraint in certain positions may contribute to such deaths. In this study the authors determined the frequency of physical restraint among people in a state of excited delirium who died unexpectedly. METHODS: The authors reviewed the records of 21 cases of unexpected death in people with excited delirium, which were investigated by the Office of the Chief Coroner for Ontario between 1988 and 1995. Eyewitness testimony, findings during postmortem examinations, clinical history, toxicological data and other official documents describing the events surrounding the deaths were analyzed. Specific reference was made to documented eyewitness testimony of restraint method, body position and use of capsicum oleoresin (pepper) spray. Because cocaine was detected in the blood of some of these people during the postmortem examination, the role of cocaine in excited delirium was examined by comparing the cocaine levels in these cases with levels in 2 control groups: 19 people who died from acute cocaine intoxication and 21 people who had used cocaine shortly before they died but who had died from other causes. RESULTS: In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained. The excited delirium was caused by a psychiatric disorder in 12 people (57%) and by cocaine-induced psychosis in 8 (38%). Eighteen people (86%) were in police custody when they died. Four (19%) had been sprayed with capsicum oleoresin, and heart disease was found in another 4 at autopsy. The blood level of cocaine in those whose excited delirium was cocaine induced was similar to levels found in recreational cocaine users and lower than levels found in people who died from cocaine intoxication. INTERPRETATION: Restraint may contribute to the death of people in states of excited delirium, and further studies to test this hypothesis are recommended. Meanwhile, law enforcement authorities and others should bear in mind the potential for the unexpected death of people in states of excited delirium who are restrained in the prone position or with a neck hold.

Adolescent↗

PubMed2005

[Bed sharing and sudden infant death].

BACKGROUND: The aim of the study was to investigate bed sharing as a risk factor for sudden infant death syndrome (SIDS). MATERIAL AND METHODS: Firstly, SIDS cases examined at our institute in two six-year periods before and after the back-to-sleep campaign (1984-89 and 1998-2003) were investigated. Secondly, a case-control study was performed, an investigation of variables such as bed sharing, parental smoking and breast-feeding in the SIDS group from the latter period versus 244 live control infants. RESULTS: The age distribution of the SIDS victims in the two periods with high and low SIDS rates differed significantly (p = 0.004). In the latter period, fewer SIDS cases were seen in the classical distributional peak between the third and the fourth month of life, and a larger proportion of SIDS cases were seen within the first month of life. Furthermore, a smaller proportion of SIDS victims were found dead in the prone position (decrease from 89% to 49%, p < 0.001); and bed sharing at time of death occurred more frequently (increase from 7% to 35%, p < 0.001). In the case-control study, bed sharing was a significant risk factor for SIDS in infants aged 0-2 months (multivariate OR 5.3; 95 % CI 1.3-22, p = 0.02). Bed sharing with a smoking mother was associated with a 16-fold increased risk of SIDS (OR 16; 95% CI 2.1 - 118, p = 0.007). No relationship between bed sharing and SIDS was evident for age >2 months. Only 12% of the bed sharing SIDS victims aged <2 months where found in the prone position. INTERPRETATION: Bed sharing is associated with an increased risk of SIDS for infants <2 months of age. Particularly hazardous is bed sharing with a smoking parent.

Breast Feeding↗

PubMed1998

Body and head position, covering of the head by bedding and risk of sudden infant death (SID).

We examined the position of the body and head, and the covering of the head by bedding on discovery in cases of sudden infant death (SID) in Lower Saxony. Between 1.1.1986 and 31.12.1992 structured, questionnaire-based interviews were carried out with parents of 140 SID victims. Control data were taken from a population-based cross-sectional study on infant sleeping position performed by the German Health Office (BGA) in autumn 1991. Of the SID cases 86.4% were discovered in the prone position [odds ratio (OR) = 7.4, 95% confidence interval (CI) = 4.3, 12.7] and 41.4% were found with the head covered. These infants were significantly older than those where the head was uncovered (p < 0.001) and covering of the head showed a significant association with a risk of SID (OR = 20.8; 95% CI = 11.5-37.6). Of the SID cases 27.9% were discovered in the face-down position. These infants were significantly younger than the infants who were discovered with the head in a side or supine position (p < 0.001). This study confirms the increased risk of SID associated with the prone position and suggests that this association could be related to the development of hypoxaemia or hypercapnia. Together with other factors such as heat stress or an infection, hypoxaemia or hypercapnia could culminate in SID if the arousal from sleep and auto-resuscitation apparently fails.

