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Brain & Heart Prone cardiopulmonary resuscitation

parameters, were already being undertaken before the EtCO and capnograph waveforms. Shifting positions
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2
cardiac arrest. As massive blood loss was identified as the from prone to supine raises concerns due to time
cause of the arrest, aggressive resuscitative efforts were constraints, the need for 3 – 4 operators, the surgical risk
geared toward blood replacement, adequate perfusion, and associated with open wounds and the Mayfield clamp, and
oxygenation, potentially averting or forestalling the need the potential dislodgment of airway devices. Initiating CPR
for ACLS. in the prone position has advantages, such as reducing the
Numerous studies on neuroprotective modalities for time of brain ischemia and improving the efficiency of
global cerebral ischemia have been conducted on animal chest compressions. This efficiency is due to the stiffness
models, proving to be greatly valuable in improving of the costovertebral joint, which allows for increased
neurologic status and functional outcomes in post-cardiac force delivery to the ventricles, and rapid reduction of
arrest patients despite statistical limitations. Pharmacologic intrathoracic volume due to the hard surface placed over
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approaches that diminish secondary injury from ischemia the sternum. However, complications such as pressure
and reperfusion after ROSC aim to mitigate excitotoxicity, injuries and accidental dislodgments of the advanced
improve neuronal metabolism, limit mitochondrial injury, airway may occur during prone CPR, necessitating a shift
and reduce neurologic inflammation. Pharmacologic to the supine position, which can affect the quality of
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sedation for neuronal silence in the early phase of CPR. In our case, cardiopulmonary arrest was recognized
recovery after hypoxic-ischemic brain injury permits early, and immediate high-quality CPR was commenced
damaged neurons to shut down before primary cellular in the prone position during surgical closure. EtCO was
2
dysfunction becomes irreversible. Modulation of slow- maintained at 20 – 25 mmHg, indicating high-quality CPR
wave activity may be suggestive of metabolic suppression, and optimal brain perfusion.
allowing quiescence of neuronal activity amidst insult.
Propofol, a known GABA-receptor agonist, has recently 4. Conclusion
been recognized for its neuroprotective role in brain Brain injury is recognized as the main cause of morbidity
ischemia/reperfusion injury through the induction of and mortality after cardiac arrest. Early recognition and
heme oxygenase-1 expression, reduction of hypoxic- aggressive resuscitation are crucial to prevent subsequent
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induced hippocampal neuronal injury, improvement ischemic reperfusion injury. As demonstrated in our
of alterations in neuronal structure, attenuation in patient, high-quality CPR, maintenance of EtCO above
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cortical and hippocampal caspase-3 activation to improve 20 mmHg, and the implementation of neuroprotective
cognitive function through GABA-A receptor action, efforts prove to be promising strategies for successful
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and improvement of cerebral perfusion. Its early resuscitation and improved functional outcomes post-
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post-arrest initiation has led to metabolic suppression, ROSC.
attenuation of cerebral hyperemia, and modulation of
slow-wave electroencephalogram activity. Recent reports Acknowledgments
demonstrate the neuroprotective effects of midazolam None.
through the suppression of intracellular reactive oxygen
species accumulation and its radical scavenging activities, Funding
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thereby preventing apoptosis. In our patient, maintenance
of propofol and interrupted doses of midazolam were None.
administered intraoperatively as neuroprotection during
resuscitation and post-ROSC. Despite the expected brain Conflict of interest
insults during cardiac arrest, our patient was immediately The authors declare that they have no competing interests.
fully awake and appropriately responsive in the PACU.
The patient’s position was another concern as to our Author contributions
approach to ACLS. Most providers are trained to perform Conceptualization: Geraldine Raphaela B. Jose, Cristina C.
CPR in the supine position, and reluctance to perform Arcinue-Gomez
CPR in the prone position poses challenges due to a Investigation: Geraldine Raphaela B. Jose, Cristina C.
relative lack of knowledge and experience. For patients Arcinue-Gomez, Maryko G. Guinto
with cardiac arrest undergoing neurosurgery, the 2014 Resources: Geraldine Raphaela B. Jose, Maryko G. Guinto
United Kingdom Resuscitation Council recommends Writing – original draft: Cristina C. Arcinue-Gomez
starting CPR without changing their position from prone Writing – review & editing: Geraldine Raphaela B. Jose,
to supine if chest compressions are adequate based on Cristina C. Arcinue-Gomez

Volume 2 Issue 3 (2024) 3 doi: 10.36922/bh.3392