Automated cardiopulmonary resuscitation using a load-distributing band external cardiac support device for in-hospital cardiac arrest: A single centre experience of AutoPulse-CPR

Cardiac arrest and cardiopulmonary resuscitation in "hostile" environments: Using automated compression devices to minimize the rescuers' danger

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual, "hands-on", rescuer-delivered chest compressions. The -theoretical- advantages include high-quality non-stop compressions, thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially "hazardous" victim, or from hazardous and/or difficult resuscitation conditions. Such circumstances involve cardiopulmonary resuscitation (CPR) in the Cardiac Catheterization Laboratory, especially directly under the fluoroscopy panel, where radiation is well known to cause detrimental effects to the rescuer, and CPR during/after land or air transportation of cardiac arrest victims. Lastly, CPR in a coronavirus disease 2019 patient/ward, where the danger of contamination and further serious illness of the health provider is very existent. The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these "hostile" and dangerous settings, while comparing them to manual compressions.

Back Plate Marking of a Mechanical Chest Compression Device to Reduce the Duration of Chest Compression Interruptions

Objective

Methods

Results

Conclusion

Mechanical chest compression devices under special circumstances

AIM

According to the current resuscitation guidelines, the use of mechanical chest compression devices could be considered under special circumstances like transport with ongoing resuscitation or long-term resuscitation. The aim of this study was to investigate whether survival is improved using mechanical devices under such circumstances.

METHODS

Out-of-hospital cardiac arrests from all high-quality data centres of the German Resuscitation Registry from 2007 to 2020 were investigated. The use of mechanical devices was compared separately for transport with ongoing resuscitation, prolonged resuscitation (>45 min), and resuscitation with fibrinolytic agents applied. Baseline characteristics, 30-day survival/discharged alive, and neurological function at discharge were analysed descriptively; and 30-day survival/discharged alive was additionally analysed using multivariate logistic regression.

RESULTS

Overall, patients who were treated with a mechanical device tended to be younger and were significantly more likely to have a witnessed cardiac arrest and a shockable initial rhythm. During the study period, 4,851 patients were transported to hospital with ongoing resuscitation (devices used in 44.2%). The 30-day survival was equal (odds ratio, OR: 1.13, 95%-CI: 0.79-1.60). In 3,920 cases, a resuscitation duration > 45 min was documented (9.5% with device). When a device was used, 30-day survival was significantly increased (OR 2.33, 95%-CI: 1.30-4.15). Fibrinolytic agents were used in 2,106 patients (22.2% with device). Here, 30-day survival was significantly worse with a device (OR: 0.52, 95%-CI: 0.30-0.91).

CONCLUSION

Mechanical devices are not associated with better survival when used during transport, but rescuer safety could still be an important argument for their use. Devices are associated with better survival in prolonged resuscitation, but worse survival when a fibrinolytic was used.

The role of automated compression devices in out-of- and in- hospital cardiac arrest. Can we spare rescuers’ hands?

Research regarding the use of mechanical compressions in the setting of a cardiac arrest, either outside of or inside the hospital environment has produced mixed results. The debate whether they can replace manual compressions still remains. The aim of this review is to present current literature contemplating the application of mechanical compressions in both settings, data comparing them to manual compressions as well as current guidelines regarding their implementation in everyday clinical use. Currently, their implementation in the resuscitation protocol seems to benefit the victims of an in-hospital cardiac arrest rather than the victims that sustain a cardiac arrest outside of the hospital.

Mechanical versus manual chest compressions in the treatment of in-hospital cardiac arrest patients in a non-shockable rhythm: A multi-centre feasibility randomised controlled trial (COMPRESS-RCT)

BACKGROUND

Mechanical chest compression devices deliver high-quality chest compressions. Early data suggests that mechanical devices may be superior to manual chest compressions in adults following an in-hospital cardiac arrest patients. To determine the feasibility of undertaking an effectiveness trial in this population, we undertook a feasibility randomised controlled trial.

METHODS

We undertook a multi-centre parallel group feasibility randomised controlled trial (COMPRESS-RCT). Adult in-hospital cardiac arrest patients that were in a non-shockable rhythm were randomised in a 3:1 ratio to receive mechanical CPR (Jolfe AB/Stryker, Lund, Sweden) or ongoing manual CPR. Recruitment was led by the clinical cardiac arrest team. The primary study outcome was the proportion of eligible participants randomised in the study during site operational recruitment hours. Patients were enrolled under a model of deferred consent. We report data using descriptive statistics, point estimates and 95% confidence intervals.

RESULTS

Over a two-year period, we recruited 127 patients across five UK hospitals. We recruited 55.2% (95% CI 48.5%-61.8%) of eligible study participants in site operational recruitment hours. Most participants were male (n = 76, 59.8%) with a mean age of 72 (95% CI: 69.9-74.9) years. Median arrest duration was 18 (IQR 13-29) minutes. In patients randomised to mech-CPR, median time from CPR start to device deployment was 11 (IQR 7-15) minutes. ROSC was achieved in 27.6% (n = 35) participants and 4.7% (n = 6) were alive at 30-days.

CONCLUSION

COMPRESS-RCT identified important factors that preclude progression to an effectiveness trial of mechanical CPR in the hospital setting in the UK. Findings will inform the design of future in-hospital intra-arrest intervention trials. ISRCTN38139840, date of registration 9th January 2017.

