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 Table of Contents    
RESPONSE TO COMMENTS
Year : 2020  |  Volume : 64  |  Issue : 9  |  Page : 828-829  

Reply to comments on prone CPR for COVID-19 patients


1 Department of Anaesthesiology and Critical Care, Faculty of Medicine and Health Sciences, SGT University, Gurugram, Haryana, India
2 Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, AIIMS, New Delhi, India
3 Indian Resuscitation Council, Kakinada, Andhra Pradesh, India
4 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
5 Department of Emergency Medicine, SRMC, Porur, Chennai, Tamil Nadu, India
6 Department of Anaesthesiology and Critical Care, JN Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
7 Department of Anaesthesiology and Critical Care, Narmada Trauma Center, Bhopal, Madhya Pradesh, India
8 Viranchi Hospital, Hyderabad, Telangana, India
9 Department of Anaesthesiology, Pain and Critical Care, PGIMS, Rohtak, Haryana, India
10 Department of Anaesthesiology, Gian Sagar Medical College, Patiala, Punjab, India

Date of Submission21-Jul-2020
Date of Acceptance02-Aug-2020
Date of Web Publication01-Sep-2020

Correspondence Address:
Dr. Rakesh Garg
Room No 139, First Floor, Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_981_20

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How to cite this article:
Singh B, Garg R, Rao S S, Ahmed SM, Divatia J V, Ramakrishnan T V, Mehdiratta L, Joshi M, Malhotra N, Singh Bajwa SJ. Reply to comments on prone CPR for COVID-19 patients. Indian J Anaesth 2020;64:828-9

How to cite this URL:
Singh B, Garg R, Rao S S, Ahmed SM, Divatia J V, Ramakrishnan T V, Mehdiratta L, Joshi M, Malhotra N, Singh Bajwa SJ. Reply to comments on prone CPR for COVID-19 patients. Indian J Anaesth [serial online] 2020 [cited 2020 Sep 20];64:828-9. Available from: http://www.ijaweb.org/text.asp?2020/64/9/828/294085



We thank Raphael PO [1] for his interest in the guidelines for comprehensive cardiopulmonary life support (CCLS) for suspected or confirmed corona virus disease (COVID-19) patient,[2] and his suggestion for the need of prone cardiopulmonary resuscitation (CPR). Proning is a usual practice to improve the respiratory status of the COVID-19 patient by lung recruitment. We agree that prone CPR may be 'an option' in patients with an advanced airway in situ. In the absence of a secure airway, however, prone position makes airway access extremely difficult and enhances the risk of aerosolisation.[3] Also, wherever proning is performed as a routine for management of COVID-19 patient, the delay to turn to supine position for CPR would be minimal as the team is likely to be well versed with it. The patient deserves the best attempt and most of the training related to CPR across the globe is being imparted in the supine position. So, to provide skill-based technique in a changing environment of COVID-19 for which the health care worker has not been trained appears impractical. Also, identification of the correct site for cardiac compressions in prone position is not well known and difficult to locate too. Using the inferior angle of the scapula for correct site identification may not be correct because it changes position if the arm is abducted as happens in the prone position. The largest left ventricular cross-sectional area is reported to be 0-2 vertebral segments below the inferior angle of the scapula in at least 86% of patients.[4] The remaining 14% therefore would be getting suboptimal care even if the patient is thin built and the bony landmarks are easily palpable which may not be true in obese patient. There is no consensus regarding the placement of hands also.[5] For effective compressions, a sandbag is required under the sternum for which the patient would need to be moved anyway.

The author has conceded that the outcome of prone CPR is not well elucidated and hence Indian Resucitation Council (IRC) emphasised the standard technique. CPR guidelines from other resuscitation councils also have not categorically mentioned CPR in a prone position always.[6] It is emphasised that CPR may be started with the patient in prone position till the team prepares for making patient supine to avoid delay in starting CPR.

So, we are of the opinion that the standard CPR as per the CCLS guidelines would have a better and safer outcome than an unconventional prone position CPR where determination of the precise level of compression and the position of hands is nowhere near the level of universal acceptance as the standard supine position CPR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Raphael PO. A comment on “Indian Resuscitation Council (IRC) suggested guidelines for Comprehensive Cardiopulmonary Life Support (CCLS) for suspected or confirmed coronavirus disease (COVID-19) patient”. Indian J Anaesth 2020;64:827.  Back to cited text no. 1
  [Full text]  
2.
Singh B, Garg R, Chakra RaoSSC, AhmedSM, DivatiaJV, Ramakrishnan TV, et al. Indian resuscitation council (IRC) suggested guidelines for comprehensive cardiopulmonary life support (CCLS) for suspected or confirmed coronavirus disease (COVID-19) patient. Indian J Anaesth 2020;64:14;91-6.  Back to cited text no. 2
    
3.
Bhatnagar V, Jinjil K, Dwivedi D, Verma R, Tandon U. Cardiopulmonary resuscitation: Unusual techniques for unusual situations. J Emer Trauma Shock 2018;11:31-7.  Back to cited text no. 3
    
4.
Kwon Min-Ji, Kim EH, Song IK and Lee JH. Optimizing prone cardiopulmonary resuscitation: Identifying the vertebral level correlating with the largest left ventricular cross-sectional area via computed tomography scan. Anesth Analg 2016;124:520-3.  Back to cited text no. 4
    
5.
Al Harbi MK, Alattas KA, Alnajar M, Albuthi MF. Prone cardiopulmonary resuscitation in elderly undergoing posterior spinal fusion with laminectomy. Saudi J Anaesth 2020;14:123-6.  Back to cited text no. 5
    
6.
Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19. Circulation 2020;141:e933-43.  Back to cited text no. 6
    




 

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