Performing CPR on Prone Position Patients

With nurses of all backgrounds potentially being required to work in critical care environments due to the COVID-19 pandemic, you may encounter patients who are being nursed in a prone position. As well as understanding how to care for a patient in prone position, you should also know how to perform CPR on them in the event of deterioration.

Patients experiencing respiratory distress may be manoeuvered into the prone position for the delivery of ventilation if other methods have proven unsuccessful (Malhotra & Kacmarek 2019). The prone position may also be used for patients undergoing spinal surgery or neurosurgery (Kaur et al. 2016).

These patients may begin to deteriorate or experience cardiac arrest, requiring immediate cardiopulmonary resuscitation (CPR) (Nanjangud & Nileshwar 2017). In some circumstances, though it is not ideal, CPR may need to be performed while the patient is still in a prone position.

When is Prone CPR Performed?

Prone CPR is uncommon and unusual, as it is not a preferable position for resuscitation. A face-down patient impedes access to the airway and veins, posing a significant challenge to those performing the resuscitation (Bhatnagar et al. 2018; Nanjangud & Nileshwar 2017).

However, even though the supine position is considered optimal for CPR, and supine CPR is easier, it is not always feasible to manoeuvre a patient from prone to supine before commencing resuscitation (Kaur et al. 2016; Nanjangud & Nileshwar 2017):

• The process of turning a critically ill patient supine (which may take five to six minutes) delays the commencement of compressions and means losing precious time;
• Recruiting the necessary number of staff needed to perform a safe manoeuver (approximately four to six) may also delay the commencement of compressions;
• Attempting to turn a critically ill patient may result in loss of airway or disconnection of invasive lines;
• The patient may have ongoing bleeding or an unstable spine (in the event of surgery);
• Maneuvering a patient during spinal surgery or neurosurgery may cause neural damage; and
• The manoeuvre may cause injury to the patient or staff.

(Nanjangud & Nileshwar 2017; Intensive Care Society 2019; Saracoglu & Saracoglu 2018)

The American Heart Association (2010) consider it ‘reasonable’ to provide CPR to a patient in the prone position (particularly if they have an advanced airway in place) if they cannot be placed into the supine position. However, this advice has not been reviewed since 2010 (Ah Harbi et al. 2020).

Furthermore, in the event of arrest during neurosurgery, the Resuscitation Council (2014) advises that chest compressions and/or defibrillation should be commenced immediately, without changing the patient’s position.

For these reasons, CPR may need to be performed on a patient in the prone position in some circumstances, or at least until they can be manoeuvered into the supine position (Nanjangud & Nileshwar 2017).

Is Prone CPR Successful?

Despite the infrequency of prone CPR, there have been a handful of successful resuscitations detailed in case reports (Bhatnagar et al. 2018).

In all of these cases, the patient was being mechanically ventilated and invasively monitored with an advanced airway already secured prior to deterioration. Successful cases demonstrated compressions being performed on the thoracic spine with the same rate and force as compressions that would be delivered in the supine position (Bhatnagar et al. 2018).

It has been concluded that if resuscitation is commenced immediately, and the cause of arrest is simultaneously addressed, CPR in the prone position can generate a sufficient cardiac output (Kaur 2016).

How to Perform Prone CPR

In order to perform any CPR, you must have basic or advanced life support training and knowledge on how to manage a deteriorating patient.

1. Ensure the patient is safely positioned on the bed and all therapies are optimised as per the medical team.
2. Ensure the endotracheal tube is secure.
3. Compressions should be delivered on the thoracic spine at the same rate and force as in the supine position.
   • Both hands should be interlocked and placed on the patient’s back on the midthoracic spine T7 landmark.
   • Provide sternal counter pressure such as sandbags or 1-litre fluid bags under the patient’s chest.
   • Chest compressions should be carried out at a rate of 100-120 compressions per minute.
4. Refer to advanced and basic life support as per the hospital guidelines.
5. Ensure CPR mode on the bed is activated.
6. Ensure rotation amongst peers when performing CPR, as it is physically demanding.

(Al Harbi 2020; Intensive Care Society 2019; Saracoglu & Saracoglu 2018; Bhatnagar et al. 2018; Feix & Sturgess 2014)

Possible Complications

Complications from poor positioning may lead to an increase in mortality or morbidity rates. Other complications may include:

• Pressure injuries;
• Injuries to the eye from direct pressure; and
• Accidental displacement of intubation. Air viva must be available to assist with this complication.

