Limitations of prone positioning in patients with aneurysmal subarachnoid hemorrhage and concomitant respiratory failure

• Published in: Clinical neurology and neurosurgery Vol. 232; p. 107878
• Main Authors: Leppert, Jan, Ditz, Claudia, Souayah, Noura, Behrens, Carianne, Tronnier, Volker M., Küchler, Jan
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01.09.2023; Elsevier Limited
• Subjects: Anesthesia; Aneurysm; Aneurysmal subarachnoid hemorrhage; Aneurysms; Brain tissue oxygenation; Data collection; Edema; Hemorrhage; Hypertension; Intracranial pressure; Ischemia; Medical imaging; Mortality; Neurology; Oxygenation; Patient positioning; Patients; Prone position; Respiratory failure; Subarachnoid hemorrhage; Variance analysis; Ventilators; Germany; Brain tissue oxygenation; Prone position; Intracranial pressure; Respiratory failure; Aneurysmal subarachnoid hemorrhage
• ISSN: 0303-8467; 1872-6968; 1872-6968
• DOI: 10.1016/j.clineuro.2023.107878

Prone positioning (PP) is an established treatment modality for respiratory failure. After aneurysmal subarachnoid hemorrhage (aSAH), PP is rarely performed considering the risk of intracranial hypertension. The aim of this study was to analyze the effects of PP on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and cerebral oxygenation following aSAH. Patients and methods: Demographic and clinical data of aSAH patients admitted over a 6-year period and treated with PP due to respiratory insufficiency were retrospectively analyzed. ICP, CPP, brain tissue oxygenation (pBrO2), respiratory parameters and ventilator settings were analyzed before and during PP. Thirty patients receiving invasive multimodal neuromonitoring were included. Overall, 97 PP sessions were performed. Mean arterial oxygenation and pBrO2 increased significantly during PP. We found a significant increase in median ICP compared to the baseline level in supine position. No significant changes in CPP were observed. Five PP sessions had to be terminated early due to medically refractory ICP-crisis. The affected patients were younger (p = 0.02) with significantly higher baseline ICP values (p = 0.009). Baseline ICP correlates significantly (p < 0.001) with ICP 1 h (R: 0.57) and 4 h (R: 0.55) after onset of PP. PP in aSAH patients with respiratory insufficiency is an effective therapeutic option improving arterial and global cerebral oxygenation without compromising CPP. The significant increase in ICP was moderate in most sessions. However, as some patients experience intolerable ICP crises during PP, continuous ICP-Monitoring is considered mandatory. Patients with elevated baseline ICP and reduced intracranial compliance should not be considered for PP. •Prone positioning improves cerebral oxygenation in SAH patients.•Prone positioning significantly increases ICP in SAH patients.•Medically refractory ICP crisis occur in about 5% of proning sessions.•‘Younger age’ might pose a risk factors for medically refractory ICP crisis.