Bedding and Linens↗

PubMed1995

Effect of a postural support nappy on 'flattened posture' of the lower extremeties in very preterm infants.

OBJECTIVE: To determine whether the use of a postural support nappy (PSN) would reduce the features of 'flattened posture' in the lower extremities of infants < 31 weeks gestation who are nursed prone. METHODOLOGY: Randomized, observer blind, controlled trial conducted at King Edward Memorial Hospital for Women, Perth, Western Australia. Infants were randomly assigned and stratified by gestational age to be nursed in a conventional nappy (n = 29) or a PSN (n = 31) when in the prone position. The features of 'flattened posture' were measured as angles and assessed by blinded observers prior to commencement of the intervention, 4 weeks post intervention, then bi-weekly until discharge. RESULTS: A significant reduction in the features of 'flattened posture' occurred in the PSN group after 4-6 weeks of intervention and stabilized by 8 weeks until discharge. No changes were detected in the control group. No significant difference was observed between infants < 29 weeks gestation compared to infants of 29-30 weeks gestation in either treatment group. CONCLUSIONS: Use of the PSN in infants < 31 weeks gestation who are nursed in the prone position significantly reduces the features of 'flattened posture' in the lower extremities. This is of benefit in the short term, and follow up of these infants into childhood will demonstrate whether the long-term effects of 'flattened posture' can be prevented.

Chi-Square Distribution↗

PubMed2004

Supine position is safe and effective for percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: The prone position has been widely adopted in conventional percutaneous nephrolithotomy (PCNL). Following its introduction in 1998, we changed our routine practice of PCNL from the prone to the supine position, which had numerous benefits and was safe and effective. Tract formation and stone fragmentation and retrieval were accomplished with the patient supine. PATIENTS AND METHODS: We report our experience with 62 patients (67 renoureteral units) treated in the supine position and describe the technique in detail. RESULTS: The primary stone clearance rate was 76%, and the mean number of sessions of PCNL was 1.3. There was no procedure-related major complication. There were also no splanchnic injuries. One kidney loss (emergency nephrectomy for control of hemorrhage) was noted but was not directly related to the procedure (profuse bleeding after accidental traction on the balloon nephrostomy tube by the patient 1 week after PCNL). Modification of positioning was made to suit the body build of Chinese patients. CONCLUSION: There are several advantages to the supine position for the patient and the urologist, with greater versatility of stone manipulation along the whole upper urinary tract. There are a few limitations of the supine position, but they can be overcome. Performing PCNL with the patient in the supine position is a sound alternative to the conventional prone position.

Adult↗

PubMed2006

[Pharmacokinetic simulation of high-dose administration of dexmedetomidine for decubitus treatment].

We used only dexmedetomidine to sedate a patient with Alzheimer disease, Parkinson's syndrome and emaciation for decubitus treatment in the prone position. The infusion rate of dexmedetomidine without a loading dose was increased until sufficient sedation was attained. The maximum plasma concentration and the plasma concentration in a stable state, which were calculated by pharmacokinetic simulation analysis, were 2.3 ng x ml(-1) and 1.5 ng x ml(-1), respectively. Respiration disorder did not occur and hemodynamic stability was preserved despite administration up to 11.5 mcg x kg(-1) x h(-1). An increase in the dose per weight was needed to increase the absolute dose because of emaciation. It was found by pharmacokinetic simulation analysis that the plasma concentration of dexmedetomidine required for decubitus treatment might be higher than the plasma concentration considered to be necessary for sedation in intensive care units. The simulation was conducted to administer dexmedetomidine, to estimate hemodynamic reaction, and to estimate the necessary plasma concentration. We conclude that dexmedetomidine is useful as an anesthetic agent for decubitus treatment in the prone position, although further investigations with regard to its safety are required.

Aged↗

PubMed2006

Sudden infant death: lingual thyroglossal duct cyst versus environmental factors.

