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 CO
2
, and arterial pressure tracing, with patients turned supine if insufficient.
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 CO
2
, and arterial pressure tracing, with patients turned supine if insufficient.
“…Cardiovascular collapse during neurosurgical operations is not uncommon, especially in patients with large, vascular tumors, where blood loss can be torrential. 6,7 This is especially true in children undergoing neurosurgery, where profuse blood loss can cause life-threatening hemodynamic instability. Many of these operations are performed in the sitting, lateral, and prone positions, hindering conventional resuscitation and further compounding the dangers associated with cardiovascular instability.…”
INTRAOPERATIVE cardiac arrest during neurosurgical operations can occur after massive blood loss in adults and in children. 1,2,3,4 Many of these procedures are performed in positions other than supine, and this could pose a major hurdle in successful resuscitation. 3 The practice of turning the patient supine for cardiopulmonary resuscitation (CPR) during neurosurgical operations has recently been questioned. 5 Although successful resuscitation has been reported in the prone position, there are no studies available on the feasibility of CPR in the lateral position. This is a case report of cardiac arrest due to massive blood loss in a child undergoing excision of a large brain tumor in the lateral position followed by successful resuscitation in the same position.
Case ReportA 6-yr-old boy (height, 103 cm; weight, 18 kg) with clinical features of severe intracranial hypertension on ventilatory support was referred to this hospital for definitive management. Magnetic resonance imaging revealed a large and vascular right intraventricular tumor. The child suffered a cardiac arrest in the intensive care unit the day before surgery. He was successfully resuscitated and scheduled for emergency craniotomy under American Society of Anesthesiologists grade IV. On the day of surgery, his pulse rate was 130 beats per minute, blood pressure was 130/80 mmHG, and he was on pressure support ventilation. He had normal-sized pupils that were reacting to light and normal flexor motor response and spontaneous respiratory efforts. The child was placed in the left lateral decubitus position with the head resting on a doughnut for surgery. Intraoperative monitoring included intraarterial blood pressure and central venous pressure. During surgical decompression of the tumor, there was sudden and rapid blood loss associated with bradycardia (50 -60 beats per minute) and severe hypotension and hypovolemia (systolic blood pressure, 30 -40 mmHG; central venous pressure, -5 mmHG) followed by pulseless electrical activity. External cardiac massage was commenced in the lateral position itself using the two thumb-encircling hand technique to avoid any delay in resuscitation. This technique of CPR produced a pulsatile arterial trace and systolic pressures of approximately 50 -60 mmHG, Epinephrine boluses along with rapid transfusion of blood products and inotrope infusions (dopamine and adrenaline) were administered.Life-sustaining rhythm and blood pressure (70 -80 mmHG) were obtained within 3 min. One hour later, during hemostasis, the child had another episode of severe hypotension for which similar resuscitative measures were taken. After both episodes of successful resuscitation, the surgeon could proceed with tumor decompression and hemostasis. The surgery lasted 4 h and the blood loss was 1 l, which was replaced. At the end of surgery, he was shifted to the intensive care unit in a stable hemodynamic condition. Inotropic support was tapered off by the third postoperative day, and he was weaned off the ventilator on the eighth postoperati...
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