Optimizing chest compressions during delivery-room resuscitation
Introduction
Chest compressions are an infrequent event in newly born infants, with an estimated occurrence of 0.08% for near-term and term deliveries1 and a higher frequency (2–10%) in preterm infants.2, 3, 4 Although a rare event, the consequences of a hypoperfused state on the brain and other organ systems are often severe.5 Infants who require prolonged cardiac compressions with no signs of life beyond 10 minutes are at risk for particularly grave outcomes, with a reported 83% mortality and 77% of survivors suffering from severe disability, 15% with moderate disability, 8% with mild disability, and no reported normal survivors.6 Cardiac compression methods achieve only a fraction (∼30%) of native perfusion even under the best of circumstances7, 8; however, preferential perfusion of the heart and brain during cardiopulmonary resuscitation (CPR) can result in myocardial and cerebral blood flow of greater than 50% of that in normal sinus rhythm with excellent CPR.9, 10, 11 Thus, optimization of cardiac compressions could be critical to improving outcomes in the newborn who requires CPR in the delivery room.
Section snippets
Current guidelines for cardiac compressions for newborns in the delivery room
Current International Liaison Committee on Resuscitation (ILCOR) guidelines suggest that for a newborn infant in the delivery room, chest compressions are indicated for a heart rate that is <60 bpm despite adequate ventilation with supplementary oxygen for 30 seconds.12 In accordance with ILCOR, the American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program (NRP) stresses that ventilation is the most effective action in neonatal resuscitation and, because chest
Barriers to obtaining high-level evidence for neonatal cardiac compressions
The infrequent use of cardiac compressions for newborns in the delivery room has impeded the design and completion of rigorous investigations to determine the most effective cardiac compression methodologies. Indeed, there is very little scientific evidence behind the current recommendations for cardiac compressions during neonatal resuscitation. Most of the recommendations are extrapolations from animal, pediatric, and adult literature, as well as simple physiologic plausibility and some
Optimal method of neonatal cardiac compressions (2-thumb vs. 2-finger technique)
Two different methods for performing chest compressions have been described and utilized.14 The 2-thumb technique utilizes the two thumbs to depress the sternum while the hands encircle the chest and the fingers provide firm support behind the back. The 2-finger technique utilizes the tips of the middle and index finger to depress the sternum, while the free hand is used to provide a firm support behind the baby's back.
An initial report regarding cardiac compressions in infants was a series of
Optimal chest compressions to ventilation ratios
No human data have identified an optimal compression to ventilation ratio for cardiopulmonary resuscitation in victims of any age. Compelling animal data from adult ventricular fibrillation (VF) models indicate that frequent and prolonged interruption of chest compressions is deleterious in that it worsens coronary perfusion pressure10, 27 and increases mortality.27 In addition, longer sequences of uninterrupted chest compressions improve coronary perfusion28, 29 and 24-h post-resuscitation
Where to optimally position the fingers on the sternum
The appropriate positioning of the fingers for chest compressions was initially based on the case series of Moya et al.16 and the anatomical reconstruction data of Thaler and Stobie.15 Three studies published in 1986 helped to define the position of the heart in the infant chest as being in the lower third (rather than the previously thought middle third of the sternum).45, 46, 47 The appropriate positioning of fingers for chest compressions was reassessed in a recent study to determine whether
Optimal depth of neonatal cardiac compression
In 2000, the consensus of the ILCOR Neonatal Resuscitation Working Group changed to recommend a relative rather than absolute depth of compression (i.e. compress to approximately one-third of the anterior-posterior diameter of the chest) to generate a palpable pulse.50 Thus, the actual distance compressed will depend on the size of the baby.50 The change to the relative depth was in line with the pediatric basic life-support guidelines, which made a similar suggestion. There was, and continues
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