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

Emergency medicine updates: Cardiopulmonary resuscitation

INTRODUCTION

Cardiac arrest is the loss of functional cardiac activity; emergency clinicians are integral in the management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning cardiopulmonary resuscitation (CPR).

DISCUSSION

Cardiac arrest includes shockable rhythms (i.e., pulseless ventricular tachycardia and ventricular fibrillation) and non-shockable rhythms (i.e., asystole and pulseless electrical activity). The goal of cardiac arrest management is to achieve survival with a good neurologic outcome, in part by restoring systemic perfusion and obtaining return of spontaneous circulation (ROSC), while seeking to diagnose and treat the underlying etiology of the arrest. CPR includes high-quality chest compressions to optimize coronary and cerebral perfusion pressure. Chest compressions should be centered over the mid-sternum, with the compressor's body weight over the middle of the chest. A compression depth of 5-6 cm is recommended at a rate of 100-120 compressions per minute, while allowing the chest to fully recoil between each compression. Clinicians should seek to minimize any interruptions in compressions. When performed by bystanders, compression-only CPR may be associated with improved survival to hospital discharge when compared to conventional CPR with ventilations. However, in trained personnel, there is likely no difference with compression-only versus conventional CPR. Mechanical approaches for CPR are not associated with improved patient outcomes, including ROSC or survival with good neurologic function, but mechanical compression devices may be beneficial in select circumstances (e.g., few rescuers available, prolonged arrest/transport). Monitoring of chest compressions is not associated with improved ROSC, survival, or neurologic outcomes, but it can improve guideline adherence. Types of monitoring include real-time feedback, a CPR coach, end tidal CO2, arterial line monitoring, regional cerebral tissue oxygenation, and point-of-care ultrasound.

CONCLUSIONS

An understanding of CPR literature updates can improve the ED care of patients in cardiac arrest.

A Comparative Study of Time to Initiate Chest Compressions and Chest Compression Fraction in the Supine and Prone Positions Using Simulation

Repositioning a patient from the prone to supine position can delay the initiation of cardiopulmonary resuscitation (CPR). Investigators used high-fidelity simulation to assess the time to initiate chest compressions and the time during which compressions did not occur for supine and prone CPR. Sixty participants completed a knowledge assessment before and after attending an education session and completing two simulations (ie, supine, prone). Mean (SD) knowledge scores improved from 48.7% (17.4%) to 85.3% (14.7%) after the education and simulations (t59 = -12.32, P < .001). Prone CPR resulted in a significant reduction in the time to initiate chest compressions (13 seconds, prone; 314 seconds, supine; t11 = -31.79; P < .001) and a higher chest compression fraction (84% prone versus 42% supine; t11 = 19.1, P < .001). When compared to repositioning to supine, prone CPR decreased chest compression interruptions, and may therefore be beneficial during the perioperative period.

Evaluating Prone Cardiopulmonary Resuscitation Techniques in the Surgical Settings: A Systematic Review of Case Studies

PURPOSE

Examine the prone cardiopulmonary resuscitation techniques in patients undergoing surgery.

DESIGN

Systematic review.

METHODS

Using the preferred reporting items for systematic reviews and meta-analysis guidelines, PubMed, CINAHL, Cochrane Library, Google Scholar, and gray literature databases were searched to obtain eligible studies. The methodological quality of the case studies was assessed using the tool proposed by Murad and colleagues. Case reports involving surgical patients in a prone position were included.

FINDINGS

A total of 21 patients undergoing neurologic or spinal surgeries were evaluated. The most common cardiac rhythms observed before arrest were pulseless electrical activity, asystole, ventricular tachycardia, ventricular fibrillation, and sudden bradycardia. The etiologies of the cardiac arrests included venous air embolism, hemorrhagic shock, and hypovolemia. Posterior compressions at T7 to T9 vertebral segment, with or without counterpressure, were immediately instituted. Return of spontaneous circulation was achieved in each instance, with an average time to return of spontaneous circulation of 5.60 minutes. Using a quality assessment tool, we determined that all case reports were of high quality and exhibited a low risk of bias.

CONCLUSIONS

Prone resuscitation during neurosurgical or spinal surgeries has demonstrated promising outcomes. Additionally, the findings of this review further emphasize the need to train health care personnel in the techniques of prone cardiopulmonary resuscitation.

Exploration of cardiopulmonary resuscitation teamwork training for maternal cardiac arrest using the SimMan intelligent simulation platform: A simulation teaching study

Background and Aims

Maternal cardiac arrest is the most urgent clinical event in obstetrics and can lead to serious consequences, such as maternal or fetal death. Therefore, the training of team cardiopulmonary resuscitation (CPR) skills for obstetricians is essential. The aim of this study was to investigate the effect of applying intelligent simulation to CPR in maternal cardiac arrest teamwork training for obstetricians.

