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CRITICAL CARE AND TRAUMA

The Effects of Prone Positioning on Intraabdominal Pressure and Cardiovascular and Renal Function in Patients with Acute Lung Injury

Rudolf Hering, MD^*, Hermann Wrigge, MD^*, Ralph Vorwerk, MD^*, Karl A. Brensing, MD, Stefan Schröder, MD^*, Jörg Zinserling, MSc^*, Andreas Hoeft, MD^*, Tilman V. Spiegel, MD^*, and Christian Putensen, MD^*

Departments of *Anesthesiology and Intensive Care Medicine and Internal Medicine, Rheinische Friedrich-Wilhelms University, Bonn, Germany

Address correspondence and reprint requests to Rudolf Hering, MD, Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms University, Sigmund-Freud Strasse 25, 53105 Bonn, Germany. Address e-mail to hering{at}uni-bonn.de

To detect any harmful effects of prone positioning on intraabdominal pressure (IAP) and cardiovascular and renal function, we studied 16 mechanically ventilated patients with acute lung injury randomly in prone and supine positions, without minimizing the restriction of the abdomen. Effective renal blood flow index and glomerular filtration rate index were determined by the paraaminohippurate and inulin clearance techniques. Prone positioning resulted in an increase in IAP from 12 ± 4 to 14 ± 5 mm Hg (P < 0.05), PaO₂/fraction of inspired oxygen from 220 ± 91 to 267 ± 82 mm Hg (P < 0.05), cardiac index from 4.1 ± 1.1 to 4.4 ± 0.7 L/min (P < 0.05), mean arterial pressure from 77 ± 10 to 82 ± 11 mm Hg (P < 0.01), and oxygen delivery index from 600 ± 156 to 648 ± 95 mL · min^-1 · m^-2 (P < 0.05). Renal fraction of cardiac output decreased from 19.1% ± 12.5% to 15.5% ± 8.8% (P < 0.05), and renal vascular resistance index increased from 11762 ± 6554 dynes · s · cm^-5 · m² to 15078 ± 10594 dynes · s · cm^-5 · m² (P < 0.05), whereas effective renal blood flow index, glomerular filtration rate index, filtration fraction, urine volume, fractional sodium excretion, and osmolar and free water clearances remained constant during prone positioning. Prone positioning, when used in patients with acute lung injury, although it is associated with a small increase in IAP, contributes to improved arterial oxygenation and systemic blood flow without affecting renal perfusion and function. Apparently, special support to allow free chest and abdominal movement seems unnecessary when mechanically ventilated, hemodynamically stable patients without abdominal hypertension are proned to improve gas exchange.

Implications: Prone positioning is increasingly used to improve gas exchange in patients with acute lung injury. However, during prone positioning an increase in intraabdominal pressure in these critically ill patients may promote dysfunction of other organs. Therefore, we performed a randomized study in mechanically ventilated patients with acute lung injury to investigate the cardiovascular and renal effects of prone positioning.

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