International Journal of Cardiology 180 (2015) 7–14
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Automated cardiopulmonary resuscitation using a load-distributing band external cardiac support device for in-hospital cardiac arrest: A single centre experience of AutoPulse-CPR☆ J.R. Spiro, S. White, N. Quinn, C.J. Gubran, P.F. Ludman, J.N. Townend, S.N. Doshi ⁎ The Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
a r t i c l e
i n f o
Article history: Received 16 June 2014 Received in revised form 1 October 2014 Accepted 16 November 2014 Available online 18 November 2014 Keywords: Automated cardiopulmonary resuscitation In-hospital cardiac arrest Emergency percutaneous coronary intervention
a b s t r a c t Background: Poor quality cardiopulmonary resuscitation (CPR) predicts adverse outcome. During invasive cardiac procedures automated-CPR (A-CPR) may help maintain effective resuscitation. The use of A-CPR following in-hospital cardiac arrest (IHCA) remains poorly described. Aims & methods: Firstly, we aimed to assess the efficiency of healthcare staff using A-CPR in a cardiac arrest scenario at baseline, following re-training and over time (Scenario-based training). Secondly, we studied our clinical experience of A-CPR at our institution over a 2-year period, with particular emphasis on the details of invasive cardiac procedures performed, problems encountered, resuscitation rates and in-hospital outcome (AutoPulseCPR Registry). Results: Scenario-based training: Forty healthcare professionals were assessed. At baseline, time-to-position device was slow (mean 59 (±24) s (range 15–96 s)), with the majority (57%) unable to mode-switch. Following re-training time-to-position reduced (28 (±9) s, p b 0.01 vs baseline) with 95% able to mode-switch. This improvement was maintained over time. AutoPulse-CPR Registry: 285 patients suffered IHCA, 25 received A-CPR. Survival to hospital discharge following conventional CPR was 28/260 (11%) and 7/25 (28%) following A-CPR. A-CPR supported invasive procedures in 9 patients, 2 of whom had A-CPR dependant circulation during transfer to the catheter lab. Conclusion: A-CPR may provide excellent haemodynamic support and facilitate simultaneous invasive cardiac procedures. A significant learning curve exists when integrating A-CPR into clinical practice. Further studies are required to better define the role and effectiveness of A-CPR following IHCA. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Background Survival following in-hospital cardiac arrest (IHCA) remains low [1], with poor quality cardiopulmonary resuscitation (CPR) predicting adverse outcome [2–5]. Automated-CPR (A-CPR) may provide superior circulatory support than manual CPR, increase incidence of return of spontaneous circulation (ROSC) and facilitate invasive cardiac procedures during simultaneous resuscitation. The use of A-CPR to treat out-of-hospital cardiac arrest (OHCA) has been energetically studied over recent years [6–9]. However, despite favourable animal [10] and human [11] haemodynamic data, survival among patients treated with A-CPR remains disappointing. Following OHCA, A-CPR has failed to demonstrate a reliable or sustained improvement in short- or long-term survival with either LUCAS (Lund University Cardiac Arrest System, Jolife AB, Lund, Sweden) ☆ This is an original manuscript and does not relate to another paper, either published or in press. ⁎ Corresponding author. E-mail address: [email protected] (J.R. Spiro).
http://dx.doi.org/10.1016/j.ijcard.2014.11.109 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
[6], or AutoPulse (ZOLL Medical Corporation, Chelmsford, MA, USA) [7] devices, as compared to manual-CPR (M-CPR) alone. Indeed device use has been associated with worse neurological outcome [7] and increased interruptions in CPR [12]. Following in-hospital cardiac arrest (IHCA), the role of A-CPR remains unclear, with data only available from two small series of patients treated with LUCAS [13,14] and one case report using AutoPulse [15]. Current resuscitation guidelines suggest that A-CPR may be used in ‘specific settings’ of cardiac arrest but there remains insufficient evidence to support routine use [16]. One potential clinical setting may be to support emergency invasive cardiac procedures directed towards correcting the cause of cardiac arrest. Indeed, the LUCAS A-CPR device has been described in patients who required emergency procedures during cardiac arrest in the catheter laboratory [13,14], however no such data exist for AutoPulse. Furthermore, AutoPulse is reported to be easy to use on a mannequin, by first-aiders who have only received brief training [17], however it remains unclear how this translates into real-life clinical practice and what it's effect would be on well-established conventional CPR algorithms.
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2. Aims & methods
3. Results
In this study we aimed firstly to assess the efficiency and competence of trained healthcare professionals within our department at using the AutoPulse-CPR in a cardiac arrest scenario. Secondly, we aimed to describe our department's experience with AutoPulse-CPR during real-life IHCA.
3.1. Scenario-based training
2.1. Scenario-based training Forty healthcare staff from a multi-disciplinary background (10 cardiologists, 25 cardiology nurses, 5 auxiliary healthcare workers) working in the cardiology department of The Queen Elizabeth Hospital, Birmingham, UK, volunteered to take part. All participants had received prior training from an industry representative (ZOLL Medical Corporation, Chelmsford, MA, USA). Without prior warning participants were led individually to a training room containing the AutoPulse device and a resuscitation mannequin (Laerdal Medical, NY 12590, USA). They were instructed to position AutoPulse on the mannequin, activate the device to begin chest compressions, and then mode-switch (from 30:2 to continuous activation). Time taken to place and activate the device (time-to-position), and ability to mode-switch, were measured at (1) baseline, (2) immediately following intensive re-training from a clinician experienced in use of AutoPulse and (3) after a period of time (mean 64 days, range 39–76 days).
2.2. AutoPulse-CPR Registry Patients suffering in-hospital cardiac arrest (IHCA) at our institution over a 2-year period (Sept 2011–Sept 2013) were identified. Patients who received AutoPulse-CPR (intention to treat) were identified and became our study group. Clinical characteristics, resuscitation details and in-hospital outcome were assessed with particular emphasis placed on the reporting of practical problems encountered when using the device, advantages of AutoPulse-CPR and details of invasive cardiac procedures performed during support.
2.3. Statistical methodology Repeated measures in the same individual were assessed using a paired Student's t-test, SPSS. Observational data are expressed as mean ± standard deviation or range.
