Note: To do this technique properly, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.
Today on the podcast, I address the last little bit from my SMACC lecture on the new management of the intra-arrest: hemodynamic, individualized dosing of epinephrine.
Articles/Posts on Epinephrine by ACLS Guidelines
- [cite source='pubmed']15306666[/cite],
- [cite source='pubmed']24846323[/cite]
- [cite source='pubmed']19934423[/cite]
Epinephrine Dosing Based on DBP
Three Swine Study
(Crit Care Med. 2013 Dec;41(12):2698-704)
(Resuscitation. 2013 May;84(5):696-701)[cite source='pubmed']25321490[/cite] [cite source='pubmed']24945902[/cite]
AIM: Advances in cardiopulmonary resuscitation (CPR) have focused on the generation and maintenance of adequate myocardial blood flow to optimize the return of spontaneous circulation and survival. Much of the morbidity associated with cardiac arrest survivors can be attributed to global brain hypoxic ischemic injury. The objective of this study was to compare cerebral physiological variables using a hemodynamic directed resuscitation strategy versus an absolute depth-guided approach in a porcine model of ventricular fibrillation (VF) cardiac arrest.
METHODS: Intracranial pressure and brain tissue oxygen tension probes were placed in the frontal cortex prior to induction of VF in 21 female 3month old swine. After 7minutes of VF, animalswere randomized to receive one of three resuscitation strategies: 1) Hemodynamic Directed Care (CPP-20): chest compressions (CCs) with depth titrated to a target systolic blood pressure of 100mmHg and titration of vasopressors to maintain coronary perfusion pressure (CPP)> 20mmHg; 2) Depth 33mm(D33): target CC depth of 33mm with standard American Heart Association (AHA) epinephrine dosing; or 3) Depth 51mm(D51): target CC depth of 51mm with standard AHA epinephrine dosing.
RESULTS: Cerebral perfusion pressures (CerePP )were significantly higher in the CPP-20 group compared to both D33 (p<0.01) and D51 (P=0.046), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Brain tissue oxygen tension was also higher in the CPP-20 group compared to both D33 (P<0.01) and D51 (P=0.013), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Subjects with a CPP>20mm Hg were 2.7 times more likely to have a CerePP>30mm Hg (P< 0.001).
CONCLUSIONS: Hemodynamic directed resuscitation strategy targeting coronary perfusion pressure>20mmHg following VF arrest was associated with higher cerebral perfusion pressures and brain tissue oxygen tensions during CPR. University of Pennsylvania IACUC protocol #803026.
Perhaps we can extrapolate from these pig studies to–shoot for SBP of >=100 with compression efficacy and CPP>20 (DBP>40) with vasoconstriction. REBOA or SAAP may solve both
Human Study by Dr. Paradis
Coronary Perfusion Pressure and the Return of Spontaneous Circulation in Human Cardiopulmonary Resuscitation[cite source='doi']10.1001/jama.1990.03440080084029[/cite]
Coronary perfusion pressure (CPP), the aortic-to-right atrial pressure gradient during the relaxation phase of cardiopulmonary resuscitation, was measured in 100 patients with cardiac arrest. Coronary perfusion pressure and other variables were compared in patients with and without return of spontaneous circulation (ROSC). Twenty-four patients had ROSC. Initial CPP (mean±SD) was 1.6 ± 8.5 mm Hg in patients without ROSC and 13.4 ± 8.5 mm Hg in those with ROSC. The maximal CPP measured was 8.4 ±10.0 mm Hg in those without ROSC and 25.6 ±7.7 mm Hg in those with ROSC. Differences were also found for the maximal aortic relaxation pressure, the compression-phase aortic-to— right atrial gradient, and the arterial Po2. No patient with an initial CPP less than 0 mm Hg had ROSC. Only patients with maximal CPPs of 15 mm Hg or more had ROSC, and the fraction of patients with ROSC increased as the maximal CPP increased. A CPP above 15 mm Hg did not guarantee ROSC, however, as 18 patients whose CPPs were 15 mm Hg or greater did not resuscitate. Of variables measured, maximal CPP was most predictive of ROSC, and all CPP measurements were more predictive than was aortic pressure alone. The study substantiates animal data that indicate the importance of CPP during cardiopulmonary resuscitation.
Good Review on Epinephrine
AHA Cardiopulmonary Resuscitation Quality Statement
by Meaney P. et al (Circulation 2013;128:417)
- Rate 100-120
- 5cm depth
- Full Recoil
- <12 BPM, Minimal Chest Rise
- Art/CVP CPP>20
- Just Art Line DBP>25-30 (I disagree)
- ETCO2>20 mm Hg
If DBP < 20 optimize compressions or vasopressors (Circulation 2011;123:e236)
CVP can be higher during the poor flow of the arrest state [cite]3970745[/cite],(Am J Emerg Med. 1985 Jan;3(1):11-4.), and [cite]3946853[/cite] and this one had a mean of 16 [cite source='doi']10.1161/01.CIR.80.2.361[/cite]
so I would shoot for 35-40 mm Hg
Goal is to give less epineprhine
Hemodynamic-directed CPR Review[cite]24783998[/cite]
Now on to the Podcast…
- COVID19 – Awake Pronation (aka the Pig Roast) A guest write-up by David Gordon, MD - April 6, 2020
- EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients - April 4, 2020
- EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer - March 31, 2020