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Chest compression ratio

Question Type:
Intervention
Full Question:
In neonates receiving cardiac compressions  (P), do other ratios (5:1, 9:3, 15:2, asynchronous)  (I), versus 3:1 (C), decrease compressor fatigue, improve perfusion and gas exchange during CPR, decrease time to ROSC, increase survival rates, improve neurologic outcomes, decrease tissue injury  (O)?
Consensus on Science:
Animal studies demonstrate no advantage to higher compression-to-ventilation ratios (very-low-quality evidence, downgraded for potential bias, indirectness, and imprecision) regardingShort-term survival (2 randomized controlled trials including 54 pigs) (Solevag 2010, 1571; Solevag 2011, F417)Gas exchange during CPR (2 randomized controlled trials including 54 pigs) (Solevag 2010, 1571; Solevag 2011, F417)Time to ROSC (2 randomized controlled trials including 54 pigs) (Solevag 2010, 1571; Solevag 2011, F417)Markers of tissue injury (lung/brain) (2 randomized controlled trials including 54 pigs) (Dannevig 2012, 89; Dannevig 2013, 163)There was no evidence identified to address the critical issue of neurologic outcome.Manikin studies demonstrated a disadvantage to higher compression-to-ventilation ratios (5:1, 9:3, 15:2) (very-low-quality evidence, downgraded for potential bias, imprecision, and indirectness) with regard toCompressor fatigue (better depth of compression, less decay in depth over time; 1 randomized controlled trial including 32 resuscitation providers) (Solevag 2012, 73; Hemway 2013, F42)Minute ventilation (1 randomized controlled trial including 32 resuscitation providers) (Hemway 2013, F42-F45)A single manikin study demonstrated higher minute ventilation for asynchronous compressions (120 compressions: 40 ventilations) compared with 3:1 (90 compressions:30 ventilations) (1 randomized controlled trial including 2 resuscitation providers with 5 different sessions per treatment arm) (Solevag 2012, 73)
Treatment Recommendation:
We suggest continued use of a 3:1 compression-to-ventilation ratio for neonatal CPR (weak recommendation, very-low-quality evidence). Values, Preferences, and Task Force InsightsWe prefer to retain our prior recommendation of 3:1 compression-to-ventilation ratio for neonatal CPR, because there is no compelling evidence suggesting a benefit to other ratios for the newborn. Since asphyxia is the predominant cause of cardiovascular collapse in the newborn, effective resuscitation requires significant focus on ventilation. In addition, we value consistency in the resuscitation algorithm and education programs unless new evidence drives the change.All studies were done in young posttransitioned piglets (no human or animal data in a transitioning model). Since there is no evidence in either a human or animal with fluid-filled lungs, we need to be clear when communicating with other groups (pediatrics and basic life support providers) that neonates have unique cardiopulmonary physiology, prompting our unique 3:1 ratio. Some may not agree, but the values and preferences statement expresses why we still favor a 3:1 ratio.
CoSTR Attachments:
GRADE GRID - NRP 895 CV Ratios for CPR_n.docx    

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