Methods

Twenty-four obstetricians who participated in the "Maternal First Aid Workshop," organized by our hospital in 2018, were selected as training participants. The SimMan intelligent comprehensive patient simulator was used to train the CPR team collaboration with first-aid skills. Each team participating in the training was assessed before and after the training using a questionnaire survey.

Results

The evaluation of the results after the training showed that all four teams were qualified and that the timing of the cesarean section was 100% correct. The mean score, team collaboration score, and chest compression fraction were significantly higher than before training. Teamwork CPR assessment time, interruption time of chest compressions, and artificial airway establishment time were significantly shorter than before training. The questionnaire survey showed that 95.8% of the physicians reported that the training was rewarding and helpful to their clinical work, and 100% of the physicians believed that obstetricians require similar training.

Conclusion

Using the SimMan intelligent comprehensive patient simulator to train obstetricians for CPR of maternal cardiac arrest teamwork first-aid skills can significantly improve the training effect, clinical first-aid skills, and teamwork awareness.

Cardiopulmonary Resuscitation: The Importance of the Basics

Cardiac arrest is the loss of organized cardiac activity. Unfortunately, survival to hospital discharge is poor, despite recent scientific advances. The goals of cardiopulmonary resuscitation (CPR) are to restore circulation and identify and correct an underlying etiology. High-quality compressions remain the foundation of CPR, optimizing coronary and cerebral perfusion pressure. High-quality compressions must be performed at the appropriate rate and depth. Interruptions in compressions are detrimental to management. Mechanical compression devices are not associated with improved outcomes but can assist in several situations.

Outcomes of Patients Transported in the Prone Position to a Regional Extracorporeal Membrane Oxygenation Center: A Retrospective Cohort Study

Prone positioning is associated with improved mortality in patients with moderate/severe acute respiratory distress syndrome (ARDS) and has been increasingly used throughout the COVID-19 pandemic. In patients with refractory hypoxemia, transfer to an extracorporeal membrane oxygenation (ECMO) center may improve outcome but may be challenging due to severely compromised gas exchange. Transport of these patients in prone position may be advantageous; however, there is a paucity of data on their outcomes.

OBJECTIVES

The primary objective of this retrospective cohort study was to describe the early outcomes of ARDS patients transported in prone position for evaluation at a regional ECMO center. A secondary objective was to examine the safety of their transport in the prone position.

DESIGN

Retrospective cohort study.

SETTING

This study used patient charts from Ornge and Toronto General Hospital in Ontario, Canada, between February 1, 2020, and November 31, 2021.

PARTICIPANTS

Patient with ARDS transported in the prone position for ECMO evaluation to Toronto General Hospital.

MAIN OUTCOMES AND MEASURES

Descriptive analysis of patients transported in the prone position and their outcomes.

RESULTS

One hundred fifteen patients were included. Seventy-two received ECMO (63%) and 51 died (44%) with ARDS and sepsis as the most common listed causes of death. Patients were transported primarily for COVID-related indications (93%). Few patients required additional analgesia (8%), vasopressors (4%), or experienced clinically relevant desaturation during transport (2%).

CONCLUSIONS AND RELEVANCE

This cohort of patients with severe ARDS transported in prone position had outcomes ranging from similar to better compared with existing literature. Prone transport was performed safely with few complications or escalation in treatments. Prone transport to an ECMO center should be regarded as safe and potentially beneficial for patients with ARDS and refractory hypoxemia.

Management of Intraoperative Cardiac Arrest

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.

Prone Dispatch-Directed CPR in Out-of-Hospital Cardiac Arrest: Two Successful Cases

Historically, dispatch-directed cardiopulmonary resuscitation (CPR) protocols only allow chest compression instructions to be delivered for patients able to be placed in the traditional supine position. For patients who are unable to be positioned supine, the telecommunicator and caller have no option except to continue attempts to position supine, which may result in delayed or no chest compressions being delivered prior to emergency medical services arrival. Any delay or lack of bystander chest compressions may result in worsening clinical outcomes of out-of-hospital cardiac arrest (OHCA) victims. We present the first two cases, to the best of our knowledge, of successfully delivered, bystander-administered, prone CPR instructions by a trained telecommunicator for two OHCA victims unable to be positioned supine.

Patient care during interfacility transport: a narrative review of managing diverse disease states

BACKGROUND

When critically ill patients require specialized treatment that exceeds the capability of the index hospitals, patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care. Therefore, appropriate and efficient care for patients during the process of transport between two hospitals (interfacility transfer) is an essential part of patient care. While medical adverse events may occur during the interfacility transfer process, there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.

METHODS

We conducted searches from the PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and Scopus databases up to June 2022. Two reviewers independently screened the titles and abstracts for eligibility. Studies that were not in the English language and did not involve critically ill patients were excluded.

