Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival

Abstract

Background: Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of CPR quality but note that "specific values to guide therapy have not been established in children." Methods: This prospective observational cohort study was an NHLBI-funded ancillary study of children in the ICU-RESUS citation trial (NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks post-gestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and had evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mmHg vs. <20 mmHg based on adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation (ROSC), survival to discharge with favorable neurologic outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: 1) invasively measured systolic and diastolic blood pressures and 2) CPR quality and chest compression mechanics metrics (i.e., time to CPR start; chest compression rate, depth, and fraction; ventilation rate). Results: Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mmHg. After controlling for a priori covariates, average ETCO2 ≥20 mmHg was associated with higher incidence of survival to hospital discharge (86/133 (65%) versus 48/101 (48%); aRR 1.33, CI95 1.04 – 1.69, p=0.023) and ROSC (95/133 (71%) versus 59/101 (58%); aRR 1.22, CI95 1.00 – 1.49, p=0.046) compared with lower values. ETCO2 ≥20 mmHg was not associated with survival with favorable neurologic outcome or new morbidity among survivors. Average ETCO2 ≥20 mmHg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups. Conclusions: In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mmHg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.

Survival After Out-of-Hospital Cardiac Arrest Before and After Legislation for Bystander CPR

“…Fourth, this study cannot control for unrecorded variables, such as the quality of bystander CPR, which may cause bias in the results. Poor CPR quality may decrease survival in patients with OHCA . Such information is essential for a more precise evaluation of the effectiveness of legislation.…”

Near-Infrared Spectroscopy in Pediatric Cardiac Arrest: A Piece of the Clinical Picture*

“…ediatric in-hospital cardiac arrest (IHCA) affects approximately 15,000 children annually with current survival to hospital discharge (SHD) of 30-40% (1). Improvements over time in survival and functional outcomes after IHCA can be attributed to numerous factors, an important one being the establishment of cardiopulmonary resuscitation (CPR) quality metrics, which includes: compression rate and depth, chest wall recoil, chest compression fraction, degree of ventilation, and hemodynamic-directed CPR (HD-CPR) (2)(3)(4)(5). HD-CPR requires the presence of invasive monitoring for continuous arterial blood pressure and noninvasive monitoring of end-tidal Co 2 (etco 2 ).…”

“…HD-CPR requires the presence of invasive monitoring for continuous arterial blood pressure and noninvasive monitoring of end-tidal Co 2 (etco 2 ). Established targets for HD-CPR have been incorporated into resuscitation guideline recommendations (2,3,5).…”

Targeting Hemodynamics of Cardiopulmonary Resuscitation to Cardiac Physiology—The Next Frontier for Resuscitation Science?*

“…Last, Yates et al (1) report no association between ET co 2 measurements, available in 35 patients, and survival with favorable neurologic outcome among the ICU-RESUS ECPR cohort. In a recent publication of the entire ICU-RESUS cohort (234 patients), Morgan et al (14) found that average ET co 2 greater than or equal to 20 mm Hg during CPR was associated with improved survival to hospital discharge but was also not associated with favorable neurologic outcome. There was a high prevalence of CHD in the ICU-RESUS ECPR cohort with 85% diagnosed with CHD, compared with 66% cardiac medical or surgical patients in analysis by Morgan et al (14).…”

“…In a recent publication of the entire ICU-RESUS cohort (234 patients), Morgan et al (14) found that average ET co 2 greater than or equal to 20 mm Hg during CPR was associated with improved survival to hospital discharge but was also not associated with favorable neurologic outcome. There was a high prevalence of CHD in the ICU-RESUS ECPR cohort with 85% diagnosed with CHD, compared with 66% cardiac medical or surgical patients in analysis by Morgan et al (14). Indeed, the ICU-RESUS cohort included 12 infants with interstage SV physiology, four with BDG, nine patients with systemic to pulmonary artery shunt.…”