Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited

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Transcript of Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited

  • CORRESPONDENCE Intensive Care Med (1996) 22:1272-1282 9 Springer-Verlag 1996

    P.-E Dequin E. Hazouard A. Legras R. Lanotte D. Perrotin

    Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited

    Received: 11 March 1996 Accepted: 17 May 1996

    Sir: It has been proposed that severely hypoxemic patients be ventilated in the prone position, in an attempt to improve gas exchange [1]. Testing this position in patients with the acute respiratory distress syndrome (ARDS) is recommended [21. However, no guidelines are available for cases of life-threatening events occurring with the patient in the prone position especially cardiac arrest. We report a case of successful cardiopulmonary resuscita- tion of a patient ventilated in the prone position, without changing the patient's position.

    A 48-year-old man was being ven- tilated for community-acquired pneumonia. His gas exchange (partial pressure of oxygen in arterial blood 4.3 kPa and of carbon dioxide 16.4 kPa and pH 7.14) deteriorated despite control- mode ventilation with 10 cmH20 positive end-expiratory pressure, 100 p. 100 frac- tional inspired oxygen, and 20 ppm inhal- ed nitric oxide. He was then turned to the prone position. A few minutes later, asytole developed and blood pressure became unobtainable. Cardiac massage was begun immediately with the patient in the prone position. One physician plac- ed the flat of one hand under the pa- tient's sternum, while another physician compressed the mid-thoracic spine rhythmically with both hands (Fig. 1). Arterial radial blood pressure was main- tained at least at 80/35 mmHg throughout resuscitation. Epinephrine (1 mg i.v.) was injected twice at a 3-min interval. Five minutes after starting cardiac compres- sion, sinus rhythm resumed and blood pressure was maintained at 140/85 mmHg. Gas exchange dramatically improved a few hours later. Seven days

    after the incident, the patient was awake and well oriented.

    The conventional approach of closed chest compression is well established with the patient in the supine position [3]. However, cardiac massage might be re- quired for patients in the prone position, e.g., during anesthesia for spinal or posterior fossa surgery. Three cases of successful resuscitation have been reported in these circumstances [4, 5] in which resuming the supine position might have injured the brain or spinal cord. Chang- ing the position has some other draw- backs for ARDS patients ventilated in the prone position: (a) it is time consuming and delays initiation of cardiac massage; (b) moving the patient into the supine position without proper protection may induce certain complications, e.g., ac- cidental extubation, dislodging the venous catheter, or shoulder injury to the patient; (c) turning a patient from one position in- to another requires at least four members of staff, who are not always immediately available in emergency situations. For these reasons, we suggest trying the

    Fig. 1 Position of the hands during car- diac massage in the prone position

    "reversed precordial compression" [41 when cardiac arrest occurs in patients in the prone position, provided that an arterial catheter, or preferably a cap- nograph, proves efficacy. If it appears to be inefficient, then the patient should ob- viously be moved into the supine position. From a technical point of view, such car- diac massage may be performed by one physician, either placing one hand on the patient's back and the other against the lower third of the sternum [4] or using both hands to compress the thoracic spine, without a counterforce other than the operating table or the bed [5]. How- ever, we think the procedure is probably easier and more effective with two physi- cians, one performing the compression with both hands and the other placing one or both hands against the sternum, serving as a counterforce to the compres- sion of the thorax [4].


    l. Douglas WW, Rehder K, Froukje MB, Sessler AD, Marsh HM (1974) Improv- ed oxygenation in patients with respiratory failure: the prone position. Am Rev Respir Dis 115:559-566

    2. Langer M, Mascheroni D, Marcolin R, Gattinoni L (1988) The prone position in ARDS patients: a clinical study. Chest 94:103-107

    3. Kouwenhouven WB, Jude JR, Knicker- bocker CG (1960) Closed-chest cardiac massage. JAMA 173:1064-1067

    4. Sun WZ, Huang FH, Kung KL, Fan SZ, Chert TL (1992) Successful cardio- pulmonary resuscitation of two pa- tients in the prone position using reversed precordial compression. Anesthesiology 77:202-204

    5. Loewenthal A, DeAlbuquerque AM, Lehmann-Meurice C, Otteni JC (1993) Efficacit6 du massage cardiaque ex- terne chez une patiente en d6cubitus ventral. Ann Fr Anesth Reanim 12:587-589

    P.-E Dequin (~) 9 E. Hazouard A. Legras 9 R. Lanotte 9 D. Perrotin Medical Intensive Care Unit, Bretonneau Hospital and University of Tours, F-37044 Tours Cedex, France FAX: +33/47396536