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Prone cardiopulmonary resuscitation: A scoping and expanded grey literature review for the COVID-19 pandemic

      Abstract

      Aim

      To identify and summarize the available science on prone resuscitation. To determine the value of undertaking a systematic review on this topic; and to identify knowledge gaps to aid future research, education and guidelines.

      Methods

      This review was guided by specific methodological framework and reporting items (PRISMA-ScR). We included studies, cases and grey literature regarding prone position and CPR/cardiac arrest. The databases searched were MEDLINE, Embase, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Scopus and Google Scholar. Expanded grey literature searching included internet search engine, targeted websites and social media.

      Results

      Of 453 identified studies, 24 (5%) studies met our inclusion criteria. There were four prone resuscitation-relevant studies examining: blood and tidal volumes generated by prone compressions; prone compression quality metrics on a manikin; and chest computed tomography scans for compression landmarking. Twenty case reports/series described the resuscitation of 25 prone patients. Prone compression quality was assessed by invasive blood pressure monitoring, exhaled carbon dioxide and pulse palpation. Recommended compression location was zero-to-two vertebral segments below the scapulae. Twenty of 25 cases (80%) survived prone resuscitation, although few cases reported long term outcome (neurological status at hospital discharge). Seven cases described full neurological recovery.

      Conclusion

      This scoping review did not identify sufficient evidence to justify a systematic review or modified resuscitation guidelines. It remains reasonable to initiate resuscitation in the prone position if turning the patient supine would lead to delays or risk to providers or patients. Prone resuscitation quality can be judged using end-tidal CO2, and arterial pressure tracing, with patients turned supine if insufficient.

      Keywords

      Introduction

      For patients to have the best chance of surviving sudden cardiac arrest, high quality chest compressions and defibrillation need to be initiated without delay.
      • Zhan L.
      • Yang L.J.
      • Huang Y.
      • He Q.
      • Liu G.J.
      Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest.
      Traditionally, cardiopulmonary resuscitation (CPR) is taught and performed in the supine position, but even short delays- such as would occur if proned patients are first turned to the supine position — can be clinically detrimental.
      • Bamford P.
      • Denmade C.
      • Newmarch C.
      • et al.
      Guidance for: prone positioning in adult critical Care.
      The question of whether to supine patients before initiating resuscitation has long been relevant for out-of-hospital arrest patients found face down, and for intraoperative arrests during prone surgeries i.e. spine surgery, neurosurgery, retroperitoneal surgery. More recently, there has been an increase in prone mechanical ventilation in Intensive Care Unit (ICU) patients, since the 2013 Prone Positioning in Severe Acute Respiratory Distress Syndrome trial.
      • Parker A.M.
      • Guerin C.
      • PROSEVA Study Group
      • et al.
      Prone positioning in severe acute respiratory distress syndrome.
      Since the COVID-19 pandemic, however, the issue of prone resuscitation has become especially important.
      • Barker J.
      • Koeckerling D.
      • West R.
      A need for prone position CPR guidance for intubated and non-intubated patients during the COVID-19 pandemic.
      This is because, while we await robust evidence, prone positioning has been recommended in both confirmed and suspected cases, and in severely-ill/sedated patients and less ill/awake patients.

      J. Farkas, PulmCrit - Awake Proning for COVID-19. EMCrit Project, 5 May 2020, https://emcrit.org/pulmcrit/awake-prone-covid/

      • Caputo N.D.
      • Strayer R.J.
      • Levitan R.
      Early self‐proning in awake, non‐intubated patients in the emergency department: a single ED’s experience during the COVID-19 pandemic.
      • Valter C.
      • Christensen A.M.
      • Tollund C.
      • SchOnemann N.K.
      Response to the prone position in spontaneously breathing patients with hypoxemic respiratory failure.
      • Pérez-Nieto O.R.
      • Guerrero-Gutiérrez M.A.
      • Deloya-Tomas E.
      • Ñamendys-Silva S.A.
      Prone positioning combined with high-flow nasal cannula in severe noninfectious ARDS.
      • Scaravilli V.
      • Grasselli G.
      • Castagna L.
      • et al.
      Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study.
      ‘Flipping’ a patient from prone to supine, especially during an emergency, comes with potential risks to both patient and staff.
      • The Faculty of Intensive Care Medicine
      • The Intensive Care Society
      Guidance for: prone positioning in adult critical care.
      Other than time delay, there could be endotracheal tube dislodgement, disconnection of vascular lines, disconnection of ventilation tubing, and staff contamination. There is also the mechanical challenge of turning obese patients, and potential injury to staff and patients. Especially relevant during pandemics, rolling a patient means that extra people (often six in total) enter a potentially contaminated space. There means extra delays until all of these staff have appropriately donned protective equipment, and the cumulative risks associated with doffing.
      While almost all practitioners will supine patients before attempting an advanced airway, there is an initial period where compressions and defibrillation are performed before airway capture or supplementary breaths. Moreover, resuscitation guidelines have acknowledged that there are incidences where initiation of non-supine resuscitation is appropriate.
      • Cave D.M.
      • Gazmuri R.J.
      • Otto C.W.
      • et al.
      Part 7: CPR techniques and devices: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
      To date, most frontline clinicians have limited knowledge of the literature surrounding prone resuscitation. This is noteworthy now that proning is increasing. The goal of this scoping review is to assist clinicians forced to decide, in the midst of an emergency, whether CPR should be initiated with the patient ‘proned’, or whether the risks and delays of ‘supine-ing’ are unavoidable. More specifically, our objectives are: (i) to examine the extent of research into prone resuscitation, (ii) determine the value of undertaking a full systematic review, (iii) summarize and disseminate research related to prone resuscitation, (iv) and identify strategic gaps in the literature to aid future research, education and guidelines. Scoping review methods were selected (instead of systematic review) to identify available evidence types, clarify concepts, identify and analyse knowledge gaps. Furthermore a scoping review can determine if adequate research exists to undertake and systematic review, meta-analysis and risk of bias assessments that can inform guidelines and decision making.

