Phased chest and abdominal compression decompression cardiopulmonary resuscitation in cardiac arrest


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Edward M. Omron MD, MPH
Pulmonary, Critical Care Medicine
Morgan Hill, CA 95037

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Phased chest and abdominal compression decompression cardiopulmonary resuscitation in cardiac arrest

  1. 1. syndrome (ACS): The long road to the final 16. Malbrain ML, Deeren DH: Effect of bladder agement of severe sepsis and septic shock. publications, how did we get there? Acta Clin volume on measured intravesical pressure: A Intensive Care Med 2004; 30:536 –555 Belg Suppl 2007; 62:44 –59 prospective cohort study. Crit Care 2006; 10:R98 24. Annane D, Sebille V, Charpentier C, et al: 8. Cheatham ML, White MW, Sagraves SG, et al: 17. Chiumello D, Tallarini F, Chierichetti M, Effect of treatment with low doses of hydro- Abdominal perfusion pressure: A superior pa- et al: The effect of different volumes and cortisone and fludrocortisone on mortality in rameter in the assessment of intra-abdomi- temperatures of saline on the bladder pres- patients with septic shock. JAMA 2002; 288: nal hypertension. J Trauma 2000; 49:621– sure measurement in critically ill patients. 862– 871 626 Crit Care 2007; 11:R82 25. van den Berghe G, Wouters P, Weekers F, 9. De Potter TJ, Dits H, Malbrain ML: Intra- and 18. Cheatham ML, De Waele J, De Keulenaer B, et al: Intensive insulin therapy in the criti- interobserver variability during in vitro vali- et al: The effect of body position on intra- cally ill patients. N Engl J Med 2001; 345: dation of two novel methods for intra- abdominal pressure measurement: A multi- 1359 –1367 abdominal pressure monitoring. Intensive center analysis. Acta Clin Belg Suppl 2007; 26. Bernard GR, Vincent JL, Laterre PF, et al: Care Med 2005; 31:747–751 62:246 Efficacy and safety of recombinant human10. Balogh Z, De Waele JJ, Malbrain ML: Contin- 19. De Waele J, Cheatham ML, De Keulenaer B, activated protein C for severe sepsis. N Engl uous intra-abdominal pressure monitoring. J Med 2001; 344:699 –709 et al: The optimal zero reference transducer Acta Clin Belg Suppl 2007; 62:26 –32 27. Otero RM, Nguyen HB, Huang DT, et al: position for intra-abdominal pressure mea-11. De Waele JJ, De laet I, Malbrain ML: Rational Early goal-directed therapy in severe sepsis surement: A multicenter analysis. Acta Clin intra-abdominal pressure monitoring: How and septic shock revisited: Concepts, contro- Belg Suppl 2007; 62:247 to do it? Acta Clin Belg Suppl 2007; 62:16 –25 versies, and contemporary findings. Chest 20. Bellomo R, Kellum JA, Ronco C: Defining12. Malbrain ML, De laet I, De Waele JJ: Contin- 2006; 130:1579 –1595 and classifying acute renal failure: From ad- uous intra-abdominal pressure monitoring: 28. Ivatury RR, Sugerman HJ: Abdominal com- This is the way to go! Int J Clin Pract 2008; vocacy to consensus and validation of the partment syndrome: A century later, isn’t it 62:359 –362 RIFLE criteria. Intensive Care Med 2007; 33: time to pay attention? Crit Care Med 2000;13. Malbrain ML, De Laet I, Viaene D, et al: In 409 – 413 28:2137–2138 vitro validation of a novel method for con- 21. Kimball EJ, Kim W, Cheatham ML, et al: 29. Sugrue M: Intra-abdominal pressure: Time tinuous intra-abdominal pressure monitor- Clinical awareness of intra-abdominal hyper- for clinical practice guidelines? Intensive ing. Intensive Care Med 2008; 34:740 –745 tension and abdominal compartment syn- Care Med 2002; 28:389 –39114. Malbrain ML: Different techniques to mea- drome in 2007. Acta Clin Belg Suppl 2007; 30. Malbrain ML: Is it wise not to think about sure intra-abdominal pressure (IAP): Time 62:66 –73 intra-abdominal hypertension in the ICU? for a critical re-appraisal. Intensive Care Med 22. Rivers E, Nguyen B, Havstad S, et al: Early Curr Opin Crit Care 2004; 10:132–145 2004; 30:357–371 goal-directed therapy in the treatment of se- 31. Malbrain ML: Incidence of intra-abdominal15. De Waele J, Pletinckx P, Blot S, et al: Saline vere sepsis and septic shock. N Engl J Med hypertension in the intensive care unit: For volume in transvesical intra-abdominal pres- 2001; 345:1368 –1377 the Critically Ill and Abdominal Hyperten- sure measurement: Enough is enough. In- 23. Dellinger RP, Carlet JM, Masur H, et al: Sur- sion (CIAH) Study Group. Crit Care Med tensive Care Med 2006; 32:455– 459 viving Sepsis Campaign guidelines for man- 