Neonatal Life Support

Octubre - 2020

---

 

 

V.- CIRCULATORY SUPPORT

 

For each of the following topics, the EvUps were performed to identify any evidence relevant to the topic that was published after the most recent NLS CoSTR
on the topic. The goal was to determine if there was sufficient evidence to suggest a need for a SysRev that might change recommendations about performance of cardiac compressions for the few neonates who require circulatory support at birth.

1.- CPR Ratios for Neonatal Resuscitation (NLS 895: EvUp)

Chest compressions administered in a 3:1 compression to-ventilation ratio are recommended for resuscitation of newborn infants.1,9,10 At birth, the fluid filling the lungs of the newborn must be absorbed during the initial breaths. Lung aeration triggers an increase in pulmonary blood flow. If a newborn infant has sufficient compromise in gas exchange to cause severe bradycardia or cardiac arrest, successful resuscitation must first achieve adequate lung aeration and ventilation to avoid circulation of blood with progressively lower oxygen saturation.

Many newborn infants, even those who are asphyxiated, will respond to respiratory support alone. As a result, the focus of newborn resuscitation is aimed first at establishing effective ventilation, and support of circulation is provided only for those who have persistent bradycardia or asystole. When circulatory support is needed, it is important that it be as effective as possible. This EvUp was performed to identify the most effective compression- to-ventilation ratio for neonatal resuscitation.

Most studies identified by the EvUp (see Supplement Appendix C-6) either supported the 2015 treatment recommendations or did not refute it. As a result, the NLS Task Force agreed that no SysRev is needed and there is no change to the 2015 treatment recommendation. 1,9,10 The NLS Task Force is aware of an ongoing
study of a new neonatal compression technique, with compressions delivered while maintaining a sustained inflation (NCT02858583 at Clinicaltrials.gov). The NLS Task Force agreed that a SysRev may be indicated after publication of the results of that study.
 

Population, Intervention, Comparator, Outcome, Study Design, and Time Frame

• Population: In newborn infants receiving cardiac compressions

• Intervention: other ratios (5:1. 9:3, 15:2, synchronous, etc)

• Comparator: 3 compressions, 1 ventilation

• Outcome²¹ :

  • Return of spontaneous circulation (ROSC) (critical)

  • Survival (critical)

  • Neurodevelopmental impairment (critical)

  • Time to ROSC (critical)

  • Perfusion (important)

  • Gas exchange (important)

  • Tissue injury (important)

  • Compressor fatigue (important)

Treatment Recommendation

• This treatment recommendation (below) is unchanged from 2015.^1,9,10

• We suggest continued use of a 3:1 compression-toventilation ratio for neonatal CPR (weak recommendation, very low-quality evidence).

• 2-Thumb Versus 2-Finger Compressions for Neonatal Resuscitation (NLS 605: EvUp)

  • In the past, providers used a variety of techniques to perform chest compressions during resuscitation of newborn infants. The most common techniques used 2 thumbs with the remaining fingers surrounding the lateral and posterior chest, or 2 fingers placed vertically on the lower sternum.

  • The most recent review of the topic of chest compressions was included in the 2015 CoSTR for NLS.^1,9,10 This EvUp was performed to identify any evidence published after the 2015 CoSTR that would suggest the need for a new SysRev and reevaluation of the treatment recommendation.

  • The only new evidence identified by the EvUp (see Supplement Appendix C-7) supports the 2015 treatment recommendations.^1,9,10

  • Thus, no new SysRev or change in the 2015 treatment recommendation is warranted.

  • The task force noted that initial reports of a few alternative compression techniques (vertical thumbs, thumb and index finger, 2 thumbs with fisted hands) have been studied in manikin models.

  • Studies testing any of these in a comparative trial in human infants may prompt a future SysRev.

Population, Intervention, Comparator, Outcome, Study Design, and Time Frame

• Population: In newborn infants receiving cardiac compressions

• Intervention: 2-thumb technique

• Comparator: 2-finger technique

• Outcome21 :

  • ROSC (critical)

  • Survival (critical)

  • Neurodevelopmental impairment (critical)

  • Perfusion (important)

  • Gas exchange (important)

  • Compressor fatigue (important)

Treatment Recommendation

• This treatment recommendation (below) is unchanged from 2015.^1,9,10

• We suggest that chest compressions in the newborn infant should be delivered by the 2-thumb, handsencircling-  the-chest method as the preferred option (weak recommendation, very low-certainty evidence).

---