Chest compressions in children before ECPR cannulation: Do we have time for pauses?

Abstract

Despite the survival rate of children with in-hospital cardiac arrest (IHCA) markedly improved over the last two decades, more than half of them still do not survive at hospital discharge. 1. Girotra S. Spertus J.A. Li Y. et al. American Heart Association Get With the Guidelines-Resuscitation Investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes. 2013; 6: 42-49 Crossref PubMed Scopus (217) Google Scholar , 2. Berg R.A. Sutton R.M. Reeder R.W. et al. Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) Pediatric Intensive Care Quality of Cardio-Pulmonary Resuscitation (PICqCPR) investigators. Association between diastolic blood pressure during pediatric in-hospital cardiopulmonary resuscitation and survival. Circulation. 2018; 137: 1784-1795 Crossref PubMed Scopus (68) Google Scholar , 3. Holmberg M.J. Wiberg S. Ross C.E. et al. Trends in survival after pediatric in-hospital cardiac arrest in the United States. Circulation. 2019; 140: 1398-1408 Crossref PubMed Scopus (36) Google Scholar Survival outcome is associated with several factors, including the patient’s underlying disease, event’s cause, initial cardiac arrest (CA) rhythm, quality of cardiopulmonary resuscitation (CPR) delivered, duration of CA and quality of post-cardiac arrest care. 4. Sutton R.M. Niles D. Nysaether J. et al. Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents. Pediatrics. 2009; 124: 494-499 Crossref PubMed Scopus (133) Google Scholar High-quality CPR has the goal of supporting vital organ perfusion until the return of spontaneous circulation (ROSC) is attained, or while extracorporeal CPR (ECPR) is started in patients with reversible clinical conditions who are not responding to conventional CPR. Nowadays, advances in technology allow for defining high-quality CPR in quantitative terms, usually utilizing CPR quality-monitoring defibrillators. 5. Sutton R.M. Niles D. French B. et al. First quantitative analysis of cardiopulmonary resuscitation quality during in-hospital cardiac arrests of young children. Resuscitation. 2014; 85: 70-74 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Several CPR delivery metrics include adequate rate and depth of chest compressions (CC), full chest wall recoil, chest compression fraction (CCF) and frequency and length of pauses, among others. 6. Hunt E.A. Jeffers J. McNamara L. et al. Improved cardiopulmonary resuscitation performance with CODE ACES2: A resuscitation quality bundle. J Am Heart Assoc. 2018; 7e009860 Crossref Scopus (39) Google Scholar The AHA guidelines underline the value of minimizing pause duration to improve CPR quality, recommending a CCF > 80% and CC pause duration of less than 10 s. 7. Topjian A.A. Raymond T.T. Atkins D. et al. on behalf of the Pediatric Basic and Advanced Life Support Collaborators. Part 4: pediatric basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142: S469-S523 PubMed Google Scholar In fact, prolonged CPR interruptions may markedly compromise coronary and cerebral blood flow, and are associated with worse survival outcomes. In a prospective study, Brouwer et al. evaluated defibrillator data from 319 out-of- hospital arrests in adults and found that the odds for survival decreased for each 5-second increase in the longest CC pause. 8. Brouwer T.F. Walker R.G. Chapman F.W. Koster R.W. Association between chest compression interruptions and clinical outcomes of ventricular fibrillation out-of-hospital cardiac arrest. Circulation. 2015; 132: 1030-1037 Crossref PubMed Scopus (67) Google Scholar Other authors reported low CPR quality performance due to poor CCF and avoidable CC interruption time in pediatric clinical and simulation settings. 9. O'Connell K.J. Keane R.R. Cochrane N.H. et al. Pauses in compressions during pediatric CPR: Opportunities for improving CPR quality. Resuscitation. 2019; 145: 158-165 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar , 10. Jones S.I. Jeffers J.M. Perretta J. et al. Closing the Gap: Optimizing Performance to Reduce Interruptions in Cardiopulmonary Resuscitation. Pediatr Crit Care Med. 2020; 21: e592-e598 Crossref PubMed Scopus (4) Google Scholar However, some CC pauses are necessary during CPR. For instance, to diagnose or manage reversible causes of CA, or to accomplish difficult procedures, such as attempts at tracheal intubation or ECPR cannulation.