At baseline, all participants in the cardiac arrest scenario successfully positioned and activated the device onto the mannequin; mean timeto-position 59 (±24) s (range 15–96 s), considerably longer than the industry advertised 20 s [18]. However, following intensive re-training participants became more efficient (time-to-position 28 (±9) s, range 15–61 s, p b 0.01 vs baseline) and this improvement was maintained over time (time-to-position at follow-up 30 (± 12) s, range 18–68 s, p ≤ 0.01 vs baseline), Fig. 1. Operation of the device (ability to modeswitch) was achieved by 17 (43%) participants at baseline, which improved to 38 (95%) after re-training and 37 (93%) at follow-up, Fig. 2. There was no significant correlation between time-to-position and the time period from industry training to baseline testing (Fig. 3A) or from re-training to follow-up testing (Fig. 3B). 3.2. AutoPulse-CPR Registry Over a 2-year period 285 patients suffered IHCA at our institution; 177 (62%) male, mean age 68 ± 16 years (range 21–99 years). From this cohort twenty-nine consecutive patients were identified as having received an intention-to-treat with AutoPulse-CPR; 19 (66%) were male, mean age 71 ± 17 years (range 26–95 years). There was significant diagnostic heterogeneity, including ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute coronary syndrome (NSTE-ACS), complex cyanotic adult congenital heart disease (ACHD), patients with symptomatic severe aortic stenosis either after or at the time of transcatheter aortic valve implantation (TAVI), and one patient who was undergoing a complex cardiac electrophysiological procedure. Clinical characteristics are shown in Table 1. 3.3. A-CPR using AutoPulse A-CPR was successfully delivered in 25/29 (86%) patients, with conventional CPR continued in 4 patients in whom A-CPR had been unsuccessful (Fig. 4). Mean time from IHCA to A-CPR was 7.4 ± 6.6 min (range 1–30 min), with part of this time taken to assess patient response to initial conventional resuscitation. A-CPR was provided for a mean time of 22.2 ± 14.9 min (range 2–60 min), Table 2. A-CPR was observed to provide excellent circulatory support when invasive haemodynamic readings were measured (Fig. 5). All patients undergoing A-CPR underwent endotracheal intubation by an anaesthetist on the resuscitation team.
Fig. 1. Individual (A) and mean ± SD (B) time-to-position AutoPulse-CPR in a cardiac arrest scenario.
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Fig. 2. Operation of the AutoPulse device (mode-switch). Chart represents participants who were able (dark grey) and unable (light grey) to operate the device at (A) baseline, (B) after intensive re-training and (C) at follow-up.
3.4. Survival from IHCA Among patients receiving conventional CPR, 28/260 (11%) survived to hospital discharge. Following A-CPR, 12/25 (48%) patients achieved ROSC, with 7/25 (28%) surviving to hospital discharge (Table 3). Of the 5 patients who died despite ROSC 1 died following re-arrest in the catheter lab, due to massive pulmonary embolism (case 16), 1 died from progressive sepsis (case 20), 2 died from multi-organ failure (cases 10 & 27) and 1 died from heart failure (case 17). 3.5. Invasive procedures during AutoPulse-CPR 15/25 (60%) patients received A-CPR at some stage during an invasive cardiac procedure. Invasive procedures were paused to allow resuscitation in 6/15 (40%), whereas the remaining 9/15 (60%) patients received A-CPR during simultaneous invasive procedures; 4 patients underwent percutaneous coronary intervention (PCI), 4 had coronary angiography (with additional transoesophageal echocardiography, n = 1, and transvenous endocardial pacing, n = 1) and 1 other patient received drainage of pericardial tamponade (Table 2 and Fig. 6). Of note 3 of these 9 patients (cases 2, 8 & 9) were transferred to the catheter laboratory in cardiac arrest, and with an A-CPR dependant circulation. Following PCI in 2 of these patients (cases 2 and 9) A-CPR could be terminated following ROSC. Both patients made a full recovery and were discharged from hospital with normal cerebral function (Cerebral Performance Category [19] (CPC) 1). The remaining patient (case 8) underwent emergency coronary angiography, which demonstrated normal coronary arteries, with subsequent post mortem confirming cause of death as massive pulmonary embolism.
this we established an A-CPR team approach to device positioning. This simple strategy greatly improved the efficiency and speed of device positioning and was analogous to the previously described ‘pit crew’ protocol [20] with each team member having a pre-defined and wellpracticed role, Fig. 7. 3.7. Problems using A-CPR Failure of AutoPulse occurred in 4 patients, details described below. In these situations the device was removed and patients received manual CPR. 3.7.1. Problem 1: battery depletion (case 6) During resuscitation the device failed to commence chest compressions. Subsequent analysis demonstrated that the battery within the device was low on charge. This incidence prompted us to introduce a policy of daily battery changes, even if the device had not been used the preceding day. 3.7.2. Problem 2: difficult backboard placement (case 24) Due to large body habitus (BMI 32), bifemoral arterial sheaths and intra-aortic balloon pump, this patient could not be lifted sufficiently upright to allow correct backboard placement. Consequently fluoroscopic screening was significantly limited and the device was removed. PCI was completed once the patient was resuscitated using manual CPR.
3.6. Maximising chest compression fraction (the ‘A-CPR team’ approach)
3.7.3. Problem 3: compression band twist (case 28) Despite careful placement of the device by staff experienced with the device the compression band became twisted and was drawn into the mechanism within the backboard. This resulted in complete failure of the device.
In our experience we observed that using A-CPR had the potential to significantly interfere with resuscitation due to the possibility of delay between pausing M-CPR and commencing A-CPR. In order to address
3.7.4. Problem 4: clip detachment (case 29) Following several minutes of chest compressions the A-CPR the device stopped. Inspection revealed that a clip, responsible for holding
Fig. 3. Correlation of time-to-position against (A) days from industry training to baseline testing and (B) days from re-training to follow-up testing.
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Table 1 Patient characteristics. Case
Age/sex
BMI
Patient category
AutoPulse sited
Arrest rhythm
1 2 3 4 5 6* 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24* 25 26 27 28* 29*
67M 76F 33M 49F 88F 73M 60M 65M 65M 65M 80M 95F 78M 63M 86M 79F 57F 90M 53F 74M 94F 91M 85M 60F 26F 67M 74M 77M 92M
30 22 22 22 22 37 26 28 37 29 26 22 27 26 27 24 21 24 30 27 22 25 22 32 21 25 28 31 22
STEMI STEMI ACHD STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI Heart failure STEMI STEMI NSTE-ACS Tamponade NSTE-ACS Hypothermia STEMI ACHD Heart failure STEMI NSTE-ACS STEMI
LAB CCU CCU LAB LAB CCU LAB ED ED LAB LAB LAB LAB ED ED CCU CCU LAB LAB CCU LAB LAB CCU LAB WARD CCU LAB CCU CCU
PEA PEA PEA VF VF PEA VF PEA PEA PEA PEA PEA VF VF PEA PEA VT VF VF VF PEA PEA PEA VT PEA PEA PEA PEA PEA
Key — STEMI, ST-segment elevation myocardial infarction; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; ACHD, adult congenital heart disease; LAB, cardiac catheter laboratory; ED, emergency department; CCU, coronary care unit; WARD, acute cardiology ward; PEA, pulseless electrical activity; VF, ventricular fibrillation, VT, ventricular tachycardia; *, problems using AutoPulse which limited or precluded it's use (these patients have been removed from A-CPR statistics and remain in the conventionalCPR group).
the compression band in the correct alignment with the backboard, had become detached. The device would not reactivate, despite the installation of a new band.
