Neurocritical Care

, Volume 21, Issue 2, pp 186–191 | Cite as

Does Prone Positioning Increase Intracranial Pressure? A Retrospective Analysis of Patients with Acute Brain Injury and Acute Respiratory Failure

  • Christian RothEmail author
  • Andreas Ferbert
  • Wolfgang Deinsberger
  • Jens Kleffmann
  • Stefanie Kästner
  • Jana Godau
  • Marc Schüler
  • Michael Tryba
  • Markus Gehling
Original Article



The objective of our trial was to obtain more comprehensive data on the risks and benefits of kinetic therapy in intensive care patients with intracerebral pathology.


Standardized data of prone positioning in our NeuroIntensive Care Unit were collected from 2007 onward. A post hoc analysis of all available data was undertaken, with special consideration given to values of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and oxygenation in correlation to prone (PP), or supine positioning (SP) of patients. Cases were considered eligible if kinetic therapy and ICP were documented. Prone positioning was performed in a 135° position for 8 h per treatment unit.


A total of 115 patients treated with prone positioning from 2007 to 2013 were identified in our medical records. Of these, 29 patients received ICP monitoring. Overall, 119 treatment units of prone positioning with a mean duration of 2.5 days per patient were performed. The mean baseline ICP in SP was 9.5 ± 5.9 mmHg and was increased significantly during PP (p < 0.0001). There was no significant difference between CPP in SP (82 ± 14.5 mmHg) compared to PP (p > 0.05). ICP values >20 mmHg occurred more often during PP than SP (p < 0.0001) and were associated with significantly more episodes of decreased CPP <70 mmHg (p < 0.0022). The mean paO2/FiO2 ratio (P/F ratio) was increased significantly in prone positioning of patients (p < 0.0001).


The analyzed data allow a more precise understanding of changes in ICP and oxygenation during prone positioning in patients with acute brain injury and almost normal baseline ICP. Our study shows a moderate, yet significant elevation of ICP during prone positioning. However, the achieved increase of oxygenation by far exceeded the changes in ICP. It is evident that continuous monitoring of cerebral pressure is required in this patient group.


Prone position ICP ARDS CPP Respiratory failure Intracranial pressure Monitoring 


Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.


  1. 1.
    Bein T. Positioning of patients with acute respiratory failure. Med Klin Intensivmed Notfmed. 2012;107:603–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Beuret P, Carton MJ, Nourdine K, Kaaki M, Tramoni G, Ducreux JC. Prone position as prevention of lung injury in comatose patients: a prospective, randomized, controlled study. Intensive Care Med. 2002;28:564–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, Schoenfeld D, Thompson BT. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351:327–36.PubMedCrossRefGoogle Scholar
  4. 4.
    Chesnut RM, Petroni G, Rondina C. Intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2013;368:1751–2.PubMedGoogle Scholar
  5. 5.
    Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, Malacrida R, Di GP, Fumagalli R, Pelosi P, Brazzi L, Latini R. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med. 2001;345:568–73.PubMedCrossRefGoogle Scholar
  6. 6.
    Gruber A, Reinprecht A, Illievich UM, Fitzgerald R, Dietrich W, Czech T, Richling B. Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage. Crit Care Med. 1999;27:505–14.PubMedCrossRefGoogle Scholar
  7. 7.
    Guerin C, Badet M, Rosselli S, Heyer L, Sab JM, Langevin B, Philit F, Fournier G, Robert D. Effects of prone position on alveolar recruitment and oxygenation in acute lung injury. Intensive Care Med. 1999;25:1222–30.PubMedCrossRefGoogle Scholar
  8. 8.
    Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–68.PubMedCrossRefGoogle Scholar
  9. 9.
    Mancebo J, Fernandez R, Blanch L, Rialp G, Gordo F, Ferrer M, Rodriguez F, Garro P, Ricart P, Vallverdu I, Gich I, Castano J, Saura P, Dominguez G, Bonet A, Albert RK. A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med. 2006;173:1233–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Naidech AM, Bassin SL, Garg RK, Ault ML, Bendok BR, Batjer HH, Watts CM, Bleck TP. Cardiac troponin I and acute lung injury after subarachnoid hemorrhage. Neurocrit Care. 2009;11:177–82.PubMedCrossRefGoogle Scholar
  11. 11.
    Nekludov M, Bellander BM, Mure M. Oxygenation and cerebral perfusion pressure improved in the prone position. Acta Anaesthesiol Scand. 2006;50:932–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Reinprecht A, Greher M, Wolfsberger S, Dietrich W, Illievich UM, Gruber A. Prone position in subarachnoid hemorrhage patients with acute respiratory distress syndrome: effects on cerebral tissue oxygenation and intracranial pressure. Crit Care Med. 2003;31:1831–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Romero CM, Cornejo RA, Galvez LR, Llanos OP, Tobar EA, Berasain MA, Arellano DH, Larrondo JF, Castro JS. Extended prone position ventilation in severe acute respiratory distress syndrome: a pilot feasibility study. J Crit Care. 2009;24:81–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, Caspani L, Raimondi F, Bordone G, Iapichino G, Mancebo J, Guerin C, Ayzac L, Blanch L, Fumagalli R, Tognoni G, Gattinoni L. Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2009;302:1977–84.PubMedCrossRefGoogle Scholar
  15. 15.
    Thelandersson A, Cider A, Nellgard B. Prone position in mechanically ventilated patients with reduced intracranial compliance. Acta Anaesthesiol Scand. 2006;50:937–41.PubMedCrossRefGoogle Scholar
  16. 16.
    Voggenreiter G, Aufmkolk M, Stiletto RJ, Baacke MG, Waydhas C, Ose C, Bock E, Gotzen L, Obertacke U, Nast-Kolb D. Prone positioning improves oxygenation in post-traumatic lung injury—a prospective randomized trial. J Trauma. 2005;59:333–41.PubMedCrossRefGoogle Scholar
  17. 17.
    Zambon M, Vincent JL. Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest. 2008;133:1120–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Christian Roth
    • 1
    Email author
  • Andreas Ferbert
    • 1
  • Wolfgang Deinsberger
    • 2
  • Jens Kleffmann
    • 2
  • Stefanie Kästner
    • 2
  • Jana Godau
    • 1
  • Marc Schüler
    • 3
  • Michael Tryba
    • 3
  • Markus Gehling
    • 3
    • 4
  1. 1.Department of NeurologyKlinikum KasselKasselGermany
  2. 2.Department of NeurosurgeryKlinikum KasselKasselGermany
  3. 3.Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyKlinikum KasselKasselGermany
  4. 4.Department of Anaesthesiology and Intensive Care MedicinePhilipps University of MarburgMarburgGermany

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