Optimal chest compression for cardiac arrest until the establishment of ECPR: Secondary analysis of the SAVE-J II study.

INTRODUCTION: The widespread incorporation of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest requires the delivery of effective and high-quality chest compressions prior to the initiation of ECPR. The aim of this study was to evaluate and compare the effectiveness of mechanical and manual chest compressions until the initiation of ECPR. METHODS: This study was a secondary analysis of the Japanese retrospective multicenter registry "Study of Advanced Life Support for Ventricular Fibrillation by Extracorporeal Circulation II (SAVE-J II)". Patients were divided into two groups, one receiving mechanical chest compressions and the other receiving manual chest compressions. The primary outcome measure was mortality at hospital discharge, while the secondary outcome was the cerebral performance category (CPC) score at discharge. RESULTS: Of the 2157 patients enrolled in the SAVE-J II trial, 453 patients (329 in the manual compression group and 124 in the mechanical compression group) were included in the final analysis. Univariate analysis showed a significantly higher mortality rate at hospital discharge in the mechanical compression group compared to the manual compression group (odds ratio [95% CI] = 2.32 [1.34-4.02], p = 0.0026). Multivariate analysis showed that mechanical chest compressions were an independent factor associated with increased mortality at hospital discharge (adjusted odds ratio [95% CI] = 2.00 [1.11-3.58], p = 0.02). There was no statistically significant difference in CPC between the two groups. CONCLUSION: For patients with out-of-hospital cardiopulmonary arrest who require ECPR, extreme caution should be used when performing mechanical chest compressions.

A new method of pulse control in cardiopulmonary resuscitation; Continuous femoral pulse check.

OBJECTIVES: The reliability of manual pulse checks has been questioned but is still recommended in cardiopulmonary resuscitation (CPR) guidelines. The aim is to compare the 10-s carotid pulse check (CPC) between heart massage cycles with the continuous femoral pulse check (CoFe PuC) in CPR, and to propose a better location to shorten the interruption times for pulse check. METHODS: A prospective study was conducted on 117 Non-traumatic CPR patients between January 2020 and January 2022. A total of 702 dependent pulse measurements were executed, where carotid and femoral pulses were simultaneously assessed. Cardiac ultrasound, end-tidal CO2, saturation, respiration, and blood pressure were employed for pulse validation. RESULTS: The decision time for determining the presence of a pulse in the last cycle of CPR was 3.03 ± 1.26 s for CoFe PuC, significantly shorter than the 10.31 ± 5.24 s for CPC. CoFe PuC predicted the absence of pulse with 74% sensitivity and 88% specificity, while CPC predicted the absence of pulse with 91% sensitivity and 61% specificity. CONCLUSION: CoFe PuC provides much earlier and more effective information about the pulse than CPC. This shortens the interruption times in CPR. CoFe PuC should be recommended as a new and useful method in CPR guidelines.

Fulminant sepsis secondary to severe lung contusion from the Lund University Cardiopulmonary Assist System device.

INTRODUCTION: Portable mechanical chest compression devices have been developed to improve upon many problems of manual compression, increase patient survival, and improve neurologic outcomes. However, the use of these devices is not without risk of harm to the patient. CASE REPORT: We describe a patient who received chest compressions from a mechanical compression device after cardiac arrest and subsequently developed fulminant sepsis secondary to lung contusions and a necrotizing pulmonary infection. DISCUSSION: Although injuries from the LUCAS have been reported, we believe this is the first reported fatal complication related to direct pulmonary injury from a mechanical compression device. CONCLUSION: More investigation is needed to determine the safety and efficacy of the LUCAS especially in obese patients.

Efficacy of cardiopulmonary resuscitation performance while wearing a powered air-purifying respirator.

BACKGROUND: The use of personal protective equipment for respiratory infection control during cardiopulmonary resuscitation (CPR) is a physical burden to healthcare providers. The duration for which CPR quality according to recommended guidelines can be maintained under these circumstances is important. We investigated whether a 2-min shift was appropriate for chest compression and determined the duration for which chest compression was maintained in accordance with the recommended guidelines while wearing personal protective equipment. METHODS: This prospective crossover simulation study was performed at a single center from September 2020 to October 2020. Five indicators of CPR quality were measured during the first and second sessions of the study period. All participants wore a Level D powered air-purifying respirator (PAPR), and the experiment was conducted using a Resusci Anne manikin, which can measure the quality of chest compressions. Each participant conducted two sessions. In Session 1, the sequence of 2 min of chest compressions, followed by a 2-min rest, was repeated twice; in Session 2, the sequence of 1-min chest compressions followed by a 1-min rest was repeated four times. RESULTS: All 34 participants completed the study. The sufficiently deep compression rate was 65.9 ± 31.1% in the 1-min shift group and 61.5 ± 30.5% in the 2-min shift group. The mean compression depth was 52.8 ± 4.3 mm in the 1-min shift group and 51.0 ± 6.1 mm in the 2-min shift group. These two parameters were significantly different between the two groups. There was no significant difference in the other values related to CPR quality. CONCLUSIONS: Our findings indicated that 1 min of chest compressions with a 1-min rest maintained a better quality of CPR while wearing a PAPR.

