A hemodynamic-directed approach to pediatric cardiopulmonary resuscitation (HD-CPR) improves survival

Abstract

Aim Most pediatric in-hositalcardiac arrests(IHCAs) occur in ICUs where invasive hemodynamic monitoring is frequently available. Titrating cardiopulmonary resuscitation (CPR) to the hemodynamic response of the individual improves survival in preclinical models of adult cardiac arrest. The objective of this study was to determine if titrating CPR to systolic blood pressure (SBP) and coronary perfusion pressure (CoPP) in a pediatric porcine model of asphyxia-associated ventricular fibrillation (VF) IHCA would improve survival as compared to traditional CPR. Methods After 7 minutes of asphyxia followed by VF, 4-week-old piglets received either Hemodynamic-Directed CPR (HD-CPR; compression depth titrated to SBP of 90mmHg and vasopressor administration to maintain CoPP ≥20mmHg); or Standard Care (compression depth 1/3 of the anterior-posterior chest diameter and epinephrine every 4 minutes). All animals received CPR for 10 minutes prior to the first defibrillation attempt. CPR was continued for a maximum of 20 minutes. Protocolized intensive care was provided to all surviving animals for 4 hours. The primary outcome was 4-hour survival. Results Survival rate was greater with HD-CPR (12/12) than Standard Care (6/10; p=0.03). CoPP during HD-CPR was higher compared to Standard Care (point estimate +8.1mmHg, CI95: 0.5–15.8mmHg; p=0.04). Chest compression depth was lower with HD-CPR than Standard Care (point estimate 14.0mm, CI95: 9.6–18.4mm; p<0.01). Prior to the first defibrillation attempt, more vasopressor doses were administered with HD-CPR versus Standard Care (median 5 versus 2; p<0.01). Conclusions Hemodynamic-directed CPR improves short-term survival compared to standard depth-targeted CPR in a porcine model of pediatric asphyxia-associated VF IHCA.

Effects of epinephrine on hemodynamic changes during cardiopulmonary resuscitation in a neonatal piglet model

“…In a neonatal porcine model of asphyxia, McNamara et al (16) reported significantly higher survival rates after vasopressin administration compared with epinephrine. A coronary perfusion pressure threshold of 20 mm Hg is needed to achieve ROSC and might be achieved with the combination of CC, adequate ventilation, and epinephrine administration (18). Morgan et al (18) compared a hemodynamic-directed chest compression technique with CC depth titrated to achieve a systolic blood pressure of 90 mm Hg, and vasopressors were only given if the coronary perfusion pressure was o20 mm Hg in asphyxiated piglets.…”

Epinephrine’s effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation

“…CPR was continued until sustained ROSC of ≥ 20 min was achieved, or after an additional 10 min of resuscitation post-initial defibrillation attempt, after which time resuscitative efforts were discontinued (20-min maximum of CPR). Following ROSC, animals received protocolized intensive care unit treatment that has been previously described [44,45] for a period of 4 h, after which time animals were humanely euthanized with potassium chloride (2 mEq/kg).…”

Pulmonary Vasodilator Therapy in Shock-associated Cardiac Arrest

“…The Children's Hospital of Philadelphia Institutional Animal Care and Use Committee approved the experimental protocol, which is in concordance with the National Institutes of Health Guide for the Care and Use of Laboratory Animals. Comprehensive descriptions of animal preparation, anesthetic, and surgical methods are available in our previous publications (9)(10)(11)(12)(13)22). Briefly, 3-month-old swine were anesthetized and mechanically ventilated.…”

“…To that end, our previous swine investigations in primary ventricular fibrillation and asphyxial cardiac arrest models have established that hemodynamicdirected CPR (HD-CPR) can improve outcomes compared with standard, depth-guided CPR (9)(10)(11)(12)(13). However, this HD-CPR approach has not been applied to circulatory shock-associated in-hospital cardiac arrest.…”