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Chest 1992;102;1846-1852
DOI 10.1378/chest.102.6.1846
The online version of this article, along with updated information and services
can be found online on the World Wide Web at:
http://chestjournal.chestpubs.org/content/102/6/1846
Ope n-chest direct cardiac compression represents a more intervals. Systemic blood flows averaged 198 ml@kg'@mmn'
potent but highly invasive option for cardiac resuscitation with extracorporeal circulation. This contrasted with direct
when conventional techniques of closed-chest cardiac re cardiac compression, in which flows averaged only 40
suscitation fail after prolonged cardiac arrest. We postu mlkg―min'. Coronary perfusion pressure, the major
lated that venoarterial extracorporeal circulation might be determinant ofresuscitabiity on the basis ofearlier studies,
a more effective intervention with less trauma. In the was correspondingly lower (94 vs 29 mm Hg). Extracorpo
setting of human cardiac resuscitation, however, controlled real circulation, in conjunction with transthoracic DC
studies would be limited by strategic constraints. Accord countershock and epinephrine, successfully reestablished
ingly, the effectiveness of open-chest cardiac compression spontaneous circulation in each of eight animals after 15
was compared with that of extracorporeal circulation after mm of untreated ventricular fibrillation. This contrasted
@‘
.4 . ‘- a 15-mm interval of untreated ventricular fibrillation in a with the outcome after open-chest cardiac compression, in
@ porcine model ofcardiac arrest. Sixteen domestic pigs were which spontaneous circulation was reestablished in only
. randomized to resuscitation by either peripheral venoar four of eight animals (p .038). We conclude that extracor
terial extracorporeal circulation or open-chest direct car poreal circulation is a more effective alternative to direct
diac compression. During resuscitation, epinephrine was cardiac compression for cardiac resuscitation after pro
continuously infused into the right atrium, and defibrillation tracted cardiac arrest. (Chest 1992; 102:1846-52)
was attempted by transthoracic countershock at 2-mm
E lectrical countershock is the immediate treatment Open-chest direct cardiac compression is a well
for ventricular fibrillation. When applied within established option by which substantially greater car
less than 60 s, it typically restores spontaneous circu diac output and coronary perfusion pressures may be
lation without additional interventions. ‘@
When the achieved.'2'4 The success of resuscitation under ex
duration of cardiac arrest is more prolonged, the perimental conditions is consequently increased two
success of resuscitation is contingent on the capability to threefold, contingent on the duration of cardiac
of achieving threshold levels of coronary perfusion arrest prior to open-chest cardiac massage.4'5'6 It is
pressure and therefore myocardial blood flow. The for these reasons that open-chest techniques have
coronary perfusion pressure itself is highly predictive been investigated as an option when conventional
of the success of resuscitation.47 methods of closed-chest resuscitation fail to restore
@ Current methods of closed-chest cardiac resuscita spontaneous Yet the practical issues of
tion lose effectiveness for maintaining critical coronary surgical skill and postthoracotomy patient care, to
perfusion pressures when the duration ofeardiac arrest gether with insecure proofofultimate clinical benefit,
prior to attempted cardiac resuscitation increases to have restrained the routine use of open-chest tech
more than 8 mm.89 Accordingly, the success of closed niques.
chest compression methods after more protracted More recent studies in animal models of cardiac
intervals exceeding 8 mm is remote.'°― arrest and reports on human victims of cardiac arrest
have provided evidence that extracorporeal circulation
@ the Department of Medicine, Divisions of Cardiology and (utilizing peripheral vascular access) may be a highly
Critical Care Medicine, University of Health SciencesfFhe Chi
cago Medical School, North Chicago, Illinois.
effective option for cardiac resuscitation.9―@ In our
Supported in part by National Heart, Lung and BIcod Institute studies, extracorporeal circulation successfully re
grants l-RO1-11L39148 and 1-RO1-11L42590;Institute of Critical stored spontaneous circulation in 19 of 21 pigs after a
Care Medicine, Palm Springs, Calif; and a grant-in-aid from the
American heart Association supported by Winthrop Pharmaceu 15-mm interval ofcardiac arrest. This contrasted with
ticals.