Comparison of two infant cardiopulmonary resuscitation techniques explained by phone in a non-health professionals' population: Two-thumbs encircling hand technique vs. two-fingers technique, a randomised crossover study in a simulation environment.

BACKGROUND: Paediatric out-of-hospital cardiac arrest (OHCA) is the reason for an emergency call in approximately 8/100,000 person-years. Improvement of OHCA resuscitation needs a quality chain of survival and a rapid start of resuscitation. The aim of this study was to compare the efficacy of two resuscitation techniques provided on a mannequin, the two-fingers technique (TFT) and the two-thumbs encircling hand technique (TTHT), explained by a trained emergency call responder on the phone in a population of non-health professionals. METHODS: We conducted a randomised crossover study in the simulation lab of a University Hospital. The participants included in the study were non-health professional volunteers of legal age. The participants were assigned (1:1 ratio) to two groups: group A: TFT then TTHT, group B: TTHT then TFT. Scenario and techniques were discovered during the evaluation. RESULTS: Thirty-five volunteers were randomised before the sessions and 33 ultimately came to the simulation lab. We found a better median QCPR global score during TTHT sessions than during TFT sessions (74 vs. 59, P = 0.046). Linear mixed models showed that the TTHT method was the only variable associated with a better QCPR global score [model 1: ß = 14.3; 95% confidence interval (CI), 2.4-26.2; model 2: ß = 14.5; 95% CI, 2.5-26.6]. CONCLUSION: Our study showed the superiority of TTHT for infant CPR performed by non-health professionals when an emergency call responder advised them over the phone. It seemed to be the best technique for a solo rescuer regardless of previous training.

Hands-on defibrillation with safety drapes: Analysis of compressions and an alternate current pathway.

BACKGROUND: Hands-on defibrillation (HOD) could theoretically improve the efficacy of cardiopulmonary resuscitation (CPR) though a few mechanisms. Polyethylene drapes could potentially facilitate safe HOD, but questions remain about the effects of CPR on polyethylene's conductance and the magnitude of current looping through rescuers' arms in contact with patients. METHODS: This study measured the leakage current through 2 mil (0.002 in.) polyethylene through two different current pathways before and after 30 min of continuous compressions on a CPR mannequin. The two pathways analyzed were the standardized IEC (International Electrotechnical Commission) leakage current analysis and a setup analyzing a current pathway looping through a rescuer's arms and returning to the patient. First, ten measurements involving the two pathways were obtained on a single polyethylene drape. 30 min of continuous compressions were applied to the drape on a CPR mannequin after which the ten measurements were repeated. RESULTS: Twenty patients undergoing elective cardioversion for atrial fibrillation (18/20) or atrial flutter (2/20) at Emory University Hospital underwent analysis all receiving 200 J shocks (age 38-101, 35% female). Through the IEC measurement method the peak leakage current mean was 0.70 +/- 0.02 mA before compressions and 0.59 +/- 0.19 mA after compressions. Only three of the ten measurements assessing current passing through a rescuer's arms had detectable current and each was of low magnitude. All measurements were well below the maximum IEC recommendations of 3.5 mA RMS and 5.0 mA peak. CONCLUSIONS: Polyethylene may facilitate safe HOD even after long durations of compressions. Current looping through a rescuer's arms is likely of insignificant magnitude.

Severe Vertebral Body Fracture-Dislocation as a Result of Chest Compressions: A Case Report.

BACKGROUND: Although high-quality chest compressions are an essential, lifesaving component of cardiopulmonary resuscitation, injuries are common with both manual and mechanical chest compressions. CASE REPORT: We discuss the case of a 77-year-old woman who sustained thoracic vertebral fractures after cardiopulmonary resuscitation involving both manual and mechanical chest compressions. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Routine post-cardiac arrest care should include evaluation for chest compression-related injury. If a patient has back pain, focal vertebral tenderness, or paraplegia after chest compressions, imaging to evaluate for vertebral fracture should be performed. If unable to assess for back pain or tenderness, consider imaging to evaluate for vertebral fracture in patients with kyphosis or osteopenia, as these patients are at higher risk for chest compression vertebral injury.

