Recent discussions
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Jesus Lopez-Herce
The initiation sequence of basic CPR is a controversial topic with important implications for CPR training. There is no solid scientific evidence but making a recommendation can have a great relevance for CPR training.
As the authors of this systematic review acknowledge, no studies in humans have been identified, and no new study has been found that provides significant evidence to make a recommendation on what is the best sequence for starting CPR. Only 5 studies with simulation with mannequins have been found in which, the overall certainty of evidence was rated as very low for all outcomes, downgraded for a very serious risk of bias and indirectness.
The results indicate, as is logical, that with the CAB sequence that begins with chest compressions, the start of chest compressions is done earlier than with the ABC sequence. On the contrary, with the ABC sequence ventilation starts earlier than with the CAB sequence. These results are common sense and no scientific studies are needed to deduce them. Regarding the other results there were differences between the studies.
These results do not at all support the recommendation made “In adults and children in cardiac arrest, we suggest commencing CPR with compressions rather than ventilations. This is a personal opinion of the researchers, very respectable, but not based of the results.
In our opinion, starting CPR with the CAB or ABC sequence probably does not make any relevant clinical difference because both sequences only differ in starting one manoeuvre or the other a few seconds earlier, the rest of the resuscitation being the same.
The 2020 pediatric recommendations concluded that there was insufficient evidence to make a recommendation. Resuscitation. 2020 Nov;156:A120-A155.
Furthermore, and most importantly, although the current recommendation is only a suggestion with a very low level of evidence, it can have an important impact on teaching since it can be interpreted by teaching groups as an obligation to change their recommendations, which involves an enormous teaching effort without any clinical benefit.
For these reasons, we consider that the recommendation on this subject should be “There is currently insufficient scientific evidence to recommend an initial sequence of CAB or ABC CPR in adults or children”.
Ignacio Manrique and Jesús López-Herce
Representing the Spanish Group of Pediatric and Neonatal CPR
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Jesus Lopez-Herce
The initiation sequence of basic CPR is a highly controversial topic with important implications for CPR training. As the authors acknowledge, there is no solid scientific evidence on which to base one or another recommendation. However, making a recommendation can have a greatrelevance for CPR training.
In the current systematic review, no new work has been found that really provides significant evidence to make a recommendation on what is the best sequence for starting CPR. No studies in humans have been identified. Only 5 studies with simulation with mannequins have been found in which, authors point out, the overall certainty of evidence was rated as very low for all outcomes, downgraded for a very serious risk of bias and indirectness.
The results indicate, as is logical, that with the CAB sequence that begins with chest compressions, the start of chest compressions is done earlier than with the ABC sequence. On the contrary, with the ABC sequence ventilation starts earlier than with the CAB sequence. These results are common sense and no scientific studies are needed to deduce them. Regarding the other results there were diffferences between the studies.
These results do not at all support the recommendation made “In adults and children in cardiac arrest, we suggest commencing CPR with compressions rather than ventilations”. This is a personal opinion of the researchers, very respectable, but not based of the results.
In our opinion, starting CPR with the CAB or ABC sequence probably does not make any relevant clinical difference because both sequences only differ in starting one manoeuvre or the other a few seconds earlier, the rest of the resuscitation being the same. The 2020 pediatric recommendations concluded that there was insufficient evidence to make a recommendation. Resuscitation. 2020 ;156:A120-A155. doi: 10.1016/j.resuscitation.2020.09.013.
Furthermore, and most importantly, although the current recommendation is only a suggestion, it can have an important impact on teaching since it can be interpreted by teaching groups as an obligation to change their recommendations, which involves an enormous teaching effort without any clinical benefit.
For these reasons, we consider that the recommendation should be “There is currently insufficient scientific evidence to recommend an initial sequence of CAB or ABC CPR in adults or children.
Ignacio Manrique and Jesús López-Herce
Representing the Spanish Group of Pediatric and Neonatal CPR
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Nádia Sandra Orozco Vargas
I agree that the use of vídeo laringoscopy Will be useful and brings a Lot of benefits in the medical assistance to the prematures and microprimes. With less cerebral damage.
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adriano peris
Should the duration of CPR cycles be different in the presence of in-hospital cardiac arrest distinguishing between monitored patients (ECG, Pulse O2......) and non-monitored patients?
After the onset of ROSC in a controlled environment (ED, ICU, OR..) knowing the vital parameters that precede cardiac arrest, the duration of the cycles must take into account the state of perfusion that precedes cardiac arrest? For example, if the average pressure was 80 mmHg, even if adrenaline-dependent, is it convenient to re-establish a perfusion attempt without interrupting the CPR cycles?
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marije hogeveen
I would like to thank the authors for their work. This provides us with an excellent overview on the latest evidence on the use of video laryngoscopy. Based on this evidence, I support the recommendations, especially because the main recommendations is stated as conditional on training and resources
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marije hogeveen
is there an EtD table available for easier reading?
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Nicole Udse Luis
Acredito que a recomendação de uso de videolaringoscopio seria benéfico para o procedimento em recem-nascidos prematuros. Não estaria disponível de imediato em todas as unidades mas uma recomendação nesse sentido indicaria a importância do material. Acredito que traria menor risco ao procedimento com intubacoes mais rápidas e menos tentativas.
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Celso Rebello
The use of video laryngoscopy with appropriate equipment for extremely premature infants (0-0 blade) is a step forward both in the practice and in the teaching of procedures that require laryngoscopy. This includes not only intubation (which is the subject of this public consultation) but also the administration of surfactant through a thin catheter. I agree with the proposed recommendation.
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Paulo Fernando Martins Filho
I do not face any difficulty in performing neonatal intubation using the traditional method. But I understand that this tool could help us optimize the technique and improve our intubation outcomes. However, the necessary equipment is expensive and scarcely available in maternity wards in Brazil.
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Chris Lindsell
As a person who, in their profession attends many arrests. I see the use of mechanical devices particularly the Lucus as very problematic due to poor placement and time off the chest. There needs to be more emphasis that these should not be used routinely when not necessary. I also see trauma to the skin often and am aware of the the psychological impact from family members, especially with the Lucus when hands are attached to the machine.