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Early, instead of late, automated chest compressions for in-hospital cardiac arrest
Resuscitation 113 (2017) e9–e10
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Early, instead of late, automated chest compressions for in-hospital cardiac arrest Sir, The 2015 European Resuscitation Council1 guidelines suggest that automated chest compression (A-CPR) devices should not routinely replace manual chest compressions. They also suggest that A-CPR devices are a reasonable alternative to high-quality manual chest compressions in situations where sustained highquality manual compressions are impossible, impractical or might compromise provider safety such as in a moving ambulance, in case of prolonged CPR attempts and for cardiopulmonary resuscitation during certain procedures such as coronary angiography, although these specific use cases are not in evidence in the literature referenced.1 We suggest explicitly designating in-hospital cardiac arrest as a reason for early A-CPR and would like to argue this point. In-hospital survival has not improved in line with out-ofhospital (OOH) survival. While many factors may contribute, the ability of staff to perform “high quality” compressions per se,5 and the mechanics of chest compressions in hospital beds or stretchers remain points of discussion.2 Any non-rigid support surfaces adversely affects quality of chest compressions and mattress makes depth estimation difficult. A CPR-board reduces mattress displacement, but does not alleviate it, placement takes time, and it effects the use of feedback devices.3,4 Resuscitation in beds seems a special case since “high quality” compressions cannot be guaranteed or monitored. A-CPR studies to date have focused on out-of-hospital resuscitations. Studies which included A-CPR showed late and prolonged deployment times.1,5 For hospitals, response teams typically bring their own resources and are on scene quickly. As we have done for some years now, upgrading manual to A-CPR at team arrival allows A-CPR to be started within the critical 6-min window, something not achieved in the OOH studies. While A-CPR will, unavoidably, still follow an initial period of manual chest compressions, early placement can absorb the set-up hands-off time in the transition from basic to advanced teams, and minimize further compression interruptions.3,5 In-hospital teams do not have the manpower limitations found in OOH resuscitations. The value-add of A-CPR is projected onto its reproducible, tireless, high quality compressions. The investment is in hands-off time during placement. The in-hospital environment is ideal to manage this, as lengthy resuscitations, movement of patients to cath labs, ultrasound and invasive monitoring, all occur. A well-drilled team and a clear intern protocol seem crucial to use A-CPR devices correctly. In the Elisabeth-TweeSteden Hospital we have invested in this with training and an intern protocol (Fig. 1).
http://dx.doi.org/10.1016/j.resuscitation.2017.01.019 0300-9572/© 2017 Elsevier B.V. All rights reserved.
In-hospital manual resuscitation cannot offer “high quality” compressions, cannot monitor this, and offers an opportunity for early deployment; all conditions different from OOH CPR. Late application of A-CPR may, inevitably, lead to negative, self-fulfilling, experience. Therefore, we strongly suggest a recommendation supporting “upon ALS arrival” use of automated chest compression devices inhospital, if the requirement is met that ALS teams are schooled to limit deployment related hands-off time. We call upon other centers to register their experience in detail, including time to deploying A-CPR, quality to that point, set-up times, and actual condition of the patient during in-hospital cardiac arrest, this to support further discussion for the Guidelines 2020.
Conflict of interest statement The authors have no conflicts of interest to disclose relevant to this article.
Financial disclosure The authors have no financial relationships to disclose relevant to this article.
References ¨ 1. Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 3. Adult advanced life support. Resuscitation 2015;95:100–47. 2. Noordergraaf GJ, Paulussen IWF, Venema A, et al. The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard. Resuscitation 2009;80:546–52. 3. Perkins GD, Smith CM, Augre C, et al. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med 2006;32:1632–5. 4. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81–99. 5. Li H, Wang D, Yu Y, et al. Mechanical versus manual chest compressions for cardiac arrest: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2016;24:1–10, http://dx.doi.org/10.1186/s13049-016-0202-y.
R. Nielen ∗ J. van de Minkelis Dept. of Anesthesiology, Resuscitation & Pain Management, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands P. van Berkom Dept. of Intensive Care Medicine and CPRLab, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
e10
Letter to the Editor / Resuscitation 113 (2017) e9–e10
Fig. 1. Example of the intern protocol of ventricular fibrillation and pulseless ventricular tachycardia. ∗ Corresponding
author at: Dept. of Anesthesiology, Resuscitation & Pain Management, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60 5022 GC Tilburg, The Netherlands.
