Simulation and educationLeaning is common during in-hospital pediatric CPR, and decreased with automated corrective feedback*
Introduction
Cardiopulmonary Resuscitation (CPR) guidelines recommend target values for rate and depth of chest compressions and ventilations, limiting interruptions in chest compressions (CPR-free intervals), and allowing complete release (full chest recoil) between chest compressions.1 However, recent studies in adults demonstrate that rescuers often do not comply with CPR guidelines.1, 2 Incomplete release (“leaning”) between chest compressions was associated with poor survival in both adult clinical and animal studies of cardiac arrest, presumably because high intrathoracic pressure impedes blood return to the heart.3, 4 A pediatric animal model suggests that leaning forces as little as 1.8 kg during CPR in piglets substantially decreases coronary perfusion pressure, cardiac index and myocardial blood flow.5 High quality CPR with complete release (no leaning) and interventions to reduce intrathoracic pressure improve CPR hemodynamics, blood flow to critical tissues, and survival outcomes in adults and laboratory animals.4
New force transducer technology can reduce the frequency and magnitude of leaning during CPR, using real-time automated directive and corrective audiovisual feedback. The mean leaning force for adults during out of hospital CPR was 1.7 ± 1.0 kg.6 The effectiveness of real-time feedback as an adjunct for the resuscitation team leader to minimize leaning has not been evaluated during pediatric CPR. We hypothesized that leaning during pediatric CPR would be common, and that real-time feedback would be associated with reduced leaning prevalence and force during actual CPR in a children's hospital.
Section snippets
Study design
This prospective observational study was approved by the Institutional Review Board at the Children's Hospital of Philadelphia. Data collection procedures were completed in compliance with the guidelines of the Health Insurance and Portability and Accountability Act to ensure subject confidentiality. Written informed consent was obtained from all health care providers who participated in the resuscitations. Consent from patient/families was not required.
Equipment and training
A commercial monitor/defibrillator system
Results
A total of 20 pediatric cardiac arrest events in 18 patients requiring chest compressions were treated using the MRx/Q-CPR defibrillator from October 2006 to February 2008. Data analyzed included 37,085 chest compressions during 576 min of cardiac arrest. There were 1921 chest compressions delivered with No Feedback and 35,164 chest compressions with Feedback. Real-time automated feedback was activated at the clinical team and resuscitation leaders’ discretion, and the resuscitation team was
Discussion
This prospective, single-center observational study establishes that leaning was very common during CPR for pediatric patients (≥8 years old) at a children's hospital. We documented leaning in over 89% of chest compressions. Real-time automated audiovisual feedback was associated with a significantly lower average residual leaning force between compressions (No Feedback: median 2.5 kg, IQR 1.6–3.5 kg vs. Feedback: median 1.6 kg, IQR 0.9–2.6 kg, p < 0.001). To our knowledge, this is the first report
Conclusions
During actual pediatric CPR in a children's hospital, leaning (residual force >0.5 kg) was common, occurring in approximately 90% of chest compressions, and 28% of all chest compressions had a leaning force >2.5 kg. Automated directive and corrective audiovisual leaning feedback as an adjunct to resuscitation team leader direction was associated with reduced leaning prevalence (27% vs. 50%) and reduced leaning force. Further study is necessary to determine the effect of leaning on CPR
Conflict of interest statement
The authors acknowledge the following potential conflicts of interest: Jon Nysaether is an employee of Laerdal Medical Corporation. Vinay Nadkarni, Dana Niles and Robert Sutton receive grant support from the Laerdal Foundation. Benjamin Abella receives research funding from Philips Healthcare and Cardiac Science Corporation and has received speaking honoraria from Philips.
Acknowledgments
Funding provided by Laerdal Foundation for Acute Care Medicine and the Endowed Chair of Critical Care Medicine at CHOP. We wish to thank Stephanie Tuttle MBA, Kathryn Roberts RN, Lori Boyle RN, Warren Frankenberger RN, Owen Siegel RN, and the staff of the Pediatric ICU and Emergency Department at Children's Hospital of Philadelphia for their support and contributions to this study.
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A Spanish translated version of the summary of this article appears as appendix in the final online version at doi:10.1016/j.resuscitation.2009.02.012.