Clinical paperPulse oximetry waveform: A non-invasive physiological predictor for the return of spontaneous circulation in cardiac arrest patients ---- A multicenter, prospective observational study
Introduction
Despite great advances in developing guidelines for resuscitation, cardiac arrest (CA) continues to have a high mortality and leads to enomourous economic costs worldwide1., 2., 3.. Many studies have reported monitoring physiologic values during cardiopulmonary resuscitation (CPR) and relating them to clinical outcomes for cardiac arrest patients4., 5., 6., 7.. Some have even used physiologic indicators to guide CPR actions to improve the quality of chest compressions. Previously reported objective indicators include end-tidal carbon dioxide (ETCO2)5., 8., 9., invasive arterial pressure10., 11., and near-infrared spectroscopy12. However, these methods are inapplicable to some pre-hospital situations and many emergency department (ED) initial resuscitations due to their dependence on a secured airway, arterial lines or expensive hardware. Pulse oximetry, which is easy-to-use and non-invasive, is already widely used in patient monitoring worldwide and can provide peripheral circulatory information in addition to hemoglobin oxygen saturation13., 14.. The concept of how the waveform of pulse oximetry relates to a patient’s blood pressure and microcirculation status during resuscitation has been proposed for more than 20 years15., 16., but to date there have been no rigorous prospective trials of its clinical effectiveness.
Our previous study in porcine models found that the area under the curve (AUCp) and the amplitude (Amp) of the pulse oximetry plethysmography (POP) waveform were positively correlated with the depth of chest compressions, coronary perfusion pressure (CPP) and ETCO217., 18., 19.. However, data on the utility of POP waveform analysis in clinical settings has been lacking. Therefore, we conducted this multicenter clinical study to assess the application of POP waveform analysis for predicting return of spontaneous circulation (ROSC) during chest compressions for cardiac arrest patients.
Section snippets
Study design and setting
This was a multicenter, prospective, observational study conducted from December 1, 2013 through November 30, 2014 in the EDs of 14 teaching hospitals in seven provinces located throughout China (Fig. 1A. The inclusion criteria included adults with cardiac arrest who received advanced cardiac life support (ACLS) with intubation according to American Heart Association (AHA) guidelines20 monitored by trained study staff. Exclusion criteria were those patients with a written advance directive to
Results
In total, 2954 adult patients with CA were screened in the participating EDs. 292 patients were excluded because POP was not recorded by research monitors and another 421 patients were excluded because capnography was not available. After exclusions, 150 out-of-hospital cardiac arrest (OHCA) patients and 291 in-hosptial cardiac arrest (IHCA) patients were included in our analysis (Fig. 1A). Among these, 20 (13.3%) OHCA patients and 64 (22.0%) IHCA patients developed ROSC (Table 1). The 24-hour
Discussion
This prospective observational study demonstrated that POP parameters are associated with ROSC in resuscitation, providing evidence that monitoring POP waveform could be an effective alternative to ETCO2 during CPR. Compared to ETCO2 in CA patients, POP during early CPR had similar predictive ability for ROSC.
The goal of CPR is to promote adequate tissue perfusion in order to achieve ROSC. In our study, IHCA patients who developed ROSC had significantly higher POP AUCp and Amp values than those
Conclusion
This study showed that POP had a discriminative ablitity between CA patients with and without ROSC during CPR process in clinical settings, with a prognostic value similar to ETCO2 during the early stage of resuscitation. POP may thus be a novel and effective real-time predictor of ROSC during CPR.
Literature search: Dingyu TAN, Chen LI, Jun XU;
Study design: Dingyu TAN, Jun XU, Xuezhong YU;
Data collection: Chen LI, Dingyu TAN, Jun XU;
Analysis of data: Hanqi TANG, Zhiwei WANG, Jian CAO
Manuscript
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
Financial support was received from the Special Scientific Research Funds of the Public Welfare Program of the National Health and Family Planning Commission of China (Grant Reference Number 201502019) and from the Chinese Academy of Medical Sciences Fundamental Research Fund for the Central Public Welfare Research Institute [2017PT31009]. We would like to thank Fei Han, Cheng Wang, Xiaocui Zhang, Jie Qin, Jian Cen, Xinsheng Li, the engineers from Mindray Corporation for their support.
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Contributed equally to this work.