cpcr 2015 aha/acc guidelines for prone position

1. DR. YOGESH RATHOD
DEPARTMENT OF ANAESTHESIOLOGY,
SETH GSMC & KEM HOSPITAL, PAREL,
MUMBAI.

2. 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

6. 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)

7.  The 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

9. 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)

10. •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.

11. •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 .

12. •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.
American Heart Association, “2010 American Heart As-sociation Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care,” Circulation, Vol. 122, No. 18, 2010, p. 721.

13. “Is the Upside-down Position Better in
Cardiopulmonary Resuscitation?”
Huey Wen Yien & Wei
National Yang Ming University of Medicine & Taipei Veterans
General 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 blood
pressure and intrathoracic pressure, prone CPR may be
initiated in a well controlled environment, such as the OR or
ICU, to avoid delay in onset of CPR. (Class I, Grade B)

14. 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.

15. •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.

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

17. •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

18. Hypothetical Benefits and
Limitations of Prone CPR
Clinical 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.

19. Current Evidences and Guidelines of
2005 ACLS
The 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.

20. 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

21. THANK
YOU