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Complications of Intermittent Prone Positioning in Pediatric Patients Receiving Extracorporeal Membrane Oxygenation for Respiratory Failure^*

^* From the Department of Pediatrics (Drs. Haefner, Bratton, Annich, and Custer), Division of Pediatric Critical Care Medicine, and the Department of General Surgery (Dr. Bartlett), University of Michigan, Ann Arbor, MI.

Correspondence to: Susan L. Bratton, MD, MPH, F6884 Mott/0243, Pediatric Critical Care Medicine, 1500 East Medical Center Dr, Ann Arbor, MI 48109-0243; e-mail: brattons{at}med.umich.edu

Study objective: To describe the safety and risks of placing pediatric patients in the prone position during extracorporeal membrane oxygenation (ECMO) for the treatment of respiratory failure.

Design: Single-center retrospective cohort study.

Setting: Tertiary pediatric ICUs.

Patients: All patients admitted to the pediatric ICU who required ECMO for respiratory failure from 1995 to 2000.

Interventions: None.

Measurements and results: Medical records for 93 patients representing 95 ECMO runs for treatment of respiratory failure were reviewed. Of these, 63 patients (66%) received intermittent prone positioning. Demographic data and clinical information were recorded. The median age was 12 months, and the median weight was 9.8 kg. There were 962 position changes. Complications surveyed for included bleeding from appliance insertion sites, appliance dislodgment, unplanned extubation, cutaneous pressure ulceration, corneal abrasion, and extreme hemodynamic instability. These complications were noted as to whether they were present prior to the initiation of prone positioning or whether they developed after prone positioning began. Twenty-four percent of patients had bleeding from cannulation sites prior to prone positioning, and 18% of patients had bleeding begin after prone positioning was initiated. Two patients had chest tubes dislodge after prone positioning began, but neither patient had bleeding occur or required reinsertion of the chest tube. There were no unplanned extubations, appliance displacements, development of cutaneous pressure ulcerations, or corneal abrasions associated with prone-positioning maneuvers. No patient had ECMO support removed secondary to the surveyed complications. Eighty-two percent of children who received prone positioning during ECMO for treatment of respiratory failure survived to hospital discharge.

Conclusion: We found that prone positioning may be used in pediatric ECMO patients without increasing the risk of complications. A multi-institutional, prospective, randomized, controlled study would better evaluate the efficacy of this practice and whether it is associated with a shorter length of ECMO or shorter post-ECMO ventilation and outcome.

Key Words: acute lung injury • ARDS • extracorporeal life support • extracorporeal membrane oxygenation • pediatric • prone position

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