Chest Compressions in Neonatal Cardiopulmonary Resuscitation

Vishal Kapadia, MD, MSCS, FAAPUniversity of Texas Southwestern Medical Center at Dallas

C0009 NRP® Current Issues Seminar: Monumental Changes on the Horizon

Faculty Disclosure Information

In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial

product(s) and/or provider(s) of commercial services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Session Objectives Describe indications of chest compressions

during neonatal CPR Understand goal of cardiac compression during

neonatal CPR Understand correct technique of neonatal chest

compressions Discuss evidence behind current guidelines for

neonatal CPR

Anticipate Neonatal CPR You get a page for stat C/S 20 yo G1P0 mom, No prenatal care Clinical diagnosis of Chorioamnionitis Fetal bradycardia with loss of baseline

variability Bedside sono suggest 39 wks

How to Prepare for Neonatal CPR Assessment of perinatal risk Mobilization of the team Identification of team leader and pre-resuscitation

briefing: Anticipating interventions and assigning roles. A standardized checklist to ensure that all necessary

supplies and equipment are present and functioning Decide on an estimated weight May prepare umbilical catheter and may draw up

intravenous epinephrine doses and label

Going Back to Our Baby Baby is delivered, cord clamped and given to

neonatal team Found to be not breathing and limp Airway positioned, secretions cleared, dried and

stimulation provided Remains apneic and HR around 20 Positive pressure ventilation is initiated. Pulse

oximeter is attached. Heart rate remains 20 bpm.

What is the next step?

If after initiation of PPV, HR remains < 60

You shouldA. Start chest compressions B. Stimulate the neonateC. Auscultate for full 1 minute for accurate HR

assessmentD. Attempt ventilation corrective steps: MRSOPA

Indication of Cardiac Compression during Neonatal CPR

If heart rate remains below 60 bpm despite adequate ventilation via advanced airway if possible.

Ensure that assisted ventilation is being delivered optimally before starting chest compressions

Ventilation is the most effective action in neonatal resuscitation.

Chest compressions are likely to compete with effective ventilation

Ventilation Corrective Steps

Goal of Compressions

Goal is to deliver sufficient oxygenated blood to the myocardium ( coronary) and to vital organs, especially brain.

Coronary perfusion is a determinant of return of spontaneous circulation (ROSC). As oxygenated blood reaches the heart providing the energy (ATP), it may start beating again.

Cerebral perfusion is a determinant of neurologic outcome

Compressions withMinimal Diastolic BP

Aorta

Heart

Compressions with Diastolic BP

Aorta

Heart

Coronary Perfusion Pressure

ATPATP

ATP

α-adrenergic effects of epinephrine or

uninterrupted compressions

lead to Aortic DBP

CoronaryArteries

Coronary Perfusion Pressure=Aortic DBP – Right Atrial DBP

Adequate Diastolic Blood Pressure is Critical to the Success of CPR

Compression Ventilation

CPP

Robert A. Berg et al. Circulation. 2001;104:2465-2470

Coronary Perfusion Pressure = Aortic DBP – Right Atrial DBP

Optimal Neonatal Cardiac Compressions

Location Compression depth Two thumbs versus Two finger Method Compression to ventilation ratio Synchronization

Location: Lower 1/3 of Sternum You et al. Resuscitation 2009: Retrospective review of

CT scan images. ( n= 75, mean age 4 ± 3 months) Left ventricle (Max AP diameter of heart ) located under lower third of sternum.

Clements 2000 and Saini 2012 : Anatomic relationship between the nipples and lower sternum to determine finger position is not reliable.

Running one’s fingers along the lower edge of the rib cage to locate the xiphoid, then placing the thumbs centrally and immediately above the xiphoid, avoiding direct pressure on the xiphoid.

Compression Depth Chest compressions should be

administered to a depth of approximately one-third of the AP diameter of the chest to produce a palpable pulse.

The chest should be allowed to fully recoil before the next compression to allow the heart to refill with blood.

Administer Compressions at a Depth of 1/3 the AP Diameter of the Chest

– Retrospective observational study in neonates (n=54)

– Mathematical modeling based upon neonatal chest CT scan dimensions

– 1/3 AP chest depth should be more effective than 1/4 compression depth, and safer than 1/2 AP compression depth

Meyer et al. Resuscitation 2010

What method of compressions should be used?

Two thumb technique: Hands encircling the chest and thumbs depressing the sternum

Two finger technique: Index and middle fingers to depress the sternum with the other hand behind the back providing a firm base

Which technique is recommended for providing chest compressions?

A. Two thumbs methodB. Two fingers methodC. Two thumbs method except when attempting

line placement or managing airwayD. The one you are most familiar with

Use Two-Thumb Method Rather than Two-Finger Method for Neonatal Cardiac

Compressions

Use Two-Thumb Method Rather than Two-Finger Method for Neonatal Cardiac

Compressions

Use Two-Thumb (TT) Method Rather than Two-Finger (TF) Method

11 manikin RCTs including those using newborn manikin show with TT method:• Higher BP• Appropriate compression depth• Consistent correct placement on chest• Less variance in compression quality• Less fatigue over time

Multiple human and neonatal observational studies and animal studies agree with superiority of two thumbs method.

Two Finger Method Should Not be Used

Disadvantages of two thumb method from the side of the bed.