      Methods

      This scoping review followed the methodological framework of Arksey and O’Malley and the enhancements of Levac et al.
      • Arksey H.
      • O’Malley L.
      Scoping studies: towards a methodological framework.
      • Levac D.
      • Colquhoun H.
      • O’Brien K.K.
      Scoping studies: advancing the methodology.
      It incorporated six steps: (i) research question identification, (ii) relevant study identification, (iii) selection of studies, (iv) charting the data, (v) collate, summarize and report results, and (vi) contributor provided references. Furthermore, this review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR).
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • et al.
      PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
      Our findings are presented in tabular format, accompanied by narrative summaries.

      Search strategy and inclusion criteria

      The search strategy aimed to locate published and unpublished primary studies, reviews and grey literature such as policy, procedure and social media. We constructed a minimally-restrictive review question following the “PICO” format: for (p) patients (or manikins or cadavers) in the prone position in at the time of cardiac arrest (real or simulated), (i) who receive cardiopulmonary resuscitation, (c) no comparison criteria, and (o) any outcome. Full strategy is available in Appendix 1 (Supplementary material). Studies were eligible if they were peer-reviewed and examined or reported any characteristic or outcome of interest to prone CPR. Both qualitative and quantitative studies were eligible for inclusion. Studies using animal models of prone CPR were excluded.

      Data sources

      A systematic literature search was conducted by a health sciences librarian (MCT) using the following bibliographic databases: Ovid Medline ALL, Ovid Embase, EBSCOHost CINAHL Plus With full Text, Wiley Cochrane Central Register of Controlled Trials, Wiley Cochrane Database of Systematic Reviews, and Scopus. The search included a combination of controlled vocabulary (e.g., MeSH) and keywords representing the concepts of prone positioning and CPR/compressions. There were no limits on language, date, or study design. The MEDLINE search strategy was developed by the librarian and principal investigator (MJD), then translated for each database, and conducted on April 25, 2020. We also hand-searched bibliographies from previous systematic reviews for eligible studies. Multiple structured searches of Google Scholar were also performed and experts reviewed our search strategy and helped identify any missing articles.
      Grey literature, such as regulatory data, unpublished trial data, government publications, policy and procedure, was searched in addition to the published peer reviewed literature to ensure the retrieval of all relevant evidence that may not indexed in traditional bibliographic databases. Our systematic grey literature search strategy was designed by author MD and followed previously accepted, peer-reviewed, methods.
      • Godin K.M.
      • Kirkpatrick S.I.
      • Hanning R.M.
      • Stapleton J.
      • Leatherdale S.T.
      Examining guidelines for school-based breakfast programs in Canada: a systematic review of the grey literature.
      It consisted of four parts: (i) internet search engine (Chrome anonymous browser for de-personalized Google search without geographical bias) (EM), (ii) targeted website searching of emergency department, critical care and resuscitation organizations (TC), (iii) grey literature database searching (KS & EM), and (iv) social media platform searching, including blogs (DOD). Grey literature sources were identified using accepted resources.
      • The Canadian Agancy for Grugs and Technologies in Health (CADTH)
      Grey matters: a practical tool for searching health-related grey literature [Internet].
      The purpose of our grey literature search was: (i) to identify relevant cases of prone resuscitation and inquire as to their publication and (ii) gain insight from relevant policy, procedure and clinical governance documents. Our grey literature search strategy is detailed in Appendix 2 (Supplementary material).

      Study selection

      References were imported to Covidence [Vertias Health Innovation, Melbourne, Australia] for deduplication, title, abstract, and full text screening. Authors DA, MJD, DOD and LM independently screened titles, abstracts and full text articles against the selection criteria. Disagreements were resolved by discussion and consensus.

      Data extraction and charting

      Data were extracted by a single author (EM) and ratified by co-authors (TC and CP). Data were extracted into a Google Spreadsheet [Google, Mountain View California, USA]. An a priori data extraction table used to describe the characteristics of each study including: the authors(s), year of publication, study design, country, population, intervention and comparator (if applicable), major finding and outcome(s) examined. Data extracted from case reports/series included author, year, age, sex, diagnosis, type of surgery, initial rhythm, CPR quality and outcome (MJD and PGB).

