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An update on the mechanical versus manual cardiopulmonary resuscitation in cardiac arrest patients
Critical Care ( IF 8.8 ) Pub Date : 2024-10-22 , DOI: 10.1186/s13054-024-05131-7
Ayman El-Menyar, Mashhood Naduvilekandy

The cardiopulmonary resuscitation (CPR) technique and its outcome remains a debate. In response to Zhao et al.'s [1] regarding the inclusion of duplicated studies in the meta-analysis [2], we have conducted a thorough review of the two studies published by Ong et al. (2012) and Casner et al. (2005). After that, we removed these two studies, along with an additional data point from Halperin et al. (1993), which exhibited high variance and did not meet the variance thresholds set for our updated analysis, and then we performed a revised meta-analysis to maintain consistency. Despite these changes, the results remained consistent, with an (Odds Ratio (OR) of 1.11; 95% CI 0.99–1.22) (Fig. 1). Thus, our original umbrella review findings [2] and Zhao et al.'s analysis showed that mechanical CPR was not superior to manual CPR in achieving the return of spontaneous circulation (ROSC).

We respectfully disagree with Zhao et al. second point regarding the inclusion of Axelson et al. (2013) and Jennings et al. (2012) in the meta-analysis. A few relevant data required for our analysis were obtained from the already published systematic review (SR) by Sheraton et al. (2021) [3]. The ROSC-related ORs were extracted from the second graph of the Sheraton et al. meta-analysis [3]. It is also worth noting that Zhao et al. [1] included a study published by Hallstrom et al. (2006) [4], even though this study did not explicitly mention ROSC as an outcome in the original work.

We agree that data derived solely from abstracts can affect the robustness of outcomes; therefore, we intended to gather and synthesize as much data as possible from the published SRs and not from individual studies or abstracts for the umbrella review [2]. However, for the umbrella meta-analysis, data from 3 abstracts (Lairet et al. (2005), Paradis et al. (2009), and Morozov et al. (2012)) were used. The ORs from these abstracts were extracted from a meta-analysis published by Bonnes et al. (2016) and their illustrations [5]. Thus, in this letter, we recalculated the ORs after removing data gathered from abstracts or did not report ROSC-related ORs in the original works. The results of the revised analysis did not show any significant difference (OR 1.09; 95% CI 0.97–1.20) compared to our previous results (OR 1.05; 95% CI 0.94–1.15) [2] (Fig. 2).

We also disagree with Zhao et al. on their concern for inclusion of Couper et al. (2021) Randomized Clinical Trial (RCT) [6]. Our previous meta-analysis [2] focused on publications from April 2021 to February 2024; this RCT was published in January 2021. Therefore, it fell outside our search period and was not included in our new SR and meta-analysis.

The survival rate post-cardiac arrest varies according to several factors, including the location of arrest (in-hospital (IHCA) vs out-of-hospital (OHCA) cardiac arrest), time to ROSC, and the impact of the post-cardiac arrest myocardial dysfunction or syndrome. After IHCA, the survival is almost twice that of OHCA, as an early ROSC is highly attained after IHCA (≈ 50%) [7]. Zhao et al. results were consistent with our findings, showing that in patients with OHCA, mechanical CPR did not improve the ROSC in RCTs and non-RCTs, while after IHCA, RCTs showed improved ROSC with mechanical CPR. However, the subgroup analysis for the IHCA group included very old RCTs (two out of four, namely Taylor 1978 and Halperin 1993), in addition to the comparatively high variances [1]. It is essential to highlight those significant changes in the resuscitation protocols and advancements in technology that have occurred over the past decades. The age of these studies presents a considerable challenge, as they were conducted under vastly different clinical environments and standards of care compared to more recent studies. These variations, including differences in CPR techniques, medications, and post-resuscitation care, further contribute to the heterogeneity and bias of the outcomes data.

It is of utmost importance that the data used in our umbrella review and SR showed a heterogeneity due to the different methodologies employed in the original studies and SRs. The design and quality of studies were also of concern [2]. Moreover, the definitions of ROSC and the cause of cardiac arrest varied across studies, introducing additional complexity to the analysis. We meticulously addressed these issues in our review including a comprehensive limitations section for the readers [2].

