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Hopper K, Epstein SE, Burkitt-Creedon JM, Fletcher DJ, Boller M, Fausak ED, Mears K, Crews M. 2024 RECOVER Guidelines: Basic Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care (San Antonio) 2024; 34 Suppl 1:16-43. [PMID: 38924625 DOI: 10.1111/vec.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To systematically review evidence and devise treatment recommendations for basic life support (BLS) in dogs and cats and to identify critical knowledge gaps. DESIGN Standardized, systematic evaluation of literature pertinent to BLS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by 2 Evidence Evaluators, and findings were reconciled by BLS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk to benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS Twenty questions regarding animal position, chest compression point and technique, ventilation strategies, as well as the duration of CPR cycles and chest compression pauses were examined, and 32 treatment recommendations were formulated. Out of these, 25 addressed chest compressions and 7 informed ventilation during CPR. The recommendations were founded predominantly on very low quality of evidence and expert opinion. These new treatment recommendations continue to emphasize the critical importance of high-quality, uninterrupted chest compressions, with a modification suggested for the chest compression technique in wide-chested dogs. When intubation is not possible, bag-mask ventilation using a tight-fitting facemask with oxygen supplementation is recommended rather than mouth-to-nose ventilation. CONCLUSIONS These updated RECOVER BLS treatment recommendations emphasize continuous chest compressions, conformation-specific chest compression techniques, and ventilation for all animals. Very low quality of evidence due to absence of clinical data in dogs and cats consistently compromised the certainty of recommendations, emphasizing the need for more veterinary research in this area.
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Affiliation(s)
- Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Jamie M Burkitt-Creedon
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Manuel Boller
- VCA Canada Central Victoria Veterinary Hospital, Victoria, British Columbia, Canada
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erik D Fausak
- University Library, University of California, Davis, Davis, California, USA
| | - Kim Mears
- Robertson Library, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Molly Crews
- Department of Small animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
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2
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de la Mata Navazo S, Manrique G, Fernández SN, Pérez G, Butragueño-Laiseca L, García M, Slöcker M, González R, Herrera L, Mencía S, Del Castillo J, Solana MJ, Sanz D, Cieza R, López J, Rodríguez Martínez A, Santiago MJ, Urbano J, López-Herce J. Volumetric capnography and return of spontaneous circulation in an experimental model of pediatric asphyxial cardiac arrest. Sci Rep 2023; 13:12247. [PMID: 37507472 PMCID: PMC10382559 DOI: 10.1038/s41598-023-37827-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
A secondary analysis of a randomized study was performed to study the relationship between volumetric capnography (VCAP) and arterial CO2 partial pressure (PCO2) during cardiopulmonary resuscitation (CPR) and to analyze the ability of these parameters to predict the return of spontaneous circulation (ROSC) in a pediatric animal model of asphyxial cardiac arrest (CA). Asphyxial CA was induced by sedation, muscle relaxation and extubation. CPR was started 2 min after CA occurred. Airway management was performed with early endotracheal intubation or bag-mask ventilation, according to randomization group. CPR was continued until ROSC or 24 min of resuscitation. End-tidal carbon dioxide (EtCO2), CO2 production (VCO2), and EtCO2/VCO2/kg ratio were continuously recorded. Seventy-nine piglets were included, 26 (32.9%) of whom achieved ROSC. EtCO2 was the best predictor of ROSC (AUC 0.72, p < 0.01 and optimal cutoff point of 21.6 mmHg). No statistical differences were obtained regarding VCO2, VCO2/kg and EtCO2/VCO2/kg ratios. VCO2 and VCO2/kg showed an inverse correlation with PCO2, with a higher correlation coefficient as resuscitation progressed. EtCO2 also had an inverse correlation with PCO2 from minute 18 to 24 of resuscitation. Our findings suggest that EtCO2 is the best VCAP-derived parameter for predicting ROSC. EtCO2 and VCO2 showed an inverse correlation with PCO2. Therefore, these parameters are not adequate to measure ventilation during CPR.
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Affiliation(s)
- Sara de la Mata Navazo
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Gema Manrique
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain.