4. Discussion Maintenance of sufficient myocardial and cerebral perfusion following cardiopulmonary arrest remains dependent on effective manual CPR (M-CPR) with poor quality chest compressions, caused by CPR-provider fatigue [2], insufficient compression depth [3], slow compression rate [4] or low chest compression fraction (CCF) [5], predicting adverse outcome. Mechanical support during cardiac arrest, using percutaneous venoarterial extracorporeal membrane oxygenation (ECMO) [21] and left ventricular assist devices (LVADs) such as Impella [22] (Abiomed Inc., Danvers, MA, USA) or Tandem Heart [23] (CardiacAssist Inc., Pittsburgh, PA, USA), has been described with favourable outcomes. However, these devices are invasive, complex and require skilled teams in order to institute them urgently. They therefore have limited applicability to widespread use. However, external automated chest compression devices (A-CPR) may represent an attractive alternative. In clinical practice two devices are currently available; the AutoPulse load-distributing band (LDB) (ZOLL Medical Corporation, Chelmsford, MA, USA) and the LUCAS (Lund University Cardiac Arrest System, Jolife AB, Lund, Sweden) mechanical piston device. Despite encouraging animal [10] and human [11] experimental data, clinical studies of automated vs manual-CPR for out-of-hospital cardiac arrest (OHCA) have failed to consistently demonstrate a survival benefit in favour of A-CPR [6–9]. These disappointing observations might be explained by significant reductions in CCF experienced during device application [24]. Recently a meta-analysis consisting of 12 studies, involving a total of 6538 subjects who suffered OHCA, concluded that A-CPR provided a higher incidence of ROSC as compared to M-CPR (OR 1.62 (95% CI 1.36– 1.92, p b 0.001)), with the LDB-CPR device appearing to outperform the piston-driven device [25]. However, further studies are required in
Fig. 4. Flow chart demonstrating total number of patients suffering in-hospital cardiac arrest (IHCA), number treated with AutoPulse-CPR (A-CPR), number achieving return of spontaneous circulation (ROSC) and number surviving to hospital discharge.
J.R. Spiro et al. / International Journal of Cardiology 180 (2015) 7–14 Table 2 Resuscitation details.
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Table 3 Outcome and details of deaths. A-CPR timing in relation to procedure
Case
ROSC
If ROSC; time to death
Survived to discharge
Cause of death
Place of death
1 2 3 4 5 6* 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24* 25 26 27 28* 29*
Yes Yes No Yes Yes No Yes No Yes Yes No No No No No Yes Yes No No Yes No Yes No Yes No No Yes No No
Survived Survived – Survived Survived – Survived – Survived 20 h – – – – – 30 min 20 min – – Day 12 – Survived – Survived – – 3h – –
Yes (CPC1) Yes (CPC1) No Yes (CPC1) Yes (CPC1) No Yes (CPC1) No Yes (CPC1) No No No No No No No No No No No No Yes (CPC1) No Yes (CPC1) No No No No No
– – Sepsis – – Cardiac tamponade – PE – MOF Ischaemic CS Ischaemic CS Ischaemic CS Ischaemic CS Ischaemic CS PE Severe LVSD/DCM Ischaemic CS PE Sepsis/MOF Aortic annular rupture – Hypothermia – Fontan obstruction Severe AS and LVSD Ischaemic CS and MOF Ischaemic CS IHD and GI bleed
– – CCU – – CCU – LAB – ICU LAB LAB LAB LAB LAB LAB CCU LAB LAB ICU LAB – CCU – WARD CCU ICU CCU CCU
Case
Duration A-CPR, min
CCF, %
Procedure(s) performed
Before
During
After
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
10 48 25 5 15 0* 28 60 30 17 20 10 5 34 34 45 10 26 35 18 12 2 15 0* 30 20 5 2* 5*
91 94 94 92 92 94 92 93 96 94 94 99 92 93 95 97 96 98 92 97 94 94 96 94 94 93 88 92 91
PCI PCI No procedure PCI PCI PCI PCI Angiogram PCI PCI PCI PCI PCI PCI TPW, angiogram Angiogram No procedure Angiogram TOE, angiogram PCI Pericardial drain PCI No procedure PCI No procedure BAV PCI No procedure Angiogram
No Yes NA No No No No Yes Yes No No No No No Yes Yes NA No No No No No NA No NA No No NA No
Yes Yes• NA No No No Yes Yes• Yes No Yes• Yes Yes• Yes• Yes• Yes• NA No Yes• No Yes• Yes NA Yes NA No Yes NA No
No No NA Yes Yes Yes No No No Yes No No No No No No NA Yes Yes Yes Yes No NA No NA Yes No NA Yes
Definition of A-CPR being performed ‘before, during and after’ a procedure: Before, A-CPR occurring during hospital admission but before an invasive procedure; during, A-CPR performed whilst an invasive procedure is being performed (the symbol • identify patients who received A-CPR simultaneously during an invasive cardiac procedure; absence of this symbol reflects a temporary pause in the procedure to allow A-CPR); and after, A-CPR performed following the conclusion of an invasive procedure. Key — A-CPR; automated (AutoPulse) cardiopulmonary resuscitation; TPW, temporary pacing wire; BAV, balloon aortic valvuloplasty; PCI, percutaneous coronary intervention; CCF, chest compression fraction; ROSC, return of spontaneous circulation; TOE, transoesophageal echocardiography; NA, not applicable; *, problems using AutoPulse which limited or precluded it's use (these patients have been removed from A-CPR statistics and remain in the conventional-CPR group); angiogram, diagnostic coronary angiogram only.
order to better understand the apparent disconnect between improved rates of ROSC and an absence of robust survival benefit. It is hoped that results from three large on-going studies (Circulation Improving Resuscitation Care [CIRC] [26], Prehospital Randomized Assessment of a Mechanical Compression Device in Cardiac Arrest [PARAMEDIC] [27] and LUCAS in Cardiac Arrest [LINC] [28]) may help to better define the timing and role of A-CPR.
Key — ROSC, return of spontaneous circulation; CPC, cerebral performance criteria; TGA, transposition of the great arteries; Mustard, surgical correction of TGA (atrial switch); PEA, pulseless electrical activity; PE, pulmonary embolus; PPCI, primary percutaneous coronary intervention; ICU, intensive care unit; MOF, multi-organ failure; LAB, cardiac catheter laboratory; CCU, coronary care unit; CS, cardiogenic shock; LVSD, left ventricular systolic dysfunction; DCM, dilated cardiomyopathy; WARD, acute cardiology ward; AS, aortic stenosis; IHD, ischaemic heart disease; GI, gastrointestinal; NA, not applicable; *, problems using AutoPulse which limited or precluded it's use (these patients have been removed from A-CPR statistics and remain in the conventional-CPR group).