Of note is that the likelihood of ROSC and survival is expected to significantly improve when CPR is performed promptly and at a high-quality level using advanced technology and guidelines. Despite advances in CPR, poor survival rates remain challenging, even with achieving the ROSC. Therefore, ROSC should not be the end of the game, and research must also focus on preventing the post-cardiac arrest syndrome that could occur within several hours of the arrest and ROSC [7]. A recent SR (24 studies) showed no statistically significant differences in ROSC and survival between the two kinds of CPR following OHCA. However, a favorable neurological outcome (OR 1.41; 95% CI 1.07–1.84) was observed with manual CPR in 13 of these OHCA studies [8]. Therefore, we addressed these essential outcomes after CPR along with the ROSC, such as survival to hospital admission, survival to hospital discharge, 30-day survival, and neurological outcomes. Additionally, we investigated the impact of gender, age, type of device, initial rhythm, duration of CPR, and location of arrest on the CPR outcomes in subgroups, ensuring comprehensive and robust analysis. Consequently, we urge well-designed multicenter RCT and living SR and umbrella review to support favorable post-CPR outcomes and overcome the gaps in contemporary literature.

No datasets were generated or analysed during the current study.

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Authors and Affiliations

Clinical Research, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
Ayman El-Menyar & Mashhood Naduvilekandy
Department of Medicine, Weill Cornell Medicine, Doha, Qatar
Ayman El-Menyar

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Ayman El-MenyarView author publications
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MN was responsible for literature research, data extraction, and figure production. AE was responsible for supervision. All the authors participated in the draft writing, review, and editing.

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Correspondence to Ayman El-Menyar.

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El-Menyar, A., Naduvilekandy, M. An update on the mechanical versus manual cardiopulmonary resuscitation in cardiac arrest patients. Crit Care 28, 340 (2024). https://doi.org/10.1186/s13054-024-05131-7

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Received: 09 October 2024
Accepted: 11 October 2024
Published: 22 October 2024
DOI: https://doi.org/10.1186/s13054-024-05131-7

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中文翻译：

心脏骤停患者机械与手动心肺复苏的更新

心肺复苏（CPR）技术及其结果仍然存在争议。针对 Zhao 等人 [1] 关于在荟萃分析中纳入重复研究 [2] 的说法，我们对 Ong 等人（2012 年）和 Casner 等人（2005 年）发表的两项研究进行了全面回顾。之后，我们删除了这两项研究，以及 Halperin 等人（1993）的额外数据点，这些数据点表现出高方差，没有达到我们更新分析设定的方差阈值，然后我们进行了修订的荟萃分析以保持一致性。尽管有这些变化，结果仍然一致，（比值比（OR）为 1.11;95% CI 0.99–1.22）（图 1）。因此，我们最初的伞式综述结果 [2] 和 Zhao 等人的分析表明，机械 CPR 在实现自主循环恢复（ROSC）方面并不优于手动 CPR。

我们尊重地不同意 Zhao 等人的第二点，即在荟萃分析中包括 Axelson 等人（2013 年）和 Jennings 等人（2012 年）。我们分析所需的一些相关数据是从 Sheraton 等人（2021）已经发表的系统评价（SR）中获得的 [3]。ROSC 相关的 OR 是从 Sheraton 等人荟萃分析的第二张图中提取的 [3]。还值得注意的是，Zhao et al. [1] 包括 Hallstrom et al. （2006） [4] 发表的一项研究，尽管该研究在原始工作中没有明确提到 ROSC 作为结果。

我们同意仅从摘要中获得的数据会影响结果的稳健性;因此，我们打算从已发表的 SR 中收集和综合尽可能多的数据，而不是从单个研究或总括综述的摘要中收集和综合数据 [2]。然而，对于伞式荟萃分析，使用了来自 3 篇摘要（Lairet et et al. （2005）， Paradis et al. （2009）和 Morozov et al. （2012））的数据。这些摘要的 OR 摘自 Bonnes et al. （2016）发表的荟萃分析及其插图 [5]。因此，在这封信中，我们在删除了从摘要中收集的数据后重新计算了 ORs，或者没有在原始作品中报告与 ROSC 相关的 ORs。与我们之前的结果（OR 1.05;95% CI 0.94-1.15）相比，修订后的分析结果没有显示任何显著差异（OR 1.09;95% CI 0.97-1.20）[2]（图 2）。

