Understanding the Risks: Which of the following complications is associated with the prone position?

October 1, 2025 •

4 min read

Prone positioning has been used since the 1970s to improve oxygenation in patients with severe respiratory failure, yet it is not a benign procedure. Understanding which of the following complications is associated with the prone position is crucial for mitigating risks and ensuring patient safety, particularly in critical care and surgical settings.

Quick Summary

The prone position carries risks including pressure-related injuries, nerve damage, ocular complications, and significant hemodynamic changes. Specialized care and proper positioning techniques are essential to minimize the frequency and severity of these adverse effects during critical illness or surgery.

Key Points

Pressure Ulcers: Prolonged pressure on bony areas like the face, chest, and knees can cause skin breakdown and tissue necrosis, especially during extended procedures or intensive care stays.
Nerve Injuries: Compression or stretching of peripheral nerves, such as the brachial plexus and ulnar nerve, can lead to post-operative weakness or palsy.
Ocular Complications: Increased intraocular pressure, potentially exacerbated by direct eye pressure or venous congestion, can result in ischemic optic neuropathy and even permanent visual loss.
Cardiovascular Instability: The prone position can increase intra-abdominal pressure, which in turn decreases venous return to the heart and can cause hypotension and hemodynamic compromise.
Airway Issues and Edema: Risks include accidental extubation or airway obstruction, as well as significant facial and tongue swelling due to impaired venous drainage, which can complicate extubation.
Risk Mitigation: Careful, multi-person patient positioning, adequate padding, specialized supports, and continuous monitoring are essential strategies to minimize complications.

The Dual Nature of the Prone Position

Prone positioning, where a patient lies face down, is a life-saving intervention used extensively in critical care for patients with Acute Respiratory Distress Syndrome (ARDS). By shifting the weight of the heart and abdomen off the lungs, it improves gas exchange and reduces ventilation-perated lung injury. Similarly, in surgery, particularly spinal and neurosurgical procedures, the prone position provides optimal access to posterior anatomical structures. While offering significant benefits, this position places unique physiological stressors on the body, increasing the risk of potentially severe and disabling complications.

Major Complications Associated with Prone Positioning

Pressure Ulcers and Skin Damage

Prolonged pressure on the body’s anterior surfaces is a major risk factor for developing pressure ulcers, or pressure injuries. The duration of the procedure, a patient’s age, and obesity are known risk factors. Vulnerable areas include:

The face (forehead, cheekbones, chin, and nose)
The chest and breasts
The iliac crests and knees
Genitalia
The shoulders and elbows Extended time in this position, especially combined with high levels of skin moisture, can lead to tissue ischemia and necrosis. The use of specialized supports and mattresses is vital to redistribute pressure away from these sensitive areas.

Neuropathies and Peripheral Nerve Injuries

The compression and stretching of peripheral nerves can lead to significant and sometimes permanent damage. Some of the most commonly affected nerves and plexuses include:

Brachial Plexus: This network of nerves in the shoulder can be stretched or compressed if the arms are improperly positioned, particularly with excessive abduction or external rotation.
Ulnar Nerve: Pressure on the elbow region, for example from an inadequately padded armrest, can cause ulnar nerve palsy.
Lateral Femoral Cutaneous Nerve: Compression from improperly placed pelvic supports can result in meralgia paresthetica, causing pain and numbness in the thigh. Proper positioning and vigilant monitoring are critical to prevent these injuries.

Ocular Injuries and Visual Loss

One of the most devastating, though rare, complications is postoperative visual loss (POVL). The prone position increases intraocular and venous pressure in the head, while surgical hypotension can reduce ocular perfusion pressure. The resulting ischemia can damage the optic nerve, leading to conditions such as ischemic optic neuropathy (ION) or central retinal artery occlusion (CRAO). Direct pressure on the eyes can also cause corneal abrasions. Measures like using special head supports that avoid direct eye pressure and vigilant hemodynamic management are crucial preventative steps.

