My opinion

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When we as anesthesia providers can no longer imagine providing anesthesia and even sedation to our even emergently boarded surgical patients without continuous quantitative waveform capnography, it is ironic that American Heart Association is awaiting more evidence before it can universally mandate its recommendation of continuous quantitative waveform capnography [1-3] during cardiopulmonary resuscitation despite it being the single monitor that can give real time glimpses into not only pulmonary resuscitation parameters but also cardiac resuscitation parameters especially when recognizing adequacy of mechanical or manual chest compressions-supported circulation transitioning into return of spontaneous circulation unless pulseless electrical activity is still persisting per continuous quantitative waveform capnography thus warranting to continue mechanical or manual chest compressions. It is interesting that how inconvenient it can be to attach continuous quantitative waveform capnography to HEPA filter's Luer port [4-5] for side-stream gas sampling line when HEPA filter is now universally recommended during cardiopulmonary resuscitation in evolving post-pandemic era. Unless continuous quantitative waveform capnography involves too high costs when universally accessible, it is amusing that anesthesia ventilators even for elective case scenarios universally have continuous quantitative waveform capnography while critical care unit ventilators [6-7] are yet to have continuous quantitative waveform capnography universally even for emergent case scenarios. Moreover, only time will tell whether continuous quantitative waveform capnography-based management may turn out to be more important than non-invasive blood pressure-based management for highly fluctuating hypotensive and very low cardiac output states during post-cardiac arrest care [8-10]. It is a question for a different time that why American Heart Association is still awaiting to recommend mechanical chest compressors [11-13] over manual chest compressors despite technology taking over and superseding most if not all aspects when dealing with emergencies to protect and save humans. Moreover, it is anybody's guess when American Heart Association will include ECPR (extracorporeal cardiopulmonary resuscitation [14-15]) in their routine algorithms so that ECPR comes first before switching on to correcting 5Hs and 5Ts of cardiac arrest if those corrective surgical and procedural interventions need access to intra/extra-thoracic areas thus precluding mechanical or manual chest compressions during such corrective surgical and procedural interventions. In the interim, American Heart Association can at least consider recommending use of bag-valve-mask capnography without any advanced airway devices in situ so that instead of 30:2 (effectively 75:5 per minute) compression-ventilation ratios, continuous chest compressions at 100:10 per minute compression-ventilation ratios can be continued from the get-go without pausing to visualize chest rise as a measure for adequacy of appropriately delivered capnography quantified breaths via bag-valve-mask devices with ample jaw thrust along with or without oropharyngeal/nasopharyngeal airway in situ. Moreover, there may be no hurry to hurriedly intubate patients and pause chest compressions for failed intubation attempts when able to effectively bag-valve-mask ventilate patients as visibly confirmed in real-time via continuous quantitative waveform capnography. Future may hold a vision for anesthesia providers carrying along mini-crash cart rather than mini-crash box/bag wherein besides one mechanical chest compressor system, there may be one continuous quantitative waveform capnography monitor with its complete setup plus invasive blood pressure monitor with its complete setup to leave by the patient's bedside to be retrieved later on after resuscitation has been completed or ceased thus requiring at least one additional replacement mechanical chest compressor system plus one additional replacement monitor equipped with above-mentioned two monitoring modalities available for anesthesia mini-crash cart all the time. The video-laryngoscopy plus ultrasound machine with vascular access probe and Doppler/Duplex capabilities on the same mini-crash cart may not be required to be left by the patient's bedside after tracheal intubation plus intravenous access as well as intra-arterial access have been successfully secured although Doppler/Duplex capabilities may help monitoring for return of spontaneous carotid/femoral pulsation [16-17] until intra-arterial access for invasive blood pressure monitoring has been secured. It may be even interesting to stock and restock this mini-crash cart with even central venous pressure monitoring capabilities [18-19] during cardiopulmonary resuscitation unless it may appear to be going too overboard just like the last resort carotid artery cannulation [20] for invasive blood pressure monitoring during cardiopulmonary resuscitation although intraosseus vascular access systems may have to already become an integral part of crash carts universally. Futuristically, after providing effective bilateral jaw-thrust [21] based bag-valve-mask ventilation as visible on continuous quantitative waveform capnography followed by successful endotracheal intubation of the patients with video-laryngoscopy for which pausing the chest compressions may or may not be required as similar to pausing the chest compressions may or may not be required for supraglottic airway device insertion [22-29], the anesthesia providers may immediately move on to radial or brachial artery cannulation [30-35] during the ongoing effective chest compressions which themselves may allow palpation of radial or brachial pulses thus making arterial cannulation to happen swiftly with or without ultrasound assistance well before the recurring resuscitative doses of intravenous epinephrine potentially making peripheral pulses unpalpable. As compared to non-invasive blood pressure monitoring, this invasive blood pressure monitoring along with continuous quantitative waveform capnography may allow overcoming near-hits-near-misses when impending or recurring pulseless electrical activity after return of spontaneous circulation may be happening due to very low cardiac output states during post-cardiac arrest care.    