1. No easy access to the umbilicus for line and medication. Many providers switch to TF method during line placement.

2. Must reach across the patient and body is not aligned to use large muscle groups for effective chest compressions.

Head of Bed Compressions Allows Continuous Two-thumb Technique

Once an airway is secured, move the compressor to head of bed

Potential Advantages: Arms are in a more natural position, Umbilical access is more readily available while continuing Two-thumb technique, More space for person giving meds at the patient’s side

Less compressor fatigue (Unpublished data, Sparks et al)

Two finger method should no longer be used.

What Ratio of Compression to Ventilation to Use (C:V ratio)

In Adult V-fib model: problem with flow, not the content of the blood

• Forward flow from left ventricle ceases • Blood has near normal carbon dioxide, oxygen and pH.• Emphasis on chest compression over ventilation In Neonatal asphyxial arrest, left ventricular blood has much

lower oxygen tension, higher carbon dioxide and lower pH.• Neonatal CPR needs adequate airway and ventilation to

oxygenate the blood and good quality chest compression to move that blood forward.

In Asphyxia Animal Model, Chest Compression with Ventilation is Superior to Ventilation or Compression

AloneCC + V(n=10)

CCC(n=10)

V(n=10)

Baseline (before asphyxia)

Arterial pH 7.42 ± 0.01 7.42 ± 0.02 7.40 ± 0.01

Arterial pCO2 (mmHg) 43 ± 1 42 ± 1 45 ± 2

After 1 min of CPR

Arterial pH 7.20 ± 0.03 7.17 ± 0.04 7.23 ± 0.04

Arterial pCO2 (mmHg) 68 ± 5 77 ± 11 51 ± 3

ROSC obtained in < 2 min, n (%)*

10 (100%) 4 (40%) 6 ( 60%)

Berg RA et al. Circulation 2000*p 0.01

What Ratio of Compression to Ventilation to Use

Study Year Design Total Pts Population

Solevag 2010 RCT 32 Pigs (12-36 hrs)

Solevag 2011 RCT 22 Pigs (12-36 hrs)

Solevag 2012 RCT 2 (x 5 runs) Neo Resus Providers

Dannevig 2012 RCT 31 Pigs (12-36 hrs)

Dannevig 2013 RCT 54 Pigs ( 14-34 hrs)

Hemway 2013 RCT 32 Neo Resus Providers

Schmolzer 2014 RCT 16 Pigs (1-4 days)

Compression to Ventilation Ratio 15:2 is Not Superior to 3:1 in Neonatal Asphyxia Model

3:1(n=9)

15:2(n=9)

P Value

Cardiac Compression/min 58 ± 7 75 ± 5 <0.001

Increase in DBP during compression cycles (mmHg) 4.8 ± 2.6 7.1 ± 2.8 0.004

Number of animals with no ROSC 2 2 NS

Time to ROSC (sec)* 150 (140-180) 195 (145-358) NS

pH following ROSC 6.6 ± 0.1 6.6 ± 0.1 NS

pCO2 ( kPa) 11.2 ± 4.3 9.6 ± 2.7 NS

Solevåg et al. ADC 2011DBP=Diastolic Blood Pressure, ROSC=return of spontaneous circulation

Continue Use of 3:1 Compression to Ventilation Ratio

Animal studies: No advantage to higher C:V ratio for tissue injury, gas exchange during CPR, time to return of spontaneous circulation.

Manikin studies ( Hemway 2013, Solevag 2012): disadvantage of higher ratio regarding compressor fatigue and minute ventilation.

A 3:1 C:V ratio is recommended, with 90 compressions and 30 breaths to achieve approximately 120 events per minute to maximize ventilation at an achievable rate.

Rescuers may consider using higher ratios (eg, 15:2) if the arrest is believed to be of cardiac origin

Should we continue to coordinate the compressions and ventilations?

Compressions and ventilations should be coordinated to avoid simultaneous delivery.

Asynchronous CPR Appears Equivalent to 3:1 CPR in Asphyxiated Neonatal Pigs

Term newborn piglets, 8/group

After ROSC CCaV group had higher pCO2, lower pH and higher lactate.

No difference in− ROSC− Survival− Hemodynamic parameters− Minute ventilation

Schmölzer et al Resuscitation 2014

◦ 3:1• Asynchronous◦ 3:1

• Asynchronous

What is the recommended method to estimate heart rate during neonatal CPR?

A. AuscultationB. Palpation of umbilical cordC. ECG monitorD. Pulse oximetryE. Palpation of radial pulse

Continue Good Practice and Change in Practice

Anticipate need for resuscitation Optimal assisted ventilation via advanced airway before

starting chest compressions Use ECG monitor during CPR Always two thumb compressions. Move to head of the bed

during emergent umbilical line placement. Continue 3:1 C:V ratio. Compress lower third of sternum. Avoid unnecessary interruption of chest compression as CPP

drops when interrupted. Be aware of compressor fatigue and switch

Evidence Based Resuscitation

Guideline documents: Perlman JM, Wyllie J, Kattwinkel J, Wyckoff M, Aziz K,

Guinsburg R, Kim HK, Liley H, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S. Part 7: Neonatal resuscitation: 2015 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2015; In press.

Wyckoff MH, Aziz K, Escobedo M, Kapadia V, Kattwinkel J, Perlman JM, Simon W, Weiner GM, Zaichkin J. Part 13:Neonatal resuscitation: 2015 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; In press.

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