      Results

      The search process retrieved 327 references from bibliographic databases. Once duplicates were removed, 202 references remained. An additional 126 references were identified from other sources as per the methods described above. A further 59 duplicates were identified and removed, resulting in a total of 269 items for title and abstract screening. After applying the inclusion/exclusion criteria to titles/abstracts, 46 articles underwent full text screening. Subsequently, 22 more articles were excluded for the following reasons: the patient was returned to the supine position prior to initiating resuscitation (n = 6), cardiac arrest could not be confirmed (n = 6), no new data was presented (n = 4), data was from a pilot of a study already included (n = 2), no resuscitation was attempted (n = 2), or we were unable to obtain a full text article (n = 2). See PRISMA flow sheet (Fig. 1) for more details. Overall, of 453 identified studies, 24 (5%) studies met our inclusion criteria and underwent extraction and narrative summary.
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Burki A.M.
      • Mahboob S.
      • Fatima T.
      CPR in prone position during neurosurgery.
      • Chauhan V.
      • Tiwari A.
      • Rath G.P.
      • Banik S.
      Asystole during lumbar discectomy: a case report.
      • Cho S.-J.
      • Lee E.H.
      • Hwang J.-Y.
      • Park S.-J.
      • Hahn S.-H.
      • Kim J.-H.
      Percutaneous cardiopulmonary support for the management of recurrent cardiac arrest during scoliosis correction surgery in the prone position — a case report.
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      • Dooney N.
      Prone CPR for transient asystole during lumbosacral spinal surgery.
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      • Kaur J.
      • Kane D.
      • Shinde S.
      • Dongre V.
      Abstract PR030: cardiac arrest in prone position; when do I make patient supine?.
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      • Loewenthal A.
      • De Albuquerque A.M.
      • Lehmann-Meurice C.
      • Otteni J.C.
      Efficacité du massage cardiaque externe chez une patiente en décubitus ventral.
      • Mayorga-Buiza M.J.
      • Rivero-Garvia M.
      • Gomez-Gonzalez E.
      • Marquez-Rivas J.
      Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients.
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      • Taylor J.C.L.
      • Buchanan C.C.R.
      • Rumball M.J.
      Cardiac arrest during craniotomy in prone position.
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      • Mazer S.P.
      • Weisfeldt M.
      • Bai D.
      • et al.
      Reverse CPR: a pilot study of CPR in the prone position.
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.
      • Atkinson M.C.
      The efficacy of cardiopulmonary resuscitation in the prone position.
      • Kwon M.-J.
      • Kim E.-H.
      • Song I.-K.
      • Lee J.-H.
      • Kim E.-H.
      • Kim J.-T.
      Optimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan.
      Fig. 1
      Fig. 1Prone cardiopulmonary resuscitation PRISMA flow diagram.

      Study characteristics

      Four original research studies met inclusion criteria: (i) a feasibility study of blood pressure during supine versus prone compressions in six intensive care patients after prolonged cardiac arrest;
      • Mazer S.P.
      • Weisfeldt M.
      • Bai D.
      • et al.
      Reverse CPR: a pilot study of CPR in the prone position.
      (ii) a study of cadavers (n = 11) and healthy volunteers (n = 10) on blood pressures and tidal volumes generated by prone compressions;
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.
      (iii) a prone compression quality manikin study;
      • Atkinson M.C.
      The efficacy of cardiopulmonary resuscitation in the prone position.
      and (iv) a retrospective descriptive study of chest computed tomography scans of 100 patients to identify ideal prone compression hand position.
      • Kwon M.-J.
      • Kim E.-H.
      • Song I.-K.
      • Lee J.-H.
      • Kim E.-H.
      • Kim J.-T.
      Optimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan.
      Refer to Table 1 for summary table of included research.
      Table 1Details of included original studies.
      Author, yearDesign, countryPopulationIntervention/comparatorOutcomes
      Atkinson, 2000
      • Atkinson M.C.
      The efficacy of cardiopulmonary resuscitation in the prone position.
      Feasibility trial; Edinburgh, Scotland36 registered nursesNurses performed 100 compressions on a manikin with a gel-filled pad between sternum and standard examination couch. Landmark was midline ∼2/3 up the body of the manikin i.e. “between imaginary scapula”.3376 chest compressions: 1168 (34.6%) effective (4–5 cm compression), 1370 (40.6%) partially effective (2–4 cm), 838 (24.6%) ineffective (<2 cm depth). 22/36 (61%) nurses able to deliver effective compressions (mean of 53% compressions were effective). Wide variations in compression effectiveness.
      Kwon, 2017
      • Kwon M.-J.
      • Kim E.-H.
      • Song I.-K.
      • Lee J.-H.
      • Kim E.-H.
      • Kim J.-T.
      Optimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan.
      Retrospective descriptive study; Seoul, Republic of Korea100 proned patients (54 male; 46 female; mean age 63 ± 12 years).Single investigator, retrospective chest CT images of 100 prone patients: to identify the surface anatomical landmark, and approximate hand position during prone CPR.Largest LV cross-sectional area is 0–2 vertebral segments below inferior angle of the scapulae in 86% of proned patients.
      Mazer, 2003
      • Mazer S.P.
      • Weisfeldt M.
      • Bai D.
      • et al.
      Reverse CPR: a pilot study of CPR in the prone position.
      Pilot feasibility study, participants not blinded to blood pressure; New York, USA6 adult ICU patients enrolled over 1 year from CICU (n = 4) and MICU (n = 2); 4 male; 2 female.15 min of supine compressions then rolled for 15 min of prone compression (hands over the T7−10 vertebrae).SBP improved 48 mmHg–72 mmHg, MAP from 32 mmHg to 46 mmHg from supine to prone. No survivors and no ROSC.
      Wei, 2006
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.
      Part 1: cadavers. Part 2: healthy volunteers. TaiwanPart 1: 11 cadavers (mean body weight 65.4 ± 9.0 kg).Part 1: standard pre-cordial cardiac massage, then prone compressions.Part 1: Prone CPR resulted in SBP 79.4 ± 20.3 mmHg, and DBP 16.7 ± 10.3 mmHg. Supine CPR produced increase in SBP of 55.4 ± 20.3/13.0 ± 6.7 mmHg to (79 ± 20/17 ± 10) (P = 0.028).
      Part 2: 10 healthy volunteers (mean body weight 63.3 ± 14.7 kg)Part 2: respiratory assessment during prone compressions.Part 2: External back compression on volunteers generated a mean tidal volume of 399 ± 110 mL.
      Abbreviations: BP – blood pressure; CICU – cardiac intensive care unit; CPR – cardiopulmonary resuscitation; CT – computed tomography; DBP – diastolic blood pressure; ETCO2 – end tidal carbon dioxide; ETT – endotracheal tube; ICU – intensive care unit; IV – intravenous; LV – left ventricle; MAP – mean arterial pressure; MICU – medical intensive care unit; PEA – pulseless electrical activity; ROSC – return of spontaneous circulation; TTE – transthoracic echocardiography; SBP – systolic blood pressure; SVT – supraventricular tachycardia; VF – ventricular fibrillation.

