a) What are the advantages of the prone position?

Increase in FRC Changes in diaphragmatic excursions Improved ventilationperfusion matching

All these can significantly improve oxygenation in the prone position. This technique has been utilized for treatment of refractory hypoxaemia and in early acute respiratory distress syndrome 7080% of patients turned prone initially benefit from improved oxygenation. Other benefit -Surgical access for certain procedures eg neurosurgery, surgery on the back. Etc

b) What problem may be encountered by a patient in the prone position undergoing a lumbar microdiscectomy? Prone position is associated with airway ,breathing,circulatory and pressure related problems. These can be avoided if adequate steps are taken Airway Accidental extubation is a problem.Difficulty in accessing the airway and reintubation Swelling of the tongue and mouth can cause potential airway obstruction and delayed extubation. The mechanism is assumed to be obstruction of venous drainage from the head and neck secondary to excessive flexion of the neck. The subsequent increase in hydrostatic pressure causes the equivalent of dependent oedema.

Breathing Increase in external pressure on the chest leading to reduced thoracic compliancerequiring high airway pressure and can cause barotrauma

circulatory Cardiac index in one study dropped by an average of 24%. This was mainly as a result of decreasing stroke volume with little change in heart rate. Pressure on the abdomen can cause high intra-abdominal pressure which can cause inferior vena caval compression, reduced venous return and subsequent poor cardiac output.

Pressure related injuries Direct pressure can cause occlusion to an arterial supply or venous drainage Occlusion to the venous drainage, or any generalised rise in venous pressure will raise the IOP, as will use of a head-down position. MAP may be reduced either by deliberate hypotension or abdominal compression. If ocular perfusion pressure is too low to adequately perfuse the eyes then ischaemic damage will result Nerve injury--Chest support can compress nerves in the axilla. Direct compression of the ulnar nerve in the cubital tunnel Indirect compression of the axillary neurovascular bundle by axial pressure from the humerus. nerves exiting at the superior orbital fissure are at risk, Lateral cutaneous nerve of the thigh.

Excess pressure on the nose and eyes. The dorsum of the foot as well as knees, pelvic area,breasts, axilla, elbows and face are all at risk of pressure necrosis in this position. Others--The lower limbs are at increased risk of compartment syndrome in the tuck position, where both knees and hips are flexed. Arterial blood flow and MAP decrease, and limb pressure increases. This can result in rhabdomyolysis and compartment syndrome, which when complicated by renal failure can be