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Dallas 2015
TFQO: Myra Wyckoff #COIEVREV 1: Myra Wyckoff #COIEVREV 2: Lindsay Mildenhall #107Taskforce: NRP
NRP: 605Two thumb verses two finger
Dallas 2015COI Disclosure (specific to this systematic review)
EVREV 1 COI#Commercial/industry• Nil
Potential intellectual conflicts• Nil
EVREV 2 COI #107Commercial/industry• Nil
Potential intellectual conflicts• Nil
Dallas 20152010 CoSTR
Chest compressions in the newborn should be delivered by the 2 thumb–encircling hands method as the preferred option.
Compressions should be centered over the lower third of the sternum and should compress the chest one third the anterior-posterior diameter.
Any chest compressions should be performed in combination with adequate inflation breaths.
Dallas 2015C2015 PICO
Population: Neonates receiving cardiaccompressions
Intervention: Does the use of a Two thumb technique
Comparison: As opposed to a Two finger technique
Outcomes: 9-Critical decrease time to ROSC9-Critical improve neurological outcomes9-Critical increase survival rates8-Critical improve perfusion/gas exchange6-Important decreased compressor fatigue
Dallas 2015Inclusion/Exclusion& Articles Found
InclusionsNeonatal / Infants / Animal / ManikinsRCT, Observational
Exclusions: Adult, V-Fib, Abstracts, Editorials
Number of Articles initially identified 80
Finally Included in Evidence Profile tables
RCTs 13non-RCTs 15Excluded52
Dallas 20152015 Proposed Treatment Recommendations
We suggest that chest compressions in the newborn should be delivered by the two thumb, hands encircling the chest method as the preferred option
(weak recommendation, very low quality of evidence).
Compressions should be delivered over the lower 1/3 of sternum.
Dallas 2015 Risk of Bias in studies
Dallas 2015 Risk of Bias in studies
Dallas 2015 Key data from key studies
Reference: Case Hx: David, 1988; Moya, 1962; Thaler, 1963; Todres, 1975
P: Neonates receiving chest compressionsI: TTC: TFO:
David 1988, 552 Todres 1975, 781
Dallas 2015 Key data from key studies
Reference: Menegazzi 1993; Houri 1997 P: Piglets receiving chest compressionsI: TTC: TFO:
Houri 1997, 65 Menegazzi 1993, 240
Dallas 2015Evidence profile table(s)
Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Decrease time to ROSC
Decrease time to ROSC
No data
CRITICAL-9
Outcome No of studiesAuthor Year 1st page
Study Design
Risk of bias
Inconsist-ency
Indirect-ness
Imprecision Other (including publication bias)
Quality of evidence for outcome
Importance
Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Improve neurologic outcomes
Outcome No of studiesAuthor Year 1st page
Study Design
Risk of bias
Inconsist-ency
Indirect-ness
Imprecision Other (including publication bias)
Quality of evidence for outcome
Importance
Improve neurologic outcomes
No data
CRITICAL-9
Dallas 2015Evidence profile table(s)
Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Increase survival rates
Outcome No of studiesAuthor Year 1st page
Study Design
Risk of bias
Inconsist-ency
Indirect-ness
Imprecision Other (including publication bias)
Quality of evidence for outcome
Importance
Increase survival rates
No data
CRITICAL-9
Dallas 2015Evidence profile table(s)
Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Improved perfusion and gas exchange during CPR
Outcome No of studiesAuthor Year 1st page
Study Design
Risk of bias
Inconsist-ency
Indirect-ness
Imprecision Other (including publication bias)
Quality of evidence for outcome
Importance
Improved perfusion and gas exchange during CPR
15 Studies
Christman, 2010, 99Dorfsman, 2000, 1077Houri, 1993, 65Martin, 2013, 576Martin, 2013, 666Martin, 2013, 1125Menegazzi, 1993, 240Udassi, 2010, 712Whitelaw, 2000, 213
David, 1988, 552Moya, 1962, 798Thaler, 1963, 606Todres, 1975, 781
Dellimore , 2013, 350Park, 2014, 1659
RCT
Non-RCT
Serious Not Serious
Serious(manikins or swine model)
Human case reports
Manikins
Serious Not Serious
VeryLow
CRITICAL-8
Dallas 2015Evidence profile table(s)
Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Decrease Compressor fatigue
Outcome No of studiesAuthor Year 1st page
Study Design
Risk of bias
Inconsist-ency
Indirect-ness
Imprecision Other (including publication bias)
Quality of evidence for outcome
Importance
DecreasedCompressor fatigue
4 Studies
Dorfsman, 2000, 1077Huynh, 2012, 658Udassi, 2009, 328Udassi, 2010,712
RCT
Serious Not Serious
Serious(manikins only)
Serious Not Serious
VeryLow
IMPORTANT-6
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of Time to ROSC, we found
no data.
For the critical outcome of Survival Rates, we found no data
For the critical outcome of Neurologic Injury, we found no data.
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of “improved perfusion and gas
exchange during CPR” we identified low quality evidence from 9
RCT’s (7 manikin and 2 piglet down graded for indirectness and
imprecision) and
6 Non-RCT’s (4 human and 2 manikin down graded for
indirectness, imprecision and high risk of bias)
Summary: Higher BP (force) generation identified with the two thumb method verses the two finger.
Dallas 2015Proposed Consensus on Science statements
For the important outcome of “compressor fatigue” we identified
low quality evidence from 4 RCT’s using manikins (downgraded for
indirectness and imprecision):
2 identifying less fatigue with the two thumb technique and 2
finding no difference.
Dallas 2015Proposed Consensus on Science statements
New Compression Methods:
Fakhraddin, 2011, 15: New method (Thumb and index finger-TIF) compared with TT and TF on manikins.
Udassi, 2009, 1158: Manikin study using adhesive glove compared with standard CPR in 4 groups including infant group.
Summary: No evidence that the new thumb and index finger technique is superior to two thumb method. Adhesive glove enhanced active decompression but did not reduce fatigue.
Dallas 2015Proposed Consensus on Science statements
Best Location on the Sternum: 8 non-RCT’s
Infants: Phillips, 1986; Orlowski, 1986; Clements, 2000; Saini, 2012; supporting chest compressions best performed over lower third of the sternum plus further support for TT over TF
Infant CT scan / manikin measurements: You, 2009; Lee, 2011; Lim, 2012; Lee, 2013; LV mostly under lower third of sternum. TT and superimposed thumbs method less likely to compress other structures
Summary: Lower one third of sternum remains the best location to compress the newborn heart. Superimposed thumbs maybe the better technique.
Dallas 20152015 Draft Treatment Recommendations
We suggest that chest compressions in the newborn should be delivered by the two thumb, hands encircling the chest method as the preferred option
(weak recommendation, very low quality of evidence).
Compressions should be delivered over the lower 1/3 of sternum.
Dallas 2015Knowledge Gaps
No studies of any kind available regarding the most critical outcomes
No data from good transitional models
Very limited human neonatal data
Dallas 2015Next Steps
This slide will be completed during Task Force Discussion (not EvRev) and should include:
Consideration of interim statementPerson responsibleDue date
Essential slide (one slide only). Estimated time <30 sec