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain.
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain.
| | - Sarah Nicole Fernández
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Gema Pérez
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Laura Butragueño-Laiseca
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Miriam García
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - María Slöcker
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Rafael González
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
- Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Laura Herrera
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Santiago Mencía
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
- Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Jimena Del Castillo
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
- Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Débora Sanz
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Raquel Cieza
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Jorge López
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Alicia Rodríguez Martínez
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - María José Santiago
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
- Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Gregorio Marañón University Hospital, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
- Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
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3
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Manrique G, Pérez G, Butragueño-Laiseca L, García M, Slöcker M, González R, Herrera L, Mencía S, Del Castillo J, Solana MJ, Sanz D, Cieza R, Fernández SN, López J, Urbano J, López-Herce J. Effects of airway management and tidal volume feedback ventilation during pediatric resuscitation in piglets with asphyxial cardiac arrest. Sci Rep 2021; 11:16138. [PMID: 34373497 PMCID: PMC8352976 DOI: 10.1038/s41598-021-95296-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/20/2021] [Indexed: 11/09/2022] Open
Abstract
To compare the effect on the recovery of spontaneous circulation (ROSC) of early endotracheal intubation (ETI) versus bag-mask ventilation (BMV), and expiratory real-time tidal volume (VTe) feedback (TVF) ventilation versus without feedback or standard ventilation (SV) in a pediatric animal model of asphyxial cardiac arrest. Piglets were randomized into five groups: 1: ETI and TVF ventilation (10 ml/kg); 2: ETI and TVF (7 ml/kg); 3: ETI and SV; 4: BMV and TVF (10 ml/kg) and 5: BMV and SV. Thirty breaths-per-minute guided by metronome were given. ROSC, pCO2, pO2, EtCO2 and VTe were compared among groups. Seventy-nine piglets (11.3 ± 1.2 kg) were included. Twenty-six (32.9%) achieved ROSC. Survival was non-significantly higher in ETI (40.4%) than BMV groups (21.9%), p = 0.08. No differences in ROSC were found between TVF and SV groups (30.0% versus 34.7%, p = 0.67). ETI groups presented lower pCO2, and higher pO2, EtCO2 and VTe than BMV groups (p < 0.05). VTe was lower in TVF than in SV groups and in BMV than in ETI groups (p < 0.05). Groups 1 and 3 showed higher pO2 and lower pCO2 over time, although with hyperventilation values (pCO2 < 35 mmHg). ETI groups had non significantly higher survival rate than BMV groups. Compared to BMV groups, ETI groups achieved better oxygenation and ventilation parameters. VTe was lower in both TVF and BMV groups. Hyperventilation was observed in intubated animals with SV and with 10 ml/kg VTF.
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Affiliation(s)
- Gema Manrique
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Gema Pérez
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Laura Butragueño-Laiseca
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Miriam García
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - María Slöcker
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Laura Herrera
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - Santiago Mencía
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Jimena Del Castillo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Débora Sanz
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - Raquel Cieza
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - Sarah N Fernández
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Jorge López
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain.
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain.
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid, Madrid, Spain.
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain.
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain.
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid, Madrid, Spain.
