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Interposed abdominal compression CPR in pediatric cardiac arrest: early results from a multicenter comparison to
Daniel Stromberg1, Tia T Raymond2, Gabriela Centers3
1Texas Center for Pediatric and Congenital Heart Disease, University of Texas at Austin, Dell Medical School and Dell Children's Medical Center, Austin, TX, United States; Department of Pediatrics and Surgery and Perioperative Care, University of Texas at Austin, Dell Medical School, United States.
Insights
Interposed abdominal compression CPR (IAC-CPR) significantly increased diastolic and systolic blood pressure in pediatric ICU patients with congenital heart disease compared to standard CPR. This technique shows promise for improving outcomes in pediatric cardiac arrest.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiopulmonary Resuscitation
- Hemodynamics
Background:
- Interposed abdominal compression CPR (IAC-CPR) is an adjunct to standard CPR (S-CPR) recommended by the American Heart Association.
- IAC-CPR augments venous return, cardiac output, and diastolic blood pressure (DBP), with potential benefits for coronary and cerebral perfusion.
- Previous studies in animals and adults suggest improved hemodynamic parameters with IAC-CPR.
Purpose of the Study:
- To evaluate the effect of IAC-CPR on diastolic blood pressure (DBP) in pediatric cardiac intensive care unit (PCICU) patients.
- To compare hemodynamic parameters between IAC-CPR and S-CPR in pediatric patients.
- To assess survival and neurological outcomes associated with IAC-CPR.
Main Methods:
- Prospective, multicenter quality assurance study (Dec 2020 - July 2024) involving three PCICU sites.
- Hemodynamic data collected from sequential 1-2 minute epochs of S-CPR and IAC-CPR in pediatric patients (≤3 years old) with complex congenital heart disease.
- Comparison of hemodynamic waveforms, return of spontaneous circulation (ROSC), survival rates, and neurological outcomes (Pediatric Cerebral Performance Category - PCPC).
Main Results:
- Seventeen infants with complex congenital heart disease were included; 14/17 had single ventricle physiology postoperatively.
- IAC-CPR demonstrated a significant increase in DBP (11.6 mmHg, p=0.018) and SBP (15.4 mmHg, p=0.044) compared to S-CPR.
- ROSC achieved in 65%, ROC with ECMO in 29%, and survival to discharge or 30 days in 47%. All survivors had favorable neurological outcomes. No IAC-CPR complications were reported.
Conclusions:
- IAC-CPR significantly improved DBP and SBP compared to S-CPR in pediatric ICU patients with complex congenital heart disease.
- These findings support further investigation into IAC-CPR hemodynamics and outcomes in a broader pediatric population.
- IAC-CPR is a potentially valuable adjunct for pediatric resuscitation, with no observed complications in this cohort.
Introduction:
Interposed abdominal compression CPR (IAC-CPR) is an American Heart Association Class IIb recommended adjunct to standard CPR (S-CPR) that employs abdominal counter-pulsation during the "diastolic" (release) phase of thoracic compressions. Animal and adult studies have demonstrated IAC-CPR augmentation of venous return to the right heart with enhanced cardiac output, and increased diastolic blood pressure (DBP) with improved retrograde flow to the coronary arteries and brain. We hypothesized that IAC-CPR (compared with S-CPR) would result in higher DBP which has been associated with improved survival outcomes in pediatric cardiac intensive care unit (PCICU) patients.
Methods:
As participants in a prospective, multicenter, quality assurance collaborative (PediRes-Q.org) from Dec 2020 - July 2024, three participating PCICU sites used IAC-CPR within usual care, and systematically collected hemodynamic data from 1 to 2 min sequential epochs of S-CPR and IAC-CPR within the same patient. IAC-CPR training via video (https://youtu.be/cd3Gxu7Maqk), digital slide presentation, and in-person mannequin demonstration of technique competency at each participating center were required. Single rescuer resuscitation of children ≤ 3 years old proceeded with S-CPR for 1-2 min, followed by 1-2 min of IAC-CPR. Choice of CPR technique for the remainder of the cardiac arrest event was then left to the clinical care team. Hemodynamic waveforms from epochs of S-CPR and IAC-CPR were compared. Return of spontaneous circulation (ROSC), return of circulation (ROC) with ECMO, and survival to hospital discharge or to 30 days were recorded. Neurological outcome was assessed pre-arrest and at hospital discharge by the Pediatric Cerebral Performance Category (PCPC) score. Favorable neurologic outcome was considered PCPC category 1-2, or no change from pre-arrest baseline.
Results:
Seventeen infants with complex congenital heart disease were included, the majority of which (14/17) were single ventricle patients who experienced arrest postoperatively. Intervention analyses demonstrated a DBP increase of 11.6 mmHg during IAC-CPR versus S-CPR (95% CI [2.2-21.1], p = 0.018, adjusted for non-stationarity and correlations in individual time series). Peak systolic blood pressure (SBP) increased by 15.4 mmHg during IAC-CPR versus S-CPR (95% CI [0.51 - 30.2], p = 0.044, adjusted for non-stationarity and correlations in individual time series). ROSC was achieved in 11/17 (65%), and ROC with ECMO in 5/17 (29%). Survival to hospital discharge or to 30 days occurred in 8/17 (47%), and all had a favorable neurologic outcome. No complications attributable to IAC-CPR were found.
Conclusions:
IAC-CPR was associated with significant improvements in both DBP and SBP compared to S-CPR technique in pediatric ICU patients with complex congenital heart disease. This underscores the need for study of IAC-CPR hemodynamics and outcomes in a broader cohort of cardiac and non-cardiac pediatric patients.