However, despite a paucity of robust outcome data, current resuscitation guidelines state that A-CPR devices might be useful for the treatment of cardiac arrest in specific settings [29,30]. One such setting may be the cardiac catheter lab. Wagner et al. [13] retrospectively identified 43 patients who received A-CPR with LUCAS, to treat cardiac arrest that occurred during a procedure in the catheter lab. Of the initial 43 patients, 16 achieved ROSC and 11 survived to discharge with good neurological function. Several earlier case reports had previously described LUCAS supported circulation during PCI [31–33] however a small study of 13 patients by Larsen et al. [14] reported a universally fatal outcome when LUCAS was used to support the circulation
Fig. 5. Invasive measurement of aortic pressure generated by AutoPulse-CPR; during continuous automated-CPR (left panel), device pause (middle panel) and device reactivation (right panel).
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Fig. 6. Procedures during AutoPulse-CPR. A–C, Diagnostic angiography (case 9): A, left coronary artery (RAO caudal); B, right coronary artery (LAO); C, positioning of intra-aortic balloon pump (AP). D–E, Left main stem PCI following TAVI (case 2): D, note the hazy appearance to the LMS (white arrow), which resolves following PCI (E).
of patients who had suffered cardiac arrest prior to arrival into the catheter lab. The use of AutoPulse for resuscitation from IHCA, occurring both in and distant to the catheter laboratory, remains less well reported. In the present study we describe our experience of AutoPulse-CPR in a consecutive series of patients who suffered IHCA. Our study cohort was diverse with respect to underlying diagnosis, encompassed a large range of ages and included patients who suffered cardiopulmonary arrest in or distant to the catheter laboratory (Tables 1–3). In contrast to Larsen et al. [14], who described a universally fatal outcome among patients transferred to the catheter lab with a supported circulation, we describe 2 patients (cases 2 & 9) who suffered IHCA distant to that catheter lab and with an AutoPulse-dependant circulation were transferred to the catheter lab, underwent PCI and survived to hospital discharge.
In the first patient (case 2), which has been previously published by our group [15], cardiac arrest occurred on the Coronary Care Unit secondary to left main stem obstruction 3 h following successfully TAVI. Resuscitation was prolonged (43 min of A-CPR) and involved transfer of the patient back to the catheter lab and emergency left main stem PCI, during continuous AutoPulse support. In the second patient (case 9), cardiac arrest occurred in the Emergency Department during acute anterior STEMI complicated by cardiogenic shock and pulmonary oedema. With an AutoPulse-dependant circulation the patient was intubated, ventilated and transferred to the catheter lab where he underwent stenting of both his left main stem and right coronary artery (Fig. 6). In both cases full clinical recovery was observed, with preservation of normal cerebral function. In these particular cases it seems unlikely that the same outcome could have been achieved with resuscitation limited to manual CPR, which would have been significantly interrupted during coronary
Fig. 7. The A-CPR team approach. A stepwise team approach to device positioning and operation (for illustrative purposes only A-CPR positioning is demonstrated in this mock cardiac arrest); (A) manual CPR is continued until the team is assembled. (B) Whilst the anaesthetist supports the patient's head, two team members lift the patient to an upright position so that the fourth team member can accurately position the device. (C) The patient is laid onto the backboard and manual CPR is continued whilst the compression band is connected, raised to full extension and A-CPR has commenced. (D) The team member closest to the A-CPR controls becomes the primary device operator.
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intervention. The AutoPulse is largely radiolucent apart from electronic components contained within the backboard. Antero-posterior (AP) imaging is impeded by these electronic components (Fig. 6C) however, RAO caudal and LAO cranial angulations allow unimpeded views of the coronary arteries (Fig. 6A, B, D & E). Of the 25 patients who successfully received AutoPulse-CPR, PCI was performed in 14 patients with 7 (50%) of these surviving to discharge. Indeed of the 6 patient categories receiving AutoPulse-CPR only those with STEMI/NSTE-ACS undergoing PCI survived to discharge. Advantages of AutoPulse-CPR during simultaneous invasive procedures included (i) continuous, good quality CPR, (ii) maintenance of sterile field, (iii) good visualisation of coronary arteries with cranial and caudal projections and (iv) removal of CPR-provider exposure to direct-beam fluoroscopy. Previously it has been reported that, in a scenario setting, AutoPulse may be rapidly and successfully placed by first-aid workers who have watched a short training video and received 5 minute handling the device for familiarisation [17]. In contrast we found that healthcare professionals, previously trained by industry, were often slow and ineffective at placing and operating the device during a cardiac arrest scenario. In a real-life situation these deficiencies may have led to significant interruptions or delay in providing automated CPR. Moreover in our clinical practice we encountered problems with device placement and operation that precluded its use in four (14%) patients. In an attempt to overcome these problems we established a programme of targeted re-education, provided by a clinician experience in the use of AutoPulse, using mannequin-based training. We observed significant reductions in time taken to place and operate the device, which were maintained over time. Furthermore, in real-life cardiac arrest we established that an ‘AutoPulse-CPR team’ approach (Fig. 7) was vital when attempting to correctly place the device and helped to minimise unnecessary delay, analogous to the previously described ‘pit-crew’ protocol [20]. Overall we found that a significant learning curve had to be negotiated when integrating AutoPulse-CPR into wellestablished conventional resuscitation algorithms. Correct device placement remains important not only for the provision of effective CPR but to minimise the risk of iatrogenic injury, with post mortem studies describing major musculoskeletal and intraabdominal organ injury following incorrect placement [34,35]. In the present study we did not experience any injury among AutoPulse-CPR survivors, which is remarkable considering that patients who underwent PCI were loaded with high doses of antiplatelet drugs and were therapeutically anticoagulated. Limitations of our study include the fact that cases were collected and analysed retrospectively with unavoidable selection bias. It was the decision of the clinician present at the time of cardiac arrest who decided on the appropriateness of resuscitation technique. Clearly cases presented within the current study represent resuscitation of witnessed IHCA occurring within a tertiary centre cardiology department with immediate access to catheter lab facilities. The wider application of our findings to other situations of cardiac arrest remains unclear. Finally, post mortem studies were not performed following all unsuccessful resuscitations therefore although we report no injuries sustained among A-CPR survivors we cannot comment as to whether device related injury occurred in those who died. In conclusion, we observed that a significant learning curve must be negotiated when introducing automated-CPR into clinical practice. An emphasis on re-training, regular scenario-based practice and a team approach to device placement may be helpful. However, once established automated-CPR may offer clear advantages over manual-CPR in certain situations, such as during simultaneous invasive cardiac procedures. AutoPulse-CPR in the setting of a reversible cause of cardiac arrest, such as STEMI/NSTE-ACS treated with PCI, was associated with the greatest likelihood of survival to discharge. Further studies are required to fully understand the applicability of automated-CPR for cardiopulmonary arrest and which patient populations may potentially gain greatest benefit.
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Conflict of interest There are no conflicts of interest for any authors detailed above.