Reprint 7x'que.sts:I)r @@/(‘il,
Institute ()fCrltical Care Medicine, 3333 closed-chest resuscitation, in which none of five ani
Green Bay Road, North Chicago, IL 60064 mals was resuscitated.9
@ .@..-
20j mmHg
40
FIGURE 1. Greater mean aortic pressures (MAP) and
coronary perfusion pressures (CPP) were produced by
extracorporeal circulation (ECC) than by open-chest 20 PErCO2
cardiac compression (OCCC). Significantly greater in torr
creases in end-tidal Pco, (Ps@rCOÃwere observed with
direct cardiac compression. Values are shown as mean
0 m i I U __T_.....1@*.T___;r@
I I
(circles) and standard error of the mean. VF = ventric
ular fibrillation; DF ‘defibrillation by DC counter -10-5 04 12 +1 +3+30 +60 +120 +180
shock; # = pO.Ol and * pO.OOi for ECC vs OCCC Minutes UHS/CMS RJG,MHW 2/92
by unpaired t test. Domestèc
Pigs22 . 31 Kg
Table 2—Aortic and Coronary Vein Values before, during, and after Attempted Resuscitation by
Extracorporeal Circulation and by Open-Chest Cardiac Compression5
-.
Prearrest
mmPot, —5mmVF + 12 mmResuscitation +2 mmPostresuscitation +60 mm+ 180
mm Hg
ECCAo
34±15OCCCAo
ECCCV231±36 20±2259±99 40±11(3)113±56 54±10403±34 50±16393±40
@VF@= ventricular fibrillation; ECC extracorporeal circulation; Ao aortic; CV coronary vein; OCCC open-chest cardiac compression.
Values are expressed as mean ±standard deviation. Values were Obtained in eight animals except for postresuscitation OCCC (n 4). Values
in parentheses are number ofsamples obtained during VF.
tOCCC vs ECC, p<0.05.
@OCCCvs ECC, p<O.Ol.
§OCCCvs ECC, p<O.OOl.
(8)
-.-@Resuscitated
ECCOCCC
(4)p@Bood (8)Resuscitated (4)Non-Resuscitated
diac index and PEi'CO2 and a lower myocardial oxygen than 3 min.'2'3@ This is consistent with previous
extraction ratio (Table 3). However, differences in observations on the hemodynamic effects of closed
resuscitability were not explained by differences in and open-chest cardiac compression with increasing
coronary perfusion pressures in the setting of open duration of cardiac arrest.ssm In a canine model,
chest cardiac massage. Sanders et al@reported a decrease in the coronary
perfusion pressure generated by direct cardiac com
DISCUSsIoN
pression from 59 to 39 mm Hg when the preceding
These studies confirm previous investigations in interval ofcardiac arrest, which included closed-chest
both animals and human patients on the efficacy of compression, was increased from 15 to 25 mm. Ac
extracorporeal circulation for cardiac resuscitation cordingly, the low flows and pressures observed in the
after prolonged arrest.9'@°@Extracorporeal circulation current model are best explained by the prolonged
sustained quantitatively normal systemic blood flows downtime prior to intervention.
and served to “jumpstart―the heart within as little Increasing downtime may also compromise resus
as 3 mm.9 citability by increasing the minimal coronary perfusion
With direct cardiac compression, however, cardiac pressure threshold required for successful resuscita
output was only one fifth and coronary perfusion tion.9 When the duration of untreated ventricular
pressure only one third of that generated by extracor fibrillation was increased from 9 to 15 mm in our
poreal circulation, notwithstanding optimal compres rodent model of cardiac arrest, resuscitability was
sion technique and larger doses ofepmnephrine.@ This correspondingly decreased even though coronary per
is in contrast to the near.normal cardiac outputs and fusion pressure was maintained at comparable levels.@°
coronary perfusion pressures that are generated when This may explain why only 50 percent ofanimals were
open-chest cardiac compression is initiated within less successfully resuscitated by direct cardiac compres
ECC vs OCCC
VF DF • POST-RESUSC
(n/tot)
1
0.6- M@W@@4
0.2.
@
150-
50.@
::Q.@_/r―@'@1
‘@i@L
•
GCV-Ao PCO2
occc
(4/8) b,.-
@@i@PI
@..
°ECC
•
(8/8)
S S
300 GCV-Ao [H+] b...,
nmol/I . ..
150
@ 0.@ I, ____________
)V.::@G@@r p S C
@ 4- GCV-Ao lact .@@. FIGURE 2. Extracorporeal circulation (ECC) decreased
myocardial oxygen extraction ratio (MOE) and the
0@ coronary venoarterial gradient (GCF-Ao) values for
@ Pco2 and H when compared with open-chest cardiac
compression (OCCC) without significant effect on lac
tate gradients. Values are shown as mean ±standard
-10 -5 0 4 12 +2 +30 +60 +120 +180 error of the mean. VF=ventricular fibrillation;
Minutes UHS/CMSRJG,MHW 2/92 DF = defibrillation by DC countershock; # pO.Ol
DomesticPigs 22. 31 Kg and * pO.OOl for ECC vs OCCM by unpaired t test.
