Prone CPR: ALS Systematic Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable). The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (none applicable).

CoSTR Citation

Berg K, Hsu CH, Considine J, Pawar R, Cellini J, Schexnayder S, Soar J, Olasveengen T on behalf of the Advanced Life Support, Basic Life Support and Paediatric Life Support Task Forces at the International Liaison Committee on Resuscitation (ILCOR). Cardiopulmonary Resuscitation and Defibrillation for Cardiac Arrest when Patients are in the Prone Position Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support and Basic Life Task Forces, 2021 February 08. Available from: http://ilcor.org

Methodological Preamble (and Link to Published Systematic Review if applicable)

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of cardiopulmonary resuscitation and defibrillation for cardiac arrest when patients are in the prone position (Berg et al. 2021, PROSPERO CRD42021230691) conducted by a systematic review team with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Advanced List Support, Basic Life Support and Paediatric Life Support Task Forces. These data were taken into account when formulating the Treatment Recommendations.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest occurring while in the prone position.

Intervention: Performing cardiopulmonary resuscitation (CPR) and / or defibrillation while the patient remains in the prone position.

Comparators: Turning the patient supine prior to initiation of CPR and / or defibrillation.

Outcomes: Arterial blood pressure during CPR (important-5), time to initiation of CPR (important-5), time to defibrillation for shockable rhythms during CPR (important-5), end-tidal capnography during CPR (important-5), ROSC (important-6), survival and survival with favorable neurologic outcome to discharge, 30 days or longer (critical-9).

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), case series and case reports are eligible for inclusion. Case series and reports will be included as the writing group is aware that the human data on prone CPR is extremely limited. Unpublished studies (e.g., conference abstracts, trial protocols), and editorials are excluded, although case reports published in letter form may be included. Scoping reviews and systematic reviews will be included for discussion and to assure no primary papers are missed, but data will not be extracted primarily from these reviews.

Timeframe: All years and all languages were included as long as there was an English abstract. Search was conducted on December 9, 2020.

PROSPERO Registration CRD42021230691

Due to the nature of the available evidence, formal assessment of risk of bias was rarely possible. All case reports were considered at critical risk of bias due to the selection bias inherent in case reports. The two small nonrandomized studies with a comparison group that were included were assessed for risk of bias using ROBINS-I, but were assessed at the level of the study and not the outcome as there were no differences by outcome.

Consensus on Science

This systematic review identified 29 case reports (describing 32 individual cases), 2 prospective nonrandomized studies, one simulation study and one simulation study reported in conjunction with one of the 29 case reports.

Outcomes

Of the twenty adult case reports, twelve had CPR commenced in the prone position[1-12] and eight were supinated prior to commencement of CPR [13-19].

Of the 12 paediatric case reports, 11 had CPR commenced prone [11, 20-23, 25-28, 32] while one was supinated prior to CPR[24]. Comparison of commonly reported outcomes from prone vs supine CPR are shown in Tables 1 (adult case reports) and 2 (paediatric case reports).

Of the 32 case reports (20 adult and 12 paediatric), 31 cases (19 adult and 12 paediatric) were of patients in a prone position in the operating room, most often with head fixation or other devices that could considerably hinder the ability to safely and quickly turn the patient supine. Only one adult case was a patient in the prone position in the intensive care unit.[4]

The critical outcome of survival to hospital discharge with favourable neurological outcome was not explicitly reported in any adult or paediatric case. There were implicit reports of survival to hospital discharge with favourable neurological outcome in eight adult cases (‘without neurologic deficit’ [3]; ‘no cerebral injury’ [2]; ‘recovered uneventfully’[5]; ‘without deficits’[15]; ‘awake and well oriented at 7 days’ [4]; ‘without sequelae’[6]; ‘could carry out simple tasks’ [7]; and ‘discharged from hospital in a stable neurological condition’ [12]) and seven paediatric cases (‘no evidence of significant cerebral dysfunction’ [20]; ‘returned to baseline over two weeks’ [21]; ‘recovered without sequelae’[22]; ‘no adverse neurological sequelae’[23]; ‘in good condition’[24]; ‘made an uneventful recovery’ [11]; and ‘unchanged from preoperative status’ [25]).

The critical outcome of survival with favourable neurological outcome at 30 days or longer was not explicitly reported in any adult or paediatric case. There were implicit reports of survival with favourable neurological outcome at 30 days or longer in two adult cases (‘without deficits’[15]; ‘able to perform his work and ADLs independently’ [17]) and two paediatric cases (‘no abnormal neurological signs … within accepted limits for achondroplasia’ [20]; ‘recovered without sequelae’ [22]).

The critical outcome survival to hospital discharge was explicitly reported in 13 adult cases and 11 paediatric cases. These outcomes are presented in Tables 1 and 2.

The critical outcome of survival to 30 days or longer was reported in only one adult case where CPR was initiated prone[7] and six adult cases supinated before CPR started. Five paediatric cases reported the outcome of survival to 30 days or longer. [20, 22, 26, 27]. Outcomes by prone/supine CPR initiation are summarized in Tables 1 and 2.

