Resuscitation 84 (2013) 1674–1679 Contents lists available at ScienceDirect Resuscitation j ourna l ho me p age: www.elsevier.com/locate/resuscitation Clinical paper Sternal wall pressure comparable to leaning during CPR impacts intrathoracic pressure and haemodynamics in anaesthetized children during cardiac catheterization  Andrew C. Glatz a,∗ , Akira Nishisaki b,c , Dana E. Niles c , Brian D. Hanna a , Joar Eilevstjonn d , Laura K. Diaz b , Matthew J. Gillespie a , Jonathan J. Rome a , Robert M. Sutton b , Robert A. Berg b , Vinay M. Nadkarni b,c a Division of Cardiology, Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States b Department of Anesthesia, Critical Care and Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States c The Children’s Hospital of Philadelphia, Center for Simulation, Advanced Education and Innovation, United States d Laerdal Medical, Stavanger, Norway a r t i c l e i n f o Article history: Received 1 March 2013 Received in revised form 1 July 2013 Accepted 3 July 2013 Keywords: Cardiopulmonary resuscitation Paediatric Intrathoracic pressure Coronary perfusion pressure Right atrial pressure Cardiac catheterization a b s t r a c t Aim: Force due to leaning during cardiopulmonary resuscitation (CPR) negatively affects haemodynamics and intrathoracic airway pressures (ITP) in animal models and adults, but has not been studied in children. We sought to characterize the effects of sternal force (SF) comparable to leaning force on haemodynamics and ITP in anaesthetized children. Methods: Children (6 months to 8 yrs) presenting for routine haemodynamic cardiac catheterization with anaesthesia and mechanical ventilation >6 months after cardiac transplant were studied. Haemody- namics and ITP were measured before and during incremental increases in SF of 10% and 20% body weight. Results: 20 subjects (5.4 ± 1.7 yrs of age and 18.3 ± 3.3 kg) were studied. Mean right atrial pressure (6.5 ± 2.6 at baseline vs. 7.7 ± 2.6 at 10% SF vs. 8.6 ± 2.7 mmHg at 20% SF), mean pulmonary capillary wedge pressure (10.2 ± 2.9 at baseline vs. 11 ± 3.3 at 10% SF vs. 11.8 ± 3.4 mmHg at 20% SF) and ITP (16.3 ± 3.2 at baseline vs. 17.9 ± 3.9 at 10% SF vs. 19.5 ± 4 cm H 2 O) all increased significantly with incre- mental SF (p < 0.001 for all). Aortic systolic pressure (85 ± 10 mmHg at baseline vs. 83 ± 10 mmHg at 10% SF vs. 82 ± 10 mmHg at 20% SF, p = 0.014) and coronary perfusion pressure (42 ± 7 mmHg at base- line vs. 39 ± 7 mmHg at 10% SF vs. 38 ± 7 mmHg at 20% SF, p < 0.001) both decreased significantly with incremental SF. Conclusions: In asymptomatic, anaesthetized children after cardiac transplantation, sternal forces compa- rable to leaning previously reported to occur during CPR elevate ITP and right atrial pressure and decrease coronary perfusion pressure. These haemodynamic effects may be clinically important during CPR and warrant further study. © 2013 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Quality of cardiopulmonary resuscitation (CPR) is critical for sur- vival and good neurological outcome following cardiac arrest. 1–4 Abbreviations: CPR, cardiopulmonary resuscitation; ETP, endotracheal pressure; ITP, intrathoracic airway pressure; PIP, peak inspiratory pressure; SF, sternal force.  A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.07.010. ∗ Corresponding author at: Division of Cardiology, 6th Floor, Main Building, Chil- dren’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States. E-mail address: glatz@email.chop.edu (A.C. Glatz). CPR guidelines recommend target values for rate and depth of chest compressions and ventilations, limiting interruptions in chest com- pressions, and allowing complete release (full chest recoil) between chest compressions. 5 Unfortunately, most CPR delivered by both laypersons and health care professionals is not of high quality. While incorrect chest compression rates and depths, and exces- sive ventilation have been documented, inadequate chest recoil (leaning) between compressions is particularly common. 6–14 In both animal and adult cardiac arrest studies, incomplete recoil of the chest caused by “leaning” on the sternum (i.e., ster- nal wall pressure) during the decompression (release) phase of CPR adversely affects haemodynamics, presumably by increasing intrathoracic airway pressure (ITP) and decreasing venous blood 0300-9572/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.07.010