Prone Position and .pdf
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Trabelsi, Analg Resusc: Curr Res 2013, S1
Analgesia & Resuscitation :
a SciTechnol journal
Prone Position and
Is it Rational?
Cardiac arrest is the outcome most feared by both anesthesiologists
and surgeons, especially within the context of an elective procedure.
Cardiac arrest in unusual positions, such as the prone position,
represents an additional challenge primarily because the knowledge
about the technique is not so release and the effectiveness of external
chest compressions over the back has not recognizes widely.
The current methods used are adapted from the technique of
cardiopulmonary resuscitation (CPR) in the supine position. There
are no specific guidelines on how to proceed in these circumstances.
The technique of cardiac massage by external chest compressions
(ECC) was developed for CPR in the supine position by Kouwernhoven
et al. in 1960 . Human studies on the effectiveness of resuscitation
in the prone position have significant ethical obstacles but some
studies suggest that CPR in the prone position is most advantageous,
generating higher blood pressures when compared to supine position
[2-4]. Several case reports have confirmed that the posterior thoracic
compressions are able to generate sufficient cardiac output.
The first case report of successful CPR in the prone position
was described by Sun et al. in 1992. The report consisted of two
neurosurgical cases of CPR after acute hypovolemia. Both cases were
resuscitated with the technique named by the author as “reverse
precordial compression maneuver” with one hand placed on the back
of the patient, in the mid-thoracic spine, and the other hand placed
on the lower third of the sternum serving as counter-pressure to the
compression of the back. According to the author, that second hand
can be replaced by rigid devices on the same site .
Several techniques have been described since: with or without
counter-pressure device; with compressions either directly over the
thoracic spine or adjacent to the thoracic spine on both sides if an
incision is present.
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 . Since then, few cases have
reported prone CPR in database Medline (2000-2010).
Dooney describes one case of sudden profound bradycardia and
transient asystole during lumbar microscopic discectomy, which
required initial CPR in the prone position . Haffner et al. reported
another case of CPR in the prone position during evacuation of
*Corresponding author: Walid Trabelsi, Department of Anesthesia and
Intensive Care Unit, Tunisian Military Hospital of Tunis, Tunisia, E-mail: walid_
Received: July 17, 2013 Accepted: July 20, 2013 Published: July 26, 2013
International Publisher of Science,
Technology and Medicine
cerebellar hematoma . In both cases, the resuscitation was initiated
in the prone position to decrease the no-flow-time. The return of
spontaneous circulation started before turning the patient to the
supine position. In some instances such as these reports, the cardiac
arrest may be transient and turning the patient may not be necessary
and resuscitation in the prone position was equally as effective as in
the traditional position.
Beltran et al. present two cases of cardiopulmonary arrest and
unsuccessful attempts at resuscitation after repositioning supine .
In these cases, the surgical site of bleeding became inaccessible after
repositioning, leading to the question of whether prone resuscitation
would have provided a better alternative.
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 .
Since 2005 the AHA Guidelines for CPR and ECC recommended
that CPR in the prone position may be reasonable when the patient
cannot be replaced in the supine position without prejudice,
particularly in hospitalized patients with an advanced airway in
place . In 2010, the AHA Guidelines for CPR and ECC has not
reviewed this issue . However, the new guidelines increased
focus on methods to ensure that high-quality CPR is performed by
setting targets for rate and depth of compressions as well as minimum
values obtained from the monitoring devices as capnography and
continuous arterial line. But there is no specific recommendation on
the frequency and depth of compressions to the patient in the prone
1. Kuowenhoven WB, Jude JR and Knickerbocker GG (1960) Closed Chest
Cardiac Massage. JAMA 173: 1064-1067.
2. Stewart JA (2002) Resuscitating an idea: prone CPR. Resuscitation 54: 231236.
3. Mazer SP, Weisfeldt M, Bai D, Cardinale C, Arora R, et al. (2003) Reverse
CPR: a pilot study of CPR in the prone position. Resuscitation 57: 279-285.
4. Wei J (2004) Cardiopulmonary resuscitation in prone position: a simplified
method for outpatients. Resuscitation 62: 120-121.
5. Sun WZ, Huang FY, Kung KL, Fan SZ, Chen TL (1992) Successful
cardiopulmonary resuscitation of two patients in the prone position using
reversed precordial compression. Anesthesiology 77: 202-204.
6. Brown J, Rogers J, Soar J (2001) Cardiac arrest during surgery and ventilation
in the prone position: a case report and systematic review. Resuscitation 50:
7. Dooney N (2010) Prone CPR for transient asystole during lumbosacral spinal
surgery. Anaesth Intensive Care 38: 212-213.
8. Haffner E, Sostarich AM, Fösel T (2010) [Successful cardiopulmonary
resuscitation in prone position]. Anaesthesist 59: 1099-1101.
9. Beltran SL, Mashour GA (2008) Unsuccessful cardiopulmonary resuscitation
All articles published in Analgesia & Resuscitation : Current Research are the property of SciTechnol, and is protected by
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Citation: Trabelsi W (2013) Prone Position and Cardiopulmonary Resuscitation: Is it Rational? Analg Resusc: Curr Res S1.
during neurosurgery: is the supine position always optimal? Anesthesiology
10. Miranda CC, Newton MC (2001) Successful defibrillation in the prone
position. Br J Anaesth 87: 937-938.
11. ECC Committee, Subcommittees and Task Forces of the American Heart
Association (2005) 2005 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation 112: IV1-203.
12. American Heart Association (2010) 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation 122: 721.
Department of Anesthesia and Intensive Care Unit, Tunisian Military Hospital
of Tunis, Tunisia
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