2005; 33:2150 –2153The ups and downs of a good idea: Phased chest and abdominalcompression– decompression cardiopulmonary resuscitation incardiac arrest*A pproximately 166,000 out-of- proving outcome from sudden cardiac Active phased compression– decom- hospital cardiac arrests occur arrest is a healthcare urgency, but clini- pression resuscitation (APCDR) is an al- annually in North America, cal human research is very difficult sec- ternative to standard CPR that traces its with a median reported sur- ondary to ethical concerns over informed origins from computer-based analogvival to discharge of 6.4% (1, 2). Despite consent and poor funding (3). Innova- modeling designed to optimize coronaryadvances in the delivery of care and in- tions to improve vital organ blood flow and cerebral perfusion (6). It is per-novations in cardiopulmonary resuscita- were introduced into the 2005 American formed by a hand-held seesaw-like devicetion (CPR), prognosis remains poor. Im- Heart Association CPR guidelines, which that delivers coincident positive intratho- attempted to maximize coronary and ce- racic pressure and abdominal decompres- rebral perfusion pressures and minimize sion, followed by negative intrathoracic *See also p. 1832. their loss from excessive ventilation dur- pressure and abdominal compression. Key Words: cardiopulmonary resuscitation; cardiac ing the hemodynamic phase of cardiac During the chest compression phase, thearrest; active compression– decompression resuscita- arrest (4, 5). Nevertheless, disappoint- positive intrathoracic pressure is thoughttion; death; sudden The author has not disclosed any potential con- ment with outcomes from conventional to augment cerebral perfusion pressureflicts of interest. CPR has prompted researchers to inves- with coincident decompression of the ab- Copyright © 2008 by the Society of Critical Care tigate alternative methods to improve vi- domen, which reduces ventricular after-Medicine and Lippincott Williams & Wilkins tal organ blood flow and postresuscita- load. Active chest decompression with ab- DOI: 10.1097/CCM.0b013e318176ad02 tion survival. dominal compression increases venous1974 Crit Care Med 2008 Vol. 36, No. 6
  2. 2. return and augments coronary perfusion Instruments, Grand Rapids, MI) in a pro- cumulative meta-analysis of the effective-pressure (7). Adequate coronary and ce- spective, case-control, clinical study of ness of defibrillator-capable emergencyrebral perfusion pressures after pro- prolonged cardiac arrest. medical services for victims of out-of-longed cardiac arrest but before defibril- Caveats that are appropriately noted hospital cardiac arrest. Ann Emerg Medlation are the main determinants of by the authors at the outset are that the 1999; 34:517–525survivability and neurologic outcome (8). experimental and control groups were 3. Halperin H, Paradis N, Mosesso V, et al: Rec- ommendations for implementation of com- Early animal studies with APCDR sug- not randomized, physicians were not munity consultation and public disclosuregested improved survival with increased blinded to the interventions, and the under the Food and Drug Administration’scoronary and cerebral perfusion pres- small sample sizes (Lifestick, 20; “Exception From Informed Consent Require-sures when compared with standard CPR. Thumper, 11) preclude any definitive ments for Emergency Research”: A specialTang et al. (9) induced ventricular fibril- commentary on efficacy or safety. Never- report from the American Heart Associationlation in a porcine model of cardiac ar- theless, the article by Dr. Havel and col- Emergency Cardiovascular Committee andrest. Animals were randomized to either leagues (12) provides interesting and Council on Cardiopulmonary, PerioperativeLifestick (Datascope Corporation, Fair- valuable commentary on the hemody- and Critical Care. Endorsed by the Americanfield, NJ) APCDR or standard CPR. Sig- namic and echocardiographic changes as- College of Emergency Physicians and the So-nificant improvements in coronary perfu- sociated with APCDR in humans. ciety for Academic Emergency Medicine. Cir-sion pressure, aortic pressure, end-tidal In five patients, direct measurements culation 2007; 116:1855–1863CO2, 48-hr survival, and neurologic re- revealed increased coronary perfusion 4. 