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Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Automated cardiopulmonary resuscitation using a load-distributing band external cardiac support device for in-hospital cardiac arrest: A single centre experience of AutoPulse-CPR☆ J.R. Spiro, S. White, N. Quinn, C.J. Gubran, P.F. Ludman, J.N. Townend, S.N. Doshi ⁎ The Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
a r t i c l e
i n f o
Article history: Received 16 June 2014 Received in revised form 1 October 2014 Accepted 16 November 2014 Available online 18 November 2014 Keywords: Automated cardiopulmonary resuscitation In-hospital cardiac arrest Emergency percutaneous coronary intervention
a b s t r a c t Background: Poor quality cardiopulmonary resuscitation (CPR) predicts adverse outcome. During invasive cardiac procedures automated-CPR (A-CPR) may help maintain effective resuscitation. The use of A-CPR following in-hospital cardiac arrest (IHCA) remains poorly described. Aims & methods: Firstly, we aimed to assess the efficiency of healthcare staff using A-CPR in a cardiac arrest scenario at baseline, following re-training and over time (Scenario-based training). Secondly, we studied our clinical experience of A-CPR at our institution over a 2-year period, with particular emphasis on the details of invasive cardiac procedures performed, problems encountered, resuscitation rates and in-hospital outcome (AutoPulseCPR Registry). Results: Scenario-based training: Forty healthcare professionals were assessed. At baseline, time-to-position device was slow (mean 59 (±24) s (range 15–96 s)), with the majority (57%) unable to mode-switch. Following re-training time-to-position reduced (28 (±9) s, p b 0.01 vs baseline) with 95% able to mode-switch. This improvement was maintained over time. AutoPulse-CPR Registry: 285 patients suffered IHCA, 25 received A-CPR. Survival to hospital discharge following conventional CPR was 28/260 (11%) and 7/25 (28%) following A-CPR. A-CPR supported invasive procedures in 9 patients, 2 of whom had A-CPR dependant circulation during transfer to the catheter lab. Conclusion: A-CPR may provide excellent haemodynamic support and facilitate simultaneous invasive cardiac procedures. A significant learning curve exists when integrating A-CPR into clinical practice. Further studies are required to better define the role and effectiveness of A-CPR following IHCA. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Background Survival following in-hospital cardiac arrest (IHCA) remains low [1], with poor quality cardiopulmonary resuscitation (CPR) predicting adverse outcome [2–5]. Automated-CPR (A-CPR) may provide superior circulatory support than manual CPR, increase incidence of return of spontaneous circulation (ROSC) and facilitate invasive cardiac procedures during simultaneous resuscitation. The use of A-CPR to treat out-of-hospital cardiac arrest (OHCA) has been energetically studied over recent years [6–9]. However, despite favourable animal [10] and human [11] haemodynamic data, survival among patients treated with A-CPR remains disappointing. Following OHCA, A-CPR has failed to demonstrate a reliable or sustained improvement in short- or long-term survival with either LUCAS (Lund University Cardiac Arrest System, Jolife AB, Lund, Sweden) ☆ This is an original manuscript and does not relate to another paper, either published or in press. ⁎ Corresponding author. E-mail address: [email protected] (J.R. Spiro).
http://dx.doi.org/10.1016/j.ijcard.2014.11.109 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
[6], or AutoPulse (ZOLL Medical Corporation, Chelmsford, MA, USA) [7] devices, as compared to manual-CPR (M-CPR) alone. Indeed device use has been associated with worse neurological outcome [7] and increased interruptions in CPR [12]. Following in-hospital cardiac arrest (IHCA), the role of A-CPR remains unclear, with data only available from two small series of patients treated with LUCAS [13,14] and one case report using AutoPulse [15]. Current resuscitation guidelines suggest that A-CPR may be used in ‘specific settings’ of cardiac arrest but there remains insufficient evidence to support routine use [16]. One potential clinical setting may be to support emergency invasive cardiac procedures directed towards correcting the cause of cardiac arrest. Indeed, the LUCAS A-CPR device has been described in patients who required emergency procedures during cardiac arrest in the catheter laboratory [13,14], however no such data exist for AutoPulse. Furthermore, AutoPulse is reported to be easy to use on a mannequin, by first-aiders who have only received brief training [17], however it remains unclear how this translates into real-life clinical practice and what it's effect would be on well-established conventional CPR algorithms.
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2. Aims & methods
3. Results
In this study we aimed firstly to assess the efficiency and competence of trained healthcare professionals within our department at using the AutoPulse-CPR in a cardiac arrest scenario. Secondly, we aimed to describe our department's experience with AutoPulse-CPR during real-life IHCA.
3.1. Scenario-based training
2.1. Scenario-based training Forty healthcare staff from a multi-disciplinary background (10 cardiologists, 25 cardiology nurses, 5 auxiliary healthcare workers) working in the cardiology department of The Queen Elizabeth Hospital, Birmingham, UK, volunteered to take part. All participants had received prior training from an industry representative (ZOLL Medical Corporation, Chelmsford, MA, USA). Without prior warning participants were led individually to a training room containing the AutoPulse device and a resuscitation mannequin (Laerdal Medical, NY 12590, USA). They were instructed to position AutoPulse on the mannequin, activate the device to begin chest compressions, and then mode-switch (from 30:2 to continuous activation). Time taken to place and activate the device (time-to-position), and ability to mode-switch, were measured at (1) baseline, (2) immediately following intensive re-training from a clinician experienced in use of AutoPulse and (3) after a period of time (mean 64 days, range 39–76 days).
2.2. AutoPulse-CPR Registry Patients suffering in-hospital cardiac arrest (IHCA) at our institution over a 2-year period (Sept 2011–Sept 2013) were identified. Patients who received AutoPulse-CPR (intention to treat) were identified and became our study group. Clinical characteristics, resuscitation details and in-hospital outcome were assessed with particular emphasis placed on the reporting of practical problems encountered when using the device, advantages of AutoPulse-CPR and details of invasive cardiac procedures performed during support.
2.3. Statistical methodology Repeated measures in the same individual were assessed using a paired Student's t-test, SPSS. Observational data are expressed as mean ± standard deviation or range.
