Pediatric cardiopulmonary resuscitation quality during intra-hospital transport

Abstract

Aim: To evaluate pediatric cardiopulmonary resuscitation (CPR) quality during intra-hospital transport to facilitate extracorporeal membrane oxygenation (ECMO)-CPR (ECPR). We compared chest compression (CC) rate, depth, and fraction (CCF) between the pre-transport and intra-transport periods.

Methods: Observational study of children <18 years with either in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) who underwent transport between two care locations within the hospital for ECPR and who had CPR mechanics data available. Descriptive patient and arrest characteristics were summarized. The primary analysis compared pre- to intra-transport CC rate, depth, and fraction. A secondary analysis compared the proportion of pre- versus intra-transport 60-s epochs meeting guideline recommendations for rate (100-120/min), depth (≥4 cm for infants; ≥5 cm for children ≥1 year), and CCF (≥0.80).

Results: Seven patients (four IHCA; three witnessed OHCA) met eligibility criteria. Six (86%) patients survived the event and two (28%) survived to hospital discharge. Median transport CPR duration was 7 [IQR 5.5, 8.5] minutes. There were no differences in pre- vs. intra-transport CC rate (115 [113, 118] vs. 118 [114, 127] CCs/minute; p = 0.18), depth (3.2 [2.7, 4.4] vs. 3.6 [2.5, 4.6] cm; p = 0.50), or CCF (0.89 [0.82, 0.90] vs. 0.92 [0.79, 0.97]; p = 0.31). Equivalent proportions of 60-s CPR epochs met guideline recommendations between pre- and intra-transport (rate: 66% vs. 57% [p = 0.22]; depth: 14% vs. 19% [p = 0.39]; CCF: 80% vs. 75% [p = 0.43]).

Conclusions: Pediatric CPR quality was maintained during intra-hospital patient transport, suggesting that it is reasonable for ECPR systems to incorporate patient transport to facilitate ECMO cannulation.

Keywords: CPR quality; Cardiac arrest; Cardiopulmonary resuscitation; Extracorporeal cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; Pediatric; Transport.

Figure 1:. Resuscitation Team Composition and Positioning for Cardiopulmonary Resuscitation During Intra-Hospital Transport.

1 - Patient: positioned to side of bed to allow for room for chest compressor to be on bed; side rail nearest patient is up while that on the side of the chest compressor is typically down; 2 - Chest Compressor (CC): on bed, typically in kneeling position facing patient; pre-identified as individual who can potentially provide compressions through duration of transport; 3 - Spotter: responsible for ensuring safety of chest compressor while bed is in motion; also is backup compressor if compressor switch is necessary; 4 - Airway Physician: typically Critical Care Medicine fellow physician; provides airway and ventilation monitoring and care during transport; 5 - Respiratory Therapist (RT): assists with airway and ventilation management; manages airway equipment and ventilator if applicable; 6 - Medication Nurse: provides medications during resuscitation; 7 - Nurse: assists with medications, bed movement, CPR coaching; 8 - Security: escorts patient and team to destination; 9 - Code Leader: typically attending intensivist; leads resuscitation team.

Figure 2:. Extracorporeal Cardiopulmonary Resuscitation Criteria for Non-ICU Pediatric Cardiac Arrest.

Flow diagram depicting institutional criteria for activating the extracorporeal cardiopulmonary resuscitation (ECPR) system for patients outside of the Intensive Care Unit (ICU). Resuscitation teams are encouraged to consider activating the system approximately five minutes into CPR or five minutes after arrival to the Emergency Department among patients with CPR in progress. The protocol is designed to broadly identify potential ECPR candidates; teams do not necessarily pursue ECPR on all patients meeting these criteria. ETCO2 = end-tidal carbon dioxide, SBP = systolic blood pressure, CHD = congenital heart disease