Dallas 2015

TFQO: Lindsay MildenhallEVREVs: Lindsay Mildenhall COI 107and Takahiro Sugiura Taskforce:NRP

NRP: 862: Use of Feedback CPR Devices for Neonatal Cardiac Arrest

NRP: 863: Use of Feedback CPR Devices to detect ROSC for Neonatal Cardiac Arrest

Dallas 2015COI Disclosure (specific to this systematic review)

EVREV 1 COI 107Commercial/industry• Nil

Potential intellectual conflicts• Nil

EVREV 2 COI Commercial/industry

• Nil

Potential intellectual conflicts• Nil

Dallas 20152010 CoSTR

Topic not reviewed in 2010

Dallas 2015C2015 PICO

Population: In asystolic/bradycardic neonates receiving cardiac compressions Intervention:does feedback devices such as ETCO2 monitors, pulse oximeters, or automated compression feedback devices Comparison:compared with clinical assessments of compression efficacy Outcomes:

9-Critical decreased hands off time9-Critical improve perfusion8-Critical decrease time to ROSC8-Critical increase survival rates7-Critical improve neurological outcomes

Dallas 2015Inclusion/Exclusion& Articles Found

InclusionsNeonatal / Infant / Animal / ManikinsRCT, Observational

Exclusions: Adult, V-Fib, Abstracts, Editorials

Number of Articles initially identified 691

Included in Evidence Profile tables 5 (All ETCO2)

RCTs 0non-RCTs 5Excluded 686

Dallas 2015Draft Treatment Recommendations

NRP: 862

In asystolic/bradycardic neonates we suggest against the routine reliance on any single feedback device such as ETCO2 monitors or pulse oximeters until more evidence becomes available

(weak recommendation, very low quality of evidence).

Dallas 2015 Risk of Bias in studies

Study Year DesignTotal

PatientsPopulati

onIndustry Funding

Eligibility Criteria

Exposure/Outcome

Confounding

Follow up

Berg 1996 Non RCT 40 Piglets Nil Low Low Low Low

Bhende 1995, 395 Non RCT 40 Children Nil High High High HighBhende 1995, 365 Non RCT 11 Dogs Nil High High High LowBhende 1996 Non RCT 11 Dogs Nil High High High LowChalak 2011 Non RCT 46 Piglets Nil High High High Low

Non-RCT bias asssesment

Dallas 2015

Asphyxial Arrest (ETT clamped):

Bhende MS et al Am J Emerg Med. 1996 Jul;14(4):349-50.

11 dogs HR = 0 All achieved ROSC

Key data from key studies

Dallas 2015Easy-Cap (Nellcor)

< 4mmHg (< 0.5%) Purple

4 - < 15mmHgTan (0.5 – 2%)

15 - 38mmHg (< 2%) Yellow

40 children (aged 1 week to 10 years):

Patients with higher initial ETCO2 signif. association with ROSC.

75% with >2.0% (>15mmHg) vs.

32% in the range 0.5 to 2.0% (4-15mmHg)

All patients that had not obtained ROSC. ETCO2 <2% (15mmHg)

(Bhende 1995 395)

Dallas 2015

Four animal studies including immature dogs and piglets show that

1 min CPR: ETCO2 28mmHg ROSC vs 18mmHg non ROSC

(ETT clamped: Time to arrest ?: Arrest time 10 minutes before CPR: Infrared Capnometer) (Berg 1996 245)

In an immature asphyxial dog model, the ETCO2 rose from a mean of 13.9mmHg to a mean of 27.0mmHg at or just prior to ROSC. (ETT clamped: “Few minutes” to arrest: Arrest time 5-10 minutes before CPR: Infrared Capnometer/Easy-Cap)

(Bhende 1995, 365; Bhende 1996, 349)

In asphyxia piglet model, an ETCO2 of >14mmHg had a sensitivity of 93% and specificity of 81% of HR > 60

(Vent rate : Time to arrest 48m: CPR started at asystole: Capnometer)

(Chalak 2011 401)

Key data from key studies

Dallas 2015Evidence profile table(s)

Dallas 2015Proposed Consensus on Science statements

Five small observational studies (including four animal

studies) were identified that assessed the end tidal CO2

levels associated with the onset or presence of ROSC.

We did not identify any evidence to address the critical

outcomes of:– Improved perfusion– Decreased hands off time– Decreased time to ROSC– Increased survival rates– Improved neurological outcomes

Dallas 2015Draft Treatment Recommendations

In asystolic/bradycardic neonates we suggest against the routine reliance on any single feedback device such as ETCO2 monitors or pulse oximeters until more evidence becomes available

(weak recommendation, very low quality of evidence).

Dallas 2015Knowledge Gaps (eg. ETT vs BVM)

Other specific worksheets that would be helpful

Relationship with training to ETT success

Specific research requiredAdult ETT vs BVM

Essential slide (one slide only). Estimated time <30 sec

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