At baseline, all participants in the cardiac arrest scenario successfully positioned and activated the device onto the mannequin; mean timeto-position 59 (±24) s (range 15–96 s), considerably longer than the industry advertised 20 s [18]. However, following intensive re-training participants became more efficient (time-to-position 28 (±9) s, range 15–61 s, p b 0.01 vs baseline) and this improvement was maintained over time (time-to-position at follow-up 30 (± 12) s, range 18–68 s, p ≤ 0.01 vs baseline), Fig. 1. Operation of the device (ability to modeswitch) was achieved by 17 (43%) participants at baseline, which improved to 38 (95%) after re-training and 37 (93%) at follow-up, Fig. 2. There was no significant correlation between time-to-position and the time period from industry training to baseline testing (Fig. 3A) or from re-training to follow-up testing (Fig. 3B). 3.2. AutoPulse-CPR Registry Over a 2-year period 285 patients suffered IHCA at our institution; 177 (62%) male, mean age 68 ± 16 years (range 21–99 years). From this cohort twenty-nine consecutive patients were identified as having received an intention-to-treat with AutoPulse-CPR; 19 (66%) were male, mean age 71 ± 17 years (range 26–95 years). There was significant diagnostic heterogeneity, including ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute coronary syndrome (NSTE-ACS), complex cyanotic adult congenital heart disease (ACHD), patients with symptomatic severe aortic stenosis either after or at the time of transcatheter aortic valve implantation (TAVI), and one patient who was undergoing a complex cardiac electrophysiological procedure. Clinical characteristics are shown in Table 1. 3.3. A-CPR using AutoPulse A-CPR was successfully delivered in 25/29 (86%) patients, with conventional CPR continued in 4 patients in whom A-CPR had been unsuccessful (Fig. 4). Mean time from IHCA to A-CPR was 7.4 ± 6.6 min (range 1–30 min), with part of this time taken to assess patient response to initial conventional resuscitation. A-CPR was provided for a mean time of 22.2 ± 14.9 min (range 2–60 min), Table 2. A-CPR was observed to provide excellent circulatory support when invasive haemodynamic readings were measured (Fig. 5). All patients undergoing A-CPR underwent endotracheal intubation by an anaesthetist on the resuscitation team.
Fig. 1. Individual (A) and mean ± SD (B) time-to-position AutoPulse-CPR in a cardiac arrest scenario.
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Fig. 2. Operation of the AutoPulse device (mode-switch). Chart represents participants who were able (dark grey) and unable (light grey) to operate the device at (A) baseline, (B) after intensive re-training and (C) at follow-up.
3.4. Survival from IHCA Among patients receiving conventional CPR, 28/260 (11%) survived to hospital discharge. Following A-CPR, 12/25 (48%) patients achieved ROSC, with 7/25 (28%) surviving to hospital discharge (Table 3). Of the 5 patients who died despite ROSC 1 died following re-arrest in the catheter lab, due to massive pulmonary embolism (case 16), 1 died from progressive sepsis (case 20), 2 died from multi-organ failure (cases 10 & 27) and 1 died from heart failure (case 17). 3.5. Invasive procedures during AutoPulse-CPR 15/25 (60%) patients received A-CPR at some stage during an invasive cardiac procedure. Invasive procedures were paused to allow resuscitation in 6/15 (40%), whereas the remaining 9/15 (60%) patients received A-CPR during simultaneous invasive procedures; 4 patients underwent percutaneous coronary intervention (PCI), 4 had coronary angiography (with additional transoesophageal echocardiography, n = 1, and transvenous endocardial pacing, n = 1) and 1 other patient received drainage of pericardial tamponade (Table 2 and Fig. 6). Of note 3 of these 9 patients (cases 2, 8 & 9) were transferred to the catheter laboratory in cardiac arrest, and with an A-CPR dependant circulation. Following PCI in 2 of these patients (cases 2 and 9) A-CPR could be terminated following ROSC. Both patients made a full recovery and were discharged from hospital with normal cerebral function (Cerebral Performance Category [19] (CPC) 1). The remaining patient (case 8) underwent emergency coronary angiography, which demonstrated normal coronary arteries, with subsequent post mortem confirming cause of death as massive pulmonary embolism.
this we established an A-CPR team approach to device positioning. This simple strategy greatly improved the efficiency and speed of device positioning and was analogous to the previously described ‘pit crew’ protocol [20] with each team member having a pre-defined and wellpracticed role, Fig. 7. 3.7. Problems using A-CPR Failure of AutoPulse occurred in 4 patients, details described below. In these situations the device was removed and patients received manual CPR. 3.7.1. Problem 1: battery depletion (case 6) During resuscitation the device failed to commence chest compressions. Subsequent analysis demonstrated that the battery within the device was low on charge. This incidence prompted us to introduce a policy of daily battery changes, even if the device had not been used the preceding day. 3.7.2. Problem 2: difficult backboard placement (case 24) Due to large body habitus (BMI 32), bifemoral arterial sheaths and intra-aortic balloon pump, this patient could not be lifted sufficiently upright to allow correct backboard placement. Consequently fluoroscopic screening was significantly limited and the device was removed. PCI was completed once the patient was resuscitated using manual CPR.
3.6. Maximising chest compression fraction (the ‘A-CPR team’ approach)
3.7.3. Problem 3: compression band twist (case 28) Despite careful placement of the device by staff experienced with the device the compression band became twisted and was drawn into the mechanism within the backboard. This resulted in complete failure of the device.
In our experience we observed that using A-CPR had the potential to significantly interfere with resuscitation due to the possibility of delay between pausing M-CPR and commencing A-CPR. In order to address
3.7.4. Problem 4: clip detachment (case 29) Following several minutes of chest compressions the A-CPR the device stopped. Inspection revealed that a clip, responsible for holding
Fig. 3. Correlation of time-to-position against (A) days from industry training to baseline testing and (B) days from re-training to follow-up testing.
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Table 1 Patient characteristics. Case
Age/sex
BMI
Patient category
AutoPulse sited
Arrest rhythm
1 2 3 4 5 6* 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24* 25 26 27 28* 29*
67M 76F 33M 49F 88F 73M 60M 65M 65M 65M 80M 95F 78M 63M 86M 79F 57F 90M 53F 74M 94F 91M 85M 60F 26F 67M 74M 77M 92M
30 22 22 22 22 37 26 28 37 29 26 22 27 26 27 24 21 24 30 27 22 25 22 32 21 25 28 31 22
STEMI STEMI ACHD STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI STEMI Heart failure STEMI STEMI NSTE-ACS Tamponade NSTE-ACS Hypothermia STEMI ACHD Heart failure STEMI NSTE-ACS STEMI
LAB CCU CCU LAB LAB CCU LAB ED ED LAB LAB LAB LAB ED ED CCU CCU LAB LAB CCU LAB LAB CCU LAB WARD CCU LAB CCU CCU
PEA PEA PEA VF VF PEA VF PEA PEA PEA PEA PEA VF VF PEA PEA VT VF VF VF PEA PEA PEA VT PEA PEA PEA PEA PEA
Key — STEMI, ST-segment elevation myocardial infarction; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; ACHD, adult congenital heart disease; LAB, cardiac catheter laboratory; ED, emergency department; CCU, coronary care unit; WARD, acute cardiology ward; PEA, pulseless electrical activity; VF, ventricular fibrillation, VT, ventricular tachycardia; *, problems using AutoPulse which limited or precluded it's use (these patients have been removed from A-CPR statistics and remain in the conventionalCPR group).
the compression band in the correct alignment with the backboard, had become detached. The device would not reactivate, despite the installation of a new band.
