Clinical paperPhysiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study☆
Introduction
In-hospital cardiac arrest affects approximately 200,000 patients each year in the United States.1 Although outcomes have been improving over the last decade, more than half of adults who have a cardiac arrest during their hospitalization will not survive.2, 3, 4 Many of these arrests now occur in highly monitored intensive care units (ICUs), where patients often have invasive monitoring in place at the time of arrest.2 A resuscitation strategy that takes advantage of this monitoring and uses it to incorporate a patient's physiologic response into the ongoing resuscitation can be expected to save more lives.5, 6 Experimental literature has established that survival following cardiopulmonary resuscitation (CPR) for cardiac arrest depends on provision of adequate myocardial blood flow.7, 8, 9 However, measurements of myocardial blood flow during CPR are not available to the rescuer. Therefore, the American Heart Association (AHA) now recommends using clinical surrogates closely related to myocardial blood flow (end tidal carbon dioxide (ETCO2) or diastolic blood pressure (DBP)) to monitor resuscitation quality.10 Although the conceptual relevance of hemodynamic and ETCO2 monitoring during CPR is well established, clinical studies supporting the titration of these parameters during human CPR are lacking.
The primary objective of this study was to evaluate the association between clinician-reported physiologic monitoring of CPR quality using either ETCO2 or DBP and survival outcomes. We hypothesized that use of physiology to monitor resuscitation quality would be associated with higher rates of return of spontaneous circulation (ROSC). We addressed this hypothesis in a propensity-score-matched cohort study of adult in-hospital CPR events reported to the AHA's large multicenter Get With The Guidelines®-Resuscitation (GWTG-R) registry database.
Section snippets
Methods
The GWTG-R registry is an AHA sponsored prospective multisite database of patients undergoing in-hospital resuscitation that utilizes Utstein-style data reporting.11, 12, 13 Hospitals voluntarily participate in the registry for the primary purpose of quality improvement. The design and reporting of GWTG-R has been described in detail previously (www.heart.org/resuscitation).3, 14, 15 Quintiles (Cambridge Massachusetts), through their online, interactive case report form and Patient Management
Results
Between January 1, 2006 and September 7, 2012, there were 64,556 index adult CPR events with either an invasive airway or arterial catheter in place at the time of the arrest, of which 23,429 (36%) met inclusion criteria (Fig. 1). Of 21,375 index events with an invasive airway in place at the time of the arrest, clinicians reported using ETCO2 to monitor quality in 803 (4%). Compared to earlier events, clinician-reported use of ETCO2 to monitor resuscitation quality was more common in index
Discussion
In this propensity-matched-cohort study of adults using the AHA's multicenter GWTG-R registry, clinician-reported use of physiology to monitor CPR quality with either ETCO2 or DBP was associated with improved rates of ROSC. Survival to hospital discharge and survival with favorable neurological outcome were not different between groups. In an adjusted model using the subset of 803 index events during which ETCO2 monitoring was reported as used, an ETCO2 >10 mmHg during CPR was associated with a
Conclusions
In this propensity-matched-cohort study of adult in-hospital cardiac arrest using the AHA's GWTG-R registry, clinician-reported use of physiologic monitoring of CPR quality with either continuous ETCO2 or diastolic blood pressure was associated with an improved rate of ROSC compared to no reported physiologic monitoring. However, survival to hospital discharge and survival with favorable neurological outcome were not different between groups. In the subset of index events where CPR quality was
Conflicts of interest statement
Robert Sutton has received a speaker's honoraria from the Zoll Medical Corporation. Raina Merchant has received grant/research support from the NIH (K23 10714038; R01 HL122457), and pilot funding from Physio-Control (Seattle, WA), Zoll Medical (Boston MA), Cardiac Science (Bothell, WA), and Philips Medical (Seattle, WA). Benjamin Abella has received research funding from the NIH, AHA, PCORI, and Medtronic Foundation, speaking honoraria from Philips Healthcare (Seattle, WA) and CR Bard (Murray
Acknowledgements
Robert Sutton, Alexis Topjian, and Melania Bembea are supported by career development awards (RMS: National Institute of Child Heath and Human Development; AAT and MB National Institute of Neurological Disorders and Stroke).
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.06.018.