我们也不同意 Zhao 等人对纳入 Couper 等人（2021 年）随机临床试验（RCT） [6] 的担忧。我们之前的荟萃分析 [2] 侧重于 2021 年 4 月至 2024 年 2 月的出版物;该 RCT 发表于 2021 年 1 月。因此，它超出了我们的检索期，未包含在我们新的 SR 和荟萃分析中。

心脏骤停后的生存率根据几个因素而变化，包括心脏骤停的位置（院内（IHCA）与院外（OHCA）心脏骤停）、ROSC 的时间以及心脏骤停后心肌功能障碍或综合征的影响。IHCA 后，生存率几乎是 OHCA 的两倍，因为 IHCA 后早期 ROSC 的实现率很高（≈ 50%） [7]。Zhao 等人的结果与我们的研究结果一致，表明在 OHCA 患者中，机械 CPR 在 RCT 和非 RCT 中并没有改善 ROSC，而在 IHCA 之后，RCT 显示机械 CPR 的 ROSC 有所改善。然而，IHCA 组的亚组分析除了相对较高的方差外，还包括非常古老的 RCT（四分之二，即 Taylor 1978 和 Halperin 1993）[1]。必须强调过去几十年来复苏方案的重大变化和技术进步。这些研究的年龄带来了相当大的挑战，因为与最近的研究相比，它们是在截然不同的临床环境和护理标准下进行的。这些差异，包括 CPR 技术、药物和复苏后护理的差异，进一步导致了结果数据的异质性和偏倚。

最重要的是，由于原始研究和 SR 中采用的方法不同，我们的伞式综述和 SR 中使用的数据显示出异质性。研究的设计和质量也值得关注[2]。此外，ROSC 的定义和心脏骤停的原因因研究而异，这给分析带来了额外的复杂性。我们在综述中仔细讨论了这些问题，包括为读者提供了一个全面的限制部分 [2]。

值得注意的是，当使用先进的技术和指南及时并以高质量水平进行 CPR 时，预计 ROSC 的可能性和生存率将显着提高。尽管 CPR 取得了进步，但即使达到 ROSC，低生存率仍然具有挑战性。因此，ROSC 不应是游戏的终点，研究还必须侧重于预防心脏骤停后综合征，这种综合征可能在心脏骤停和 ROSC 后数小时内发生 [7]。最近的一项 SR（24 项研究）显示，OHCA 后两种 CPR 之间的 ROSC 和生存率没有统计学意义差异。然而，在这些 OHCA 研究中，有 13 项人工 CPR 观察到良好的神经系统结局（OR 1.41;95% CI 1.07–1.84） [8]。因此，我们在 CPR 和 ROSC 后解决了这些基本结果，例如入院生存率、出院生存率、30 天生存率和神经系统结果。此外，我们调查了性别、年龄、设备类型、初始心律、CPR 持续时间和停止位置对亚组 CPR 结果的影响，确保分析全面而有力。因此，我们敦促精心设计的多中心 RCT 和活体 SR 和伞式综述，以支持良好的 CPR 后结果并克服当代文献中的空白。

在当前研究期间没有生成或分析数据集。

Zhao Y， Chen D， Wang Q. 心脏骤停机械与手动心肺复苏的比较。暴击护理。2024;28(1):319.https://doi.org/10.1186/s13054-024-05088-7。

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El-Menyar A、Naduvilekandy M、Rizoli S、Di Somma S、Cander B、Galwankar S、Lateef F、Abdul Rahman MA、Nanayakkara P、Al-Thani H. 机械与手动心肺复苏（CPR）：当代系统评价等的总括性评价。暴击护理。2024;28(1):259.https://doi.org/10.1186/s13054-024-05037-4。

文章： PubMed PubMed Central Google Scholar
文章： PubMed PubMed Central Google Scholar
Hallstrom A、Rea TD、Sayre MR、Christenson J、Anton AR、Mosesso VN Jr、Van Ottingham L、Olsufka M、Pennington S、White LJ、Yahn S、Husar J、Morris MF、Cobb LA。院外心脏骤停后复苏期间手动胸外按压与使用自动胸外按压装置：一项随机试验。美国医学会。2006;295(22):2620–8.https://doi.org/10.1001/jama.295.22.2620。

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临床研究，创伤和血管外科，哈马德医疗公司，卡塔尔多哈
Ayman El-Menyar & Mashhood Naduvilekandy
卡塔尔多哈威尔康奈尔医学院医学系
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