What is the recommended depth of chest compression during CPR in a pediatric patient with a history of acute kidney injury and severe hyperkalemia?

Recommended Depth of Chest Compression During CPR in Children

For pediatric CPR, compress the chest at least one-third of the anterior-posterior diameter, which equates to approximately 1.5 inches (4 cm) in infants and 2 inches (5 cm) in children, regardless of underlying medical conditions including acute kidney injury or hyperkalemia. 1

Age-Specific Compression Depth Guidelines

Infants (Birth to 1 Year)

• Compress at least one-third of the anterior-posterior chest diameter, approximately 1.5 inches (4 cm) 1, 2
• Use 2-finger technique for single rescuers or 2-thumb encircling hands technique for two healthcare providers 1, 3
• Position compressions just below the intermammary line on the sternum 1, 3

Children (1 Year to Puberty)

• Compress at least one-third of the anterior-posterior chest diameter, approximately 2 inches (5 cm) 1, 2
• May use either 1-hand or 2-hand technique depending on child size and rescuer capability 1
• Compress in the middle of the chest 1

Adolescents (Post-Puberty)

• Use adult compression depth of at least 5 cm but no more than 6 cm 1
• This applies to adolescents of average adult size 1

Critical Performance Parameters

Compression Rate

• Maintain 100-120 compressions per minute 1, 3
• Rates below 100/min or exceeding 120/min are associated with worse hemodynamics 1

Complete Chest Recoil

• Allow complete chest recoil after each compression 1, 3
• Residual leaning is common but impairs venous return and cardiac output 1

Minimize Interruptions

• Limit pauses in compressions to no more than 10 seconds for rhythm checks 1
• Perform rhythm checks approximately every 2 minutes 1

Evidence Supporting Current Depth Recommendations

The one-third anterior-posterior diameter recommendation is based on three anthropometric studies demonstrating that pediatric chests can be compressed to this depth without damaging intrathoracic organs 1. Additionally, observational data from pediatric in-hospital cardiac arrest showed improved rates of return of spontaneous circulation and 24-hour survival when compression depth exceeded 5 cm 1.

Important Nuance: Emerging Concerns About Depth Targets

Recent research suggests potential issues with current guidelines:

• A 2024 Japanese study using laser distance measurements found that guideline-recommended absolute depths (4 cm for infants, 5 cm for children) would result in over-compression in 49% of young infants (0-2 months) and 45.5% of toddlers (12-17 months) 4
• A 2022 swine model study demonstrated that compressions to 1/3 anterior-posterior diameter caused significantly more rib fractures, sternal fractures, and hemothorax compared to 1.5-inch compressions, without improving return of spontaneous circulation 5
• However, a 2025 infant swine model found no difference in injury between 1.5 inches and 1/3 anterior-posterior diameter strategies 6

Despite these emerging concerns, the 2020 American Heart Association Guidelines remain the authoritative standard for clinical practice 1. The guideline recommendations are based on the best available evidence showing improved survival outcomes with adequate compression depth 1.

Special Considerations

Compression Technique Modifications

• If unable to achieve guideline-recommended depths with standard technique, it may be reasonable to use the heel of one hand for infants 1
• Use a firm surface or backboard during in-hospital cardiac arrest to improve compression depth 1
• Activate "CPR mode" on hospital beds when available to increase mattress stiffness 1

Clinical Context

The presence of acute kidney injury or severe hyperkalemia does not alter chest compression depth recommendations 1. These conditions may have precipitated the cardiac arrest but do not change the mechanical requirements for effective CPR. Focus remains on achieving adequate perfusion pressure through guideline-compliant compressions while simultaneously addressing the underlying hyperkalemia with appropriate advanced life support medications.

Common Pitfalls to Avoid

• Inadequate compression depth is extremely common and compromises perfusion 3
• Compressing too rapidly (>120/min) reduces diastolic filling time and coronary perfusion 1
• Failing to allow complete chest recoil impairs venous return 1, 3
• Excessive interruptions for pulse checks or rhythm analysis reduce overall CPR quality 1
• Rescuer fatigue degrades compression quality—rotate compressors every 2 minutes 3