RESULTS

The search identified 75 articles, and we included 48 studies for our narrative review. Most studies were observational studies.

CONCLUSION

The review provided the current evidence-based management of diverse disease states during the interfacility transfer process, such as proning positioning for respiratory failure, extracorporeal membrane oxygenation (ECMO), obstetric emergencies, and hypertensive emergencies (aortic dissection and spontaneous intracranial hemorrhage).

Guidance for Cardiopulmonary Resuscitation of Children With Suspected or Confirmed COVID-19

This article aims to provide guidance to health care workers for the provision of basic and advanced life support to children and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19). It aligns with the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular care while providing strategies for reducing risk of transmission of severe acute respiratory syndrome coronavirus 2 to health care providers. Patients with suspected or confirmed COVID-19 and cardiac arrest should receive chest compressions and defibrillation, when indicated, as soon as possible. Because of the importance of ventilation during pediatric and neonatal resuscitation, oxygenation and ventilation should be prioritized. All CPR events should therefore be considered aerosol-generating procedures. Thus, personal protective equipment (PPE) appropriate for aerosol-generating procedures (including N95 respirators or an equivalent) should be donned before resuscitation, and high-efficiency particulate air filters should be used. Any personnel without appropriate PPE should be immediately excused by providers wearing appropriate PPE. Neonatal resuscitation guidance is unchanged from standard algorithms, except for specific attention to infection prevention and control. In summary, health care personnel should continue to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission through vaccination and use of appropriate PPE during pediatric resuscitations. Health care organizations should ensure the availability and appropriate use of PPE. Because delays or withheld CPR increases the risk to patients for poor clinical outcomes, children and neonates with suspected or confirmed COVID-19 should receive prompt, high-quality CPR in accordance with evidence-based guidelines.

100 Years of Critical Care in the Pages of Anesthesia & Analgesia

The founding of Anesthesia & Analgesia (A&A) in 1922 was roughly contemporaneous with the creation of the first intensive care unit (ICU) in the United States at Johns Hopkins in 1923. Throughout the next 100 years, the pages of A&A have mirrored the development of critical care as its own distinct specialty. Although primarily a journal focused on intraoperative anesthesia, A&A has maintained a small but steady presence in critical care research. This review highlights the history and development of critical care publications in the pages of A&A from early observations on the physiology of critical illness (1922-1949) to the groundbreaking work of Peter Safar and others on cardiopulmonary resuscitation (1950-1970), the growth of modern critical care (1970-2010), and the 2020 to 2022 coronavirus disease 2019 (COVID-19) era.

Airway Management During Cardiopulmonary Resuscitation

Purpose of the review

Recent Findings

Summary

Cardiopulmonary resuscitation and defibrillation for cardiac arrest when patients are in the prone position: A systematic review

AIM

To perform a systematic review of cardiopulmonary resuscitation (CPR) and/or defibrillation in the prone position compared to turning the patient supine prior to starting CPR and/or defibrillation.

METHODS

The search included PubMed, Embase, Web of Science, Cochrane, CINAHL Plus, and medRxiv on December 9, 2020. The population included adults and children in any setting with cardiac arrest while in the prone position. The outcomes included arterial blood pressure and end-tidal capnography during CPR, time to start CPR and defibrillation, return of spontaneous circulation, survival and survival with favorable neurologic outcome to discharge, 30 days or longer. ROBINS-I was performed to assess risk of bias for observational studies.

RESULTS

The systematic review identified 29 case reports (32 individual cases), two prospective observational studies, and two simulation studies. The observational studies enrolled 17 patients who were declared dead in the supine position and reported higher mean systolic blood pressure from CPR in prone position (72 mmHg vs 48 mmHg, p < 0.005; 79 ± 20 mmHg vs 55 ± 20 mmHg, p = 0.028). One simulation study reported a faster time to defibrillation in the prone position. Return of spontaneous circulation, survival to discharge or 30 days were reported in adult and paediatric case reports. Critical risk of bias limited our ability to perform pooled analyses.

CONCLUSIONS

We identified a limited number of observational studies and case reports comparing prone versus supine CPR and/or defibrillation. Prone CPR may be a reasonable option if immediate supination is difficult or poses unacceptable risks to the patient.

Ultrasound-guided central venous access for patients in the Intensive Care Unit in prone position: report of three cases

The prone position is extensively used to improve oxygenation in patients with severe acute respiratory distress syndrome caused by SARS-CoV-2 pneumonia. Occasionally, these patients exhibit cardiac and respiratory functions so severely compromised they cannot tolerate lying in the supine position, not even for the time required to insert a central venous catheter. The authors describe three cases of successful ultrasound-guided internal jugular vein cannulation in prone position. The alternative approach here described enables greater safety and well-being for the patient, reduces the number of episodes of decompensation, and risk of tracheal extubation and loss of in-situ vascular lines.