CPR in Prone Position

Specialties MICU

Published

Just checking to see if anyone has done CPR on a patient in prone position. I had a terrible ARDS case where the patient only saturated 45% while supine even with nitric oxide. It was looking like there was high likelihood of a code and was wondering about performing CPR while the patient remained prone. I was able to find some theoretical articles but was wondering how things go in reality. Thankfully the patient did not need CPR but now my curiosity is piqued.

Specializes in ICU.
Although I have not worked in facilities that have had the capacity to turn our ARDS patients prone yet either.

You haven't worked anywhere that had nurses and RTs available at the same time? ;)

There is this myth that proning has to be done with special beds - it works just fine with regular beds, with several nurses logrolling the patient together, with somebody making sure the lines aren't getting too horribly tangled and somebody making sure the patient doesn't get accidentally extubated in the process. We don't do it terribly often at my job, but every now and then we will prone someone, and we just keep them on the same beds we always do.

Specializes in ICU.
You haven't worked anywhere that had nurses and RTs available at the same time? ;)

There is this myth that proning has to be done with special beds - it works just fine with regular beds, with several nurses logrolling the patient together, with somebody making sure the lines aren't getting too horribly tangled and somebody making sure the patient doesn't get accidentally extubated in the process. We don't do it terribly often at my job, but every now and then we will prone someone, and we just keep them on the same beds we always do.

There's a great video on youtube that makes it look downright easy - it's one of the first results on google if you search for "proning ICU patient." The secret seems to be preparation :)

Specializes in MICU, ER, MIMU, and Cardiothoracic IMU.

I had a patient who I had on the RotoProne bed and they needed CPR. Unfortunately, the only thing you can do is to place them supine and do CPR that way and as soon as you regain pulse, hurry and flip them over. With that being said, the mortality rate is so high when this occurs because most patients who require prone therapy have severe ARDS, and by the time you re-strap them back in the bed and prone, all that pressure in their thoracic cavity puts so much pressure on their heart, that it causes bradycardia and coding again. At this stage, I would discuss with the family DNR orders. Such a sad turn of events when this occurs. Great question though!

Specializes in Critical Care.

We've kept a cafeteria plate cover in the room with proned patients in the event they require CPR.

There's no strong recommendations out there, which is due to a lack of reported cases to go off of, not due to any specific concerns about the rationale. The main issue is that there's not much reason to believe chest compressions, prone or supine, is of any benefit to someone who's suffered a respiratory caused cardiac arrest, and if the precipitating issue that caused the cardiac arrest is hypoxia, then turning the patient to a supine position, where there saturations are even worse, is counterproductive.

Isolating the sternum, using a plate cover for instance, allows for compressions that are no different prone than supine, the main issue is that you probably aren't going to get as much recoil as would supine, although none of that really matters, you're not going to fix severe hypoxia precipitating cardiac arrest with even the best quality chest compressions.

Personally I've never done CPR on a proned patient and I've never had one for whom the plan was to do CPR in the even of cardiac arrest, we typically make them a medically futile DNR, although we will typically try epinephrine and pacing if indicated.

Specializes in Quality, Cardiac Stepdown, MICU.

Dumb question: How would you do epi if you're not doing compressions to move the drug around the circulation?

Specializes in Pediatrics, Emergency, Trauma.
Dumb question: How would you do epi if you're not doing compressions to move the drug around the circulation?

Racemic epi via ET tube?

Specializes in Critical Care.
Dumb question: How would you do epi if you're not doing compressions to move the drug around the circulation?

Cardiac arrest due to a respiratory cause typically doesn't just go from a good rhythm to asystole or VT/VF, it almost always progressively slows and widens prior to true cardiac arrest, epi can turn this around but only temporarily. The epi increases myocardial oxygen demand, so if there's no way to improve the oxygen supply then it's pretty futile, although at that point it's pretty futile no matter what.

I had a patient who I had on the RotoProne bed and they needed CPR. Unfortunately, the only thing you can do is to place them supine and do CPR that way and as soon as you regain pulse, hurry and flip them over. With that being said, the mortality rate is so high when this occurs because most patients who require prone therapy have severe ARDS, and by the time you re-strap them back in the bed and prone, all that pressure in their thoracic cavity puts so much pressure on their heart, that it causes bradycardia and coding again. At this stage, I would discuss with the family DNR orders. Such a sad turn of events when this occurs. Great question though!

I am not a nurse (yet), although I am working on a career change into nursing (which is why I am on this site). Perhaps in a bit of irony, this past March, my father was admitted into the hospital with pneumonia and a few days later, he developed ARDS. Compound this with a man who had had a quadruple bypass nearly 2 years to the day he was battling ARDS. They placed him into a RotoProne bed, and for the first week in it, he was prone most of the time, with the exception of 1-2 hours, if he could tolerate it. They would just rotate him to supine and watch how he responded. There was improvement and then he was moved into a regular bed after about 2 weeks, until his condition worsened, again. When he was moved back into the Rotoprone bed because he could not maintain oxygen levels, the issue of resuscitation came up. The nurses essentially told me that 1) the fact that he was back in the Rotoprone bed was not good and did not look promising for his prognosis (I asked for candidness) and 2) if he were to get to the point of resuscitation, he would be worse off than before (which I did not think could be any worse in a nursing home with a feeding tube and respirator for the rest of his life). At that time, one of the nurses asked me if I had spoken to my mother about a DNR, and he very gently gave me the advantages to this as opposed to watching a loved one possibly struggle and suffer through resuscitation; he did not paint a rosy picture. I appreciated this, and I appreciate your perspective that it is important to talk to families about DNR orders when situations like this come up. Although we/they, may not want to hear it, I knew it was necessary in my situation. Towards the end, my father could barely stand to be supine for very long (they canceled a chest x-ray one time because he was not tolerating it), without fear of cardiac arrest. Ultimately, his kidneys began failing and we decided that it was best to let him go, and when we did, he was gone within minutes. Fortunately, we did not have to experience him going into cardiac arrest, but I think it's important to discuss this with the families of patients like this. Although I think this is a very interesting topic, particularly for ARDS patients, I think it is just as important to have that DNR talk when appropriate.

Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

KAM212, can I just tell you how sorry I am for your loss. I have taken care of many ARDS patients (although they were children) and it is one of the worst diseases I have ever had to deal with. So many little gains followed by staggering losses. Thank you for your input on how to best help a family going through this situation. It is difficult for us, sometimes, to know what to do.

Thank you, so much FlyingScot. It has been a surreal journey, however, I am in even more awe of this profession after all of this, and although the experience of losing my father like this is palpable, it reinforced my desire to help patients and their families both physically and mentally. Finally, you could not have stated the condition of ARDS any better: So many little gains followed by staggering losses.

Specializes in CVICU, CCU, Heart Transplant.

At this point it's time to consider either VV ECMO or discuss withdrawing. I would not attempt CPR while a patient is prone.

Specializes in ICU.

We actually do not use rotational beds where I work, we prone them manually which can be tough. We usually end up getting patients from other facilities who have one foot in a grave and another on a banana peel and with pronation and Flolan I have seen them turn the corner and go home with their loved ones, it doesn't work for everyone but often it does have a positive effect.

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