4. Discussion Maintenance of sufficient myocardial and cerebral perfusion following cardiopulmonary arrest remains dependent on effective manual CPR (M-CPR) with poor quality chest compressions, caused by CPR-provider fatigue [2], insufficient compression depth [3], slow compression rate [4] or low chest compression fraction (CCF) [5], predicting adverse outcome. Mechanical support during cardiac arrest, using percutaneous venoarterial extracorporeal membrane oxygenation (ECMO) [21] and left ventricular assist devices (LVADs) such as Impella [22] (Abiomed Inc., Danvers, MA, USA) or Tandem Heart [23] (CardiacAssist Inc., Pittsburgh, PA, USA), has been described with favourable outcomes. However, these devices are invasive, complex and require skilled teams in order to institute them urgently. They therefore have limited applicability to widespread use. However, external automated chest compression devices (A-CPR) may represent an attractive alternative. In clinical practice two devices are currently available; the AutoPulse load-distributing band (LDB) (ZOLL Medical Corporation, Chelmsford, MA, USA) and the LUCAS (Lund University Cardiac Arrest System, Jolife AB, Lund, Sweden) mechanical piston device. Despite encouraging animal [10] and human [11] experimental data, clinical studies of automated vs manual-CPR for out-of-hospital cardiac arrest (OHCA) have failed to consistently demonstrate a survival benefit in favour of A-CPR [6–9]. These disappointing observations might be explained by significant reductions in CCF experienced during device application [24]. Recently a meta-analysis consisting of 12 studies, involving a total of 6538 subjects who suffered OHCA, concluded that A-CPR provided a higher incidence of ROSC as compared to M-CPR (OR 1.62 (95% CI 1.36– 1.92, p b 0.001)), with the LDB-CPR device appearing to outperform the piston-driven device [25]. However, further studies are required in
Fig. 4. Flow chart demonstrating total number of patients suffering in-hospital cardiac arrest (IHCA), number treated with AutoPulse-CPR (A-CPR), number achieving return of spontaneous circulation (ROSC) and number surviving to hospital discharge.
J.R. Spiro et al. / International Journal of Cardiology 180 (2015) 7–14 Table 2 Resuscitation details.
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Table 3 Outcome and details of deaths. A-CPR timing in relation to procedure
Case
ROSC
If ROSC; time to death
Survived to discharge
Cause of death
Place of death
1 2 3 4 5 6* 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24* 25 26 27 28* 29*
Yes Yes No Yes Yes No Yes No Yes Yes No No No No No Yes Yes No No Yes No Yes No Yes No No Yes No No
Survived Survived – Survived Survived – Survived – Survived 20 h – – – – – 30 min 20 min – – Day 12 – Survived – Survived – – 3h – –
Yes (CPC1) Yes (CPC1) No Yes (CPC1) Yes (CPC1) No Yes (CPC1) No Yes (CPC1) No No No No No No No No No No No No Yes (CPC1) No Yes (CPC1) No No No No No
– – Sepsis – – Cardiac tamponade – PE – MOF Ischaemic CS Ischaemic CS Ischaemic CS Ischaemic CS Ischaemic CS PE Severe LVSD/DCM Ischaemic CS PE Sepsis/MOF Aortic annular rupture – Hypothermia – Fontan obstruction Severe AS and LVSD Ischaemic CS and MOF Ischaemic CS IHD and GI bleed
– – CCU – – CCU – LAB – ICU LAB LAB LAB LAB LAB LAB CCU LAB LAB ICU LAB – CCU – WARD CCU ICU CCU CCU
Case
Duration A-CPR, min
CCF, %
Procedure(s) performed
Before
During
After
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
10 48 25 5 15 0* 28 60 30 17 20 10 5 34 34 45 10 26 35 18 12 2 15 0* 30 20 5 2* 5*
91 94 94 92 92 94 92 93 96 94 94 99 92 93 95 97 96 98 92 97 94 94 96 94 94 93 88 92 91
PCI PCI No procedure PCI PCI PCI PCI Angiogram PCI PCI PCI PCI PCI PCI TPW, angiogram Angiogram No procedure Angiogram TOE, angiogram PCI Pericardial drain PCI No procedure PCI No procedure BAV PCI No procedure Angiogram
No Yes NA No No No No Yes Yes No No No No No Yes Yes NA No No No No No NA No NA No No NA No
Yes Yes• NA No No No Yes Yes• Yes No Yes• Yes Yes• Yes• Yes• Yes• NA No Yes• No Yes• Yes NA Yes NA No Yes NA No
No No NA Yes Yes Yes No No No Yes No No No No No No NA Yes Yes Yes Yes No NA No NA Yes No NA Yes
Definition of A-CPR being performed ‘before, during and after’ a procedure: Before, A-CPR occurring during hospital admission but before an invasive procedure; during, A-CPR performed whilst an invasive procedure is being performed (the symbol • identify patients who received A-CPR simultaneously during an invasive cardiac procedure; absence of this symbol reflects a temporary pause in the procedure to allow A-CPR); and after, A-CPR performed following the conclusion of an invasive procedure. Key — A-CPR; automated (AutoPulse) cardiopulmonary resuscitation; TPW, temporary pacing wire; BAV, balloon aortic valvuloplasty; PCI, percutaneous coronary intervention; CCF, chest compression fraction; ROSC, return of spontaneous circulation; TOE, transoesophageal echocardiography; NA, not applicable; *, problems using AutoPulse which limited or precluded it's use (these patients have been removed from A-CPR statistics and remain in the conventional-CPR group); angiogram, diagnostic coronary angiogram only.
order to better understand the apparent disconnect between improved rates of ROSC and an absence of robust survival benefit. It is hoped that results from three large on-going studies (Circulation Improving Resuscitation Care [CIRC] [26], Prehospital Randomized Assessment of a Mechanical Compression Device in Cardiac Arrest [PARAMEDIC] [27] and LUCAS in Cardiac Arrest [LINC] [28]) may help to better define the timing and role of A-CPR.
Key — ROSC, return of spontaneous circulation; CPC, cerebral performance criteria; TGA, transposition of the great arteries; Mustard, surgical correction of TGA (atrial switch); PEA, pulseless electrical activity; PE, pulmonary embolus; PPCI, primary percutaneous coronary intervention; ICU, intensive care unit; MOF, multi-organ failure; LAB, cardiac catheter laboratory; CCU, coronary care unit; CS, cardiogenic shock; LVSD, left ventricular systolic dysfunction; DCM, dilated cardiomyopathy; WARD, acute cardiology ward; AS, aortic stenosis; IHD, ischaemic heart disease; GI, gastrointestinal; NA, not applicable; *, problems using AutoPulse which limited or precluded it's use (these patients have been removed from A-CPR statistics and remain in the conventional-CPR group).
