Cardiopulmonary Resuscitation in the Prone Position in the Operating Room or in the Intensive Care Unit

A Systematic Review

Cristobal Anez, MD, PhD; Ángel Becerra-Bolaños, MD; Ariadna Vives-Lopez, MD; Aurelio Rodríguez-Pérez, MD, PhD


Anesth Analg. 2021;132(2):285-292. 

In This Article

Abstract and Introduction


The prone position is commonly used in certain surgical procedures and to improve oxygenation in mechanically ventilated patients with acute respiratory distress syndrome (ARDS). Cardiorespiratory arrest (CRA) in this position may be more challenging to treat because care providers trained in conventional cardiopulmonary resuscitation (CPR) may not be familiar with CPR in the prone position. The aim of this systematic review is to provide an overview of current evidence regarding the methodology, efficacy, and experience of CPR in the prone position, in patients with the airway already secured. The search strategy included PubMed, Scopus, and Google Scholar. All studies published up to April 2020 including CRA or CPR in the prone position were included. Of the 268 articles located, 52 articles were included: 5 review articles, 8 clinical guidelines in which prone CPR was mentioned, 4 originals, 27 case reports, and 8 editorials or correspondences. Data from reviewed clinical studies confirm that CPR in the prone position is a reasonable alternative to supine CPR when the latter cannot be immediately implemented, and the airway is already secured. Defibrillation in the prone position is also possible. Familiarizing clinicians with CPR and defibrillation in the prone position may improve CPR performance in the prone position.


The prone position is usually used in the operating room to facilitate surgical access and to optimize oxygenation in patients with severe hypoxic respiratory failure in the intensive care unit (ICU). However, if the patient suffers cardiorespiratory arrest (CRA) in this position, considerable effort is often required to return the patient to the supine position and initiate cardiopulmonary resuscitation (CPR) maneuvers. It can take as many as 5–6 people and up to 3 minutes to reposition a patient into the supine position.[1]

Patients testing positive for coronavirus disease 2019 (COVID-19) may require ICU admission for persistent refractory hypoxemia. For such patients, mechanical ventilation in the prone position may improve oxygenation.[2]

However, if patients who are mechanically ventilated in the prone position suffer cardiac arrest, it is not clear how CPR should be performed. The American Heart Association (AHA) 2010 guideline prioritizes placing the patient in the supine position to perform optimal CPR. Performing CPR in the prone position is only recommended when it is not possible to turn the patient supine. However, the recommended technique to perform prone CPR is not specified, and prone CPR is mentioned in neither the 2015 nor the 2019 updates.[3–5] A 2020 update of basic and advanced CPR recommendations for the COVID-19 pandemic[6] recommends either returning the patient to the supine position or initiating CPR in the prone position. How CPR should be performed, however, is not specified.[6,7] Because patients with COVID-19 often have severe cardiorespiratory instability, a rapid change of position might lead to greater hemodynamic instability and worsened hypoxemia. CPR in such patients may be better managed in the prone position.

We performed a systematic review of current literature regarding the efficacy and feasibility of basic or advanced CPR maneuvers in the prone position in the operating room or in the ICU. As a secondary objective, we offer a description of recommendations for basic and advanced CPR in the prone position to facilitate its application in patients undergoing CRA in this position.