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The Effect of Asphyxia Arrest Duration on a Pediatric End-Tidal co2-Guided Chest Compression Delivery Model*

Hamrick, Jennifer L. MD1; Hamrick, Justin T. MD1; O’Brien, Caitlin E. MD, MPH2; Reyes, Michael BA2; Santos, Polan T. MD2; Heitmiller, Sophie E. BA2; Kulikowicz, Ewa MS2; Lee, Jennifer K. MD2; Kudchadkar, Sapna R. MD, PhD2,3,4; Koehler, Raymond C. PhD2; Hunt, Elizabeth A. MD, MPH, PhD2,3,5; Shaffner, Donald H. MD2

Pediatric Critical Care Medicine: July 2019 - Volume 20 - Issue 7 - p e352-e361
doi: 10.1097/PCC.0000000000001968
Online Laboratory Investigation
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Objectives: To determine the effect of the duration of asphyxial arrest on the survival benefit previously seen with end-tidal co2-guided chest compression delivery.

Design: Preclinical randomized controlled study.

Setting: University animal research laboratory.

Subjects: Two-week-old swine.

Interventions: After either 17 or 23 minutes of asphyxial arrest, animals were randomized to standard cardiopulmonary resuscitation or end-tidal co2-guided chest compression delivery. Standard cardiopulmonary resuscitation was optimized by marker, monitor, and verbal feedback about compression rate, depth, and release. End-tidal co2-guided delivery used adjustments to chest compression rate and depth to maximize end-tidal co2 level without other feedback. Cardiopulmonary resuscitation for both groups proceeded from 10 minutes of basic life support to 10 minutes of advanced life support or return of spontaneous circulation.

Measurements and Main Results: After 17 minutes of asphyxial arrest, mean end-tidal co2 during 10 minutes of cardiopulmonary resuscitation was 18 ± 9 torr in the standard group and 33 ± 15 torr in the end-tidal co2 group (p = 0.004). The rate of return of spontaneous circulation was three of 14 (21%) in the standard group rate and nine of 14 (64%) in the end-tidal co2 group (p = 0.05). After a 23-minute asphyxial arrest, neither end-tidal co2 values (20 vs 26) nor return of spontaneous circulation rate (3/14 vs 1/14) differed between the standard and end-tidal co2-guided groups.

Conclusions: Our previously observed survival benefit of end-tidal co2-guided chest compression delivery after 20 minutes of asphyxial arrest was confirmed after 17 minutes of asphyxial arrest. The poor survival after 23 minutes of asphyxia shows that the benefit of end-tidal co2-guided chest compression delivery is limited by severe asphyxia duration.

1Department of Anesthesiology, Rady Children’s Hospital, San Diego, CA.

2Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Baltimore, MD.

3Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.

4Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.

5Division of Health Informatics, Johns Hopkins University School of Medicine, Baltimore, MD.

*See also p. 691.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development award R21HD072845, by the National Institute of Neurological Disorders and Stroke awards K08NS080984, R01NS060703, R01NS107417, and R21NS095036, by the National Research Service Award for Clinician Scientists in Pediatric Critical Cardiopulmonary Disease T32HL125239, and by the National Center for Research Resources of the National Institutes of Health Roadmap for Medical Research grant UL1RR025005.

Dr. O’Brien’s institution received funding from National Institutes of Health (NIH) T32 Institutional Grant (T32HL125239), and she disclosed work for hire. Dr. Lee’s institution received funding from the NIH and the American Heart Association, and she received funding from Medtronic (consulting on near-infrared spectroscopy technology in 2016). Dr. Koehler’s institution received funding from the NIH. Dr. Hunt received funding from the NIH (grant support as a coinvestigator), Zoll Medical Corporation (consulting on simulation-based medicine education innovation she created called “Rapid Cycle Deliberate Practice” and from medical education technologies that she and her research partners have created that Zoll has a nonexclusive license for two of the devices, although she has not received any royalties), and National Medical Consultants (for performing expert medical reviews). Dr. Shaffner’s institution received funding from the National Institute of Child Health and Human Development and the National Institute of Neurological Disorders and Stroke; he received funding from Wolters Kluwer. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This work was performed in the research facilities of the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Baltimore, MD.

For information regarding this article, E-mail: dshaffn1@jhmi.edu

Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies