Blood Pressure– and Coronary Perfusion Pressure–Targeted Cardiopulmonary Resuscitation Improves 24-Hour Survival From Ventricular Fibrillation Cardiac Arrest

Abstract

Objective Treatment algorithms for cardiac arrest are rescuer-centric and vary little from patient to patient. The objective of this study was to determine if cardiopulmonary resuscitation (CPR) targeted to arterial blood pressure and coronary perfusion pressure (CPP) rather than optimal Guideline Care would improve 24-hour survival in a porcine model of ventricular fibrillation (VF) cardiac arrest. Design Randomized interventional study Setting Preclinical animal laboratory Subjects Female 3-month old swine Interventions/Measurements After induction of anesthesia and 7 minutes of untreated VF, 16 female 3-month old swine were randomized to: 1) Blood Pressure (BP) care: titration of chest compression (CC) depth to a systolic blood pressure (SBP) of 100 mmHg and vasopressor dosing to maintain CPP >20mmHg or 2) Guideline care: CC depth targeted to 51 mm and standard Guideline vasopressor dosing. Animals received manual CPR for 10 minutes before the first defibrillation attempt and standardized post-resuscitation care for 24 hours. Main Results 24-hour survival was more likely with BP care versus Guideline care (0/8 versus 5/8, p<0.03), and all survivors had normal neurological examinations. Mean CPP prior to defibrillation was significantly higher with BP care (28±3 mmHg versus 10±6 mmHg, p<0.01). CC depth was lower with BP care (48±0.4 mmHg versus 44±0.5 mmHg, p<0.05) and number of vasopressor doses was higher with BP care (median 3 [range 1-7] versus 2 [range 2-2], p<0.01). Conclusions Individualized goal-directed hemodynamic resuscitation targeting SBP of 100 mmHg and CPP >20 mmHg improved 24-hour survival compared to Guideline care in this model of VF cardiac arrest.

End-Tidal Co 2–Guided Chest Compression Delivery Improves Survival in a Neonatal Asphyxial Cardiac Arrest Model*

“…Our results indicate that attempting to raise ETCO 2 levels during CPR can result in increased ETCO 2 levels that do not indicate likelihood of ROSC. Figure 3B1 shows that the relationship between the relaxation arterial pressure (a surrogate for myocardial perfusion (10, 30–32)) and survival is present in both study groups during BLS. In contrast, the ETCO 2 , SPP, and CPP levels during BLS in the non-survivors of the ETCO 2 -guided group overlap the survivors of both groups (Fig.…”

“…Extracorporeal CPR (eCPR) technology is improving, but rates of neurologic injury and failure to wean from support after recovery remain high. Hemodynamic-directed CPR has shown great promise for improving survival and neurologic outcome in preclinical models when an arterial line is present to guide epinephrine administration (8–10, 32). Near-infrared spectroscopy measurements and amplitude analysis of ventricular fibrillation are other physiologic responses that have the potential to guide resuscitation efforts.…”

“…A previously described resuscitation method that incorporates physiologic feedback is hemodynamic-directed cardiopulmonary resuscitation (CPR), which uses arterial pressure monitoring. Hemodynamic-directed CPR has been used to guide chest compression delivery (increased rate and force) and epinephrine administration frequency in adults (7) and to improve outcome in animal models (8–10). …”

Comparison of two infant chest compression techniques during simulated newborn cardiopulmonary resuscitation performed by a single rescuer: A randomized, crossover multicenter trial

“…The four main quality measurements of cardiopulmonary resuscitation are CC rate, CC depth, release force, and compression duty cycles [3,4]. The resuscitation guidelines emphasize the reduction of hands-off time in cardiopulmonary resuscitation, optimal CC frequency, depth, and full chest relaxation [4,11]. The knowledge of the newborn CC technique is important for all medical personnel, including physicians, nurses, midwifes, and paramedics [12].…”

Is there any alternative to standard chest compression techniques in infants? A randomized manikin trial of the new “2-thumb-fist” option

“…[ 12 , 22 – 25 ] Our finding is novel and striking, because for the first time, we showed that our nTTT outperformed TTEHT in SBP, MAP, and PP. Arterial blood pressure generated during CPR is a quality metric of CPR and higher pressure has been correlated with improved survival, [ 26 ] ROSC, [ 6 ] and more favorable neurological outcomes. [ 27 ] In general, of children who survive a CA, only 24% to 47% have a favorable neurological outcome.…”