Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model

Abstract

ObjectiveHead elevation at an angle of 30° during cardiopulmonary resuscitation (CPR) was hemodynamically beneficial compared to supine position in a previous porcine cardiac arrest experimental study. However, survival benefit of head-up elevation during CPR has not been clarified. This study aimed to assess the effect of head-up tilt position during CPR on 24-hour survival in a porcine cardiac arrest experimental model.MethodsThis was a randomized experimental trial using female farm pigs (n=18, 42±3 kg) sedated, intubated, and paralyzed on a tilting surgical table. After surgical preparation, 15 minutes of untreated ventricular fibrillation was induced. Then, 6 minutes of basic life support was performed in a position randomly assigned to either head-up tilt at 30° or supine with a mechanical CPR device, LUCAS-2, and an impedance threshold device, followed by 20 minutes of advanced cardiac life support in the same position. Primary outcome was 24-hour survival, analyzed by Fisher exact test.ResultsIn the 8 pigs from the head-up tilt position group, one showed return of spontaneous circulation (ROSC); all eight pigs expired within 24 hours. In the eight pigs from the supine position group, six had the ROSC; six pigs survived for 24 hours and two expired. The head-up position group showed lower 24-hour survival rate and lower ROSC rate than supine position group (P<0.01).ConclusionThe use of head-up tilt position with 30 degrees during CPR showed lower 24-hour survival than the supine position.

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

“…There remain several caveats regarding the safety of the head-up approach. Our own laboratory work, and that of others, have led us to believe that the head-up process should only begin after several minutes of providing traditional supine CPR with the ITD applied to help “prime the pump” (28, 29). It is further recommended that tilting should be implemented gradually, in a specific sequence following the “priming” step, and only with concurrent use of an ITD in particular (28–31).…”

“…Our own laboratory work, and that of others, have led us to believe that the head-up process should only begin after several minutes of providing traditional supine CPR with the ITD applied to help “prime the pump” (28, 29). It is further recommended that tilting should be implemented gradually, in a specific sequence following the “priming” step, and only with concurrent use of an ITD in particular (28–31). The main admonition is to avoid going directly to the full-tilt target at the beginning of resuscitation efforts and to use appropriate accompanying adjuncts to enhance circulation as described in this analysis considering that it otherwise may even be harmful hemodynamically (28–31).…”

The effect of the head-up position in cardiopulmonary resuscitation – A systematic review and meta-analysis

“…Only 3 studies [13,19,21] with 50 participants reported the ROSC rate. The ROSC rate was 50% (12/24) in the HUP group and 58%…”

“…In addition, facilitating venous return may increase CoPP, and a higher CoPP is associated with a higher ROSC rate [12]. However, Park YJ et al demonstrated that head-up CPR could worsen the survival rate [13]. The outcome of head-up CPR seems inconclusive, so clarifying the effect of head-up CPR is important.…”

For better resuscitation in head up position cardiopulmonary resuscitation: using echocardiography

“…With great interest, we have read the article by Park et al 1 published in Clinical and Experimental Emergency Medicine. This article shows that a 30° angle head-up positioned cardiopulmonary resuscitation (CPR) resulted in a lower 24-hour survival rate and return of spontaneous circulation rate compared with conventional supine positioned CPR.…”