Presence of an arterial line improves response to simulated hypotension and pulseless electrical activity

Abstract

With pulseless electrical activity (PEA) emerging as one of the leading cardiac arrest arrhythmias, the rapid response and accurate diagnosis of PEA is essential to improve survival rates. Although the use of invasive blood pressure monitoring to more quickly detect changes in blood pressure is widespread, evidence for its use is largely anecdotal and placement is not without risk. This is a prospective, multi-center, randomized controlled trial involving 58 senior anesthesiology residents undergoing a simulation of intraoperative PEA using high-fidelity simulation. Of the total 58 participants, 28 subjects were randomized to invasive blood pressure monitoring and 30 to non-invasive blood pressure monitoring in order to investigate the effects of arterial line information on the response time of ACLS-trained anesthesiology residents. Response times of subjects in the group provided with invasive blood pressure monitoring were faster to palpate pulses (6.5 s faster, p = .0470), initiate chest compressions (17 s faster, p = .004), and administer 1 mg of epinephrine (21 s faster, p = .0005. The absolute number of pharmacologic interventions was increased in the group with invasive blood pressure monitoring (p = .020). These findings suggest that noninvasive blood pressure monitoring and other readily available monitors are not as powerful as invasive blood pressure monitoring in influencing decision-making during a PEA event. As there is currently no specific blood pressure at which the patient is considered to be in PEA, future studies are necessary to clarify the correlation between the arterial line tracing and the appropriate trigger for ACLS initiation.

Dynamic changes in arterial blood gas during cardiopulmonary resuscitation in out-of-hospital cardiac arrest

“…In light of the role as an early predictor of ROSC, the dynamic changes in paO 2 between 0 and 10 min could provide additional information with the level of ETCO 2 . Therefore, this could be another piece of evidence to support the current guidelines on performing arterial catheterization during CPR 28 – 30 .…”

2024 RECOVER Guidelines: Monitoring. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

“…Direct, continuous ABP monitoring allows faster recognition of CPA and initiation of CPR, and so is preferred over intermittent noninvasive monitoring if feasible. 178 A single veterinary study was evaluated in which the relationship between Doppler blood pressure (DopBP) and survival or response to treatment in critically ill cats was investigated. 180 This was a retrospective study of 83 cats, and there was a significantly higher frequency of mortality in hypotensive cats.…”

“…For the outcome of time to start CPR , 1 clinical trial of simulated anesthetic events in people (very low quality of evidence, downgraded for very serious indirectness and serious imprecision) addressed the PICO question 178 . As described above, the group with access to invasive blood pressure monitoring information initiated chest compressions 17 seconds sooner than the group with only indirect blood pressure monitoring.…”

“…For the next important outcome of time to identification of CPA, 1 clinical trial of simulated anesthetic events in people (very low quality of evidence, downgraded for very serious indirectness and serious imprecision) and 1 observational study in people were identified (very low quality of evidence, downgraded for very serious indirectness). 178,179 The clinical trial included 58 senior anesthesiology residents randomized to interpret either invasive blood pressure monitoring or noninvasive blood pressure monitoring information during a simulated CPA. The group with access to invasive blood pressure monitoring palpated for pulses in the patient 6.5 seconds sooner and initiated chest compressions 17 seconds sooner than the group with indirect blood pressure monitoring.…”

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

“…7 A simulation study found that residents who were provided with invasive blood pressure monitoring were quicker to palpate pulses, initiate chest compressions, and administer adrenaline than residents who were provided with only noninvasive blood pressure monitoring. 17 A different study demonstrated that the presence of continuous arterial blood pressure monitoring resulted in improved quality of compressions during simulated cardiac arrest. 18 Transoesophageal echocardiography has been used to identify the cause of intraoperative cardiac arrest and guide management in several observational case series.…”