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, December 19, 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 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.
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 any lower concentrations of oxygen
Comparators: versus 100% oxygen as the ventilation gas
Outcomes: increase survival rates, improve neurologic outcomes, decrease time to ROSC, or decrease oxidative injury?
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: NLS 5503 Search Strategies
Data Tables: NLS 5503 Data Table
Task Force Insights
- Why this topic was reviewed.
- This topic was chosen for review by the NLS Task Force as the evidence for oxygen use during cardiac compressions had not been reviewed since 2015. The 2015 CoSTR stated the following:
“There are no human data to inform this question. Despite animal evidence showing no advantage to the use of 100% oxygen, by the time resuscitation of a newborn baby has reached the stage of chest compressions, the steps of trying to achieve ROSC using effective ventilation with low-concentration oxygen should have been attempted. Thus, it would seem prudent to try increasing the supplementary oxygen concentration (Good Practice Guidance). If used, supplementary oxygen should be weaned as soon as the heart rate has recovered (weak recommendation, very-low-quality evidence).” {Perlman 2015 S204; Perlman 2015 S120; Wyllie 2015 e169}
2. Narrative summary of evidence identified
- Even now, no human studies that compared 21% oxygen versus 100% oxygen or any other oxygen concentration during chest compression were identified.
- Seven animal studies comparing 21% with 100% inspired oxygen (O2) concentrations during chest compression after asphyxial cardiac arrest were identified.
- The published literature identified by this scoping review reported no difference in time to return of spontaneous circulation, mortality, inflammation or oxidative stress.
- None of the studies examined any longer-term outcomes.
3. Narrative Reporting of the task force discussions
- The NLS Task Force discussed concerns about low oxygen delivery (hypoxia) as well as the potential adverse effects if 100% oxygen is provided during chest compression.
- Although most of the available animal evidence suggests that resuscitation using air during neonatal chest compressions is feasible and that 100% O2 as the resuscitation gas may increase oxidative injury, we remain concerned that we have no human data to prove feasibility and none of the animal studies have evaluated use of room-air CPR for more than brief asystole. We value balancing the desire to prevent ongoing hypoxic injury in these profoundly asphyxiated neonates with the desire to prevent subsequent hyperoxic injury.
- There were insufficient studies identified to support a more specific systematic review.
- The information from the studies identified was considered insufficient to alter existing recommendations.
Knowledge Gaps
Additional research is required, ie, studies in good transitional animal model of asphyxia-induced severe bradycardia or asystole and any neonatal human data.
References
Dannevig I, Solevåg A, Saugstad OD, Nakstad B. Lung injury in asphyxiated newborn pigs resuscitated from cardiac arrest - the impact of supplementary oxygen, longer ventilation intervals and chest compressions at different compression-to-ventilation ratios. Open Respiratory Medicine Journal. 2012;6:89–96.
Dannevig I, Solevåg A, Sonerud T, Saugstad OD, Nakstad B. Brain inflammation induced by severe asphyxia in newborn pigs and the impact of alternative resuscitation strategies on the newborn central nervous system. Pediatric Research. 2013;73:163–170.
Garcia-Hidalgo C, Cheung P-Y, Vento M, O’Reilly M, Schmölzer GM. A Review of Oxygen Use During Chest Compressions in Newborns—A Meta-Analysis of Animal Data. Frontiers in Pediatrics. 2018;6:S196-7.
Linner R, Perez-de-Sa V, Cunha-Goncalves D. Circulatory recovery is as fast with air ventilation as with 100% oxygen after asphyxia-induced cardiac arrest in piglets. Pediatric Research. 2009;66:391–394.
Linner R, Cunha-Goncalves D, Perez-de-Sa V. One oxygen breath shortened the time to return of spontaneous circulation in severely asphyxiated piglets. Acta Paediatrica [Internet]. 2017;106:1556–1563. Available from: https://www.readcube.com/
Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim H-S, Liley HG, Mildenhall L, Simon WM, et al. Part 7: Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132:S204–S241.
Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, et al. Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics. 2015;136 Suppl 2:S120-166.
Solevåg A, Dannevig I, Nakstad B, Saugstad OD. Resuscitation of severely asphyctic newborn pigs with cardiac arrest by using 21% or 100% oxygen. Neonatology. 2010;98:64–72.
Solevåg AL, Garcia-Hidalgo C, Cheung P-Y, Lee T-F, O’Reilly M, Schmölzer GM. Ventilation with 18, 21, or 100% Oxygen during Cardiopulmonary Resuscitation of Asphyxiated Piglets: A Randomized Controlled Animal Trial. Neonatology. 2020;117:102–110.
Solevåg A, Schmölzer GM, O’Reilly M, Lu M, Lee T-F, Hornberger LK, Nakstad B, Cheung P-Y. Myocardial perfusion and oxidative stress after 21% vs. 100% oxygen ventilation and uninterrupted chest compressions in severely asphyxiated piglets. Resuscitation. 2016;106:7–13.
Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020 Oct 20;142(16_suppl_1):S185-S221.
Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres JW, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, et al. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187.
Wyckoff MH, Weiner CGM; Neonatal Life Support Collaborators. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics. 2021 Jan;147(Suppl 1):e2020038505C.
Wyllie J, Perlman JM, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, et al. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015;95:e169-201.