Consistent head up cardiopulmonary resuscitation haemodynamics are observed across porcine and human cadaver translational models

Moore, Johanna C.; Holley, Joe; Segal, Nicolas; Lick, Michael; Labarère, José; Frascone, Ralph J.; Dodd, Kenneth W.; Robinson, Aaron E.; Lick, Charles; Klein, Lauren R.; Ashton, Andrew; McArthur, Angela; Tsangaris, Adamantios; Makaretz, Anna; Makaretz, Mike; Debaty, Guillaume; Pepe, Paul E.; Lurie, Keith G.

doi:10.1016/j.resuscitation.2018.04.009

Cited by 31 publications

(37 citation statements)

References 22 publications

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“…Next, we excluded 27 articles (because they were review articles, not original studies, or posts/conference abstracts, studied human cadavers, not compare with supine position, lacked detailed data, letter to editor or post CPR). Initially, eight studies [ 14 – 18 , 21 , 22 , 28 ], including 147 pigs, were included; however, we excluded one study (that used different CPR methods with different angles) because of the lack of a comparison group [ 21 ]. Therefore, 7 studies with 131 subjects were ultimately analyzed in the meta-analysis (Fig.…”

Section: Resultsmentioning

confidence: 99%

“…In recent years, animal studies have revealed the head-up positions (HUP) with ACD + ITD CPR or automated (LUCAS 2.0) + ITD CPR could decrease ICP and improve CerPP [ 14 ] and that it may even improve coronary perfusion pressure (CoPP) [ 15 ] in animal experiments. As to HUP, some studies tilted whole body up, also called “the reverse-Trendelenburg position,” to lower ICP.…”

Section: Introductionmentioning

confidence: 99%

“…However, this position could also decrease MAP due to pooling more blood in lower extremities [ 15 , 16 ]. To avoid this condition, other studies elevated the “head and chest up only” [ 14 , 17 , 18 ]. No matter what HUP posed, compared to CCPR, in which the patient lies down at 0 degrees, elevating the head during CPR could accelerate brain venous return and the hydrostatic displacement of cerebrospinal fluid (CSF) from the cerebral ventricles to the spinal cavity [ 19 ].…”

Section: Introductionmentioning

confidence: 99%

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The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis

et al. 2021

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Objective Experimental studies of head-up positioning (HUP) during cardiopulmonary resuscitation (CPR) have had some degree of conflicting published results. The current study aim was to analyze and reconcile those discrepancies in order to better clarify the effects of HUP CPR compared to conventional supine (SUP) CPR. Methods Three databases (PubMed, EMBASE and Cochrane Library) were searched comprehensively (from each respective database's inception to May 2021) for articles addressing HUP CPR. The primary outcome to be observed was cerebral perfusion pressure (CerPP), and secondary outcomes were mean intracranial pressure (ICP), mean arterial pressure (MAP), coronary perfusion pressure (CoPP) and frequencies of return of spontaneous circulation (ROSC). Results Seven key studies involving 131 animals were included for analysis. Compared to SUP CPR, CerPP (MD 10.37; 95% CI 7.11–13.64; p < 0.01; I2 = 58%) and CoPP (MD 7.56; 95% CI 1.84–13.27, p = 0.01; I2 = 75%) increased significantly with HUP CPR, while ICP (MD − 13.66; 95% CI − 18.6 to –8.71; p < 0.01; I2 = 96%) decreased significantly. Combining all study methodologies, there were no significant differences detected in MAP (MD − 1.63; 95% CI − 10.77–7.52; p = 0.73; I2 = 93%) or frequency of ROSC (RR 0.9; 95% CI 0.31–2.60; p = 0.84; I2 = 65%). However, in contrast to worse outcomes in studies using immediate elevation of the head in a reverse Trendelenburg position, study outcomes were significantly improved when HUP (head and chest only) was introduced in a steady, graduated manner following a brief period of basic CPR augmented by active compression–decompression (ACD) and impedance threshold (ITD) devices. Conclusion In experimental models, gradually elevating the head and chest following a brief interval of circulatory priming with ACD and ITD devices can enhance CoPP, lower ICP and improve CerPP significantly while maintaining MAP. This effect is immediate, remains sustained and is associated with improved outcomes.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis

et al. 2021

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“…Human beings have much larger lower extremities, and other anatomical differences may alter the physiology of head-up/torso-up CPR. Accordingly, we recently compared the swine model with a cadaver model with this bundled flow augmenting approach and found similar proportional changes in blood flow (32). These findings encourage us to believe that this distinction is less of a concern, but the optimal degree of elevation (e.g., 20° vs 30°) and the actual elevation sequence and timing of elevation for human beings are all important considerations that are currently under evaluation using new technology to support the degree and timing of the head-up/torso-up implementation (33).…”

