Elsevier

Resuscitation

Volume 185, April 2023, 109716
Resuscitation

Experimental paper
High central venous pressure amplitude predicts successful defibrillation in a porcine model of cardiac arrest

https://doi.org/10.1016/j.resuscitation.2023.109716Get rights and content

Abstract

Aim

Increasing venous return during cardiopulmonary resuscitation (CPR) has been shown to improve hemodynamics during CPR and outcomes following cardiac arrest (CA). We hypothesized that a high central venous pressure amplitude (CVP-A), the difference between the maximum and minimum central venous pressure during chest compressions, could serve as a robust predictor of return of spontaneous circulation (ROSC) in addition to traditional measurements of coronary perfusion pressure (CPP) and end-tidal CO2 (etCO2) in a porcine model of CA.

Methods

After 10 min of ventricular fibrillation, 9 anesthetized and intubated female pigs received mechanical chest compressions with active compression/decompression (ACD) and an impedance threshold device (ITD). CPP, CVP-A and etCO2 were measured continuously. All groups received biphasic defibrillation (200 J) at minute 4 of CPR and were classified into two groups (ROSC, NO ROSC). Mean values were analyzed over 3 min before defibrillation by repeated-measures Analysis of Variance and receiver operating characteristic (ROC).

Results

Five animals out of 9 experienced ROSC. CVP-A showed a statistically significant difference (p = 0.003) between the two groups during 3 min of CPR before defibrillation compared to CPP (p = 0.056) and etCO2 (p = 0.064). Areas-under-the-curve in ROC analysis for CVP-A, CPP and etCO2 were 0.94 (95% Confidence Interval 0.86, 1.00), 0.74 (0.54, 0.95) and 0.78 (0.50, 1.00), respectively.

Conclusion

In our study, CVP-A was a potentially useful predictor of successful defibrillation and return of spontaneous circulation. Overall, CVP-A could serve as a marker for prediction of ROSC with increased venous return and thereby monitoring the beneficial effects of ACD and ITD.

Introduction

Each year, emergency medical services respond to more than 350,000 adult out-of-hospital cardiac arrests (CA) in the United States with similar numbers in Europe.1, 2 Functionally favorable survival is still less than 10% with little demonstrated increase since 2012.3 Modern mechanical adjuncts for cardiopulmonary resuscitation (CPR) aim to improve outcome by targeting and enhancing venous return, such as active compression-decompression (ACD) CPR and the impedance threshold device (ITD).4, 5, 6, 7, 8

To date, there is no parameter to quantify or monitor venous return during CPR. Although central venous pressure (CVP) is used to estimate blood volume, studies have shown that high mean CVP values are harmful during CPR and might not reflect venous return.9, 10, 11 Further, mean CVP does not reflect the change of direction in venous blood flow during compression and decompression.12, 13 Previously, we demonstrated that the CVP amplitude (CVP-A), reflecting the difference between the maximum and minimum central venous pressure (CVPMin) during chest compressions, might reflect changes in blood volume more accurately and serve as a marker of venous return and CPR quality.14

Thus, the objective of this study was to evaluate CVP-A as a marker to predict successful defibrillation and the return of spontaneous circulation (ROSC) compared to coronary perfusion pressure (CPP) and end-tidal CO2 (etCO2) using ACD + ITD CPR in a porcine model of CA.

Section snippets

Methods

This study is a post-hoc analysis of the control group (9 animals) of a previously conducted study (unpublished). We were able to use the data for our exploratory and confirmatory study and, thus, comply with the 3Rs principle of humane animal research. The original study was approved by the Institutional Animal Care and Use Committee of the University of Minnesota (protocol number: 1810-36421A). All animal care was compliant with the National Research Council’s 1996 Guidelines for the Care and

Results

Nine animals were instrumented without complications. After successful induction of VF and 4 min of CPR, all animals were still in VF and defibrillated. Four animals achieved ROSC with 1 shock and another animal with 2 shocks; these animals required no further chest compressions (ROSC group). Two animals achieved ROSC after prolonged resuscitation requiring additional medications and > 2 defibrillations, and 2 animals never achieved ROSC after 8 defibrillations (NO ROSC group). There were no

Discussion

Our study evaluated the role of CVP-A during chest compressions in a porcine model of CA and ACD + ITD CPR and suggests this variable as a potentially useful marker for predicting ROSC. Compared with other existing markers of blood flow during CPR and predictors of successful defibrillation, we not only introduced CVP-A as a new and at least equivalent parameter but also demonstrated better discriminatory power compared with CVP and etCO2.

We showed that increased CVP-A with values greater than

Conclusion

In this porcine model of CA and high-quality CPR, CVP-A was a potential predictor for successful defibrillation and ROSC and as least as reliable as etCO2 or CPP. Overall, CVP-A could serve as a robust marker for prediction of ROSC with increased venous return and thereby monitor the beneficial effects of ACD and ITD.

Conflict of interest statement

None of the authors has any financial and personal relationships with other people or organisations that could inappropriately have influenced this work.

CRediT authorship contribution statement

Claudius Balzer: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization, Funding acquisition. Susan S. Eagle: Conceptualization, Methodology, Writing – review & editing. Demetris Yannopoulos: Conceptualization, Methodology, Validation, Investigation, Writing – review & editing, Supervision, Project administration, Funding acquisition. Tom P. Aufderheide: Conceptualization,

Acknowledgements

The authors thank Dr. Andreas Leha (Department of Medical Statistics, University of Goettingen, Germany) for statistical consulting on this project and Dr. Franz J. Baudenbacher (Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA) and Dr. Robert W. Neumar (Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA) for their technical advice.

Dr. Balzer was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation,

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