      Case reports/series characteristics

      Twenty case reports/series describe 25 prone patients undergoing resuscitation including compressions.
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Burki A.M.
      • Mahboob S.
      • Fatima T.
      CPR in prone position during neurosurgery.
      • Chauhan V.
      • Tiwari A.
      • Rath G.P.
      • Banik S.
      Asystole during lumbar discectomy: a case report.
      • Cho S.-J.
      • Lee E.H.
      • Hwang J.-Y.
      • Park S.-J.
      • Hahn S.-H.
      • Kim J.-H.
      Percutaneous cardiopulmonary support for the management of recurrent cardiac arrest during scoliosis correction surgery in the prone position — a case report.
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      • Dooney N.
      Prone CPR for transient asystole during lumbosacral spinal surgery.
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      • Kaur J.
      • Kane D.
      • Shinde S.
      • Dongre V.
      Abstract PR030: cardiac arrest in prone position; when do I make patient supine?.
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      • Loewenthal A.
      • De Albuquerque A.M.
      • Lehmann-Meurice C.
      • Otteni J.C.
      Efficacité du massage cardiaque externe chez une patiente en décubitus ventral.
      • Mayorga-Buiza M.J.
      • Rivero-Garvia M.
      • Gomez-Gonzalez E.
      • Marquez-Rivas J.
      Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients.
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      • Taylor J.C.L.
      • Buchanan C.C.R.
      • Rumball M.J.
      Cardiac arrest during craniotomy in prone position.
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      All but five occurred in an operating theatre.
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      Over half involved pediatric patients (n = 14).
      • Burki A.M.
      • Mahboob S.
      • Fatima T.
      CPR in prone position during neurosurgery.
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      • Kaur J.
      • Kane D.
      • Shinde S.
      • Dongre V.
      Abstract PR030: cardiac arrest in prone position; when do I make patient supine?.
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      • Mayorga-Buiza M.J.
      • Rivero-Garvia M.
      • Gomez-Gonzalez E.
      • Marquez-Rivas J.
      Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      ,
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      The arrest precipitant was incompletely described, but, five patients had air emboli,
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      • Loewenthal A.
      • De Albuquerque A.M.
      • Lehmann-Meurice C.
      • Otteni J.C.
      Efficacité du massage cardiaque externe chez une patiente en décubitus ventral.
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      three had cardiac decompensation,
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      three had airway obstruction,
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      two had excessive parasympathetic stimulation
      • Kaur J.
      • Kane D.
      • Shinde S.
      • Dongre V.
      Abstract PR030: cardiac arrest in prone position; when do I make patient supine?.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      and one had cardiac tamponade.
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      The most common initial rhythm was pulseless electrical activity (n = 11, 44%),
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Burki A.M.
      • Mahboob S.
      • Fatima T.
      CPR in prone position during neurosurgery.
      • Chauhan V.
      • Tiwari A.
      • Rath G.P.
      • Banik S.
      Asystole during lumbar discectomy: a case report.
      • Cho S.-J.
      • Lee E.H.
      • Hwang J.-Y.
      • Park S.-J.
      • Hahn S.-H.
      • Kim J.-H.
      Percutaneous cardiopulmonary support for the management of recurrent cardiac arrest during scoliosis correction surgery in the prone position — a case report.
      • Dooney N.
      Prone CPR for transient asystole during lumbosacral spinal surgery.
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      followed by asystole (n = 4, 16%).
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      • Loewenthal A.
      • De Albuquerque A.M.
      • Lehmann-Meurice C.
      • Otteni J.C.
      Efficacité du massage cardiaque externe chez une patiente en décubitus ventral.
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      Refer to Table 2 for summary table of included cases.
      Table 2Characteristics of included case studies.
      Author, yearAgeSexDiagnosisType of surgeryRhythmConfirmation of CPR qualityCause of arrestOutcome (neurological ideally)
      Al Harbi, 2020
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.
      80MaleSpine surgeryPosterior spinal fusion with laminectomyPEA, asystoleETCO2 10 mmHg with prone CPR but no palpable pulse. When switched to supine, ETCO2 increased & had palpable CPR pulsesIntraoperative NSTEMI due to hypovolemiaSurvived
      Brock-Utne, 2011
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      28MalePelvic fracturesOpen reduction internal fixationPEASystolic pressures over 80 mmHg (from arterial wave form)Pulmonary embolusSurvived (discharged from hospital with intact neurologic status)
      Burki, 2017
      • Burki A.M.
      • Mahboob S.
      • Fatima T.
      CPR in prone position during neurosurgery.
      6FemaleVentricle tumor excisionPosterior cranial fossaPEANot discussedHemorrhagic shockROSC, died 5 days post-surgery
      Chauhan, 2016
      • Chauhan V.
      • Tiwari A.
      • Rath G.P.
      • Banik S.
      Asystole during lumbar discectomy: a case report.
      49MaleProlapsed intervertebral discLumbar discectomyPEA, asystoleNot discussedUnknownSurvived
      Cho, 2010
      • Cho S.-J.
      • Lee E.H.
      • Hwang J.-Y.
      • Park S.-J.
      • Hahn S.-H.
      • Kim J.-H.
      Percutaneous cardiopulmonary support for the management of recurrent cardiac arrest during scoliosis correction surgery in the prone position — a case report.
