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key takeaways

  • High-quality manual CPR is the gold standard for IHCA, but the use of mechanical CPR increased during the COVID-19 pandemic
  • Benefits of mechanical CPR include improved CPR quality, fewer people in the code room, and reduced stress for responders
  • Initial reports are promising, but more research is needed to guide future recommendations

High-quality cardiopulmonary resuscitation (CPR) is at the core of any successful resuscitation event, but that doesn’t mean it’s easy to execute and maintain. Even the most seasoned responders aren’t immune to the challenges: For those performing CPR, the sheer physical exertion and laser focus required to maintain 100-120 compressions per minute at a depth of 2 inches. And for those tasked with overseeing CPR quality, the stress and mental fatigue of monitoring those parameters in real time under life-or-death circumstances. And despite everyone’s best efforts, responders often fall short. It begs the question: Is there a better way?

In settings such as cardiac catheterization laboratories, clinicians have increasingly turned to mechanical CPR instead.1 And it makes sense: with fatigue and inconsistency top barriers to effective manual CPR, using an automated device is a logical alternative. But with research on the use of mechanical CPR for in-hospital cardiac arrest (IHCA) lacking, do these devices have a place in Code Blue response?

In this article, we’ll evaluate the pros and cons of mechanical CPR, look at the recommendations for IHCA and how they changed during the COVID-19 pandemic, and identify some key takeaways.

Mechanical CPR and IHCA: A brief history

low-quality data and 2015 consensus

Data on mechanical CPR in the hospital setting is limited.2 Although preliminary studies have shown an association between mechanical CPR and improved outcomes, that evidence is low-quality and hasn’t yet been tested in randomized clinical trials.3 Not surprisingly, in 2015 both the International Liaison Committee on Resuscitation and the American Heart Association (AHA) recommended against the standard use of mechanical CPR — with some exceptions made for scenarios where it would be particularly challenging to deliver CPR manually.3-4 In the hospital setting, that might include situations in which space or staffing is limited, or in cases of prolonged CPR.

2020 revisions

The AHA revised its stance 5 years later in light of the COVID-19 pandemic. Looking to curb the spread of the virus and protect both healthcare workers and patients, the AHA’s interim guidelines recommended using mechanical CPR — where available and if protocols were in place — to reduce the number of people in the room during a code event. And the AHA wasn’t the only authority to pivot in response to the pandemic. In a 2020 publication on clinical management during COVID-19, the Department of Defense issued a similar recommendation.5

where do we go from here?

It’s too soon to gather any real data on the impact of these revised guidelines, but preliminary reports are promising. For example, Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts implemented the LUCAS® mechanical CPR device rapidly in April 2020 with an overall positive response.6 In a survey of nurses and physicians who used the device, over half of the respondents strongly agreed that it reduced the number of people in the room, improved compression quality, and led to a more controlled resuscitation experience.6

So what does the expanded use of mechanical CPR during the COVID-19 pandemic mean for hospitals? We still need more data to say for sure, but we can start by taking a closer look at the pros and cons and identifying areas of further research.

Benefits of mechanical CPR

1. Improves CPR quality

Physical fatigue and inconsistent compressions are significant obstacles to high-quality manual CPR. To address these challenges, response teams are accustomed to utilizing any number of resources: metronomes, feedback devices, end-tidal carbon dioxide monitoring, continuous coaching, and substituting compressors, to name a few. But mechanical CPR offers a simpler and more effective solution, using machine precision to consistently hit the proper compression depth and rate without incident.7

2. Requires fewer responders

Reducing the number of people needed to perform CPR has obvious safety advantages for healthcare workers during a pandemic. This was particularly true in the early months of COVID-19, when research on virus transmission was still in its infancy and hospitals faced personal protective equipment shortages. But the benefits extend even further. For one, it’s a more efficient use of staff and resources. If high-quality CPR can be achieved with fewer responders, it frees up clinicians to care for other patients in need.

There are important advantages for the code team as well. Overcrowding can increase the noise and stress levels in the room, but it’s not always possible to avoid when hospitals need to ensure enough staff to deliver CPR. With fewer people in the room waiting their turn for compressions, the code team can work together and communicate more effectively.

