Anesthetic Management in Prone Position

Preoperative Preparation

The anesthesiologist should control the head, neck, and airway during prone positioning, requiring a minimum of four additional personnel to facilitate safe transfer of the anesthetized patient 1
A multidisciplinary risk-benefit assessment should be performed before proceeding with prone positioning if certain conditions are present, such as open abdomen, spinal instability, increased intracranial pressure, cardiac arrhythmias with hemodynamic consequences, or shock 2

The volume status should be optimized before positioning 3, 2
Ongoing vasopressor therapy is not a contraindication for prone positioning, as the intervention is generally well-tolerated hemodynamically 3, 2
Patients may experience an improvement in right ventricular loading in the prone position 3

Obese patients require individual consideration of benefits versus risks, particularly those with abdominal obesity or previous abdominal surgery 3, 2
The prone position can increase intra-abdominal pressure from 12±4 mmHg to 14±5 mmHg in obese patients 3

A protective ventilation strategy with a low tidal volume of 6-8 ml/kg predicted body weight should be used 4
The initial PEEP should be set at 5 cm H₂O, and individualized to avoid increases in driving pressure (Pplat-PEEP) while maintaining low tidal volume 4
The prone position and PEEP have additive effects on improving oxygenation 3

Continuous hemodynamic monitoring should be performed during and after positioning 3
Regular inspection of pressure points should be performed throughout the procedure 2
For patients at risk of increased intracranial pressure, continuous or close monitoring of intracranial pressure should be performed 2

Regional techniques should be considered when possible to reduce opioid use 5
Non-opioid neuroaxial analgesia reduces risks compared to techniques that include opioids 5
Non-steroidal anti-inflammatory agents should be used when acceptable to reduce opioid use 5

The head should be elevated before emergence from anesthesia to prevent atelectasis and improve oxygenation 6
The patient should be positioned with approximately 30-45° of head and upper torso elevation 6
Supplemental oxygen should be administered continuously until the patient can maintain their baseline saturation breathing room air 5

The British Journal of Anaesthesia recommends verifying and documenting tracheal tube depth before positioning, and the Anaesthesia journal suggests ensuring tracheal tube cuff pressure is 20-30 cm H₂O 7, 8
The Anaesthesia journal advises securing all tubes and lines, and applying prophylactic foam dressings to vulnerable pressure areas before positioning 8

The Anaesthesia journal recommends using closed tracheal suction systems, and maintaining HME filter close to the patient rather than heated humidified circuit 8
The British Journal of Anaesthesia and Anaesthesia journal suggest verifying tracheal tube depth and cuff pressure after positioning, and confirming bilateral breath sounds and adequate chest rise 7, 8

The British Journal of Anaesthesia recommends maintaining continuous waveform capnography throughout prone positioning, and monitoring and documenting tracheal tube depth at every shift change 7, 8
The Anaesthesia journal advises checking cuff pressure and tracheal tube depth before and after any patient repositioning, nasogastric tube manipulation, tracheal suction, or oral care 8

The British Journal of Anaesthesia and Anaesthesia journal suggest nominating an experienced team member solely to safeguard the airway during high-risk interventions, and verifying cuff pressure and tube depth both before and after these procedures 7, 8
The Anaesthesia journal recommends packing the pharynx while administering 100% oxygen and preparing for re-intubation if cuff leak develops, and immediately pausing the ventilator before re-intubation 8

The British Journal of Anaesthesia recommends not relying on chest X-ray alone to confirm tracheal placement, and using waveform capnography to confirm tracheal vs. esophageal placement 7
The British Journal of Anaesthesia suggests assuming apparent cuff leak to be partial extubation until proven otherwise 7