Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Bruckner M, Wyckoff MH, and Schmölzer GM have all published studies regarding neonatal cardiac compressions. 2 reviewers were used to select or exclude each paper for this scoping review and no reviewer was allowed to determine inclusion or exclusion of their own publications.
Task Force Scoping Review Citation
Ramachandran S, Bruckner M, Wyckoff MH, Schmölzer GM on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Neonatal Cardiac Compressions Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 12/20/2022. Available from: http://ilcor.org
Methodological Preamble
The continuous evidence evaluation process started with a scoping review of neonatal cardiac compressions literature conducted by the ILCOR NLS Task Force and Content Expert Scoping Review Team comprised of Shalini Ramachandran, MD, Marlies Bruckner, MD, Myra Wyckoff MD, Georg M. Schmölzer MD, PhD. Neonatal cardiac compression literature was sought via a structured search strategy with the help of an information specialist, Ms. Helen Mayo from the University of Texas Southwestern Medical Center. Studies identified were evaluated using Covidence. This allowed independent title and abstract review by two authors (SR and MB) to see if full text review was warranted. When MB was an author on a study under consideration, she was recused from the decision and MW gave the second opinion. Abstracts put forward by both reviewers were included for full text review. Conflicting opinions were reviewed, discussed and resolved with the help of MW and GS as long as they were not authors on the paper under consideration. The Neonatal Life Support Task Force considered the findings for each included PICOST and developed Task Force insights regarding the compiled literature for each PICOST.
Studies screened by title / abstract, those undergoing full text review and those extracted for data analysis for the scoping review are shown in the PRISMA diagram.
Attachment: NLS 5501 PRISMA
Link to Published Scoping Review
Ramachandran S, Bruckner M, Wyckoff MH, Schmölzer GM. Chest compressions in newborn infants: a scoping review. Arch Dis Child Fetal Neonatal Ed. 2022 Dec 1:fetalneonatal-2022-324529. doi: 10.1136/archdischild-2022-324529.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In neonates receiving cardiac compressions
Intervention: does use of any other technique (2 finger or other)
Comparators: versus the 2-thumb technique
Outcomes: increase survival rates, improve neurologic outcomes, decrease time to return of spontaneous circulation
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model and animal studies were eligible for inclusion in the scoping reviews. Conference abstracts and unpublished studies (e.g. trial protocols) were excluded.
Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated to Nov 22, 2021.
Search Strategies
Inclusion and Exclusion criteria
We included animal, manikin, and human studies if there was an abstract in English. Reviews, unpublished studies, or studies published in abstract only, and studies that did not specifically address the PICOST questions were excluded.
Data Tables: NLS 5501 Data Table
Task Force Insights
- Why this topic was reviewed
- The 2015 ILCOR CoSTR suggested use of the 2-thumb, hand-encircling-technique during neonatal chest compressions (weak recommendation, very-low-quality evidence).{Perlman 2015 S204; Perlman 2015 S120; Wyllie 2015 e169} There was no clinical evidence for this suggestion and it was based on animal and manikin studies. Use of the 2-thumb, hand-encircling-technique was reaffirmed in 2020 after a brief evidence update.{Wyckoff 2020 S185; Wyckoff 2020 A156, Wyckoff 2020 e2020038505C} Because the 2020 evidence update identified multiple new manikin and animal studies, the task force felt an in depth scoping review was warranted.
2. Narrative summary of evidence identified
- The current scoping review identified 29 randomized crossover manikin studies, one observational, and one randomized study comparing various finger/hand positions. {Dorfsman 2000 1077; Whitelaw 2000 213; Udassi 2010 712; Christman 2011 F99; Fakhraddin 2011 15; Huynh 2012 658; Saini 2012 690; Jiang 2015 531; Jo 2015 32; Na 2015 e70; Kim 2016 997; Smereka 2016 589; Jo 2017 462; Smereka 2017 604; Smereka 2017 e5915; Smereka 2017 1420; Jang 2018 36; Ladny 2018 e9386; Lee 2018 372; Park 2018 1; Smereka 2018 159; Smereka 2018 761; Jung 2019 261; Paek 2019 e0226632; Pellegrino 2019 104; Rodriquez-Ruis 2019 1529; Yang 2019 1217; Lee 2020 e700; Martin 2020 133; Cheung 2020 559; Reynolds 2020 133}.
- The main outcomes described in these studies include adequacy of chest compression depth and rescuer fatigue. The available data confirmed that the 2-thumb-technique resulted in higher chest compression depth, lower fatigue, and higher proportion of correct hand placement when compared to 2-finger-technique. While several alternative finger and/or hand position techniques have been described, none resulted in over-all better performance measures compared to the 2-thumb-technique.
3. Narrative Reporting of the task force discussions
- The Neonatal TF discussed concerns about providing adequate chest compression depth by using the correct finger/hand position. The published literature identified by this scoping review included animal, manikin, and 1 human study. This scoping review confirmed that the 2-thumb-techniques resulted in improved chest compression depth, lower fatigue, and higher proportion of correct hand placement compared to 2-finger-technique. Although studies also examined alternative finger and/or hand position techniques, none has had improved performance compared to the 2-thumb-technique.
- There were no randomized controlled trials that would prompt a systematic review of this PICOST at this time. The information from the studies identified was considered insufficient to alter existing recommendations.
Knowledge Gaps
- There are no studies that have evaluated this question in the clinical setting. No RCTs compared intervention with standard care in any newborn infant population. Thus, the gaps in knowledge remain immense.
- We need clinical newborn infant data.
- How many compressions in a row are required to achieve forward blood flow and adequate coronary perfusion pressure during newborn asphyxial arrest?
- How many interposed ventilations are needed to achieve and maintain normocapnia during cardiac compressions due to newborn asphyxial arrest?
- Asynchronous techniques and sustained inflation cardiac compressions deserve more investigation.
- Techniques to limit interruptions in compressions to assess efficacy
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