Patient-centric blood pressure-targeted cardiopulmonary resuscitation improves survival from cardiac arrest

Abstract

Rationale: Although current resuscitation guidelines are rescuer focused, the opportunity exists to develop patient-centered resuscitation strategies that optimize the hemodynamic response of the individual in the hopes to improve survival.

Objectives: To determine if titrating cardiopulmonary resuscitation (CPR) to blood pressure would improve 24-hour survival compared with traditional CPR in a porcine model of asphyxia-associated ventricular fibrillation (VF).

Methods: After 7 minutes of asphyxia, followed by VF, 20 female 3-month-old swine randomly received either blood pressure-targeted care consisting of titration of compression depth to a systolic blood pressure of 100 mm Hg and vasopressors to a coronary perfusion pressure greater than 20 mm Hg (BP care); or optimal American Heart Association Guideline care consisting of depth of 51 mm with standard advanced cardiac life support epinephrine dosing (Guideline care). All animals received manual CPR for 10 minutes before first shock. Primary outcome was 24-hour survival.

Measurements and main results: The 24-hour survival was higher in the BP care group (8 of 10) compared with Guideline care (0 of 10); P = 0.001. Coronary perfusion pressure was higher in the BP care group (point estimate +8.5 mm Hg; 95% confidence interval, 3.9-13.0 mm Hg; P < 0.01); however, depth was higher in Guideline care (point estimate +9.3 mm; 95% confidence interval, 6.0-12.5 mm; P < 0.01). Number of vasopressor doses before first shock was higher in the BP care group versus Guideline care (median, 3 [range, 0-3] vs. 2 [range, 2-2]; P = 0.003).

Conclusions: Blood pressure-targeted CPR improves 24-hour survival compared with optimal American Heart Association care in a porcine model of asphyxia-associated VF cardiac arrest.

Keywords: asphyxia; heart arrest; vascular access devices.

Figures

Figure 1.

Protocol design. During protocol resuscitation period, animals were randomized to receive one of two resuscitation strategies. Guideline care refers to target depth of 51 mm and standard advanced cardiac life support epinephrine dosing. BP care refers to cardiopulmonary resuscitation (CPR) directed to attain a systolic blood pressure (SBP) of 100 mm Hg and a coronary perfusion pressure (CPP) greater than 20 mm Hg. BP = blood pressure; ETT = endotracheal tube; ROSC = return of spontaneous circulation; VF = ventricular fibrillation.

Figure 2.

Mean diastolic coronary perfusion pressure during each minute of cardiopulmonary resuscitation (CPR) across treatment groups. Error bars represent SEM. Guideline care refers to target depth of 51 mm and standard advanced cardiac life support epinephrine dosing. BP care refers to CPR directed to attain a systolic blood pressure of 100 mm Hg and a coronary perfusion pressure greater than 20 mm Hg. BP = blood pressure.