Interact CardioVasc Thorac Surg 2009;8:148-151. doi:10.1510/icvts.2008.195974
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
Could we use abdominal compressions rather than chest compression in patients who arrest after cardiac surgery?
Zulfiquar Adama,*,
Safwaan Adama,
Pia Khanb and
Joel Dunningb
a Department of Cardiology, James Cook University Hospital, Middlesbrough TS4 3BW, UK
b Department of Cardio-thoracic Surgery, James Cook University Hospital, Middlesbrough TS4 3BW, UK
Received 6 October 2008;
accepted 7 October 2008
*Corresponding author. Tel.: +44 164 2282410; fax: +44 164 2282887.
E-mail address: adamz{at}doctors.org.uk (Z. Adam).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether abdominal cardiopulmonary resuscitation (CPR) could be used instead of external cardiac massage either to protect the recent sternotomy or while chest compressions are not possible whilst a sternotomy is being performed. Altogether 386 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Patients who arrest after cardiac surgery and require chest reopening will have a period of no external chest compression and therefore, no cerebral or coronary perfusion. In addition, if a patient arrests prior to cardiac surgery there will be a period of time performing the sternotomy during which there will be no external compressions. We found only one paper in a porcine model that looked at the effectiveness of abdominal only CPR although it did show that abdominal CPR was actually 60% better than chest CPR. Interposed abdominal and chest compressions has been much more extensively studied and has been shown to be significantly better in return of spontaneous circulation than chest compressions alone. We conclude that currently there is very little evidence to support abdominal only CPR although these studies may support the concept that it may potentially increase the coronary and cerebral perfusion pressure.
Key Words: Cardiopulmonary resuscitation; Abdominal compression
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients who require salvage sternotomy or resternotomy] is [abdominal CPR] of benefit to improve [coronary perfusion pressure]?
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3. Clinical scenario
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A patient returns to the intensive care unit following emergency coronary artery bypass grafting. His sternum is very fragile and therefore, a Robicsek sternal closure is performed. One hour post surgery, he suddenly arrests. The nurses start to perform external cardiac massage. You are concerned that the arrest may be due to tamponade and proceed to reopen the chest. It is taking longer than usual to reopen the chest. During this time, no active external chest compression is taking place. You have heard of a novel resuscitation technique called abdominal only compression (OAC) and you get your nurse to try it. You eventually manage to reopen the chest and later resolve to check the literature.
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4. Search strategy
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Medline 1950 to September 2008 using OVID interface.
[Abdominal compression$.mp OR abdominal CPR.mp OR abdominal counterpulsation.mp].
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5. Search outcome
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Three hundred and eighty-six papers were found using the reported search. From these, 10 papers were identified that provided the best evidence to answer the question. These are presented in Table 1.
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6. Results
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We found only one study that looked at abdominal only compression (OAC) cardiopulmonary resuscitation which was in animals. Geddes et al. [2] measured the coronary perfusion index in 11 pigs to determine the efficacy of CPR during ventricular fibrillation (VF). They were able to show that OAC-CPR was superior to standard CPR (SCPR), providing 60% higher coronary perfusion than standard CPR.
No other studies look at abdominal only compressions but there has been considerable interest in adding this to chest compressions. The 2005 International Liaison Committee on Resuscitation (ILCOR) consensus on science document provided a summary of the literature and concluded that when abdominal compression is interposed with chest compression, there is an improved return of spontaneous circulation [12]. There have been three level 1 studies [4–6] that have shown an improvement in outcome measures of interposed abdominal compression-CPR (IAC-CPR) for in-hospital cardiac arrest. Sack et al. [4] in their study of 103 patients showed that 29/48 (60%) of patients had return of spontaneous circulation (ROSC) compared to 14/55 (25%) with SCPR (P=0.03). They also showed better survival to discharge with 12/48 (25%) in the IAC-CPR group vs. 4/55 (7%) in the SCPR group (P=0.02). Another study by Sack et al. [5], which compared 143 patients who had cardiac arrest where the initial rhythm was pulseless electrical activity or asystole, showed that 33/67 (49%) had ROSC in the IAC-CPR group compared to 21/76 (28%) in the SCPR group (P=0.01). Ward et al. [6] in their study of 33 patients measured end tidal PCO2 (ETPCO2) and showed ETPCO2 averaged 17.1 mmHg with IAC-CPR vs. 9.6 mmHg with SCPR (P<0.001). They also showed that 6/16 (37%) in the IAC-CPR group had ROSC compared to 1/17 (6%) in the SCPR group (P=0.07). Trials involving CPR are often small but a meta-analysis of IAC-CPR [7] limited to human clinical trials comparing IAC-CPR to SCPR also showed a statistically significant benefit in favour of IAC-CPR in terms of return of spontaneous circulation. Babbs [11] has also shown in his computer model, using an idealized 70 kg human, that high frequency abdominal CPR can produce sufficient systemic perfusion pressures during cardiac arrest.
