Current situation of mechanical CPR devices in donors after cardiac death

doi:10.4236/ojem.2013.12002

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Vol.1, No.2, 5-7 (2013) Open Journal of Emergency Medicine

http://dx.doi.org/10.4236/ojem.2013.12002

Current situation of mechanical CPR devices in

donors after cardiac death

Alonso A. Mateos Rodríguez1*, José María Navalpotro Pascual1,

Vicnete Sanchez Brunete Ingelmo1, Francesc Carmona Jiménez2

1Servicio de Urgencias Médicas de Madrid SUMMA112 (Emergency Medical Services of Madrid), Madrid, Spain;

*Corresponding Autho r : [email protected]

2Servei Emergencies Mediques (Emergency Medical Services), Barcelona, Spain

Received 17 October 2013; revised 19 November 2013; accepted 5 December 2013

tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

ABSTRACT

Mechanical CPR (cardi o pu lm on ary r es us ci tation)

devices help performing correct chest compres-

sions in the event of a cardiorespiratory arrest.

These devices are comfortable and useful, they

keep chest compression following the recom-

mendations as they do not depend on interper-

sonal variability, they do not get tired, their use

is simple and one of the rescuers is released

from this task, thus facilitating the assistance.

Besides, the ir use in tran sport c onditi ons ma kes

it safer. However, when coming to results, these

mechanical CPR devices have not clearly dem-

onstrated such an advantage, neither in the field

of cardiac arrest, nor in organ preservation in

the case of d onors after cardiac death . In donors

after cardiac death they are widely used by most

of the emergency services involved, but a num-

ber of injuries produced in lungs during the ear-

ly years of their use have made it controversial.

In this paper w e make a review of the road trav-

eled by mechanical CPR dev ices a nd of the main

articles which mark the way.

Keywords: Emergency Medical Services; Donors

after Cardiac Death; Cardi oc o mpressors

1. INTRODUCTION

In the last few years, several mechanical devices have

been developed to replace manual cardiac massage in the

event of a cardiorespiratory arrest. These devices have

shown to improve quality of cardiopulmonary resuscita-

tion [1] and, in some cases, an improvement of short-

term survival has been proven [2,3]. Two devices are

currently being used: LUCAS©, Lung University Cardiac

Arrest System, from the company Physio-Control, and

Autopulse©, from Zoll. There is a third device in the

market from the company Corpuls based on a piston-arm

with a base recalling the o ld devices, but improved.

LUCAS© is a piston system with a suction cup which

attaches the patient chest in a specific point. By means of

oxygen or compressed air in version 1 and rechargeable

batteries in version 2, it exerts pressure up and down.

Autopulse© exerts the same pressure on the chest, but

does so by means of a load distribution band which em-

braces the patient trunk, and uses rechargeable batteries.

Both devices have two possibilities for performing chest

compressions: rhythm 30:2 or continuous massage, and

they present as an additional advantage the fact that one

of the rescuers involved in resuscitation is released from

this task. Their use and placement are very simple. They

are widely used by most of the emergency services in

cardiopulmonary arrest cases and in organ donation in

asystole [4]. Due to its cost it is complicated for these

devices to be shipped with the whole fleet of mobile re-

sources, therefore, most emergency services carry them

on a special vehicle featured in the scene at the request of

the professionals. Their primary use is intended for the

return of spontaneous circulation, and if this is not achi-

eved, devices are used for the transfer of the potential

donor if this is the case.

In Spain, the Organización Nacional de Trasplantes

(National Transplant Organization), in its consensus

document for promoting donors after cardiac death, rec-

ommends the use of these devices as a way of imple-

menting programs of donation in asystole. At European

level, a document is being drafted in the same direction

of the Spanish one recommending their use as well [5].

A. A. M. Rodríguez et al. / Open Journ al of Emergency Medicine 1 (2013) 5-7

Many studies have been published referring to the pos-

sible injuries that mechanical CPR devices could cause

to patients. Smekal et al. already proved that injuries pro-

duced by these devices were similar to those found on

cases of manual chest compression [6]. However, in spite

of studies like this, the repu tation of the mechanical CPR

devices was determined on the side of injuries. In this

review we want to debunk this myth on the basis of sev-

eral articles published in the last few years.

