Cardiopulmonary Resuscitation in the Prone Position in the Operating Room or in the Intensive Care Unit: A Systematic Review

The authors conducted a systematic literature review for evidence regarding prone positioning during cardiopulmonary resuscitation (CPR).  Three observational or experimental studies determined that systolic blood pressure generated in the prone position was over 20 mmHg higher than supine, tidal volumes were within the recommended range of 6 mL/kg, and a majority of compressions met standard criteria.  An additional CT study led to the recommendation for hand positioning at the T7-T9 level in the midline, where the anatomy of the left ventricle is widest.  Fourteen case reviews revealed that return of spontaneous circulation was achieved in all cases after a median of 5 minutes, without repositioning the patient.  Recommended placement of defibrillator pads are illustrated as bilaterally under the axilla or alternatively, one midline under the left axilla and another above the right scapula.  This evidence suggests that prone CPR may generate superior blood flow due the relative stiffness of the costovertebral joint which allows greater exertional force, displacement of the diaphragm and abdominal viscera, but may be more strenuous for the rescuer. It should be noted that all patients in the case reports experienced a witnessed arrest with a secured airway, and CPR was initiated rapidly. While acknowledging that publication bias is likely, the authors conclude it is reasonable to perform CPR in the prone position for several minutes before repositioning. Given the recent increase in prone positioning due to COVID, this report is a timely review that is of great interest to OR and ICU providers.