An 8-month-old female baby was found collapsed in the prone position 30 min after being positioned under soft-bedding. She was taken to the emergency room with cardiopulmonary arrest. Her heartbeat was recovered after resuscitation and continued for 20 h under artificial respiration, at which point the child died. At autopsy, the child showed no significant pathological abnormalities apart from a thyroglossal duct cyst of 2.0 cm diameter, therefore, it seemed that the cyst, which was close to the epiglottis, had caused asphyxia through airways occlusion. However, the child had shown no respiratory problems before death, and the risk of airway occlusion as a result of lingual cysts is more likely in a supine rather than a prone position. A small amount of evidence suggested that the child died as a result of suffocation from being covered by soft-bedding, which could have caused fatal asphyxia; it is also possible that a hypoxic state induced by airway obstruction might have been enhanced by being covered with bedding. It seemed reasonable to assume that death was caused by a combination of the lingual thyroglossal duct cysts and asphyxia caused by being covered in bedding, though the main factor appeared to be the large cyst.

Airway Obstruction↗

PubMed1989

Elbow arthroscopy: a new technique.

Elbow arthroscopy is a useful diagnostic and therapeutic tool for the orthopedic surgeon. In the standard technique, the patient is positioned supine with the arm suspended overhead and an anterolateral portal is used. We have modified this technique by placing the patient in a prone position and using a proximal medial portal. Use of the prone position improves scope mobility, facilitates joint manipulation, and provides more complete intraarticular visualization. This technique simplifies the treatment of a wide variety of elbow pathology, including loose bodies, osteochondritis dissecans, persistent synovitis, suspected cartilaginous lesions, posterior osteophytes, selected radial head fractures, and chronically undiagnosed painful elbows.

Arthroscopy↗

PubMedDate not supplied

Spinal anesthesia with hypobaric bupivacaine for knee arthroscopies: effect of posture on motor block.

BACKGROUND AND OBJECTIVES: The clinical impact of patient positioning on motor block during unilateral spinal anesthesia was the focus of our study. It was assumed that a 45 degrees rotation toward the prone position would minimize blocking the ventral motor roots compared with using the conventional lateral decubitus position. METHODS: Spinal anesthesia with 3.4 mL of hypobaric 0.18% bupivacaine via a 27-gauge Whitacre needle was administered to 70 patients undergoing knee arthroscopy. The patients were kept either in a lateral decubitus position (group I) or rotated approximately 45 degrees toward the prone position (group II). No prophylactic vasopressors or infusions were used. The intensity of motor block (modified Bromage scale) was assessed for both the operative and the contralateral side. RESULTS: The patients in group I had a slightly more pronounced motor block, but statistical significance could be shown only 20 minutes following the block. There was no statistical difference between the groups in the need of additional analgesics during the operation. None of the patients needed general anesthesia. The hemodynamics were stable and none of the patients developed postspinal headache or backache. CONCLUSIONS: The position of the patient affects the spread of the spinal anesthesia when clearly hypobaric agents are used. However, this small modification in positioning of the patient did not lead to a clinically meaningful difference in the spread of the motor block.

Anesthesia, Spinal↗

PubMed2000

Exercise after cryotherapy greatly enhances intramuscular rewarming.

OBJECTIVE: To determine the effect of moderate-intensity walking on rewarming of the triceps surae muscle group after a 20-minute application of a crushed-ice pack. DESIGN AND SETTING: Subjects were randomly assigned to either the ice-rest or the ice-exercise group. All subjects were treated on the left calf for 20 minutes with a 1.8-kg ice pack. The ice-exercise group walked on a treadmill at 5.63 km/h for 10 minutes and then assumed a prone position on an examining table for 20 minutes. The ice-rest group assumed a prone position on an examining table for 30 minutes after the cryotherapy treatment. SUBJECTS: Twenty-eight (19 men and 9 women) college-student volunteers. MEASUREMENTS: Intramuscular temperature was recorded at 10-second intervals for 50 minutes at 1 cm below the subcutaneous fat with a thermocouple implanted via a 21-gauge sterile hypodermic needle. Differences were analyzed within and between groups at pretreatment (T(0)), the end of the ice treatment (T(20)), 11 minutes after the end of ice treatment (T(31)), and 30 minutes posttreatment (T(50)). RESULTS: We found no differences at T(0) and T(20) but significant differences at T(31) and T(50). At T(31), the ice-exercise group was only 0.61 degrees C colder than at pretreatment levels, while the ice-rest group was 8.05 degrees C colder. By T(50), the temperatures were 0.93 degrees C and 6.95 degrees C colder, respectively, than at pretreatment levels. CONCLUSION: Moderate walking significantly enhanced rewarming of the triceps surae.

