title: Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support.
abstract: BACKGROUND
  End-tidal carbon dioxide (ETCO2) correlates with systemic blood flow and resuscitation rate during cardiopulmonary resuscitation (CPR) and may potentially direct chest compression performance. We compared ETCO2-directed chest compressions with chest compressions optimized to pediatric basic life support guidelines in an infant swine model to determine the effect on rate of return of spontaneous circulation (ROSC).
  
  
  RESULTS
  Forty 2-kg piglets underwent general anesthesia, tracheostomy, placement of vascular catheters, ventricular fibrillation, and 90 seconds of no-flow before receiving 10 or 12 minutes of pediatric basic life support. In the optimized group, chest compressions were optimized by marker, video, and verbal feedback to obtain American Heart Association-recommended depth and rate. In the ETCO2-directed group, compression depth, rate, and hand position were modified to obtain a maximal ETCO2 without video or verbal feedback. After the interval of pediatric basic life support, external defibrillation and intravenous epinephrine were administered for another 10 minutes of CPR or until ROSC. Mean ETCO2 at 10 minutes of CPR was 22.7±7.8 mm Hg in the optimized group (n=20) and 28.5±7.0 mm Hg in the ETCO2-directed group (n=20; P=0.02). Despite higher ETCO2 and mean arterial pressure in the latter group, ROSC rates were similar: 13 of 20 (65%; optimized) and 14 of 20 (70%; ETCO2 directed). The best predictor of ROSC was systemic perfusion pressure. Defibrillation attempts, epinephrine doses required, and CPR-related injuries were similar between groups.
  
  
  CONCLUSIONS
  The use of ETCO2-directed chest compressions is a novel guided approach to resuscitation that can be as effective as standard CPR optimized with marker, video, and verbal feedback.
authors.affiliation: Department of Pediatric Anesthesiology and Pain Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Hamrick
authors.forename: Justin T
authors.initials: JT
authors.lastname: Hamrick
authors.forename: Jennifer K
authors.initials: JK
authors.lastname: Lee
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Lee
authors.forename: Raymond C
authors.initials: RC
authors.lastname: Koehler
authors.forename: Donald H
authors.initials: DH
authors.lastname: Shaffner
mesh_terms: D000367:Age Factors; D000818:Animals; D000831:Animals, Newborn; D001307:Auditory Perception; D015415:Biomarkers / Q000378:metabolism; D001944:Breath Tests; D019296:Capnography; D002245:Carbon Dioxide / Q000378:metabolism*; D016887:Cardiopulmonary Resuscitation / Q000379:methods*; D004195:Disease Models, Animal; D045853:Exhalation; D030141:Feedback, Psychological; D006323:Heart Arrest / Q000175:diagnosis / Q000378:metabolism / Q000503:physiopathology / Q000628:therapy*; D006439:Hemodynamics; D008991:Monitoring, Physiologic / Q000379:methods*; D011237:Predictive Value of Tests; D012121:Respiration, Artificial; D013552:Swine; D013647:Task Performance and Analysis; D013997:Time Factors; D014741:Video Recording; D014796:Visual Perception
chemical_list: D015415:Biomarkers; D002245:Carbon Dioxide
keywords: CPR; end‐tidal carbon dioxide; pediatrics; resuscitation
references.citation: Ann Emerg Med. 1989 Jul;18(7):732-7
references.pmid: 2500044
references.citation: Crit Care. 2003 Dec;7(6):411-2
references.pmid: 14624676
references.citation: Resuscitation. 2010 Jun;81(6):718-23
references.pmid: 20226582
references.citation: Crit Care. 2008;12(5):R115
references.pmid: 18786260
references.citation: Crit Care Med. 2000 Jul;28(7):2415-9
references.pmid: 10921572
references.citation: Pediatrics. 2009 Jul;124(1):e69-74
references.pmid: 19564271
references.citation: JAMA. 2005 Jan 19;293(3):305-10
references.pmid: 15657323
references.citation: Resuscitation. 2000 Jan;43(2):129-40
references.pmid: 10694173
references.citation: Ann Emerg Med. 1996 May;27(5):553-62
references.pmid: 8629775
references.citation: Crit Care Med. 1985 Nov;13(11):907-9
references.pmid: 3931979
references.citation: Am J Emerg Med. 1996 Jul;14(4):349-50
references.pmid: 8768152
references.citation: Circulation. 1988 Jan;77(1):234-9
references.pmid: 3121209
references.citation: Ann Emerg Med. 1993 Apr;22(4):669-74
references.pmid: 8457093
references.citation: Anesth Analg. 1997 Jan;84(1):51-3
references.pmid: 8988998
references.citation: Anesth Analg. 2001 Sep;93(3):649-55
references.pmid: 11524335
references.citation: Pediatrics. 1988 Apr;81(4):552-4
references.pmid: 3353189
references.citation: JAMA. 1989 Sep 8;262(10):1347-51
references.pmid: 2761035
references.citation: Ann Emerg Med. 1983 Sep;12(9):527-32
references.pmid: 6614604
references.citation: Circulation. 2005 Feb 1;111(4):428-34
references.pmid: 15687130
references.citation: Circulation. 2010 Nov 2;122(18 Suppl 3):S862-75
references.pmid: 20956229
references.citation: JAMA. 1960 Jul 9;173:1064-7
references.pmid: 14411374
references.citation: N Engl J Med. 1988 Mar 10;318(10):607-11
references.pmid: 3125432
references.citation: J Am Coll Cardiol. 1989 Apr;13(5):1184-9
references.pmid: 2494245
references.citation: Resuscitation. 1978;6(4):259-63
references.pmid: 755268
references.citation: Pediatrics. 2009 Jul;124(1):49-55
references.pmid: 19564282
references.citation: Am J Emerg Med. 1999 Mar;17(2):203-6
references.pmid: 10102328
references.citation: JAMA. 1987 Jan 23-30;257(4):512-5
references.pmid: 3098993
references.citation: Ann Emerg Med. 1995 Sep;26(3):300-3
references.pmid: 7661418
references.citation: Crit Care. 2003 Dec;7(6):R139-44
references.pmid: 14624688
references.citation: Ann Emerg Med. 1994 Mar;23(3):568-72
references.pmid: 8135436
references.citation: Circulation. 1997 Apr 15;95(8):2185-95
references.pmid: 9133534
references.citation: Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908
references.pmid: 20956230
references.citation: Anaesthesia. 1995 Oct;50(10):858-62
references.pmid: 7485874