• Justin T Hamrick, Jennifer L Hamrick, Utpal Bhalala, Jillian S Armstrong, Jeong-Hoo Lee, Ewa Kulikowicz, Jennifer K Lee, Sapna R Kudchadkar, Raymond C Koehler, Elizabeth A Hunt, and Donald H Shaffner.
• 1Department of Pediatric Anesthesiology and Pain Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR. 2Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, The Children's Hospital of San Antonio, San Antonio, TX. 3Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 4Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD. 5Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD.
• Pediatr Crit Care Me. 2017 Nov 1; 18 (11): e575-e584.

ObjectivesTo determine whether end-tidal CO2-guided chest compression delivery improves survival over standard cardiopulmonary resuscitation after prolonged asphyxial arrest.DesignPreclinical randomized controlled study.SettingUniversity animal research laboratory.Subjects1-2-week-old swine.InterventionsAfter undergoing a 20-minute asphyxial arrest, animals received either standard or end-tidal CO2-guided cardiopulmonary resuscitation. In the standard group, chest compression delivery was optimized by video and verbal feedback to maintain the rate, depth, and release within published guidelines. In the end-tidal CO2-guided group, chest compression rate and depth were adjusted to obtain a maximal end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation included 10 minutes of basic life support followed by advanced life support for 10 minutes or until return of spontaneous circulation.Measurements And Main ResultsMean end-tidal CO2 at 10 minutes of cardiopulmonary resuscitation was 34 ± 8 torr in the end-tidal CO2 group (n = 14) and 19 ± 9 torr in the standard group (n = 14; p = 0.0001). The return of spontaneous circulation rate was 7 of 14 (50%) in the end-tidal CO2 group and 2 of 14 (14%) in the standard group (p = 0.04). The chest compression rate averaged 143 ± 10/min in the end-tidal CO2 group and 102 ± 2/min in the standard group (p < 0.0001). Neither asphyxia-related hypercarbia nor epinephrine administration confounded the use of end-tidal CO2-guided chest compression delivery. The response of the relaxation arterial pressure and cerebral perfusion pressure to the initial epinephrine administration was greater in the end-tidal CO2 group than in the standard group (p = 0.01 and p = 0.03, respectively). The prevalence of resuscitation-related injuries was similar between groups.ConclusionsEnd-tidal CO2-guided chest compression delivery is an effective resuscitation method that improves early survival after prolonged asphyxial arrest in this neonatal piglet model. Optimizing end-tidal CO2 levels during cardiopulmonary resuscitation required that chest compression delivery rate exceed current guidelines. The use of physiologic feedback during cardiopulmonary resuscitation has the potential to provide optimized and individualized resuscitative efforts.

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