      18FemaleCongenital posterior scoliosisDeformity correction and fusion with instrumentationPEA, VFNot discussedUnknownSurvived
      Dequin, 1996
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      48MalePneumoniaProne ICU ventilationAsystoleArterial BP > 80/35 mmHg throughout CPRUnknownSurvived
      Dooney, 2010
      • Dooney N.
      Prone CPR for transient asystole during lumbosacral spinal surgery.
      43MaleLeft lower leg pain and weaknessL4–L5 microscopic discectomyBradycardic PEA to asystoleETCO2 = 28 mmHgUnknownSurvived
      Gueugniaud, 1995
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      15MaleMarfan’s syndromeCorrection of a right dorsal and left lumbar scoliosisPEA to asystole. Prone CPR to Supine CPR then ROSCNo palpable carotid pulse, ETCO2 < 10 mmHgUnknownSurvived, extubated after 18 h, full neurologic recovery
      Haffner, 2010
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      81MaleCerebellar hemorrhageCraniotomy with acute cerebellar hemorrhagePEAETCO2 33 mmHg with compressions. Visible arterial BP waveform correlated with CPRTTE confirmed intraoperative right cardiac decompensationVasopressors weaned day 2, recovered some neurologic function. Rearrested & died 1-month post discharge
      Kaloria, 2017
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      1FemaleSplit cord malformation type1 with tethered cordTethered cord release and bone spur removalBradycardic PEANot discussedMassive venous air embolusSurvived
      Kaur, 2016
      • Kaur J.
      • Kane D.
      • Shinde S.
      • Dongre V.
      Abstract PR030: cardiac arrest in prone position; when do I make patient supine?.
      14MaleKoch’s spineThoracic spine deformity correctionSevere bradycardia to asystoleNot discussedParasympathetic stimulationCPRx4 min then ROSC. Re-Arrested at 12 h and died
      Kelleher, 1995
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      6 monthsFemaleAchondroplasia, congenital cervical cord compressionForamen magnum decompressionMultifocal PVCs, bradycardia, asystole. 7 m prone CPR then ROSC. PEA after 10 min ROSC, prone CPR x4 min then ROSCInvasive BP with 40 mmHg waveform correlated to compressionsHemorrhage and venous air embolus in coronariesSurvived, ICU discharge day 7. Mild cognitive delay.
      Loewenthal, 1993
      • Loewenthal A.
      • De Albuquerque A.M.
      • Lehmann-Meurice C.
      • Otteni J.C.
      Efficacité du massage cardiaque externe chez une patiente en décubitus ventral.
      53FemaleMeningiomaCraniotomyAsystole, prone CPR x3 min then ROSCPalpable femoral pulse correlated to CPRVenous air embolusSurvived
      Mayorga-Buiza, 2018
      • Mayorga-Buiza M.J.
      • Rivero-Garvia M.
      • Gomez-Gonzalez E.
      • Marquez-Rivas J.
      Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients.
      10N/aPosterior fossa tumorPosterior fossa tumor excisionPulseless SVT to VF. CPR x8 min then ROSCNot discussedNot discussedSurvived
      Mishra, 2019
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      35FemaleC2–C3 intradural extramedullary meningiomaLaminectomy and tumor excisionRhythm not discussed. Prone CPR x1m, then flipped for supine CPR x2m then ROSCNot discussedCardiac tamponadeSurvived to discharge.
      Sun, 1992
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      14FemaleOpen occipital fracture with left intracerebellar hematomaPosterior fossa craniectomyBradycardia, PEA, idioventricularArterial line systolic pressure throughout: 100–160 mmHg.Torn transverse sinus, blood loss, brain retraction progressing to severe bradycardia and hypotensionSurvived, uneventful recovery
      Sun, 1992
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      34MaleCompression fracture of third cervical vertebrae, incomplete severance of cervical spinal cordDecompression laminectomyPEA, VFArterial systolic pressure throughout: 120–200 mmHgEndotracheal tube occlusionSurvived, uneventful recovery
      Sutherland, 1997
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      8FemaleLimb girdle muscular dystrophy, progressive 55″ thoraco-lumbar scoliosisT1-sacrum posterior spinal fusion with sublaminar wiringAsystoleCPR produced central venous pressure waveform but no arterial waveformAir embolusDeceased
      Sutherland, 1997
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      12FemaleAthetoid cerebral palsy, 90″ progressive thoraco-lumbar scoliosisT2-sacrum posterior spinal fusion with sublaminar wiringAsystoleNot discussedAir embolusDeceased
      Taylor, 2013
      • Taylor J.C.L.
      • Buchanan C.C.R.
      • Rumball M.J.
      Cardiac arrest during craniotomy in prone position.
      69MaleMetastatic melanoma and hypertrophic cardiomyopathyposterior craniotomyVT, progressed into VFPulsatile pressure tracing visible on the arterial line, and an ETCO2 of 15 mmHg.UnknownSurvived, full neurologic recovery
      Tobias, 1994
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      12MaleSpastic quadriplegia, progressive scoliosis.Spinal fusionBradycardia, asystole, idioventricularCompressions pressures of 80−90 mm Hg from both arterial line and non-invasive BP cuff.>4 L blood loss: abrupt decrease in MAP to 40 mmHg.Survived, no change in neurologic status
      Woo-Ming 1966
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      2MaleWhooping coughn/aNo monitoringNot discussedAirway occlusionSurvived
      Woo-Ming 1966
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      3FemaleStridor due to laryngeal diphtheriaEmergency tracheostomyNo monitoringNot discussedLaryngeal diphtheriaSurvived, no deficits
      Woo-Ming 1966
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      3 monthMaleRespiratory tract infectionn/aNo monitoringNot discussedHypovolemia, airway occlusionSurvived
      Woo-Ming 1966
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      7 weeksMaleStaphylococcal pneumonian/aNo monitoringNot discussedUnknownSurvived
      Abbreviations: PEA – pulseless electrical activity; VF – ventricular fibrillation; SVT – supraventricular tachycardia; M – minute(s); ROSC – return of spontaneous circulation; TTE – transthoracic echocardiogram.