Journal Article↗

PubMed2005

Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic emergency department.

BACKGROUND: Shoulder dislocations account for almost 50% of all joint dislocations, which are most commonly anterior (90-98%) and occur due to trauma. This prospective study was conducted to report our experiences of using the scapular manipulation technique (SMT) to reduce traumatic anterior shoulder dislocations. METHODS: Between March 2002 and March 2003, SMT was applied to 41 patients who presented with traumatic anterior shoulder dislocation to the Gulhane Military Medical Academy, Department of Emergency Medicine, Ankara, Turkey, which is a level 1 trauma centre with an annual attendance of 85,000 patients. The technique was applied to patients in the prone position by a single operator. Where necessary, a procedural sedation/analgesia (PSA) protocol was followed. RESULTS: The study population consisted of 26 (63.4%) male patients aged between 17 and 76 years (SD 15.6). History of recurrent shoulder dislocations at the same site were taken from seven (17.1%) of the patients. Mean (SD) trauma to reduction time was approximately 61.5 (72) minutes (range 10-480). Five patients (12%) had a greater tuberosity fracture. SMT was attempted twice to only four (9.8%) patients by a standard PSA protocol. We experienced a success rate of 90.2% at the first attempt and 100% overall. None of the patients encountered any complication. CONCLUSIONS: We report the successful use of SMT in the prone position for the reduction of traumatic anterior shoulder dislocations, mainly without requirement of any sedatives or opiate analgesics. We believe that SMT may also be applied by inexperienced physicians, as it is simple, applicable, and easily understood. As no single method has a 100% success rate, SMT is a useful one to know.

Adolescent↗

PubMed1997

[The diagnostic accuracy and reproducibility of computed tomography with water distention and induced hypotonia in the preoperative staging of gastric tumors].

Thirty-five patients with gastric cancer were preoperatively examined with CT performed in the prone position. Patient preparation consisted in filling the stomach with tap water and i.v. glucagon administration. The CT images were independently reviewed by two radiologists, who staged each tumor according to the TNM classification. The results were compared with surgical and histological findings. The overall accuracy for T staging ranged 74-77%, overstaging 17-23%; understaging was 3%. Diagnostic sensitivity, specificity and accuracy for serosal invasion were 100%, 80%, 85% and 100%, 84% e 88%, respectively, for the two radiologists. The overall accuracy for N staging was 48% and 51% for the two observers, respectively. Considering N1 and N2 as a single group, accuracy ranged 68-77%. The interobserver agreement analyzed by the "K tests" was 80%, with a K index of 60%. CT performed with the patient in the prone position, after preparation with gastric wall hypotony and distension with water, is a valid technique permitting excellent depiction of the gastric wall and providing useful preoperative information to the surgeon.

Adult↗

PubMed2005

Ischemic optic neuropathy following spine surgery.

Perioperative visual loss (POVL) is a devastating injury that has been reported infrequently after nonocular surgery. The most common cause of POVL is ischemic optic neuropathy (ION). Increasing numbers of cases of ION are being reported after spine surgery, but the etiology of postoperative ION remains poorly understood. After a MEDLINE search of the literature, we reviewed published case reports of ION, specifically those reported after spine surgery performed with the patient in the prone position. Most of the cases involved posterior ION (PION, n = 17), and the remainder anterior (AION, n = 5). Most patients had no or few preoperative vascular disease risk factors. All except one PION and 2 of 5 AION cases reported symptom onset within the first 24 hours after surgery. Visual loss was frequently bilateral (40% of AION, 47% of PION cases). Mean operative time exceeded 450 minutes. The lowest average intraoperative mean arterial blood pressure was 64 mm Hg and the mean lowest intraoperative hematocrit was 27%. The average blood loss was 1.7 L for AION and 5 L for PION patients. PION patients received an average of 8 L of crystalloid solution and 2.2 L of colloid intraoperatively. This compilation of case reports suggests that a combination of prolonged surgery in the prone position, decreased ocular perfusion pressure, blood loss and anemia/hemodilution, and infusion of large quantities of intravenous fluids are some of the potential factors involved in the etiology of postoperative ION. However, levels of blood pressure and anemia intraoperatively were frequently at levels considered acceptable in anesthesia practice. The etiology of postoperative ION remains incompletely understood. Potential strategies to avoid this complication are discussed.