3. Reduces stress for the response team

 Harder to capture with data — but no less important — is the sense of calm that pervades the room when clinicians are relieved of the physical and mental burden of manual CPR. And with clinician burnout and turnover on the rise, anything that can help decrease clinician stress during Code Blues should be a key consideration.

Drawbacks of mechanical CPR

Of course, there are still drawbacks to mechanical CPR that warrant our attention.

1. Chest compressions must be paused to place the device. This can be detrimental if the pauses are prolonged, causing delays in CPR.3

2. There are limits to its use. Mechanical CPR devices are not one-size-fits-all, so they may not be available or appropriate for all body types. This includes adults whose body weight exceeds the weight limits of the device, infants, and children.

3. Most importantly, we still lack strong evidence that mechanical CPR improves outcomes over manual CPR. Without that evidence, organizations like the AHA have been understandably reluctant to endorse its routine use for IHCA.

The risk of chest compression pauses can likely be mitigated with proper training, particularly in the in-hospital setting, where it could be incorporated and reinforced in mock Code Blues and other trainings. But solutions to the other drawbacks are less clear. And while preliminary research on mechanical CPR and IHCA shows promise, it’s hard to draw any firm conclusions without more robust evidence.

Where do we go from here?

So what does this mean for the future? And what can we learn from the experience of hospitals, like BIDMC, that increased their use of mechanical CPR for IHCA?

1. Now more than ever, we need IHCA-specific research on mechanical CPR. The research is still lacking — the expanded use of mechanical CPR during the COVID-19 pandemic hasn’t changed that. But it did highlight some of the potential benefits (even if only anecdotally so far), making that research all the more necessary, timely, and important.

2. Outcomes are the priority, but not the only consideration. The jury is still out on whether mechanical CPR improves return of spontaneous circulation, survival to discharge, and neurological prognosis — and its impact on these outcomes will, of course, take precedence. But if the research shows no significant change in either direction, it may be time to look beyond the numbers alone:

    • By reducing the number of responders, does mechanical CPR contribute positively to the atmosphere in the room during the code?
    • Can it reduce the stress and mental burden of the code team?
    • Can all these improvements contribute to increased staff satisfaction and reduced burnout?

Provided there’s no negative impact to outcomes, these factors can have a substantial impact on Code Blue response and may be equally important to consider.

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References

  1. Venturini, J. M., Retzer, E., Estrada, J., Friant, J., Beiser, D., Edelson, D., Paul, J., Blair, J., Nathan, S., & Shah, A. P. (2017). Mechanical chest compressions improve rate of return of spontaneous circulation and allow for initiation of percutaneous circulatory support during cardiac arrest in the cardiac catheterization laboratory. Resuscitation, 115, 56–60. https://doi.org/10.1016/j.resuscitation.2017.03.037
  2. Couper, K., Yeung, J., Nicholson, T., Quinn, T., Lall, R., & Perkins, G. D. (2016). Mechanical chest compression devices at in-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation, 103, 24–31. https://doi.org/10.1016/j.resuscitation.2016.03.004
  3. Poole, K., Couper, K., Smyth, M.A., Yeung, J., & Perkins, G.D. (2018). Mechanical CPR: Who? When? How? Critical Care, 22:140, 1-9. https://doi.org/10.1186/s13054-018-2059-0
  4. The American Heart Association. 2015 AHA guidelines update for CPR and ECC. (2015). Circulation, 132:18. Available at: Guidelines-RCP-AHA-2015-Full.pdf (icscyl.com)
  5. Department of Defense. (2020). DoD COVID-19 practice management guide: clinical management of COVID-19. Available at: https://www.health.mil/Reference-Center/Technical-Documents/2020/03/24/DoD-COVID-19-Practice-Management-Guide
  6. Bhatnagar, A., Khraishah, H., Lee, J., Hsu, D., Hayes, M., Joseph, B., & Moskowitz, A. (2020). Rapid implementation of a mechanical chest compression device for in-hospital cardiac arrest during the COVID-19 pandemic. Resuscitation, 156, 4–5. https://doi.org/10.1016/j.resuscitation.2020.08.122
  7. Morley, P. (2018). Mechanical cpr in a new light: A new approach to the analyses of resuscitation studies. Resuscitation, 130, A1–A2. https://doi.org/10.1016/j.resuscitation.2018.06.016
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