However, despite a paucity of robust outcome data, current resuscitation guidelines state that A-CPR devices might be useful for the treatment of cardiac arrest in specific settings [29,30]. One such setting may be the cardiac catheter lab. Wagner et al. [13] retrospectively identified 43 patients who received A-CPR with LUCAS, to treat cardiac arrest that occurred during a procedure in the catheter lab. Of the initial 43 patients, 16 achieved ROSC and 11 survived to discharge with good neurological function. Several earlier case reports had previously described LUCAS supported circulation during PCI [31–33] however a small study of 13 patients by Larsen et al. [14] reported a universally fatal outcome when LUCAS was used to support the circulation
Fig. 5. Invasive measurement of aortic pressure generated by AutoPulse-CPR; during continuous automated-CPR (left panel), device pause (middle panel) and device reactivation (right panel).
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Fig. 6. Procedures during AutoPulse-CPR. A–C, Diagnostic angiography (case 9): A, left coronary artery (RAO caudal); B, right coronary artery (LAO); C, positioning of intra-aortic balloon pump (AP). D–E, Left main stem PCI following TAVI (case 2): D, note the hazy appearance to the LMS (white arrow), which resolves following PCI (E).
of patients who had suffered cardiac arrest prior to arrival into the catheter lab. The use of AutoPulse for resuscitation from IHCA, occurring both in and distant to the catheter laboratory, remains less well reported. In the present study we describe our experience of AutoPulse-CPR in a consecutive series of patients who suffered IHCA. Our study cohort was diverse with respect to underlying diagnosis, encompassed a large range of ages and included patients who suffered cardiopulmonary arrest in or distant to the catheter laboratory (Tables 1–3). In contrast to Larsen et al. [14], who described a universally fatal outcome among patients transferred to the catheter lab with a supported circulation, we describe 2 patients (cases 2 & 9) who suffered IHCA distant to that catheter lab and with an AutoPulse-dependant circulation were transferred to the catheter lab, underwent PCI and survived to hospital discharge.
In the first patient (case 2), which has been previously published by our group [15], cardiac arrest occurred on the Coronary Care Unit secondary to left main stem obstruction 3 h following successfully TAVI. Resuscitation was prolonged (43 min of A-CPR) and involved transfer of the patient back to the catheter lab and emergency left main stem PCI, during continuous AutoPulse support. In the second patient (case 9), cardiac arrest occurred in the Emergency Department during acute anterior STEMI complicated by cardiogenic shock and pulmonary oedema. With an AutoPulse-dependant circulation the patient was intubated, ventilated and transferred to the catheter lab where he underwent stenting of both his left main stem and right coronary artery (Fig. 6). In both cases full clinical recovery was observed, with preservation of normal cerebral function. In these particular cases it seems unlikely that the same outcome could have been achieved with resuscitation limited to manual CPR, which would have been significantly interrupted during coronary
Fig. 7. The A-CPR team approach. A stepwise team approach to device positioning and operation (for illustrative purposes only A-CPR positioning is demonstrated in this mock cardiac arrest); (A) manual CPR is continued until the team is assembled. (B) Whilst the anaesthetist supports the patient's head, two team members lift the patient to an upright position so that the fourth team member can accurately position the device. (C) The patient is laid onto the backboard and manual CPR is continued whilst the compression band is connected, raised to full extension and A-CPR has commenced. (D) The team member closest to the A-CPR controls becomes the primary device operator.
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intervention. The AutoPulse is largely radiolucent apart from electronic components contained within the backboard. Antero-posterior (AP) imaging is impeded by these electronic components (Fig. 6C) however, RAO caudal and LAO cranial angulations allow unimpeded views of the coronary arteries (Fig. 6A, B, D & E). Of the 25 patients who successfully received AutoPulse-CPR, PCI was performed in 14 patients with 7 (50%) of these surviving to discharge. Indeed of the 6 patient categories receiving AutoPulse-CPR only those with STEMI/NSTE-ACS undergoing PCI survived to discharge. Advantages of AutoPulse-CPR during simultaneous invasive procedures included (i) continuous, good quality CPR, (ii) maintenance of sterile field, (iii) good visualisation of coronary arteries with cranial and caudal projections and (iv) removal of CPR-provider exposure to direct-beam fluoroscopy. Previously it has been reported that, in a scenario setting, AutoPulse may be rapidly and successfully placed by first-aid workers who have watched a short training video and received 5 minute handling the device for familiarisation [17]. In contrast we found that healthcare professionals, previously trained by industry, were often slow and ineffective at placing and operating the device during a cardiac arrest scenario. In a real-life situation these deficiencies may have led to significant interruptions or delay in providing automated CPR. Moreover in our clinical practice we encountered problems with device placement and operation that precluded its use in four (14%) patients. In an attempt to overcome these problems we established a programme of targeted re-education, provided by a clinician experience in the use of AutoPulse, using mannequin-based training. We observed significant reductions in time taken to place and operate the device, which were maintained over time. Furthermore, in real-life cardiac arrest we established that an ‘AutoPulse-CPR team’ approach (Fig. 7) was vital when attempting to correctly place the device and helped to minimise unnecessary delay, analogous to the previously described ‘pit-crew’ protocol [20]. Overall we found that a significant learning curve had to be negotiated when integrating AutoPulse-CPR into wellestablished conventional resuscitation algorithms. Correct device placement remains important not only for the provision of effective CPR but to minimise the risk of iatrogenic injury, with post mortem studies describing major musculoskeletal and intraabdominal organ injury following incorrect placement [34,35]. In the present study we did not experience any injury among AutoPulse-CPR survivors, which is remarkable considering that patients who underwent PCI were loaded with high doses of antiplatelet drugs and were therapeutically anticoagulated. Limitations of our study include the fact that cases were collected and analysed retrospectively with unavoidable selection bias. It was the decision of the clinician present at the time of cardiac arrest who decided on the appropriateness of resuscitation technique. Clearly cases presented within the current study represent resuscitation of witnessed IHCA occurring within a tertiary centre cardiology department with immediate access to catheter lab facilities. The wider application of our findings to other situations of cardiac arrest remains unclear. Finally, post mortem studies were not performed following all unsuccessful resuscitations therefore although we report no injuries sustained among A-CPR survivors we cannot comment as to whether device related injury occurred in those who died. In conclusion, we observed that a significant learning curve must be negotiated when introducing automated-CPR into clinical practice. An emphasis on re-training, regular scenario-based practice and a team approach to device placement may be helpful. However, once established automated-CPR may offer clear advantages over manual-CPR in certain situations, such as during simultaneous invasive cardiac procedures. AutoPulse-CPR in the setting of a reversible cause of cardiac arrest, such as STEMI/NSTE-ACS treated with PCI, was associated with the greatest likelihood of survival to discharge. Further studies are required to fully understand the applicability of automated-CPR for cardiopulmonary arrest and which patient populations may potentially gain greatest benefit.
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Conflict of interest There are no conflicts of interest for any authors detailed above.
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