BackgroundEnd‐tidal carbon dioxide (ETCO2) correlates with systemic blood flow and resuscitation rate during cardiopulmonary resuscitation (CPR) and may potentially direct chest compression performance. We compared ETCO2‐directed chest compressions with chest compressions optimized to pediatric basic life support guidelines in an infant swine model to determine the effect on rate of return of spontaneous circulation (ROSC).Methods and ResultsForty 2‐kg piglets underwent general anesthesia, tracheostomy, placement of vascular catheters, ventricular fibrillation, and 90 seconds of no‐flow before receiving 10 or 12 minutes of pediatric basic life support. In the optimized group, chest compressions were optimized by marker, video, and verbal feedback to obtain American Heart Association‐recommended depth and rate. In the ETCO2‐directed group, compression depth, rate, and hand position were modified to obtain a maximal ETCO2 without video or verbal feedback. After the interval of pediatric basic life support, external defibrillation and intravenous epinephrine were administered for another 10 minutes of CPR or until ROSC. Mean ETCO2 at 10 minutes of CPR was 22.7±7.8 mm Hg in the optimized group (n=20) and 28.5±7.0 mm Hg in the ETCO2‐directed group (n=20; P=0.02). Despite higher ETCO2 and mean arterial pressure in the latter group, ROSC rates were similar: 13 of 20 (65%; optimized) and 14 of 20 (70%; ETCO2 directed). The best predictor of ROSC was systemic perfusion pressure. Defibrillation attempts, epinephrine doses required, and CPR‐related injuries were similar between groups.ConclusionsThe use of ETCO2‐directed chest compressions is a novel guided approach to resuscitation that can be as effective as standard CPR optimized with marker, video, and verbal feedback.

Approximately 1 of every 300 children in the United States has type 1 diabetes mellitus (T1D), and these patients may require anesthetics for a variety of procedures. Perioperative coordination is complex, and attention to perioperative fasting, appropriate insulin administration, and management of hypo- and hyperglycemia, as well as other metabolic abnormalities, is required. Management decisions may be impacted by the patient’s baseline glycemic control and home insulin regimen, the type of procedure being performed, and expected postoperative recovery. If possible, preoperative planning with input from the patient’s endocrinologist is considered best practice. A multi-institutional working group was formed by the Society for Pediatric Anesthesia Quality and Safety Committee to review current guidelines in the endocrinology and anesthesia literature and provide recommendations to anesthesiologists caring for pediatric patients with T1D in the perioperative setting. Recommendations for preoperative evaluation, glucose monitoring, insulin administration, fluid management, and postoperative management are discussed, with particular attention to increasingly prevalent insulin pumps and continuous glucose monitoring (CGM).

Objective To determine whether end-tidal carbon dioxide (ETCO2)-guided chest compression delivery improves survival over standard cardiopulmonary resuscitation (CPR) after prolonged asphyxial arrest. Design Preclinical randomized controlled study. Setting University animal research laboratory. Subjects 1–2-week-old swine. Interventions After undergoing a 20-minute asphyxial arrest, animals received either standard or ETCO2-guided CPR. 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 ETCO2-guided group, chest compression rate and depth were adjusted to obtain a maximal ETCO2 level without other feedback. CPR included 10 minutes of basic life support followed by advanced life support for 10 minutes or until return of spontaneous circulation (ROSC). Measurements and Main Results Mean ETCO2 at 10 minutes of CPR was 34 ± 8 torr in the ETCO2 group (n=14) and 19 ± 9 torr in the standard group (n=14; p=0.0001). The ROSC rate was 7/14 (50%) in the ETCO2 group and 2/14 (14%) in the standard group (p=0.04). The chest compression rate averaged 143 ± 10/minute in the ETCO2 group and 102 ± 2/minute in the standard group (p<0.0001). Neither asphyxia-related hypercarbia nor epinephrine administration confounded the use of ETCO2-guided chest compression delivery. The response of the relaxation arterial pressure and cerebral perfusion pressure to the initial epinephrine administration was greater in the ETCO2 group than in the standard group (p=0.01 and p=0.03, respectively). The prevalence of resuscitation-related injuries was similar between groups. Conclusions ETCO2-guided chest compression delivery is an effective resuscitation method that improves early survival after prolonged asphyxial arrest in this neonatal piglet model. Optimizing ETCO2 levels during CPR required that chest compression delivery rate exceed current guidelines. The use of physiologic feedback during CPR has the potential to provide optimized and individualized resuscitative efforts.