Time to Get Personal with CPR

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Science Translational Medicine  10 Dec 2014:
Vol. 6, Issue 266, pp. 266ec212
DOI: 10.1126/scitranslmed.aaa3458

“Push hard, push fast” is the mantra taught for cardiopulmonary resuscitation (CPR), which combines chest compressions, ventilation, vasoactive drugs, and cardiac defibrillation to treat victims of cardiac arrest. Current treatment guidelines recommend standardized CPR using fixed rates and depth of chest compressions, along with vasoactive drugs given at fixed doses and intervals. This approach emphasizes CPR quality, but new findings from Sutton et al. suggest that a more individualized approach to CPR may improve survival from cardiac arrest.

The authors report the results of an experiment in a swine model of asphyxia causing cardiac arrest with ventricular fibrillation. They compared a standard approach that used a fixed compression depth and vasopressor dosing schedule following current clinical guidelines with an approach where the chest compression depth was goal-directed and individualized by being titrated to a systolic blood pressure of 100 mm Hg, while the vasopressor drugs were titrated to a coronary perfusion pressure greater than 20 mm Hg. The researchers found that better-quality CPR (as it is currently defined) was delivered in the standard-guideline group, but this did not translate to improved outcomes. Fully 100% (10/10) of animals in the goal-directed group achieved return of spontaneous circulation, compared with only 33% (3/10) of animals in the guideline-based group. At 24 hours, 80% of animals receiving goal-directed care were alive, compared with zero in the guideline-based group. Importantly, 70% of the animals in the goal-directed group demonstrated favorable neurological outcomes, as assessed by a cerebral performance category scale.

The major technical hurdle to clinical translation of these findings is access to reliable real-time continuous hemodynamic monitors to guide CPR. However, this study demonstrates that the time has come to address these technical hurdles and start getting personal with CPR.

R. M. Sutton et al., Patient-centric blood pressure-targeted cardiopulmonary resuscitation improves survival from cardiac arrest. Am. J. Respir. Crit. Care Med. 190, 1255–1262 (2014). [Abstract]

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