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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5
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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6
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Küçükceran K, Ayrancı MK, Dündar ZD. Comparison of cardiopulmonary resuscitation that applied synchronous 30 compressions–2 ventilations with that applied asynchronous 110/min compression–10/min ventilation: A mannequin study. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920958861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: CPR model of a resuscitation to be ventilated with a bag valve mask constitutes a discussion when evaluated with the current guidance. Objective: This study aims to compare the synchronous (30–2) ventilation–compression method with asynchronous 110/min compression–10/min ventilation in cardiac arrests where an advanced airway management is not applied and where ventilation is provided by a bag valve mask on a mannequin. Methods: This simulation trial was performed using two clinical cardiopulmonary resuscitation scenarios: an asynchronous scenario with 10 ventilations per minute asynchronously when compression is applied as 110 compression per minute and a synchronous scenario in which 30 compressions:2 ventilations were performed synchronously. A total of 100 people in 50 groups applied these two scenarios on mannequin. Ventilation and compression data of both scenarios were recorded. Results: Evaluating the compression criteria in both the scenarios performed by 50 groups in total, in terms of all criteria except compression fraction, there was no statistically difference between the two scenarios (p > 0.05). Compression fraction values in the asynchronous scenario were found to be statistically significantly higher than the synchronous scenario (96.02 ± 2.35, 81.34 ± 4.42, p < 0.001). Evaluating the ventilation criteria in both the scenarios performed by 50 groups in total; there was a statistically significant difference in all criteria. Mean ventilation rate of the asynchronous scenario was statistically higher than the synchronous scenario (7.22 ± 2.42, 5.08 ± 0.75, p < 0.001). Mean ventilation volume of the synchronous scenario was statistically higher than the asynchronous scenario (353.24 ± 45.46, 527.40 ± 96.60, p < 0.001). Ventilation ratio in sufficient volume of the synchronous scenario was statistically higher than the asynchronous scenario (36.84 ± 14.47, 75.00 ± 21.24, p < 0.001). Ventilation ratio below the minimum volume limit of the asynchronous scenario was statistically higher than the synchronous scenario (62.48 ± 14.72, 17.86 ± 19.50, p < 0.001). Conclusion: In our study, we concluded that the cardiopulmonary resuscitation applied by the synchronous method reached better ventilation volumes. Evaluating together with any interruption in compression, comprehensive studies are needed to reveal which patients would benefit from this result.
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Affiliation(s)
- Kadir Küçükceran
- Emergency Medicine, Critical Care, Trauma, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Mustafa Kürşat Ayrancı
- Emergency Medicine, Critical Care, Toxicology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Zerrin Defne Dündar
- Emergency Medicine, Critical Care, Geriatric, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
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7
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López J, Arias P, Domenech B, Horcajo D, Nocete JP, Zamora L, Fernández SN, López-Herce J. Effect of ventilation rate on recovery after cardiac arrest in a pediatric animal model. PLoS One 2020; 15:e0237736. [PMID: 32817703 PMCID: PMC7440626 DOI: 10.1371/journal.pone.0237736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/31/2020] [Indexed: 11/19/2022] Open
Abstract
AIMS To assess the impact of two different respiratory rates in hemodynamic, perfusion and ventilation parameters in a pediatric animal model of cardiac arrest (CA). METHODS An experimental randomized controlled trial was carried out in 50 piglets under asphyxial CA. After ROSC, they were randomized into two groups: 20 and 30 respirations per minute (rpm). Hemodynamic, perfusion and ventilation parameters were measured 10 minutes after asphyxia, just before ROSC and at 5, 15, 30 and 60 minutes after ROSC. Independent medians test, Kruskal-Wallis test and χ2 test, were used to compare continuous and categorical variables, respectively. Spearman's Rho was used to assess correlation between continuous variables. A p-value <0.05 was considered significant. RESULTS Arterial partial pressure of carbon dioxide (PaCO2) was significantly lower in the 30 rpm group after 15 minutes (41 vs. 54.5 mmHg, p <0.01), 30 minutes (39.5 vs. 51 mmHg, p < 0.01) and 60 minutes (36.5 vs. 48 mmHg, p = 0.02) of ROSC. The percentage of normoventilated subjects (PaCO2 30-50 mmHg) was significantly higher in the 30 rpm group throughout the experiment. pH normalization occurred faster in the 30 rpm group with significant differences at 60 minutes (7.40 vs. 7.34, p = 0.02). Lactic acid levels were high immediately after ROSC in both groups, but were significantly lower in the 20 rpm group at 30 (3.7 vs. 4.7 p = 0.04) and 60 minutes (2.6 vs. 3.6 p = 0.03). CONCLUSIONS This animal model of asphyxial CA shows that a respiratory rate of 30 rpm is more effective to reach normoventilation than 20 rpm in piglets after ROSC. This ventilation strategy seems to be safe, as it does not cause hyperventilation and does not affect hemodynamics or cerebral tissue perfusion.
