title: Prone Positioning in Cardiac Surgery: For Many, But Not for Everyone.
abstract: Prone positioning is a therapeutic maneuver to improve arterial oxygenation in patients with acute lung injury that is not implemented in most centers performing adult cardiac surgery. The aim of this study was to review our experience with prone positioning to assess the effects of this maneuver in patients with postoperative acute respiratory failure. From 2010-2014, 127 adult patients with postoperative acute respiratory failure were treated with prone positioning in addition to specific therapy. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors associated with in-hospital mortality. In-hospital mortality was 22.8% (n = 29). No significant differences were observed in preoperative risk factors between patients who survived (S) and those who died (D), except for age (62.7 ± 11.2 vs 70.2 ± 11.3; P = 0.007-at multivariate analysis P = 0.03, odds ratio [OR] = 1.1/year). Preproning values of PaO2/FiO2were significantly different between groups (D vs S: 115 ± 46 vs 150 ± 56; P = 0.006), but only preproning FiO2remained highly significant at multivariate analysis (D vs S: 0.82 ± 0.18 vs 0.67 ± 0.16; P = 0.001, OR = 1.07; with FiO2> 0.75 vs < 75, OR = 19.6). D showed a higher improvement of PaO2/FiO2immediately after prone positioning (207 ± 100 vs 219 ± 90, P = 0.56; within-group analysis between preproning and 1 hour after proning: S-P = 0.49, D-P = 0.019; at 12 hours: 286 ± 123 vs 240 ± 120, P = 0.06; within-group analysis between 1 hour and 12 hours after proning: S-P = 0.15; D-P = 0.17; between groups-P = 0.05). D had higher peak WBC count (26 ± 9.8 vs 17.7 ± 5.9×103/mL; P = 0.0001) and a higher rate of low output syndrome (15 vs 9 patients-51.7% vs 9.2%; P = 0.0001). At multivariate analysis, white blood cell count: P = 0.005, OR = 1.11/103white blood cell; low output syndrome: P = 0.0002, OR = 20.5. In conclusion, our results show that prone positioning, if performed early, is a safe and effective adjunct measure for patients with postoperative acute hypoxemic respiratory failure of noncardiogenic origin.
authors.affiliation: Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
authors.forename: Che
authors.initials: C
authors.lastname: von Wardenburg
authors.affiliation: Department of Anesthesiology, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Wenzl
authors.affiliation: Department of Cardiac Surgery, University Hospital Münster, Münster, Germany.
authors.forename: Angelo M
authors.initials: AM
authors.lastname: Dell'Aquila
authors.affiliation: Department of Anesthesiology, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Junger
authors.affiliation: Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
authors.forename: Theodor
authors.initials: T
authors.lastname: Fischlein
authors.affiliation: Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany. Electronic address: g.santarpino@libero.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Santarpino
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D005858:Germany; D017052:Hospital Mortality; D006801:Humans; D000860:Hypoxia / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D056888:Patient Positioning / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D018579:Patient Selection; D016684:Prone Position; D012128:Respiratory Distress Syndrome / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: ARDS; Acute respiratory distress syndrome; Outcomes; Postoperative care; Respiratory therapy; Ventilation