The critical outcome of time to CPR was reported in eight adult[1, 4, 6, 9, 11, 12, 14, 17] and seven paediatric cases [11, 20-22, 26, 27]. ‘Immediate’ prone CPR was reported in six adult cases[1, 4, 6, 9, 11, 12] and seven paediatric cases[11, 20-22, 26, 27]. One adult case reported CPR ‘immediately’ after supination[14] and one adult case reported CPR commenced after supination 6 minutes following cardiac arrest[17].

Two simulation studies reported that the time to supinate in order to commence CPR was 50 +/- 34 seconds[29] to 110 seconds [3]. Time to CPR (in supine position) of 77+/- 31 seconds was reported in one simulation study[29].

For the critical outcome of time to defibrillation we identified one simulation study that reported time to prone defibrillation without chest compressions or turning the patient of 22 seconds (1 group) compared with an average time (13 groups) of 108+/- 61 seconds when the patient was supinated for CPR and defibrillation[29]. The critical outcome of time to defibrillation was not reported in any adult or paediatric case report.

The important outcome of ROSC was reported in all studies. Occurrence of ROSC in those with CPR started prone vs supine is presented in Tables 1 and 2.

For the important outcome of arterial blood pressure during CPR, we identified very low-certainty evidence (downgraded for risk of bias, indirectness and imprecision) from two small nonrandomized studies enrolling a total of 17 patients who had already been declared dead after conventional supine CPR, comparing arterial blood pressure during CPR delivered with the patient in the prone position to that obtained with the patient in the supine position[30, 31]. Both studies reported significantly higher systolic blood pressure during prone compressions (72mmHg vs 48mmHg, p<0.005 [30]; 79+/-20 mmHg vs 55+/-20 mmHg, p=0.028 [31]), while only one found a significant increase in diastolic pressure with prone compressions (34 mmHg vs 24 mmHg, NS [30]; 17+/-10 mmHg vs 13+/-7 mmHg, p=0.028 [31]). Supine data were missing in 3/11 patients in the second study [31].

The important outcome of end-tidal carbon dioxide (ETCO₂) during CPR was reported in five adult cases[5-7, 12, 16], with values ranging from 15mmHg[12] to 33mmHg[7]; and two paediatric cases both of which reported ETCO₂ ≥10 mmHg with prone compressions[27, 32].

Table 1: Commonly reported outcomes for CPR commenced in prone vs supine position: 20 adult cases

Table 2: Commonly reported outcomes for CPR commenced in prone vs supine position: 12 paediatric cases

Treatment Recommendations

Treatment recommendations:

For patients with cardiac arrest occurring while in the prone position with an advanced airway already in place, and where immediate supination is not feasible or poses significant risk to the patient, initiating CPR while the patient is still prone may be a reasonable approach (Good practice statement).

Invasive blood pressure monitoring and continuous ETCO₂ monitoring may be useful to ascertain whether prone compressions are meeting benchmarks for adequate perfusion or not, and this information could inform decision making on when to prioritize supination (Good practice statement).

For patients with cardiac arrest occurring while in the prone position without an advanced airway already in place, we recommend turning the patient supine as quickly as possible and beginning CPR (strong recommendation, very low certainty of evidence).

For patients with cardiac arrest with a shockable rhythm who are in the prone position and cannot be supinated immediately, attempting defibrillation in the prone position is a reasonable approach (Good practice statement).

Justification and Evidence to Decision Framework Highlights

TF discussed that normally we would not generate treatment recommendations based on the level of evidence available for this question, which is of extremely low certainty, but that the COVID-19 pandemic and the large increase in the number of critically-ill patients treated with prone positioning has made this an important question for clinicians around the world.

TF discussed weighing the possible risk of delaying CPR start and defibrillation against the possible risk of prone CPR/defibrillation being less effective, and acknowledged that the balance of effects is very unclear.

TF discussed that additional studies, which would be quite feasible to perform, would be very useful. These could include larger case series representing the total experience of a. center or centers, or even additional case reports that report quality metrics such as ETCO2 and arterial blood pressure during prone compressions. More data on ICU patients particularly is needed, as virtually all published case reports on prone CPR are in patients proned for spinal or brain surgery in the operating room.

TF discussed the fact that in many ICU settings, patients who are proned and on mechanical ventilation are highly likely to have arterial lines in place and ETCO₂ monitoring ongoing, thus allowing for the rapid assessment of whether prone compressions are effective.

TF discussed that the difficulty of supinating a patient will vary widely based on patient size, personnel immediately available, and interventions in place such as chest tubes, advanced airways, IV lines, personal protective equipment and isolation requirements, and potentially open wounds/exposed hardware (in the case of patients in the operating room).

TF discussed that the etiology of the cardiac arrest will determine the urgency of supination. For example a primary airway problem such as a dislodged tracheal tube will require immediate supination, whereas the need for hemorrhage control during surgery in the prone position surgery may necessitate CPR in the prone position.

Knowledge Gaps

There is almost no evidence beyond case reports on this topic. Some highlighted knowledge gaps include:

• Average time taken to supinate a critically ill or operating room patient in a real clinical setting
• Outcomes data in patients arresting in prone position who received CPR or defibrillation while prone compared to those who were supinated before CPR start/defibrillation
• Comparative data on CPR metrics such as ETCO₂ and arterial blood pressure during compressions done in prone vs supine position, as well as time to CPR start and first defibrillation or dose of adrenaline
• Risk of aerosolization/infection transmission from supinating a patient in cardiac arrest

Attachments

PRONE-CPR-ETD

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