Cardiovascular and Hemodynamic Risks

Placing a patient prone can induce significant cardiovascular changes due to increased intrathoracic and intra-abdominal pressure. Abdominal compression can impede venous return via the inferior vena cava, leading to decreased cardiac output and hypotension. While the hemodynamic response can be variable, some patients, particularly those who are obese or have pre-existing cardiovascular conditions, are at higher risk for instability. Advanced monitoring and fluid management are often necessary.

Airway Complications and Edema

For intubated patients, airway management becomes challenging in the prone position. Risks include:

Accidental extubation or tube displacement
Airway obstruction due to kinking of the endotracheal tube
Significant facial, tongue, and oropharyngeal edema due to impeded venous and lymphatic drainage This edema can lead to breathing difficulties and complicate extubation after the procedure. Careful head and neck alignment and regular monitoring are essential.

Compartment Syndrome

Prolonged pressure on extremities can reduce blood flow to muscle compartments, leading to tissue ischemia. This can progress to compartment syndrome, a serious condition involving swelling and nerve damage. It is particularly a risk for longer procedures and in certain patients, such as those with obesity. Ensuring limbs are positioned properly with adequate padding can help prevent this.

A Comparison of Prone Position Risks


Complication Type	Primary Cause(s)	Key Mitigation Strategies
Pressure Injuries	Prolonged pressure on bony prominences; shear forces during repositioning	Specialized mattresses, gel pads, prophylactic dressings; regular repositioning and skin checks
Nerve Damage	Compression or stretching of nerves (e.g., brachial plexus, ulnar nerve)	Correct arm and neck positioning; ample padding; careful patient movement
Ocular Injuries	Increased intraocular pressure from venous congestion; direct pressure on eyes	Neutral head positioning, avoiding direct eye contact pressure; specialized headrests
Cardiovascular Risks	Increased intra-abdominal pressure impeding venous return; hypovolemia	Using supports to allow a free abdomen; meticulous fluid and hemodynamic management
Airway Complications	Tube displacement, kinking, and facial/airway edema	Secure tube fixation; controlled, experienced team turning the patient; monitoring for swelling
Compartment Syndrome	Reduced perfusion to limbs due to pressure, duration of procedure	Proper limb positioning with adequate padding; limiting procedure length where possible

Conclusion

The prone position is a valuable medical tool for improving oxygenation in critically ill patients and facilitating certain surgical procedures. However, the potential for serious complications, including pressure ulcers, nerve damage, ocular injuries, and hemodynamic instability, necessitates a highly coordinated and meticulous approach. Through careful preoperative assessment, using specialized positioning equipment, and vigilant intraoperative and post-operative monitoring, healthcare professionals can significantly reduce the associated risks. The benefits of the prone position, particularly for severe ARDS, generally outweigh these risks when comprehensive safety protocols are followed, ensuring the best possible outcome for the patient.

Visit the NIH website for more detailed information on prone positioning complications during surgery.

Frequently Asked Questions

The primary risk of the prone position in intensive care is the development of pressure injuries, or ulcers, on the patient's face, chest, and other bony prominences due to prolonged pressure.

Yes, nerve damage is a known complication. Prolonged compression or stretching, particularly of the brachial plexus and ulnar nerves, can lead to temporary or permanent neuropathy.

Ocular complications include increased intraocular pressure, corneal abrasions, and ischemic optic neuropathy, which can potentially lead to permanent vision loss if not managed properly.

The prone position can increase intra-abdominal pressure, which compresses blood vessels and decreases venous return to the heart. This can lead to decreased cardiac output and hypotension.

Yes, facial and airway edema are common, particularly with longer duration proning. This occurs due to increased venous and hydrostatic pressure in the head, causing fluid accumulation.

Airway risks include accidental extubation, kinking of the endotracheal tube, or obstruction from facial and tongue swelling, which can make extubation difficult.

Preventative measures include using specialized pressure-relieving supports, meticulous patient positioning, frequent skin checks, and vigilant monitoring of vital signs and neurological status.