2. MECHANICAL CPR DEVICES IN

CARDIORESPIRAT OR Y ARREST

Mechanical CPR devices have not yet demonstrated a

clear return of spontaneous circulation. There are two

studies which are working on th is objective in a random-

ized way. CIRC Trial studies the Autopulse©, and in pre-

liminary data it has proven to have the same rate of sur-

vival to hospital disch arg e than high-qu ality manual mas-

sage. The problem is, who can achieve this high-quality

manual massage for an extended time [7]. So does LINC

Trial with LUCAS©, the LINC study showed similar

short-term survival rates for LUCAS (23.6%) and man-

ual (23.7%) chest compressions. At 6-months, 8.5% of

the patients treated with LUCAS were alive with good

neurological outcomes compared to 7.6% in the manual

group [8].

Despite not having shown a clear improvement in

ROSC [9] (return of spontaneous circulation) or in sur-

vival to hospital discharge, they make it when it comes to

optimum fulfillment of protocols [10,11] and safety in

cardiopulmonary resuscitation [12,13]. Only these two

aspects, on equal terms with manual chest compression,

already justify their use.

3. MECHANICAL CPR DEVICES AS A

PRESERVATION METHOD FOR THE

DONORS AFTE R CARDIAC DEATH

In 2010 we published an article where we evaluated

the efficiency of CPR devices as an organ preservation

method [14]. We compared two groups of donors after

cardiac death of approximately 40 cases each; one group

was assisted with CPR devices and the other one with

manual chest compression. The rate of kidneys and the

rate of organs and tissues per donor were significantly

lower in the group of donors assisted with mechanical

CPR devices. These data made us wonder if the use of

these devices was correct, and we started to study them

further.

4. CPR DEVICES IN KIDNEY GRAFTS

The limits of our study were clear, since we collected

just a few cases and we only evaluated transplanted or-

gans without considering their evolution thereafter. In

detail, and if we just evaluate kidney grafts, data offered

by a group of donors assisted with CPR devices vs man-

ual cardiac massage are almost the same. The cases of

primary graft failure were similar in both groups and

present a very low frequency, around 8% [15]. Later, it

has been observed that long-term function of kidney

grafts is very similar in both groups of patients. Data

from a cohort of 50 other donors divided into CPR de-

vices and non-CPR devices reveal that, after 6 and 12

months, the renal function (creatinine) was somewhat

higher in the group assisted with CPR devices, but not

reaching pathological levels and without being statisti-

cally significant [16]. In a similar study, in which LU-

CAS© was evaluated, results marked a clear advantage in

favour of CPR devices [17], objectifying an improve-

ment of 0.3 kidneys transplanted per donor in the CPR

devices group and a decrease of 32.9% of kidney grafts

discarded because of poor perfusion. It seems proved that

CPR devices do not affect further evolution of kidney

grafts, actually, they may even improve it.

5. CPR DEVICES IN LUNG GRAFTS

As a matter of fact, injuries produced by CPR devices

usually appeared in lungs, as it can be easily understood

because of the pressure exerted over them during car-

diopulmonary resuscitation. These injuries have been

commented many times, but never published. Numerous

articles have appeared objectifying the presence of trau-

matic injuries on the chest and lungs of patients assisted

with mechanical CPR devices, and in all of them results

are similar: there is no significant difference between

injuries produced by manual chest compression and

those caused by mechanical devices [6,18-20]. Even in a

number of lungs evaluated for transplantation from pa-

tients which had been assisted with CPR devices, major

injuries were not noticed, or at least, not that major inju-

ries as to discard the lungs for transplantation. In patients

considered as donors 8 pathological bronchoscopes were

objectified, 3 of them with bronchial aspiration and 5

with blood-borne secretions; no rib fractures were no-

ticed but there appeared 2 cases of sternal fracture. Inju-

ries were never described as serious, and they were never

a potential reason for discarding the organ for transplan-

tation. This kind of lung grafts presents a highly satisfac-

tory evolution thereafter. Out of 20 patients receiving

lungs from donors after cardiac death, 18 survived the

first month [21]. Most of these lungs had been subjected

to CPR devices.

6. CONCLUSION

Even though it seems that at first mechanical CPR de-

vices had been associated with the presence of injuries in

organs of patients assisted with them, and that their use

A. A. M. Rodríguez et al. / Open Journ al of Emergency Medicine 1 (2013) 5-7

in donor processes seemed to decrease the number of

suitable organs, these data have not been confirmed by

further investigations. While it is true that in few occa-

sions have they shown an improvement compared to

manual chest compression, the advantages that they offer

make their use generalized and unquestionable. Further

studies with a larger number of populations are n eed ed to

know in detail the results of these mechanical CPR de-

vices in organs which are candidates to be transplanted.

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