Hemodynamic directed CPR improves short-term survival from asphyxia-associated cardiac arrest

Abstract

Aim Adequate coronary perfusion pressure (CPP) during cardiopulmonary resuscitation (CPR) is essential for establishing return of spontaneous circulation. The objective of this study was to compare short-term survival using a hemodynamic directed resuscitation strategy versus an absolute depth-guided approach in a porcine model of asphyxia-associated cardiac arrest. We hypothesized that a hemodynamic directed approach would improve short-term survival compared to depth-guided care. Methods After 7 minutes of asphyxia, followed by induction of ventricular fibrillation, 19 female 3-month old swine (31 ± 0.4 kg) were randomized to receive one of three resuscitation strategies: 1) Hemodynamic Directed Care (CPP-20): chest compressions (CCs) with depth titrated to a target systolic blood pressure of 100 mmHg and titration of vasopressors to maintain CPP > 20 mmHg; 2) Depth 33mm (D33): target CC depth of 33mm with standard American Heart Association (AHA) epinephrine dosing; or 3) Depth 51mm (D51): target CC depth of 51mm with standard AHA epinephrine dosing. All animals received manual CPR guided by audiovisual feedback for 10 minutes before first shock. Results 45-minute survival was higher in the CPP-20 group (6/6) compared to D33 (1/7) or D51 (1/6) groups; p=0.002. Coronary perfusion pressures were higher in the CPP-20 group compared to D33 (p=0.011) and D51 (p=0.04), and in survivors compared to non-survivors (p<0.01). Total number of vasopressor doses administered and defibrillation attempts were not different. Conclusions Hemodynamic directed care targeting CPPs > 20 mmHg improves short-term survival in an intensive care unit porcine model of asphyxia-associated cardiac arrest.

Carotid Doppler blood flow measurement during cardiopulmonary resuscitation is feasible: A first in man study

“…30 Treatments to specifically improve blood flow during CPR improve outcomes versus standard CPR and advanced cardiac life support. 31 Thus high performance CPR using measures of blood flow to guide resuscitation has great potential for improving outcomes. Performing goal directed therapy using non-invasive blood flow monitoring with ultrasound could provide a useful hemodynamic targets throughout resuscitative efforts and potentially improve CPR quality.…”

Patient-Centric Blood Pressure–targeted Cardiopulmonary Resuscitation Improves Survival from Cardiac Arrest

“…Building on previous work (12,13), this randomized investigation compares 24-hour survival with "patient-centric" blood pressure-targeted care (BP care) intended to attain systolic blood pressures greater than 100 mm Hg and CPP greater than 20 mm Hg versus "provider-centric" optimal American Heart Association Guideline care (Guideline care; absolute depth-guided CPR to 51 mm with standard Advanced Cardiac Life Support [ACLS] vasopressor dosing [1]) in a porcine model of asphyxia-associated ventricular fibrillation (VF) cardiac arrest. We hypothesized that the blood pressure-targeted care would improve 24-hour survival compared with optimal American Heart Association Guideline care.…”

“…A robust variance estimator with an exchangeable correlation structure was used to account for longitudinal correlation (i.e., each experiment was analyzed using multiple 15-s epochs). For our primary outcome, 10 animals were randomly assigned to each treatment to give us 80% power to detect a difference in 24-hour survival of 70% (10% in the Guideline care group and 80% in the BP care group), conservative estimates chosen from our short-term survival studies (12,13). Statistical analysis was completed using the Stata-IC statistical package (Version 12.0; StataCorp, College Station, TX).…”

Singapore Paediatric Resuscitation Guidelines 2016

“…(86,87) For the role of ETCO 2 monitoring, the taskforce (2)(3)(4) found that "the use of capnography during paediatric cardiac arrest has until now been informed by only animal data and extrapolation from adult observational data". For invasive blood pressure monitoring, there were only paediatric animal studies to infer from; these showed the benefi t of invasive blood pressure monitoring on critical outcomes such as likelihood of survival to discharge, and ROSC.…”