(Feix & Sturgess 2014)

Conclusion

Despite being a relatively uncommon procedure, prone CPR has been proven successful if the situation is attended to immediately.

If a patient goes into cardiac arrest while in a prone position, and a manoeuvre is not feasible, it is best to begin CPR immediately and reposition the patient later if required. Ensure you apply sternal counter pressure to the patient.

Note: This article is intended as supplementary learning and should not replace best-practice care. Always ensure your advanced and basic life support training is up to date and that you refer to your organisation’s policy on performing CPR.

Additional Resources

• Caring for a Patient in Prone Position, https://www.ausmed.com.au/cpd/articles/prone-position
• Intensive Care Society, Guidance For: Prone Positioning in Adult Critical Care, https://static1.squarespace.com/static/5e6613a1dc75b87df82b78e1/t/5e72187c06c2956228316545/1584535679039/FICM-ICS-Prone-Position-Adult-Full.pdf
• Resuscitation Council, Management of Cardiac Arrest During Neurosurgery in Adults, https://www.resus.org.uk/publications/management-of-cardiac-arrest-during-neurosurgery-in-adults/

References

• Al Harbi, M K, Alattas, K A, Alnajar, M & Albuthi, M F 2020, ‘Prone Cardiopulmonary Resuscitation in Elderly Undergoing Posterior Spinal Fusion with Laminectomy’, Saudi J Anaesth, vol. 14 no. 1, viewed 21 April 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970382/
• Bhatnagar, V, Jinjil, K, Dwivedi, D, Verma, R & Tandon, U 2018, ‘Cardiopulmonary Resuscitation: Unusual Techniques for Unusual Situations’, J Emerg Trauma Shock, vol. 11 no. 1, viewed 21 April 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5852913/
• Feix, B & Sturgess J 2014, ‘Anaesthesia in the Prone Position’, Continuing Education in Anaesthesia Critical Care & Pain, vol. 14 no. 6, viewed 21 April 2020, https://academic.oup.com/bjaed/article/14/6/291/247907
• Intensive Care Society 2019, Guidance For: Prone Positioning in Adult Critical Care, Intensive Care Society, viewed 21 April 2020, https://static1.squarespace.com/static/5e6613a1dc75b87df82b78e1/t/5e72187c06c2956228316545/1584535679039/FICM-ICS-Prone-Position-Adult-Full.pdf
• Kaur, J, Kane, D, Shinde, S & Dongre, V 2016, ‘Abstract PR030: Cardiac Arrest in Prone Position; When Do I Make Patient Supine?’, Anesthesia & Analgesia, vol. 123 no. 3S, viewed 21 April 2020, https://journals.lww.com/anesthesia-analgesia/FullText/2016/09002/Abstract_PR030__Cardiac_Arrest_in_Prone_Position_.33.aspx
• Malhotra, A & Kacmarek, R 2019, Prone ‘Ventilation for Adult Patients with Acute Respiratory Distress Syndrome’, UpToDate, viewed 21 April 2020, https://www.uptodate.com/contents/prone-ventilation-for-adult-patients-with-acute-respiratory-distress-syndrome#H16
• Nanjangud, P & Nileshwar, A 2017, ‘Cardiopulmonary Resuscitation in Adult Patients in Prone Position’, Indian Journal of Respiratory Care, viewed 21 April 2020, http://www.ijrconline.org/article.asp?issn=2277-9019;year=2017;volume=6;issue=2;spage=791;epage=792;aulast=Nanjangud
• Resuscitation Council 2014, Management of Cardiac Arrest During Neurosurgery in Adults, Resuscitation Council, viewed 21 April 2020, https://www.resus.org.uk/publications/management-of-cardiac-arrest-during-neurosurgery-in-adults/
• Saracoglu, A & Saracoglu, K T 2018, Cardiopulmonary Resuscitation in Prone Position During Surgical Interventions, American University of Beirut, viewed 21 April 2020, https://www.aub.edu.lb/fm/Anesthesiology/meja/Documents/Cardiopulmonary%20Resuscitation%20In%20Prone%20Position%20During%20Surgical%20Interventions.pdf#search=cpr