Interposed abdominal compression CPR in pediatric cardiac arrest: early results from a multicenter comparison to standard CPR.

INTRODUCTION

Interposed abdominal compression CPR (IAC-CPR) is an American Heart Association Class IIb recommended adjunct to standard CPR (S-CPR) that employs abdominal counter-pulsation during the "diastolic" (release) phase of thoracic compressions. Animal and adult studies have demonstrated IAC-CPR augmentation of venous return to the right heart with enhanced cardiac output, and increased diastolic blood pressure (DBP) with improved retrograde flow to the coronary arteries and brain. We hypothesized that IAC-CPR (compared with S-CPR) would result in higher DBP which has been associated with improved survival outcomes in pediatric cardiac intensive care unit (PCICU) patients.

METHODS

As participants in a prospective, multicenter, quality assurance collaborative (PediRes-Q.org) from Dec 2020 - July 2024, three participating PCICU sites used IAC-CPR within usual care, and systematically collected hemodynamic data from 1 to 2 min sequential epochs of S-CPR and IAC-CPR within the same patient. IAC-CPR training via video (https://youtu.be/cd3Gxu7Maqk), digital slide presentation, and in-person mannequin demonstration of technique competency at each participating center were required. Single rescuer resuscitation of children ≤ 3 years old proceeded with S-CPR for 1-2 min, followed by 1-2 min of IAC-CPR. Choice of CPR technique for the remainder of the cardiac arrest event was then left to the clinical care team. Hemodynamic waveforms from epochs of S-CPR and IAC-CPR were compared. Return of spontaneous circulation (ROSC), return of circulation (ROC) with ECMO, and survival to hospital discharge or to 30 days were recorded. Neurological outcome was assessed pre-arrest and at hospital discharge by the Pediatric Cerebral Performance Category (PCPC) score. Favorable neurologic outcome was considered PCPC category 1-2, or no change from pre-arrest baseline.

RESULTS

Seventeen infants with complex congenital heart disease were included, the majority of which (14/17) were single ventricle patients who experienced arrest postoperatively. Intervention analyses demonstrated a DBP increase of 11.6 mmHg during IAC-CPR versus S-CPR (95% CI [2.2-21.1], p = 0.018, adjusted for non-stationarity and correlations in individual time series). Peak systolic blood pressure (SBP) increased by 15.4 mmHg during IAC-CPR versus S-CPR (95% CI [0.51 - 30.2], p = 0.044, adjusted for non-stationarity and correlations in individual time series). ROSC was achieved in 11/17 (65%), and ROC with ECMO in 5/17 (29%). Survival to hospital discharge or to 30 days occurred in 8/17 (47%), and all had a favorable neurologic outcome. No complications attributable to IAC-CPR were found.

CONCLUSIONS

IAC-CPR was associated with significant improvements in both DBP and SBP compared to S-CPR technique in pediatric ICU patients with complex congenital heart disease. This underscores the need for study of IAC-CPR hemodynamics and outcomes in a broader cohort of cardiac and non-cardiac pediatric patients.