      Prone compression quality

      Compression quality was assessed by invasive blood pressure monitoring, exhaled carbon dioxide and pulse palpation. A 2003 single-center case series reports of patients in intensive care with prolonged cardiac prone CPR was associated with improvements in both systolic (23 ± 14 mmHg, p < 0.05) and mean arterial blood pressure (14 ± 11 mmHg, p < 0.05)
      • Mazer S.P.
      • Weisfeldt M.
      • Bai D.
      • et al.
      Reverse CPR: a pilot study of CPR in the prone position.
      In a fresh cadaver study, Wei et al. (2006) found similarly greater systolic and diastolic blood pressures (SDP, DBP) in the prone (79 ± 20 /17 ± 10 mmHg) versus supine (55 ± 20/13 ± 7 mmHg) position p = 0.028).
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.
      In five cases, prone compressions generated SBPs over 80 mmHg.
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      In one case, SBP did not rise above 40 mmHg in one case,
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      and in a cardiac arrest following air embolus, prone compressions produced a central venous but no arterial waveform.
      • Sutherland R.W.
      • Winter R.J.
      Two cases of fatal air embolism in children undergoing scoliosis surgery.
      During craniotomy for acute cerebellar hemorrhage in an octogenarian, an EtCO2 of 33 mmHg was achieved during prone compressions for an arrest linked to right-sided cardiac decompensation.
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      During a microscopic discectomy in a 43 year old, an EtCO2 level of 28 mmHg was achieved during prone compressions following cardiac arrest of unknown cause.
      • Dooney N.
      Prone CPR for transient asystole during lumbosacral spinal surgery.
      Two additional cases reported EtCO2 of 15 and <10,
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Taylor J.C.L.
      • Buchanan C.C.R.
      • Rumball M.J.
      Cardiac arrest during craniotomy in prone position.
      and AlHarbi reported lower EtCO2 in the prone position than supine.
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.

      Tidal volumes generated by prone compressions

      One study examined the effect of prone compressions on tidal volumes.
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.
      In healthy volunteers, external back compressions generated mean tidal volumes of 399 ± 110 mL in five male and five female volunteers.
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.

      Landmarking and hand position

      In order to ascertain the best position for prone compressions, one study retrospectively reviewed chest computed tomography (CT) to correlate the surface landmarks overlying the left ventricle.
      • Kwon M.-J.
      • Kim E.-H.
      • Song I.-K.
      • Lee J.-H.
      • Kim E.-H.
      • Kim J.-T.
      Optimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan.
      The largest left ventricle cross-section area was determined to be zero to two vertebral segments below the inferior angle of the scapula in at least 86% of patients in the prone position.
      • Kwon M.-J.
      • Kim E.-H.
      • Song I.-K.
      • Lee J.-H.
      • Kim E.-H.
      • Kim J.-T.
      Optimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan.

