Prone CPR: evidence and decisions in the operating room

The Dilemma: Starting Resuscitation and Deciding the Turn

In the operating room or ICU, a patient may have a cardiac arrest while in the prone position. Turning them may require freeing devices, protecting the airway, and coordinating several people; keeping them in that position also imposes access difficulties. The decision is not only about choosing a position: it must consider whether effective interventions can be administered without avoidable delays. AHA 2025 maintains supine as the preferred position for compressions. If safe turning is not possible, it suggests considering prone CPR.

Recognition and Perioperative Context

Monitoring an anesthetized patient provides information that must be interpreted jointly. The electrocardiographic tracing describes electrical activity; invasive blood pressure and capnography provide additional signals about circulation and ventilation. An isolated change requires checking its context, including the measuring devices. ERC 2025 places recognition, team communication, quality CPR, and the search for reversible causes within the response to cardiac arrest in the operating room. This synthesis does not turn a single monitor number into a universal diagnosis.

The airway separates distinct scenarios

ILCOR distinguishes the patient who already has an advanced airway from the one who does not. When it exists and immediate supination is not feasible or presents a significant risk, initiating CPR in the prone position may be reasonable. Without an advanced airway, it recommends supination as soon as possible and starting CPR. The first is a good practice statement; the second is a strong recommendation supported by very low-certainty evidence. It is important to preserve both the clinical difference and the uncertainty of the evidence.

Posterior compressions: what publications describe

Published protocols adapt access to the posterior thoracic region. McCraw and colleagues describe anatomical landmarks around T7–T10 and the use of support to provide counterpressure. This description comes from institutional experience and review, not from a comparison validating a single technique for all patients. The surgical field, supports, and anatomical constraints change feasibility; the technique should be trained in the real environment and contrasted with its original sources, rather than inferred from a conceptual illustration.

Monitoring: assess response and avoid isolated rules

ILCOR considers that invasive blood pressure and continuous capnography help assess whether compressions generate perfusion and inform the decision to turn. These signals alone do not demonstrate neurological recovery or superiority of a position. ETCO₂ should not be interpreted without considering ventilation and context. This guideline does not use an isolated ETCO₂ or blood pressure cutoff point as automatic permission to remain prone; reassessment of the whole is prioritized.

Defibrillation when immediate turning is not possible

For a shockable rhythm, ILCOR considers it reasonable to attempt defibrillation in the prone position when immediate supination is not possible. Publications describe alternative patch placements, but one feasible option in an ICU may not be practical with an open dorsal field. The McCraw protocol illustrates lateral and oblique options; its description does not establish a universally superior configuration. The team needs to recognize available access and coordinate intervention without making position change an automatic requirement for every shock.

Reassess the need and safety of repositioning

Starting in the prone position does not obligate continuing in that position throughout the entire resuscitation. The physiological response, the possibility to ventilate, and the required access to treat the cause may change. A possible turn demands coordination and device protection: the timing and method must respond to the scenario and local protocol. McCraw's institutional experience assigns the leader the decision to continue or switch to supine. It is an example of local organization, not a fixed duration applicable to all arrests.

What do the systematic review and case reports show?

The review by Hsu and colleagues gathered very limited and heterogeneous evidence, including case reports, small non-randomized studies, and simulation. Published cases demonstrate feasibility in selected situations but are subject to selection and publication bias; they do not allow direct comparison of two strategies as if they were equivalent groups. A case of return of spontaneous circulation (ROSC) in the prone position does not establish what would have happened if the same patient had been turned. Physiological results, ROSC, survival to discharge, and neurological outcomes must be distinguished.

Ultrasound during CPR: a described possibility, not a definitive test

Patail and colleagues describe a case in the ICU where ultrasound of the popliteal artery was used to observe pulsations during compressions in the prone position. It is a single-patient experience exploring how to obtain information in a difficult access situation. It does not validate a universal Doppler target, a superior strategy, or a survival improvement. Its interest for this library is to show a monitoring question and its limits, not to make it a mandatory component of resuscitation.

Simulation, teamwork and transfer to the real environment

The educational study by Sundelin and collaborators included training and transfers from prone and beach chair positions. Their self-reported confidence results and exploratory exercises do not demonstrate a survival benefit. Nevertheless, it offers an example to study environmental barriers: devices, table, access, and coordination. The preparation questions that follow are an educational proposal from REASEL, compatible with the ERC emphasis on familiarity with the equipment and interdisciplinary training. The clinical effectiveness of a local adaptation requires its own evaluation.

Scope of this synthesis and extrapolation errors

This page focuses on adults and organizes information from operating room and ICU. It does not equate prone, lateral decubitus, and beach chair positions, nor does it automatically transfer pediatric experiences to adults. It also does not confuse the benefit of proning certain patients with respiratory failure with the benefit of performing CPR in prone during a cardiac arrest: these are different questions. Guidelines, studies, and editorial analysis are offered separately so the reader can recognize the source of each statement.

Questions to prepare and evaluate the team

REASEL's educational proposal to design a local practice: anticipate difficulties, agree on roles, communicate decisions, and review team performance. The purpose is to understand the scenario and prepare a coordinated response, with explicit criteria to reassess it. These questions guide training; they do not constitute a validated clinical checklist.

Your next readings with Rafael on Substack

Six analyses to broaden scenarios and questions. The texts were published on different dates: prioritize the guidelines cited here for current recommendations and use these readings as editorial analysis. Some content requires subscription.

Frequently asked questions about CPR in prone position

Scientific sources and what each contributes

Guidelines, reviews, local experiences, and case reports have different scopes. Numbered references allow recognizing the support for each section.