these conditions, extracorporeal circulation emerges resuscitation from cardiac arrest. J Am Colt Cardiol 1985; 6:113-
18
as a more effective option than open-chest cardiac 6 Gazmuri RJ, von Planta M, Weil MH, Rackow EC. Cardiac
compression. The clinical implications, however, per effects of carbon dioxide-consuming and carbon dioxide-gener
tam more specifically to unwitnessed cardiac arrest ating buffers during cardiopulmonary resuscitation. J Am Colt
with prolonged downtime, especially so in the out-of Cardiol 1990; 15:482-90
hospital setting. 7 Paradis NA, Martin GB, Rivers EP, Goetting MG, Appleton TJ,
Feingold M, et at. Coronary perfusion pressure and the return
Increases in coronary vein PCO2serve as a sensitive of spontaneous circulation in human cardiopulmonary resusci
indicator of global myocardial ischemia.3' Extracor tation. JAMA 1990; 263:1106-13
poreal circulation rapidly decreased coronary vein 8 Lee 5K, Vaagenes P. Safar P. Stezoski SW, Scanlon M. Effect of
hypercarbic acidosis with concurrent and striking cardiac arrest time on cortical cerebral blood flow during
increases in coronary vein oxygen tension.@ With subsequent standard external cardiopulmonary resuscitation in
rabbits. Resuscitation 1989; 17:105-117
direct cardiac compression, the more favorable out 9 Gazmuri RJ, Well MH, von Planta M, Gazmuri RR, Shah DM,
comes were observed in animals with greater cardiac Rackow EC. Cardiac resuscitation by extracorporeal circulation
output and smaller myocardial oxygen extraction. after failure ofconventional CPR. J Lab Clin Med 1991; 101:984-
The experimental method was planned to secure 88
uniformity of procedures and timing. Accordingly, 10 Eisenberg MS. Hallstrom AP, Copass MK, Bergner L, Short F,
Pierce J. Treatment of ventricular fibrillation: emergency med
vascular catheterization and thoracotomy were per ical technician defibrillation and paramedic services. JAMA
formed prior to initiation of cardiac arrest, and the 1984; 251:1723-26
studies were performed in pentobarbital-anesthetized 11 Stueven H, Troiano P. Thompson B, Mateer JR. Kastenson EH,
animals. These conditions do not directly correspond Tonsfeldt D, et at. Bystander/first responder CPR: ten years
to those that prevail in clinical settings of cardiac experience in a paramedic system. Ann Emerg Med 1986;
15:707-10
resuscitation. However, the results confirm that extra 12 Del Guercio LRM, Feins NR, Cohn JD, Coomaraswamy RP,
corporeal circulation is hemodynamically more effec Woliman SB, State D. Comparison ofblood flow during external
tive than open-chest direct cardiac compression after and internal cardiac massage in man. Circulation 1965; 31(suppl
prolonged cardiac arrest. It more promptly restores 1):l171-80
myocardial oxygenation, reverses hypercarbia, and 13 Byrne D, Pass HI, Neely WA, Turner MD, Crawford FA Jr.
External versus internal cardiac massage in normal and chroni
consequently restores spontaneous circulation. cally ischemic dogs. Am Surg 1980; 46:657-62
These studies dmdnot address ultimate survival and 14 Bircher N, Safar P Comparison of standard and “new―
closed
cerebral resuscitability. Earlier reports, however, pro chest CPR and open-chest CPR in dogs. Crit Care Med 1981;
vide evidence of satisfactory recovery of brain func 9:384-85
tion.9m Accordingly, extracorporeal circulation is likely 15 Fleisher G, Sag)7 M, Swedlow DB, Belani K. Open- versus
closed-chest cardiac compression in a canine model of pediatric
to emerge as a more effective alternative to direct cardiopulmonary resuscitation. Am J Emerg Med 1985; 3:305-
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This not withstanding, open-chest direct cardiac corn 16 Kern KB, Sanders AB, Badylak SF, Janas W, Carter AB, Tacker
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tion. Circulation 1987; 25:498-503
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objective measurement of hemodynamic effectiveness 18 Standards and guidelines for cardiopulmonary resuscitation
of resuscitation procedures, as demonstrated in this (CPR)andemergency cardiaccare(ECC). JAMA1986;255:2843-
study (Table 3) and in human victims ofcardiac arrest.@ 989
19 Phillips SJ, Ballentine B, Slonine D, Hall J, Vandehaar J,
Kongtahworn C, et al. Percutaneous initiation of cardiopulmo
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@ 59thANNUALSCIENTIFICASSEMBLY
@ October 24