      Survival

      Twenty of the 25 cases (80%) were associated with post-resuscitation survival, although few cases included long term outcome.
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Chauhan V.
      • Tiwari A.
      • Rath G.P.
      • Banik S.
      Asystole during lumbar discectomy: a case report.
      • Cho S.-J.
      • Lee E.H.
      • Hwang J.-Y.
      • Park S.-J.
      • Hahn S.-H.
      • Kim J.-H.
      Percutaneous cardiopulmonary support for the management of recurrent cardiac arrest during scoliosis correction surgery in the prone position — a case report.
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      • Dooney N.
      Prone CPR for transient asystole during lumbosacral spinal surgery.
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      • Loewenthal A.
      • De Albuquerque A.M.
      • Lehmann-Meurice C.
      • Otteni J.C.
      Efficacité du massage cardiaque externe chez une patiente en décubitus ventral.
      • Mayorga-Buiza M.J.
      • Rivero-Garvia M.
      • Gomez-Gonzalez E.
      • Marquez-Rivas J.
      Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients.
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      • Taylor J.C.L.
      • Buchanan C.C.R.
      • Rumball M.J.
      Cardiac arrest during craniotomy in prone position.
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.
      The most commonly reported survival endpoint was alive at the end of surgery,
      • Al Harbi M.
      • Alattas K.
      • Alnajar M.
      • Albuthi M.
      Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy.
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Burki A.M.
      • Mahboob S.
      • Fatima T.
      CPR in prone position during neurosurgery.
      • Chauhan V.
      • Tiwari A.
      • Rath G.P.
      • Banik S.
      Asystole during lumbar discectomy: a case report.
      • Cho S.-J.
      • Lee E.H.
      • Hwang J.-Y.
      • Park S.-J.
      • Hahn S.-H.
      • Kim J.-H.
      Percutaneous cardiopulmonary support for the management of recurrent cardiac arrest during scoliosis correction surgery in the prone position — a case report.
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      • Dooney N.
      Prone CPR for transient asystole during lumbosacral spinal surgery.
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      • Kaloria N.
      • Bhagat H.
      • Singla N.
      Venous air embolism during removal of bony spur in a child of split cord malformation.
      • Kaur J.
      • Kane D.
      • Shinde S.
      • Dongre V.
      Abstract PR030: cardiac arrest in prone position; when do I make patient supine?.
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      • Mayorga-Buiza M.J.
      • Rivero-Garvia M.
      • Gomez-Gonzalez E.
      • Marquez-Rivas J.
      Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients.
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      • Taylor J.C.L.
      • Buchanan C.C.R.
      • Rumball M.J.
      Cardiac arrest during craniotomy in prone position.
      followed by survival to hospital discharge,
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Haffner E.
      • Sostarich A.M.
      • Fösel T.
      Erfolgreiche kardiopulmonale Reanimation in Bauchlage.
      • Kelleher A.
      • Mackersie A.
      Cardiac arrest and resuscitation of a 6-month old achondroplastic baby undergoing neurosurgery in the prone position.
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      and seven cases reported full neurological recovery.
      • Brock-Utne J.G.
      Case studies of near misses in clinical anesthesia.
      • Gueugniaud P.-Y.
      • Muchada R.
      • Bertin-Maghit M.
      • Griffith N.
      • Petit P.
      Non-invasive continuous haemodynamic andPetCO2 monitoring during peroperative cardiac arrest.
      • Mayorga-Buiza M.J.
      • Rivero-Garvia M.
      • Gomez-Gonzalez E.
      • Marquez-Rivas J.
      Cardiac pulmonary resuscitation in prone position. The best option for posterior fossa neurosurgical patients.
      • Mishra N.
      • Singh S.
      • Elayat A.
      • Kaushal A.
      Cardiac arrest in the prone position caused by central venous cannulation-induced cardiac tamponade.
      ,
      • Taylor J.C.L.
      • Buchanan C.C.R.
      • Rumball M.J.
      Cardiac arrest during craniotomy in prone position.
      • Tobias J.D.
      • Mencio G.A.
      • Atwood R.
      • Gurwitz G.S.
      Intraoperative cardiopulmonary resuscitation in the prone position.
      • Woo-Ming M.O.
      Cardiorespiratory resuscitation in the prone position in small children.