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Affiliation(s)
- Jorge López
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
| | - Patricia Arias
- School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Beatriz Domenech
- School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Daniel Horcajo
- School of Medicine, Complutense University of Madrid, Madrid, Spain
| | | | - Laura Zamora
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Sarah Nicole Fernández
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Mother-Child Health and Development Network (RedSAMID) of Carlos III Health Institute, Madrid, Spain
- School of Medicine, Complutense University of Madrid, Madrid, Spain
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The authors reply. Crit Care Med 2020; 48:e160-e161. [PMID: 31939825 DOI: 10.1097/ccm.0000000000004100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES The objective of this study was to associate ventilation rates during in-hospital cardiopulmonary resuscitation with 1) arterial blood pressure during cardiopulmonary resuscitation and 2) survival outcomes. DESIGN Prospective, multicenter observational study. SETTING Pediatric and pediatric cardiac ICUs of the Collaborative Pediatric Critical Care Research Network. PATIENTS Intubated children (≥ 37 wk gestation and < 19 yr old) who received at least 1 minute of cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arterial blood pressure and ventilation rate (breaths/min) were manually extracted from arterial line and capnogram waveforms. Guideline rate was defined as 10 ± 2 breaths/min; high ventilation rate as greater than or equal to 30 breaths/min in children less than 1 year old, and greater than or equal to 25 breaths/min in older children. The primary outcome was survival to hospital discharge. Regression models using Firth penalized likelihood assessed the association between ventilation rates and outcomes. Ventilation rates were available for 52 events (47 patients). More than half of patients (30/47; 64%) were less than 1 year old. Eighteen patients (38%) survived to discharge. Median event-level average ventilation rate was 29.8 breaths/min (interquartile range, 23.8-35.7). No event-level average ventilation rate was within guidelines; 30 events (58%) had high ventilation rates. The only significant association between ventilation rate and arterial blood pressure occurred in children 1 year old or older and was present for systolic blood pressure only (-17.8 mm Hg/10 breaths/min; 95% CI, -27.6 to -8.1; p < 0.01). High ventilation rates were associated with a higher odds of survival to discharge (odds ratio, 4.73; p = 0.029). This association was stable after individually controlling for location (adjusted odds ratio, 5.97; p = 0.022), initial rhythm (adjusted odds ratio, 3.87; p = 0.066), and time of day (adjusted odds ratio, 4.12; p = 0.049). CONCLUSIONS In this multicenter cohort, ventilation rates exceeding guidelines were common. Among the range of rates delivered, higher rates were associated with improved survival to hospital discharge.
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Lapid FM, O’Brien CE, Kudchadkar SR, Lee JK, Hunt EA, Koehler RC, Shaffner DH. The use of pressure-controlled mechanical ventilation in a swine model of intraoperative pediatric cardiac arrest. Paediatr Anaesth 2020; 30:462-468. [PMID: 31900987 PMCID: PMC7182496 DOI: 10.1111/pan.13820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/29/2019] [Accepted: 01/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current pediatric resuscitation guidelines suggest that resuscitators using an advanced airway deliver 8-10 breaths per minute while carefully avoiding excessive ventilation. In the intraoperative setting, having a dedicated ventilation rescuer may be difficult because of limited personnel. Continuing pressure-controlled mechanical ventilation during resuscitation for intraoperative cardiac arrest reduces personnel needed and the risk of hyperventilation but might risk hypoventilation during chest compression delivery. AIMS To determine whether the use of pressure-controlled mechanical ventilation at prearrest settings provides normoxia and normocarbia during resuscitation from cardiac arrest. METHODS We retrospectively analyzed combined data from preclinical randomized controlled trials. Two-week-old swine (3-4 kg) underwent asphyxia-induced cardiac arrest. Animals were resuscitated with periods of basic and advanced life support. During resuscitation, pressure-controlled mechanical ventilation was delivered at the prearrest respiratory rate, peak inspiratory pressure, and positive end-expiratory pressure. Arterial blood gases were measured prearrest, at 11 minutes of asphyxia, and at 8 and 20 minutes of cardiopulmonary resuscitation. RESULTS Piglets (n = 154) received pressure-controlled mechanical ventilation before and during cardiopulmonary resuscitation with a peak inspiratory pressure of 14-15 cm H2 O, positive end-expiratory pressure of 4 cm H2 O, 20 breaths/minute, and an inspiratory:expiratory ratio of 1:2. During asphyxia, the arterial blood gas showed the expected severe hypercarbia and hypoxia. Continuing pressure-controlled mechanical ventilation using prearrest parameters and increasing the FiO2 to 1.0 returned the PaCO2 to prearrest levels and slightly increased the partial pressure of arterial oxygen at 8 and 20 minutes of cardiopulmonary resuscitation. CONCLUSION In this piglet model of resuscitation from asphyxial arrest, pressure-controlled mechanical ventilation during cardiopulmonary resuscitation at the prearrest ventilator settings with an FiO2 of 1.0 provides adequate oxygenation and restores normocarbia. Clinical investigation is warranted to determine the benefits of continuing pressure-controlled mechanical ventilation at prearrest parameters during pediatric cardiopulmonary resuscitation.