2005 American Heart Association guidelinescovery over standard CPR were demon- pressures and, in 15 patients, increases in for cardiopulmonary resuscitation and emer-strated. Wenzel et al. (10) performed a end-tidal CO2 during Lifestick APCDR gency cardiovascular care. Circulation 2005;confirmatory study of the hemodynamic relative to mechanical precordial com- 112(Suppl 1)IV-1–IV-211effects of Lifestick APCDR relative to pression, supportive of preserved and 5. Ewy GA: Cardiocerebral resuscitation: Thestandard CPR, also in the porcine model. possibly improved coronary perfusion new cardiopulmonary resuscitation. Circula-Lifestick APCDR animals again demon- pressures and cardiac output. tion 2005; 111:2134 –2142strated improved coronary and cerebral Transesophageal echocardiography was 6. Babbs CF, Weaver C, Ralston S, et al: Cardiac,perfusion, mean arterial pressure, and performed in a limited number of Lifestick thoracic, and abdominal pump mechanisms in cardiopulmonary resuscitation: Studies inend-tidal CO2 compared with standard and Thumper patients, revealing that likely an electrical model of the circulation. Am JCPR. More significantly, Wenzel et al. both thoracic and cardiac pump mecha- Emerg Med 1984; 2:299 –308(10) were able show that the survival and nisms are mutually operative to maintain 7. Babbs CF: CPR techniques that combine chestneurologic improvements from earlier blood flow during CPR (13). and abdominal compression and decompres-animal studies were associated with im- At this time, Lifestick resuscitation sion: Hemodynamic insights from a spread-proved coronary and cerebral perfusion cannot be recommended in cardiac arrest sheet model. Circulation 1999; 100:2146 –2152pressures compared with standard CPR. because of the lack of any objective ben- 8. Ewy GA, Kern KB, Sanders AB, et al: Cardio- Arntz et al. (11) performed a prospec- efit and limited human studies. Neverthe- cerebral resuscitation for cardiac arrest.tive, blinded feasibility and safety study of less, Dr. Havel and colleagues (12) should Am J Med 2006; 119:6 –950 patients randomized to Lifestick be congratulated on moving forward an 9. Tang W, Weil MH, Schock RB, et al: PhasedAPCDR (n 24) or conventional CPR adjunctive resuscitation technique that chest and abdominal compression-decom-(n 26) in patients with nontraumatic remains promising. Future studies pression: A new option for cardiopulmonaryout-of-hospital cardiac arrest. Although should be directed to further clarify the resuscitation. Circulation 1997; 95:1335–no improvement in outcome was demon- hemodynamic consequences of Lifestick 1340strated, Lifestick APCDR demonstrated resuscitation earlier in cardiac arrest, 10. Wenzel V, Lindner KH, Prengel AW, et al:no significant chest or abdominal com- with higher compression and lower ven- Effect of phased chest and abdominal com-plications. Rescue personnel considered tilation ratios to be consistent with cur- pression-decompression cardiopulmonaryapplication of the Lifestick device practi- rent American Heart Association CPR resuscitation on myocardial and cerebralcal and relatively easy to fixate to the guidelines. blood flow in pigs. Crit Care Med 2000; 28:chest. Notably absent was any objective Edward M. Omron, MD, MPH, 1107–1112 FCCP 11. Arntz HR, Agrawal R, Richter H, et al: Phasedhemodynamic assessment of Lifestick or chest and abdominal compression-decom-conventional CPR. Overall, Lifestick ap- Pulmonary and Critical Care pression versus conventional cardiopulmo-plication seemed feasible and safe, but Service nary resuscitation in out-of-hospital cardiacthe small sample size and variability in Ingham Regional Medical arrest. Circulation 2001; 104:768 –772presenting rhythms between the groups Center 12. Havel C, Berzlanovich A, Sterz F, et al:limited any assessment of hemodynamic Lansing, MI Safety, feasibility, and hemodynamic andefficacy. blood flow effects of active compression– In the current issue of Critical Care REFERENCES decompression of thorax and abdomen inMedicine, Dr. Havel and colleagues (12) 1. Rea TD, Eisenberg MS, Sinibaldi G, et al: patients with cardiac arrest. Crit Care Medexamine the safety, feasibility, and hemo- Incidence of EMS-treated out of hospital car- 2008; 36:1832–1837dynamic consequences of Lifestick diac arrest in the United States. Resuscita- 13. Andreka P, Frenneaux MP: HaemodynamicsAPCDR compared with mechanical chest tion 2004; 63:17–24 of cardiac arrest and resuscitation. Curr Opincompression (Thumper device, Michigan 2. Nichol G, Stiell IG, Laupacis A, et al: A Crit Care 2006; 12:198 –203Crit Care Med 2008 Vol. 36, No. 6 1975