Section: Discussionmentioning

confidence: 92%

Confirming the Clinical Safety and Feasibility of a Bundled Methodology to Improve Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest Compression Technique

Pepe

Scheppke

Antevy

et al. 2019

Critical Care Medicine

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Objectives: Combined with devices that enhance venous return out of the brain and into the thorax, preclinical outcomes are improved significantly using a synergistic bundled approach involving mild elevation of the head and chest during cardiopulmonary resuscitation. The objective here was to confirm clinical safety/feasibility of this bundled approach including use of mechanical cardiopulmonary resuscitation provided at a head-up angle. Design: Quarterly tracking of the frequency of successful resuscitation before, during, and after the clinical introduction of a bundled head-up/torso-up cardiopulmonary resuscitation strategy. Setting: 9-1-1 response system for a culturally diverse, geographically expansive, populous jurisdiction. Patients: All 2,322 consecutive out-of-hospital cardiac arrest cases (all presenting cardiac rhythms) were followed over 3.5 years (January 1, 2014, to June 30, 2017). Interventions: In 2014, 9-1-1 crews used LUCAS (Physio-Control Corporation, Redmond, WA) mechanical cardiopulmonary resuscitation and impedance threshold devices for out-of-hospital cardiac arrest. After April 2015, they also 1) applied oxygen but deferred positive pressure ventilation several minutes, 2) solidified a pit-crew approach for rapid LUCAS placement, and 3) subsequently placed the patient in a reverse Trendelenburg position (~20°). Measurements and Main Results: No problems were observed with head-up/torso-up positioning ( n = 1,489), but resuscitation rates rose significantly during the transition period (April to June 2015) with an ensuing sustained doubling of those rates over the next 2 years (mean, 34.22%; range, 29.76–39.42%; n = 1,356 vs 17.87%; range, 14.81–20.13%, for 806 patients treated prior to the transition; p < 0.0001). Outcomes improved across all subgroups. Response intervals, clinical presentations and indications for attempting resuscitation remained unchanged. Resuscitation rates in 2015–2017 remained proportional to neurologically intact survival (~35–40%) wherever tracked. Conclusions: The head-up/torso-up cardiopulmonary resuscitation bundle was feasible and associated with an immediate, steady rise in resuscitation rates during implementation followed by a sustained doubling of the number of out-of-hospital cardiac arrest patients being resuscitated. These findings make a compelling case that this bundled technique will improve out-of-hospital cardiac arrest outcomes significantly in other clinical evaluations.

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“…In a swine study, CerPP remained significantly higher in the HUP-CPR pigs, especially when an impedance threshold device was used [47]. These physiological changes were recently replicated in deceased human cadaver models; HUP-CPR resulted in decreased ICP and increased CerPP, further supporting its use in patients in cardiac arrest [48]. Nevertheless, the compression-related cardiac output may be impaired during human HUP-CPR due to pooling of blood in the lower extremities.…”

Section: Neuroprotection During Cardiopulmonary Resuscitation: Brain mentioning

confidence: 88%

Personalized physiology-guided resuscitation in highly monitored patients with cardiac arrest—the PERSEUS resuscitation protocol

2019

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Resuscitation guidelines remain uniform across all cardiac arrest patients, focusing on the delivery of chest compressions to a standardized rate and depth and algorithmic vasopressor dosing. However, individualizing resuscitation to the appropriate hemodynamic and ventilatory goals rather than a standard Bone-size-fits-all^treatment seems a promising new therapeutic strategy. In this article, we present a new physiology-guided treatment strategy to titrate the resuscitation efforts to patient's physiologic response after cardiac arrest. This approach can be applied during resuscitation attempts in highly monitored patients, such as those in the operating room or the intensive care unit, and could serve as a method for improving tissue perfusion and oxygenation while decreasing post-resuscitation adverse effects.

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Consistent head up cardiopulmonary resuscitation haemodynamics are observed across porcine and human cadaver translational models

Cited by 31 publications

References 22 publications

The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis

The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis

Confirming the Clinical Safety and Feasibility of a Bundled Methodology to Improve Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest Compression Technique

Personalized physiology-guided resuscitation in highly monitored patients with cardiac arrest—the PERSEUS resuscitation protocol

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