DR. YOGESH RATHODDEPARTMENT OF ANAESTHESIOLOGY,SETH GSMC & KEM HOSPITAL, PAREL,MUMBAI.

CPCR IN PRONE POSITION

Guidelines and changes of 2015 ACLS

When the patient cannot be placed in the supine position, it may be reasonable for rescuers to provide CPR with the patient in the prone position, particularly in hospitalized patients with an advanced airway in place (ClassIIb, LOE C).NOT REVIEWED IN 2015

EFFICACY OF CPCR IN PRONE POSITION

Efficient CPCR can be performed on a mannequin in the prone position, although additional instructions in technique is required. This may be applicable to patients turned to the prone position.(Critical Care & Resuscitation 2000;2:188-190)

CPCR IN PRONE POSITIONThe first case report of successful CPR

in the prone position was described by Sun et al. in 1992. Two neurosurgical cases of CPR after acute hypovolemia.

“REVERSE PRECORDIAL COMPRESSION MANEUVER”

One hand placed on the back of the patient, in the mid-thoracic spine & other hand placed on the lower third of the sternum serving as counter-pressure to the compression of the back

Brown et al. reported a systematic review of literature and found only 22 cases of CPR in the prone position published from 1966 to 1999, with survival of 10 patients [6]. Since then, few cases have reported prone CPR in database Medline (2000-2010)

CASE REPORTS

•Beltran et al. present two cases of cardiopulmonary arrest and unsuccessful attempts at resuscitation after repositioning supine.•The surgical site of bleeding became inaccessible after repositioning.•Prone resuscitation would have provided a better alternative.

CPCR IN PRONE POSITION

•Miranda et al. described a case in which electrical defibrillation was successfully performed in the prone position in a patient undergoing complex spinal surgery.

•They suggest that, if defibrillation were required in ventilated patients positioned prone, defibrillation should be attempted in the prone position, as turning the patient supine would consume valuable minutes and reduce the chances of successful defibrillation .

VT/VF cases

•No specific recommendation on the frequency and depth of compressions to the patient in the prone position.•The frequency maintained above 100 cpm and depth sufficient to produce good perfusion indicators but without generating instability between the thoracic and cervical spine, which was fixed by Manfield head-holder.

CPCR IN PRONE POSITION

American Heart Association, “2010 American Heart As-sociation Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” Circulation, Vol. 122, No. 18, 2010, p. 721.

“Is the Upside-down Position Better inCardiopulmonary Resuscitation?”Huey Wen Yien & WeiNational Yang Ming University of Medicine & Taipei VeteransGeneral Hospital, Taiwan.

(J China Med Assoc, May 2006, vol 69, No 5)P-CPR: 79 ± 20/ 17 ±10 mmHg. M.T.Volume: 300 ± 110 ml.S-CPR: 55 ± 20/ 13 ± 7 mmHg.

Conclusions: In some case reports of higher mean bloodpressure and intrathoracic pressure, prone CPR may beinitiated in a well controlled environment, such as the OR orICU, to avoid delay in onset of CPR. (Class I, Grade B)

Prone CPR is performed frequently in the operating room (OR) on patients

• Spine surgeries- deformity corrections• Neurosurgery• other surgical procedures on the back

In some situations in the intensive care unit (ICU)•Adult respiratory distress syndrome(ARDS)where all patients are intubated and ventilated PRONE under full-monitoring support.

CPCR IN PRONE POSITION

CPCR IN PRONE POSITION•The first pilot study that documented a higher blood pressure using prone CPR was published by Mazer et al in 2003.•The first systematic review of 16 articles, written by Brown et al in 2001, documented that there were a total of 22 intubated hospitalized patients who received CPR in the prone position, and 10 of them survived to discharge.•Although Stewart emphasized that prone CPR was superior to standard CPR, there is currently no evidence to prove a beneficial outcome.

When prone CPR was performed•sternal support with sandbags•gel-filled pads•500-mL bags of IV fluid was suggested.

Technique and Associated Devices in Prone CPR

•The thoracic pump model supported prone CPR more than the cardiac pump model.

•Increased intrathoracic pressure and systolic blood pressure in 6 cases resuscitated with rhythmic back pressure and sternal counterpressure in the prone position.

•A unique mechanism to support this effect is that less anterior displacement of the abdomen during thoracic compressions could enhance the efficiency of CPR effort

Mechanisms of Prone CPR

Hypothetical Benefits and Limitations of

Prone CPRClinical trials of CPR in hospitalized patients or out-of-hospital victims are challenging because interventions must frequently be implemented at a time when informed consent is almost impossible to obtain.

Stewart JA. Resuscitating an idea: prone CPR. Resuscitation 2002;53:231–6.

Current Evidences and Guidelines of 2005 ACLSThe 2005 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care (ECC)1 did not endorse the prone position as the standard CPR.

It is accepted only as a less-than optimal alternative to supine CPR in certain situations.

The recommendation is that “when the patient cannot be placed in the supine position, rescuers may consider providing CPR with the patient in the prone position, particularly in hospitalized patients with an advanced airway in place” (Level of evidence 5; Class IIb)

The leader of a resuscitation team should adapt the guidelines to specific circumstances.

Prone CPR may be initiated in a well controlled environment, such as the OR or ICU, to avoid delay in onset of CPR.As in bystander CPR for unconscious and unintubated persons, further evidence-based trials of prone CPR should be expected before becoming an alternative practice

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