Anesthesiology, V 120 • No 4 797 April 2014 T HE well-written article by Deras et al., 1 “Fatal Pancre- atic Injury Due to Trauma After Successful Cardiopulmonary Resuscitation With Automatic Mechanical Chest Compression,” presents an unfortunate case of a patient with resuscitated car- diac arrest who subsequently died with a pancreatic rupture pre- sumably caused by the LUCAS ™ Chest Compression System (Physio-Control, Redmond, WA). Tere is a renewed focus on automated cardiopulmonary resuscitation (CPR) in the United States because it provides con- sistent rates and depths of CPR which have been felt to be cru- cial to optimize survival. Manual high-quality CPR can be dif- cult to train and to maintain for a very long time. Te LUCAS ™ device does more than just pro- viding consistent, high-quality CPR works; it works by creating a positive intrathoracic pressure when the chest is compressed. Tis increased pressure is trans- mitted to the blood inside the heart. Te blood then moves from the relatively high pressure inside the heart to the lower pressure of the systemic vasculature. Con- versely, when the chest wall recoils, a small, but critical, negative pressure is created which draws blood back into the heart thereby creating preload. Tese alternating directional changes in intrathoracic pressure result in enhanced cardiac output, demonstrating that the compression and decom- pression phases of CPR are equally important. A common problem during manual CPR is that the chest does not always recoil because of an increase in chest wall compliance (softens). Although other CPR devices provide consistent compression depth and rate, the LUCAS ™ device, because of its integrated suction cup, is the only automated device that assists the decompres- sion phase by drawing up on the chest and returning it to neutral. In a recently completed clini- cal trial, survival with a favorable neurologic outcome was higher in patients receiving manual active compression/decompression CPR with a suction cup device used with an impedance thresh- old device (ITD), compared with manual CPR. Te manual suc- tion cup device (ResQPUMP ® , CardioPump ® ; Advanced Circu- latory Systems, Inc., Roseville, MN) was used at a higher lifting force (−20 lbs) during the study compared with lifting force used by the LUCAS ™ device (−3 lbs). Te ITD is placed in the ventila- tory circuit and prevents air from moving into the chest during the decompression phase. Tis allows for even greater negative intra- thoracic pressure and thus greater preload. Te rate of adverse chest and abdominal injuries between manual CPR and active compres- sion/decompression CPR, in that study of more than 1,600 subjects, was similar. 2 Te literature is full of case reports and reviews of manual CPR–induced complications, including cardiac rupture, aortic and vena cava injuries, esophageal rupture, solid organ rupture, and multiple rib fractures. 3 However, there is a paucity of any sound meth- odological studies that compare the true complication rates of CPR methods. Te best human study we have is the one referenced by Deras et al., the authors concluded that the injuries seen with LUCAS ™ appear to be of the same variety and incidence as those seen with manual CPR. 4 Te only animal study in the literature actually showed fewer injuries caused by LUCAS ™ than manual CPR in a swine model. 5 The Risk versus Benefit of LUCAS Is It Worth It? Ralph J. Frascone, M.D., F.A.C.E.P. Copyright © 2014, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:797-8 “Although the case pre- sented by Deras et al. is an extremely important reminder of the need to pay close attention throughout the cardiac arrest treat- ment cycle, it is important to remember this is a single case with an unfortunate outcome.” Image: Alcor Life Extension Foundation. Corresponding article on page 1038. Accepted for publication December 18, 2013. From the Department of Emergency Medicine, University of Minnesota, Oakdale, Minnesota.