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Affiliation(s)
- Francis M. Lapid
- Departments of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA
| | - Caitlin E. O’Brien
- Departments of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA
| | - Sapna R. Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA,Departments of Pediatrics, Johns Hopkins University School
of Medicine, Department of Anesthesiology, Baltimore, USA,Departments of Physical Medicine & Rehabilitation,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA
| | - Jennifer K. Lee
- Departments of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA
| | - Elizabeth A. Hunt
- Departments of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA,Departments of Pediatrics, Johns Hopkins University School
of Medicine, Department of Anesthesiology, Baltimore, USA,Division of Health Sciences Informatics, Johns Hopkins
University School of Medicine, Department of Anesthesiology, Baltimore, USA
| | - Raymond C. Koehler
- Departments of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA
| | - Donald H. Shaffner
- Departments of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Department of Anesthesiology,
Baltimore, USA
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Manrique G, López-Herce J, López J, Urbano J. In a pediatric animal model of cardiac arrest: Is diastolic blood pressure associated with survival during resuscitation? Resuscitation 2019; 145:208-209. [PMID: 31639463 DOI: 10.1016/j.resuscitation.2019.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Gema Manrique
- Pediatric Intensive Care Department, Gregorio Marañon University Hospital, Madrid, Spain; Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Spain; Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain; Research Network on Maternal and Child Health and Development (RedSAMID), Spain.
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Gregorio Marañon University Hospital, Madrid, Spain; Maternal and Child Public Health Department, School of Medicine, Complutense University of Madrid, Spain; Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain; Research Network on Maternal and Child Health and Development (RedSAMID), Spain.
| | - Jorge López
- Pediatric Intensive Care Department, Gregorio Marañon University Hospital, Madrid, Spain; Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain; Research Network on Maternal and Child Health and Development (RedSAMID), Spain.
| | - Javier Urbano
- Pediatric Intensive Care Department, Gregorio Marañon University Hospital, Madrid, Spain; Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain; Research Network on Maternal and Child Health and Development (RedSAMID), Spain.