Adolescent↗

PubMed1999

Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.

OBJECTIVE: To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. METHODS: The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). MAIN OUTCOME MEASURES: Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. RESULTS: In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. CONCLUSIONS: Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.

Adolescent↗

PubMed2005

Laryngohyoid fractures after agonal falls: not always a certain sign of strangulation.

Haemorrhagic fractures of the thyroid cartilage and hyoid bone are frequently observed in cases of strangulation and often regarded as evidence for an assault against the neck. In contrast, two cases of laryngohyoid fractures after agonal falls in prone position are presented to draw attention to alternative causes of these injuries with special regard to practical medicolegal casework. A 45-year-old man collapsed at a fairground and died after unsuccessful resuscitation. He showed excoriations at his elbows and right knee, a crush injury at the mentum and his mandibular front teeth were knocked out. The upper parts of the chest and the head showed blue discolouration as a marked sign of congestion due to heart failure. The right coronary artery (RCA) was completely obturated by a 5 cm long post-stenotic thrombus with subsequent myocardial infarction of the lateral part of the left ventricle. Both superior horns of the thyroid cartilage were fractured with surrounding haemorrhage, the skin and muscles of the neck uninjured. In the second case, a 63-year-old woman with a mobility handicap had fallen from a 2m high lifting platform and was found in prone position with her wheelchair on her. Resuscitation efforts were not successful. Autopsy showed signs of blunt external force against head, neck, chest and limbs. Examination of the neck revealed haemorrhage of the right sternocleidomastoid muscle, both superior horns of the thyroid cartilage were fractured, as well as the hyoid bone, with slight haemorrhage of the surrounding soft tissue and mucosa. On the same level, the fifth intervertebral disk was ruptured, without any injury of the spinal cord. These cases demonstrate that laryngohyoid fractures should not be overestimated as unequivocal indication of neck compression and may well be caused by falls, even at ground level.

Accidental Falls↗

PubMed1975

The prone chest film.

Frontal chest radiographs in the prone position enhanced visualization of the posterior lung base in the presence of pleural effusions. Though the lateral decubitus view often displaced fluid adequately, in several cases only the prone film revealed basilar lung pathology; this was due to gravitational shift of the fluid away from this region as well as improved aeration of the lower lobe in the prone position, as shown by horizontal-beam lateral views. The prone chest film is recommended for evaluation of the lung base when obscured by fluid.

Abdominal Muscles↗

PubMed2001

The use of a mobile computed tomography scanner in the pediatric intensive care unit to evaluate airway stenting and lung volumes with varying levels of positive end-expiratory pressure.

OBJECTIVE: Presentation of a case report describing the use of a mobile computed tomography (CT) scanner in the pediatric intensive care unit (PICU) to radiographically evaluate tracheobronchial stenting and lung volumes while using different levels of positive end-expiratory pressure (PEEP) and positioning in a critically ill infant. DESIGN: Case report of a single patient. SETTING: Pediatric intensive care unit in a University Hospital. PATIENT: A 6-month-old premature infant with bronchopulmonary dysplasia, tracheobronchomalacia, and progressive respiratory failure. INTERVENTIONS: CT scans of the chest were performed by using a mobile CT scanner in the PICU. Serial CT scans were performed at PEEP levels of 5, 10, 15, and 20 cm H(2)O in both the supine and prone position. Scheduled medical care and standard monitoring were continued during the course of the CT scans. MEASUREMENTS AND MAIN RESULTS: Identical anatomic levels demonstrating the trachea, bronchi, and lung parenchyma were compared while different levels of PEEP and supine or prone positioning were used. From these comparisons, the level of PEEP in which lung volumes were optimized was radiographically determined. No significant changes in large airway caliber were observed. There was no difference noted between prone and supine positioning. CT scans were completed with minimal disruption to the patient's care. CONCLUSIONS: Mobile CT scanners can be used in the PICU for the diagnostic evaluation of critically ill children. This option allows for the continuation of medical therapies and monitoring in the intensive care setting while avoiding the potential complications of transporting a critically ill child to the radiology department. The use of mobile CT scanners may disrupt PICU routine and is more expensive than use of fixed CT scanners. Mobile CT scanners may be useful in radiographically determining the optimal level of PEEP in infants with tracheobronchomalacia and bronchopulmonary dysplasia.

Journal Article↗