Sustained abdominal compression has also been evaluated recently in one animal based study [3]. This was rather interesting in that it showed that sustained abdominal compression produced a similar increase in coronary perfusion pressure when compared to vasopressor drugs. Abdominal binding during CPR has been previously investigated [10] and mean arterial pressure was higher in the 10 patients that were studied. Christenson et al. [8], however, showed in their experimental study that abdominal pressure in pulses was better than continuous abdominal compression during CPR.
All of the studies reported that there had been no visceral organ damage during any of the abdominal compression techniques.
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7. Clinical bottom line
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Patients who arrest after cardiac surgery who require chest reopening will have a period of no external chest compression and therefore, no cerebral or coronary perfusion. In addition, if a patient has a cardiac arrest prior to cardiac surgery there will be a period of time performing the sternotomy during which there will be no external compressions. However, we found only one paper in a porcine model that looked at the effectiveness of abdominal only CPR although it did show that abdominal CPR was actually 60% better than chest CPR. Interposed abdominal and chest compressions has been much more extensively studied and has been shown to be significantly better in return of spontaneous circulation than chest compressions alone. Currently there is very little evidence to support abdominal only CPR although these studies may support the concept that it may potentially increase the coronary and cerebral perfusion pressure.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact Cardiovasc Thorac Surg 2003;2:405–409.[Abstract/Free Full Text]
- Geddes LA, Rundell A, Lottes A, Kemeny A, Otlewski M. A new cardiopulmonary resuscitation method using only rhythmic abdominal compression: a preliminary report. Am J Emerg Med 2007;25:786–790.[CrossRef][Medline]
- Lottes AE, Rundell AE, Geddes LA, Kemeny AE, Otlewski MP, Babbs CF. Sustained abdominal compression during CPR raises coronary perfusion pressures as much as vasopressor drugs. Resuscitation 2007;75:515–524.[CrossRef][Medline]
- Sack JB, Kesselbrenner MB, Bregman D. Survival from in-hospital cardiac arrest with interposed abdominal counterpulsation during cardiopulmonary resuscitation. J Am Med Assoc 1992;267:379–385.[Abstract/Free Full Text]
- Sack JB, Kesselbrenner MB, Jarrad A. Interposed abdominal compression-cardiopulmonary resuscitation and resuscitation outcome during asystole and electromechanical dissociation. Circulation 1992;86:1692–1700.[Abstract/Free Full Text]
- Ward KR, Sullivan RJ, Zelenak RR, Summer WR. A comparison of interposed abdominal compresion CPR and standard CPR by monitoring end-tidal PCO2. Ann Emerg Med 1989;18:831–837.[CrossRef][Medline]
- Babbs CF. Simplified meta-analysis of clinical trials in resuscitation. Resuscitation 2003;57:245–255.[CrossRef][Medline]
- Christenson JM, Hamilton DR, Scott-Douglas NW, Tyberg JV, Powell DG. Abdominal compressions during CPR: hemodynamic effects of altering timing and force. J Emerg Med 1992;10:257–266.[CrossRef][Medline]
- Ralston SH, Babbs CF, Niebauer MJ. Cardiopulmonary resuscitation with interposed abdominal compression in dogs. Anesth Analg 1982;61:645–651.[Abstract/Free Full Text]
- Chandra N, Snyder LD, Weisfeldt ML. Abdominal binding during cardiopulmonary resuscitation in man. J Am Med Assoc 1981;246:351–353.[Abstract/Free Full Text]
- Babbs C. Biophysics of cardiopulmonary resuscitation with periodic z-axis acceleration or abdominal compression at aortic resonant frequencies. Resuscitation 2006;69:455–469.[CrossRef][Medline]
- International Liaison Committee on Resuscitation Part 4 Advanced Life Support, Resuscitation 2005;67:213–247.[CrossRef][Medline]
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eComment: Questioning a ‘best evidence’ search arguing against abdominal-only cardiopulmonary resuscitation and for external cardiac massage
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E. M. Rottenberg
eComment: Questioning a 'best evidence' search arguing against abdominal-only cardiopulmonary resuscitation and for external cardiac massage
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January 1, 2009;
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151 - 152.
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Abstract
1. Introduction