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Oxygen delivery during CPR (Neonatal)

Question Type:
Intervention
Full Question:
In neonates receiving cardiac compressions (P), does does 100% O2 as the ventilation gas (I), compared with compared with lower concentrations of oyxgen (C), change increase survival rates, improve neurologic outcomes, decrease time to ROSC, decrease in oxidative injury (O)?
Consensus on Science:
For the critical outcome of ROSC, we found 8 animal studies (lambs/pigs/rats) (Lipinski 1999, 221; Temesvari 2001, 812; Linner 2009, 391; Perez-de-Sa 2009, 57; Yeh 2009, 951; Solevag 2010, 64; Lakshminrusimha 2011, 1441; Walson 2011, 335) all demonstrating no advantage to 100% over 21% during CPR (very-low-quality evidence, downgraded for bias and indirectness).For the critical outcome of survival, we found 8 of 9 animal studies (lambs/pigs/rats) reporting on survival demonstrated no advantage to 100% over 21% during CPR.(Lipinski 1999, 221; Temesvari 2001, 812; Linner 2009, 391; Perez-de-Sa 2009, 57; Yeh 2009, 951; Solevag 2010, 64; Lakshminrusimha 2011, 1441; Walson 2011, 335) However, 1 study (mouse) of 9 studies evaluating this outcome found an advantage to 100% O2 (Matsiukevich 2010, 224) (very-low-quality evidence, downgraded for potential bias, inconsistency, and indirectness). All studies combined showed 80/100 (80%) versus 74/102 (73%) survival for 100% O2 versus air (not different). Eight studies with no advantage showed 70/77 (91%) versus 71/79 (90%) survival. One study with advantage for 100% showed 10/23 (43%) versus 3/23 (13%) survival (P=0.02). For the critical outcome of neurologic outcome, we found 4 animal studies (pigs/rats/mice)(Lipinski 1999, 221; Temesvari 2001, 812; Matsiukevich 2010, 224; Faa 2012, 503) reporting on neurologic outcome with varying results (very-low-quality evidence, downgraded for potential bias, inconsistency, indirectness, and imprecision). One demonstrated no difference in neurologic deficits at 72 hours, and ischemic neurons in hippocampal were not different. 218 One demonstrated worse 4-hour neurologic examination in the 100% O2 group.221 One demonstrated more hippocampal apoptosis in the 100% O2 group.222 One demonstrated more rapid restoration of cerebral blood flow but no difference in histologic brain injury scores.224For the critical outcome of oxidative injury, we found 10 animal studies reported on oxidative injury with varying results (Temesvari 2001, 812; Markus 2007, 71; Mendoza-Paredes 2008, 261; Perez-de-Sa 2009, 57; Yeh 2009, 951; Solevag 2010, 64; Lakshminrusimha 2011, 1441; Walson 2011, 335; Dannevig 2012, 89; Dannevig 2013, 163) (very-low-quality evidence, downgraded for potential bias, inconsistency, and indirectness). Six studies (pigs/mice) demonstrated no difference in various oxidative injury markers, (Temesvari 2001, 812; Perez-de-Sa 2009, 57; Matsiukevich 2010, 224; Solevag 2010, 64; Dannevig 2012, 89; Dannevig 2013, 163) 3 (lambs/rats) demonstrated more oxidative damage from using 100% O2 including apoptosis, (Markus 2007, 71; Lakshminrusimha 2011, 1441; Walson 2011, 335) and a pig study reported less striatal and hippocampal apoptosis with 100% O2 compared with 21% O2.(Mendoza-Paredes 2008, 261)
Treatment Recommendation:
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).Values, Preferences, and Task Force Insights 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.This was a much-debated topic. In the case of hypotension and bradycardia, the experimental evidence is clear: You only need to use room air. Thus, in this case, we are making the recommendation independent of the evidence. Perhaps, we say, “Despite no evidence, for the following reasons, we recommend…” In training scenarios, once chest compressions are started, failing to turn up O2 is a common error of the learner. But is it a serious error? The indirectness does not inform the recommendation. We are not even following low-level animal evidence. We are making a conscious decision to take no notice of the evidence. Can we say why this group values giving oxygen for asystole? The task force considered the option of making a neutral recommendation (with either 21% or 100% O2) and allowing councils to decide what to do. Is this a place where we do not want to suggest air or oxygen? We have no data, but we need to say something.
CoSTR Attachments:
GRADE GRID - NRP 738 O2 and CPR_n.docx    

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