Cardiopulmonary Resuscitation in Intensive Care Unit Patients With Coronavirus Disease 2019

Cardiopulmonary resuscitation (CPR) in patients with severe acute respiratory syndrome coronavirus-2–associated disease (coronavirus disease 2019) poses a unique challenge to health- care providers due to the risk of viral aerosolization and disease transmission. This has caused some centers to modify existing CPR procedures, limit the duration of CPR, or consider avoiding CPR altogether. In this review, the authors propose a procedure for CPR in the intensive care unit that minimizes the number of personnel in the immediate vicinity of the patient and conserves the use of scarce personal protective equipment. Highlighting the low likelihood of successful resuscitation in high-risk patients may prompt patients to decline CPR. The authors recommend the preemptive placement of central venous lines in high-risk patients with intravenous tubing extensions that allow for medication delivery from outside the patients’ rooms. During CPR, this practice can be used to deliver critical medications without delay. The use of a mechanical compression system for CPR further reduces the risk of infectious exposure to health- care providers. Extracorporeal membrane oxygenation should be reserved for patients with few comorbidities and a single failing organ system. Reliable teleconferencing tools are essential to facilitate communication between providers inside and outside the patients' rooms. General principles regarding the ethics and peri-resuscitative management of coronavirus 2019 patients also are discussed.

Mechanical CPR: Who? When? How?

In cardiac arrest, high quality cardiopulmonary resuscitation (CPR) is a key determinant of patient survival. However, delivery of effective chest compressions is often inconsistent, subject to fatigue and practically challenging.

Mechanical CPR devices provide an automated way to deliver high-quality CPR. However, large randomised controlled trials of the routine use of mechanical devices in the out-of-hospital setting have found no evidence of improved patient outcome in patients treated with mechanical CPR, compared with manual CPR. The limited data on use during in-hospital cardiac arrest provides preliminary data supporting use of mechanical devices, but this needs to be robustly tested in randomised controlled trials.

In situations where high-quality manual chest compressions cannot be safely delivered, the use of a mechanical device may be a reasonable clinical approach. Examples of such situations include ambulance transportation, primary percutaneous coronary intervention, as a bridge to extracorporeal CPR and to facilitate uncontrolled organ donation after circulatory death.

The precise time point during a cardiac arrest at which to deploy a mechanical device is uncertain, particularly in patients presenting in a shockable rhythm. The deployment process requires interruptions in chest compression, which may be harmful if the pause is prolonged. It is recommended that use of mechanical devices should occur only in systems where quality assurance mechanisms are in place to monitor and manage pauses associated with deployment.

In summary, mechanical CPR devices may provide a useful adjunct to standard treatment in specific situations, but current evidence does not support their routine use.

Training approaches for the deployment of a mechanical chest compression device: a randomised controlled manikin study

OBJECTIVES

To evaluate the effect of training strategy on team deployment of a mechanical chest compression device.

DESIGN

Randomised controlled manikin trial.

SETTING

Large teaching hospital in the UK.

PARTICIPANTS

Twenty teams, each comprising three clinicians. Participating individuals were health professionals with intermediate or advanced resuscitation training.

INTERVENTIONS

Teams were randomised in a 1:1 ratio to receive either standard mechanical chest compression device training or pit-crew device training. Training interventions lasted up to 1 h. Performance was measured immediately after training in a standardised simulated cardiac arrest scenario in which teams were required to deploy a mechanical chest compression device.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was chest compression flow fraction in the minute preceding the first mechanical chest compression. Secondary outcomes included cardiopulmonary resuscitation quality and mechanical device deployment metrics, and non-technical skill performance. Outcomes were assessed using video recordings of the test scenario.

RESULTS

In relation to the primary outcome of chest compression flow fraction in the minute preceding the first mechanical chest compression, we found that pit-crew training was not superior to standard training (0.76 (95% CI 0.73 to 0.79) vs 0.77 (95% CI 0.73 to 0.82), mean difference -0.01 (95% CI -0.06 to 0.03), P=0.572). There was also no difference between groups in performance in relation to any secondary outcome.

CONCLUSIONS

Pit-crew training, compared with standard training, did not improve team deployment of a mechanical chest device in a simulated cardiac arrest scenario.

TRIAL REGISTRATION NUMBER

ISRCTN43049287; Pre-results.

Mechanical chest compression devices at in-hospital cardiac arrest: A systematic review and meta-analysis

AIM

To summarise the evidence in relation to the routine use of mechanical chest compression devices during resuscitation from in-hospital cardiac arrest.

METHODS

We conducted a systematic review of studies which compared the effect of the use of a mechanical chest compression device with manual chest compressions in adults that sustained an in-hospital cardiac arrest. Critical outcomes were survival with good neurological outcome, survival at hospital discharge or 30-days, and short-term survival (ROSC/1-h survival). Important outcomes included physiological outcomes. We synthesised results in a random-effects meta-analysis or narrative synthesis, as appropriate. Evidence quality in relation to each outcome was assessed using the GRADE system.

DATA SOURCES

Studies were identified using electronic databases searches (Cochrane Central, MEDLINE, EMBASE, CINAHL), forward and backward citation searching, and review of reference lists of manufacturer documentation.

RESULTS

Eight papers, containing nine studies [689 participants], were included. Three studies were randomised controlled trials. Meta-analyses showed an association between use of mechanical chest compression device and improved hospital or 30-day survival (odds ratio 2.34, 95% CI 1.42-3.85) and short-term survival (odds ratio 2.14, 95% CI 1.11-4.13). There was also evidence of improvements in physiological outcomes. Overall evidence quality in relation to all outcomes was very low.

CONCLUSIONS

Mechanical chest compression devices may improve patient outcome, when used at in-hospital cardiac arrest. However, the quality of current evidence is very low. There is a need for randomised trials to evaluate the effect of mechanical chest compression devices on survival for in-hospital cardiac arrest.