CPR in Patients With Mechanical Circulatory Support

Peberdy MA, Gluck JA, Ornato JP, et al., on behalf of the American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation; Council on Cardiovascular Diseases in the Young; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology.
Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association. Circulation 2017;May 22:[Epub ahead of print].

The following are key points to remember from this American Heart Association Scientific Statement about cardiopulmonary resuscitation (CPR) in adults and children with mechanical circulatory support (MCS):

  1. Cardiac arrest in patients on mechanical support is a new entity brought about by the increased use of this therapy in patients with end-stage heart failure.
  2. Because of the unique characteristics of mechanical support, these patients have physical findings that cannot be interpreted the same as for patients without MCS.
  3. Clinical findings such as skin color and capillary refill are reasonable predictors of the presence of adequate flow and perfusion, especially in MCS-supported pulseless patients.
  4. Waveform capnography, which measures and displays the partial pressure of end-tidal carbon dioxide (PETCO2) in exhaled air, is used frequently to track respiration in patients undergoing mechanical ventilation, but it can also be used to track perfusion in patients in whom more common physical findings used to assess perfusion are not reliable.
  5. A PETCO2 value of <20 mm Hg in an unresponsive, correctly intubated, pulseless patient with a left ventricular assist device (LVAD) would seem to be a reasonable indicator of poor systemic perfusion and should prompt rescuers to initiate chest compressions.
  6. While pulse oximetry can be used in patients with an LVAD, the results may not be accurate because of the lack of pulsatile flow.
  7. It is the consensus recommendation that if an LVAD is definitively confirmed by a trained person and there are no signs of life, bystander CPR, including chest compressions, should be recommended by emergency medical dispatchers for cardiac arrest situations. Resuscitative care for children supported with an adult implantable ventricular assist device (VAD) should be based on algorithms outlined for adults.
  8. If there is inadequate perfusion, unresponsiveness, or other altered mental state, the VAD should be assessed for function by looking and listening for alarms, listening for a VAD hum over the left chest and left upper abdominal quadrant, ensuring secure connections to the controller, and ensuring adequate power for the VAD.
  9. It is reasonable to provide standard postarrest care, including mild therapeutic hypothermia and early percutaneous coronary intervention when indicated, to patients with an LVAD who survive a cardiac arrest.
  10. There should be a standard across the VAD and total artificial heart (TAH) centers to supply identification necklaces or bracelets to discharged MCS patients. The identification should include the device type, the center contact information, and the patient’s advance directives.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support, Interventions and ACS

Keywords: Arrhythmias, Cardiac, Acute Coronary Syndrome, Advance Directives, Capnography, Cardiopulmonary Resuscitation, Heart Arrest, Heart Failure, Heart-Assist Devices, Hypothermia, Induced, Oximetry, Percutaneous Coronary Intervention, Respiration, Artificial

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