E-mail address: [email protected] (R. Nielen) 16 January 2017 18 January 2017
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Early, instead of late, automated chest compressions for in-hospital cardiac arrest Sir, The 2015 European Resuscitation Council1 guidelines suggest that automated chest compression (A-CPR) devices should not routinely replace manual chest compressions. They also suggest that A-CPR devices are a reasonable alternative to high-quality manual chest compressions in situations where sustained highquality manual compressions are impossible, impractical or might compromise provider safety such as in a moving ambulance, in case of prolonged CPR attempts and for cardiopulmonary resuscitation during certain procedures such as coronary angiography, although these specific use cases are not in evidence in the literature referenced.1 We suggest explicitly designating in-hospital cardiac arrest as a reason for early A-CPR and would like to argue this point. In-hospital survival has not improved in line with out-ofhospital (OOH) survival. While many factors may contribute, the ability of staff to perform “high quality” compressions per se,5 and the mechanics of chest compressions in hospital beds or stretchers remain points of discussion.2 Any non-rigid support surfaces adversely affects quality of chest compressions and mattress makes depth estimation difficult. A CPR-board reduces mattress displacement, but does not alleviate it, placement takes time, and it effects the use of feedback devices.3,4 Resuscitation in beds seems a special case since “high quality” compressions cannot be guaranteed or monitored. A-CPR studies to date have focused on out-of-hospital resuscitations. Studies which included A-CPR showed late and prolonged deployment times.1,5 For hospitals, response teams typically bring their own resources and are on scene quickly. As we have done for some years now, upgrading manual to A-CPR at team arrival allows A-CPR to be started within the critical 6-min window, something not achieved in the OOH studies. While A-CPR will, unavoidably, still follow an initial period of manual chest compressions, early placement can absorb the set-up hands-off time in the transition from basic to advanced teams, and minimize further compression interruptions.3,5 In-hospital teams do not have the manpower limitations found in OOH resuscitations. The value-add of A-CPR is projected onto its reproducible, tireless, high quality compressions. The investment is in hands-off time during placement. The in-hospital environment is ideal to manage this, as lengthy resuscitations, movement of patients to cath labs, ultrasound and invasive monitoring, all occur. A well-drilled team and a clear intern protocol seem crucial to use A-CPR devices correctly. In the Elisabeth-TweeSteden Hospital we have invested in this with training and an intern protocol (Fig. 1).
http://dx.doi.org/10.1016/j.resuscitation.2017.01.019 0300-9572/© 2017 Elsevier B.V. All rights reserved.
In-hospital manual resuscitation cannot offer “high quality” compressions, cannot monitor this, and offers an opportunity for early deployment; all conditions different from OOH CPR. Late application of A-CPR may, inevitably, lead to negative, self-fulfilling, experience. Therefore, we strongly suggest a recommendation supporting “upon ALS arrival” use of automated chest compression devices inhospital, if the requirement is met that ALS teams are schooled to limit deployment related hands-off time. We call upon other centers to register their experience in detail, including time to deploying A-CPR, quality to that point, set-up times, and actual condition of the patient during in-hospital cardiac arrest, this to support further discussion for the Guidelines 2020.
Conflict of interest statement The authors have no conflicts of interest to disclose relevant to this article.
Financial disclosure The authors have no financial relationships to disclose relevant to this article.
References ¨ 1. Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 3. Adult advanced life support. Resuscitation 2015;95:100–47. 2. Noordergraaf GJ, Paulussen IWF, Venema A, et al. The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard. Resuscitation 2009;80:546–52. 3. Perkins GD, Smith CM, Augre C, et al. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med 2006;32:1632–5. 4. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81–99. 5. Li H, Wang D, Yu Y, et al. Mechanical versus manual chest compressions for cardiac arrest: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2016;24:1–10, http://dx.doi.org/10.1186/s13049-016-0202-y.
R. Nielen ∗ J. van de Minkelis Dept. of Anesthesiology, Resuscitation & Pain Management, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands P. van Berkom Dept. of Intensive Care Medicine and CPRLab, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
e10
Letter to the Editor / Resuscitation 113 (2017) e9–e10
Fig. 1. Example of the intern protocol of ventricular fibrillation and pulseless ventricular tachycardia. ∗ Corresponding
author at: Dept. of Anesthesiology, Resuscitation & Pain Management, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60 5022 GC Tilburg, The Netherlands.
E-mail address: [email protected] (R. Nielen) 16 January 2017 18 January 2017