      Discussion

      Despite growing interest in prone positioning, most healthcare professionals are unfamiliar with prone CPR. Accordingly, any practice change would need widespread education and practice. This, in turn, should be justified by robust evidence. Our review highlights that there may be more supportive literature than many clinicians realize, but also many important gaps. The first recommendation for prone CPR was over three decades ago (1989),
      • McNeil E.L.
      Re-evaluation of cardiopulmonary resuscitation.
      meaning the concept is not new. What has changed is its importance: because more patients will be ‘proned’ due to COVID-19, and because this practice may continue henceforth. In short, an increase in proning could mean more cardiac arrests in the prone position.
      Presumably, the most pressing question is whether patients survive when resuscitated proned. After all, if universally unsuccessful then it should not be performed, or we need to accept/minimize the risks and delays associated with ‘supine-ing’ patients. The first concern is that the available guidance is predominantly from single cases or case series. Studies have also yet to widely encompass the sickest ICU patients. These ICU patients often have low post-arrest survival, because of multiorgan impairment and because the arrest commonly occurs despite aggressive preemption. This means that even before COVID-19, ICU practitioners faced uncertainty regarding whether to perform default CPR. They now have added risk to themselves, and responsibility to keep their teams safe. Overall, practitioners must currently extrapolate from the operating room experience. Brown et al. reviewed 22 case reports of prone cardiac arrests, 10 of whom survived to discharge,
      • Brown J.
      • Rogers J.
      • Soar J.
      Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review.
      and Mazer et al. and Wei et al. found prone compressions generated a higher systolic and mean arterial pressure during circulatory arrest in ICU patients compared to standard CPR.
      • Mazer S.P.
      • Weisfeldt M.
      • Bai D.
      • et al.
      Reverse CPR: a pilot study of CPR in the prone position.
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.
      Overall, when blood pressures were reported there appeared to be improvements in the prone position, (five of six patients in the Mazer et al. study and seven out of eight in the Wei et al. study).
      • Mazer S.P.
      • Weisfeldt M.
      • Bai D.
      • et al.
      Reverse CPR: a pilot study of CPR in the prone position.
      • Wei J.
      • Tung D.
      • Sue S.-H.
      • Wu S.-V.
      • Chuang Y.-C.
      • Chang C.-Y.
      Cardiopulmonary resuscitation in prone position: a simplified method for outpatients.
      The certainty of these findings however are very low due to the design and methodology of these small studies.
      In terms of guidelines, and despite the dearth of data, the UK Resuscitation Council does recommend starting chest compressions without changing the position for adult patients who arrest during neurosurgery.
      • Carroll C.
      • Davies R.
      • Gwinnutt C.
      • Kamaly-Asl I.
      • Soar J.
      Management of cardiac arrest during neurosurgery in adults.
      They added that the efficacy of CPR should be judged using the end-tidal CO2 monitor, and the arterial pressure waveform. Prudently, they advise that patients be turned quickly supine if feedback from these monitors is judged insufficient. The 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care are more circumspect but still recommended: ‘when patients cannot be placed in the supine position, it may be reasonable for rescuers to provide CPR in the prone position, particularly in hospitalized patients with an advanced airway’.
      • Cave D.M.
      • Gazmuri R.J.
      • Otto C.W.
      • et al.
      Part 7: CPR techniques and devices: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
      The next issue concerns optimum technique for prone chest compressions. The Resuscitation Council and American Heart Association make no specific recommendations. However, the first two cases of successful prone chest compressions (in neurosurgical patients) were published in 1992 by Sun et al., using what they called ‘reversed precordial compression’.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      In everyday language, this means compressing over the mid-thoracic spine plus a hand under the lower sternum: for counter-pressure.
      • Sun W.-Z.
      • Huang F.-Y.
      • Kung K.-L.
      • Fan S.-Z.
      • Chen T.-L.
      Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.
      Similarly, Dequin et al. reported successful prone CPR in an ICU patient, in which they used two-handed mid-thoracic compression and a second person for sternal counter-pressure.
      • Dequin P.-F.
      • Hazouard E.
      • Legras A.
      • Lanotte R.
      • Perrotin D.
      Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited.
      Gomes and Bersot reported successful prone CPR in a neurosurgical patient, using compression over the mid-thoracic level, but no sternal counter-pressure.
      • Gomes D. de S.
      • Bersot C.D.A.
      Cardiopulmonary resuscitation in the prone position.
      Kwon et al. reviewed 100 chest CTs to determine where to compress the largest left ventricular mass. Once again, it was mid-thoracic, below the inferior angle of the scapulae.
      • Kwon M.-J.
      • Kim E.-H.
      • Song I.-K.
      • Lee J.-H.
      • Kim E.-H.
      • Kim J.-T.
      Optimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan.
      In 2020, guidelines were expedited by the UK’s Faculty of Intensive Care Medicine and Intensive Care Society, spurred by the COVID-19 pandemic.
      • The Faculty of Intensive Care Medicine
      • The Intensive Care Society
      Guidance for: prone positioning in adult critical care.
      These organizations jointly recommend a two-handed technique over the mid-thoracic spine, and between the two scapulae. The use of a second person to apply counter-pressure is optional. Given the added logistics, the contamination risk, and the overall recommendation to limit resuscitator in the room, we would recommend against this additional step.
      Clearly, our scoping review has limitations which limit its generalizability. These include a general lack of studies, a focus on operating theatre patients and a preponderance of witnessed arrests. The evidence is mostly from cases, and is therefore of comparatively low quality and predates the 2015 resuscitation guidelines. We also had to rely upon Google Translate for one French, one German and one Korean case report. Regardless, rather than prone resuscitation being as an area of niche interest, we believe our modest scoping review has highlighted an area of increasingly clinical relevance and research priority.

      Conclusion

      This scoping review demonstrated that the majority of published literature on prone resuscitation are neurosurgical cases with positive outcomes. Although this scoping review has not identified sufficient evidence to prompt a systematic reviews or reconsideration of current guidelines, it pinpoints gaps in the research evidence related to prone resuscitation, namely a lack of moderate to high-level evidence and paucity of studies of out-of-hospital cardiac arrest. We hope this review can help inform the care of prone patients during the COVID-19 pandemic should they require resuscitation.

      Author statement

      Our writing team take responsibility for and approve the submitted manuscript. All authors meet ICMJE authorship criteria.

      Competing interests

      The authors have no conflicts of interest relevant to this article to disclose.

      Funding

      This scoping review was unfunded.

      Appendix A. Supplementary data

      The following is Supplementary data to this article:

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