Reference(s)

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1.    The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity https://pubmed.ncbi.nlm.nih.gov/34416306/

2.    DELTA END-TIDAL CO2 IN PEA: DOES THE DIFFERENCE MATTER? https://cr iticalcarenow.com/delta-end-tidal-co2-in-pea-does-the-difference-matter/

3.    Impact of Modified Treatment in Echocardiographically Confirmed Pseudo-Pulseless Electrical Activity in Out-of-Hospital Cardiac Arrest Patients with Constant End-Tidal Carbon Dioxide Pressure during Compression Pauses https://journals.sagepub.com/doi/ 10.1177/147323001003800428

4.    HEPA Filters. Do We Really Know Enough? – Breathing System Filters in the Era of Covid-19 https://www.apsf.org/article/hepa-filters-do-we-really-know-enough-breathing- system-filters-in-the-era-of-covid-19/

5.    038-41-375GE, HEPA FILTER, DISPOSABLE, BOX OF 50 https://services.gehealthcare. com/gehcstorefront/p/2106570-008

6.    Capnography in Intensive Care Unit https://www.capnography.com/icu/capnograph y-in-icu

7.    Uses of capnography in the critical care unit https://academic.oup.com/bjaed/articl e/17/5/178/2726857

8.    Cardiac function after cardiac arrest: what do we know? https://pubmed.ncbi.nlm.nih.gov/32959631/

9.    Dynamic changes in arterial blood gas during cardiopulmonary resuscitation in out-of-hospital cardiac arrest https://www.nature.com/articles/s41598-021 -02764-4

10.   Why chest compressions should start when systolic arterial blood pressure is below 50 mm Hg in the anaesthetised patient https://www.bjanaesthesi a.org/article/S0007-0912(19)30877-3/fulltext

11.   EASY PULSE https://www.schiller.ch/en-hu/products/ easy-pulse-p49

12.   EMS Lifeline ARM ACC Medical chest compression device https://www.defibtech.com/products/lifel ine-arm-acc/

13.   LUCAS chest compression system https://www.lucas-cpr.com

14.   Extracorporeal Cardiopulmonary Resuscitation for Out?of?Hospital Cardiac Arrest in Adult Patients https://www.ahajournals.org/doi/10.11 61/JAHA.119.015291

15.   Extracorporeal Cardiopulmonary Resuscitation for Adults With Refractory Out-of-Hospital Cardiac Arrest: Towards Better Neurological Outcomes https://www.ahajournals.org /doi/10.1161/CIRCULATIONAHA.119.044969

16.   Finger (or is that…probe) on the Pulse | Doppler vs Manual Palpation During Arrest h ttps://journalfeed.org/article-a-day/2022/finger-or-is-that-ultrasound-probe-on-the-pulse/

17.   Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest https://www.sciencedirect .com/science/article/pii/S0300957222000326

18.   Blood flow forward into the artery and backward into the vein during chest compression in out-of-hospital cardiac arrest https://www.resus citationjournal.com/article/S0300-9572(19)30036-X/fulltext

19.   Peripheral venous pressure waveform https://journals.lww.com/co-anesthesiology/Fulltext/2009/12000/Peripheral_venous_press ure_waveform.21.aspx

20.   Carotid Artery Cannulation and Monitoring During a Major Trauma: An Extreme but Necessary Approach? https://journals.lww.com/anesthesia-analgesia/fulltext/2010/03000/ca rotid_artery_cannulation_and_monitoring_during_a.68.aspx

21.   Add Jaw-Thrust To Evolve 2-Rescuers Hands-Only CPR https://www.webmedcentral.com/article_view/5593

22.   234: MINIMIZING INTERRUPTIONS IN CPR: INTUBATE ANYWAY! https://journals.lww.com/ccmjournal/Fulltext/2019/01001/234__MINIMIZING_INTERRUPT IONS_IN_CPR__INTUBATE.200.aspx

23.   Hands-Off Time for Endotracheal Intubation during CPR Is Not Altered by the Use of the C-MAC Video-Laryngoscope Compared to Conventional Direct Laryngoscopy. A Randomized Crossover Manikin Study https://www.ncbi.nlm.nih.gov/pmc/articl es/PMC4873178/

24.   C-MAC Video Laryngoscope versus Conventional Direct Laryngoscopy for Endotracheal Intubation During Cardiopulmonary Resuscitation https://www.ncbi.nlm.nih.gov/pmc/articl es/PMC6631212/

25.   Airway and ventilation management during cardiopulmonary resuscitation and after successful resuscitation https://ccforum.biomedce ntral.com/articles/10.1186/s13054-018-2121-y

26.   Trial of Continuous or Interrupted Chest Compressions during CPR https://www.nejm.org/doi/10.1056/NEJMoa1509139

27.   Endotracheal Intubation Using the Macintosh Laryngoscope or KingVision Video Laryngoscope during Uninterrupted Chest Compression https://www.hindawi.com/journals/bmri/2014 /250820/

28.   Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts https://www.tandfonline.com /doi/abs/10.1080/10903127.2017.1308611

29.   Can the ETView VivaSight SL Rival Conventional Intubation Using the Macintosh Laryngoscope During Adult Resuscitation by Novice Physicians? A Randomized Crossover Manikin Study https://journals.lww.com/md-journal/Fulltext/2015/05050/Can_the_ETView_VivaSight_S L_Rival_Conventional.14.aspx

30.   Brachial artery catheter: Cx https://www.openanesthesia.org/br achial_artery_catheter_cx/

31.   Complications Following Brachial Arterial Catheterization in the Surgical Intensive Care Unit https://journals.sagepub.com/doi/10 .1177/0003134820964211

32.   Long-term brachial artery catheterization: Ischemic complications https://www.jvascsurg.org/art icle/0741-5214(88)90248-0/fulltext

33.   Brachial Arterial Pressure Monitoring during Cardiac Surgery Rarely Causes Complications https://pubs.asahq.org/anesthesiology/article/126/6/1065/18713/Brachial-Arterial-Pres sure-Monitoring-during

34.   Complications from brachial arterial pressure monitoring are rare in patients having cardiac surgery https://jtd.amegroups.com/article/view/186 33/15074

35.   A Modified Technique for Ultrasound-guided Cannulation of Radial and Brachial Arteries in Patients with Circulation Collapse https://www.sciencedirect .com/science/article/pii/S187545970860034X

Source(s) of Funding

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NOT APPLICABLE

Competing Interests

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NOT APPLICABLE