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Comparison between synchronized and non-synchronized ventilation and between guided and non-guided chest compressions during resuscitation in a pediatric animal model after asphyxial cardiac arrest. PLoS One 2019; 14:e0219660. [PMID: 31318890 PMCID: PMC6638932 DOI: 10.1371/journal.pone.0219660] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/29/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction There are no studies comparing synchronized and non-synchronized ventilation with bag-valve mask ventilation (BVMV) during cardiopulmonary resuscitation (CPR) in pediatric patients. The main aim is to compare between synchronized and non-synchronized BVMV with chest compressions (CC), and between guided and non-guided CC with a real-time feedback-device in a pediatric animal model of asphyxial cardiac arrest (CA). The secondary aim is to analyze the quality of CC during resuscitation. Methods 60 piglets were randomized for CPR into four groups: Group A: guided-CC and synchronized ventilation; Group B: guided-CC and non-synchronized ventilation; Group C: non-guided CC and synchronized ventilation; Group D: non-guided CC and non-synchronized ventilation. Return of spontaneous circulation (ROSC), hemodynamic and respiratory parameters, and quality of CC were compared between all groups. Results 60 piglets were included. Twenty-six (46.5%) achieved ROSC: A (46.7%), B (66.7%), C (26.7%) and D (33.3%). Survival rates were higher in group B than in groups A+C+D (66.7% vs 35.6%, p = 0.035). ROSC was higher with guided-CC (A+B 56.7% vs C+D 30%, p = 0.037). Piglets receiving non-synchronized ventilation did not show different rates of ROSC than synchronized ventilation (B+D 50% vs A+C 36.7%, p = 0.297). Non-synchronized groups showed lower arterial pCO2 after 3 minutes of CPR than synchronized groups: 57 vs 71 mmHg, p = 0.019. No differences were found in arterial pH and pO2, mean arterial pressure (MAP) or cerebral blood flow between groups. Chest compressions were shallower in surviving than in non-surviving piglets (4.7 vs 5.1 cm, p = 0.047). There was a negative correlation between time without CC and MAP (r = -0.35, p = 0.038). Conclusions The group receiving non-synchronized ventilation and guided-CC obtained significantly higher ROSC rates than the other modalities of resuscitation. Guided-CC achieved higher ROSC rates than non-guided CC. Non-synchronized ventilation was associated with better ventilation parameters, with no differences in hemodynamics or cerebral flow.
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López J, Fernández SN, González R, Solana MJ, Urbano J, Toledo B, López-Herce J. Comparison between manual and mechanical chest compressions during resuscitation in a pediatric animal model of asphyxial cardiac arrest. PLoS One 2017; 12:e0188846. [PMID: 29190801 PMCID: PMC5708730 DOI: 10.1371/journal.pone.0188846] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/14/2017] [Indexed: 02/06/2023] Open
Abstract
Aims Chest compressions (CC) during cardiopulmonary resuscitation are not sufficiently effective in many circumstances. Mechanical CC could be more effective than manual CC, but there are no studies comparing both techniques in children. The objective of this study was to compare the effectiveness of manual and mechanical chest compressions with Thumper device in a pediatric cardiac arrest animal model. Material and methods An experimental model of asphyxial cardiac arrest (CA) in 50 piglets (mean weight 9.6 kg) was used. Animals were randomized to receive either manual CC or mechanical CC using a pediatric piston chest compressions device (Life-Stat®, Michigan Instruments). Mean arterial pressure (MAP), arterial blood gases and end-tidal CO2 (etCO2) values were measured at 3, 9, 18 and 24 minutes after the beginning of resuscitation. Results There were no significant differences in MAP, DAP, arterial blood gases and etCO2 between chest compression techniques during CPR. Survival rate was higher in the manual CC (15 of 30 = 50%) than in the mechanical CC group (3 of 20 = 15%) p = 0.016. In the mechanical CC group there was a non significant higher incidence of haemorrhage through the endotracheal tube (45% vs 20%, p = 0.114). Conclusions In a pediatric animal model of cardiac arrest, mechanical piston chest compressions produced lower survival rates than manual chest compressions, without any differences in hemodynamic and respiratory parameters.
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Affiliation(s)
- Jorge López
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Pediatrics Department, School of Medicine, Complutense University of Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RETICS, Madrid, Spain
| | - Sarah N. Fernández
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Pediatrics Department, School of Medicine, Complutense University of Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RETICS, Madrid, Spain
| | - Rafael González
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Pediatrics Department, School of Medicine, Complutense University of Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RETICS, Madrid, Spain
| | - María J. Solana
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Pediatrics Department, School of Medicine, Complutense University of Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RETICS, Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Pediatrics Department, School of Medicine, Complutense University of Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RETICS, Madrid, Spain
| | - Blanca Toledo
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Pediatrics Department, School of Medicine, Complutense University of Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RETICS, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain
- Pediatrics Department, School of Medicine, Complutense University of Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RETICS, Madrid, Spain
- * E-mail:
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