Clinician Wire Puncture Injury to the Hand from Chest Compressions on a Patient with a Median Sternotomy: A Case Report.

Standard precautions, including protections from blood and body fluid exposure, are designed to protect health care providers from infections. Sharps safety practices rarely include the potential for the unconscious patient's own body to be a potential source of clinician percutaneous injury from sharp objects outside of the perioperative setting. This case report reviews a percutaneous injury to the hand of a physician who was performing chest compressions on a patient with an out-of-hospital cardiac arrest. The 76-year-old patient in cardiac arrest had undergone a medial sternotomy surgery 15 years before the arrest. The sternal wire rotated owing to the initial chest compressions, breaking the clinician's nitrile glove and producing an open wound on the thenar region of the clinician's right hand. Application of a 10 × 10 12-ply gauze pack on the chest of the patient in cardiac arrest allowed the resuscitation team to continue with the compressions with no further wounds from the wire. This case report is a novel contribution to the published literature and advances standard precautions considerations in patients with out-of-hospital cardiac arrest, with the sternotomy wire from previous surgery as a source of percutaneous clinician injury during chest compression.

Effects of Cardiac Massage and ß-Blocker Pretreatment on the Success Rate of Cardiopulmonary Resuscitation Assessed by the Canine Ischemia/Reperfusion-Induced Ventricular Fibrillation Model.

BACKGROUND: Effects of rapid electrical defibrillation and ß-blockade on coronary ischemia/reperfusion-induced ventricular fibrillation (VF) during cardiopulmonary resuscitation (CPR) remain unknown.Methods and Results:After induction of VF by 30 min of ischemia followed by reperfusion, animals were treated with defibrillation alone (Group A, n=13), 2 min of open-chest cardiac massage followed by defibrillation (Group B, n=11), or the same therapy to Group B with propranolol (1 mg/kg, i.v.) treatment before ischemia/reperfusion (Group C, n=11). If return of spontaneous circulation (ROSC) was not attained, each therapy was repeated ≤3 times (Set-1). When ROSC was not obtained within Set-1, cardiac massage was applied to all animals followed by defibrillation, which was repeated ≤3 times (Set-2). ROSC after Set-1 was 8% in Group A, 82% in Group B and 82% in Group C, whereas that after Set-2 was 62% in Group A, 100% in Group B and 82% in Group C. Each animal with ROSC in Groups A (n=8) and B (n=11) showed sinus rhythm, whereas those in Group C (n=9) had sinus rhythm (n=5), atrial fibrillation (n=1), accelerated idioventricular rhythm (n=2) and atrioventricular block (n=1). Post ROSC heart rate and mean arterial pressure were significantly lower in Group C. CONCLUSIONS: Cardiac massage increased the likelihood of ROSC vs. rapid defibrillation, but ß-blocker pretreatment may worsen hemodynamics and electrical stability after ROSC.

Incidence, Mortality, and Characteristics of 18 Pediatric Perioperative Cardiac Arrests: An Observational Trial From 22,650 Pediatric Anesthesias in a German Tertiary Care Hospital.

BACKGROUND: Recently, a very low incidence of 3 per 10,000 and a mortality of 30% were reported for pediatric perioperative cardiac arrest (POCA). However, high-risk patients, namely children already anesthetized on the intensive care unit (ICU), were excluded. This study investigates the incidence and mortality of POCA in children in whom anesthesia was induced in the ICU or in the operating room using real-world data. In addition, different classifications of POCA were compared with respect to outcome relevance. METHODS: This is a retrospective observational study conducted at a German level 1 perinatal center and tertiary care hospital between 2008 and 2018. Children ≤15 years who underwent an anesthetic procedure and suffered from POCA (defined as any condition requiring chest compressions and/or defibrillation) from the beginning of care provided by an anesthesiologist to 60 minutes after anesthesia or sedation were included. Primary end points were incidence and mortality of POCA in children with anesthesia induced in the ICU versus in the operating room. Secondary end points included incidences and outcomes with respect to the pathophysiological cause (respiratory versus circulatory associated). RESULTS: There were 18 POCA during 22,650 anesthetic procedures (incidence 7.9 per 10,000; 95% confidence interval [CI], 4.7-12.5). Thirty-day mortality was 3.5 per 10,000 (95% CI, 1.5-6.9). Incidence and mortality were higher in children in whom anesthesia was induced in the ICU versus in the operating room (incidence: 131.6; 95% CI, 57 to 257.6 versus 4.5; 95% CI, 2.2-8.3; P < .001; and mortality: 82.2; 95% CI, 26.7-190.8 versus 1.4; 95% CI, 0.3-3.9; P < .001). Mortality in circulatory-induced POCA (n = 8; 44%) was 100%, in respiratory-induced POCA (n = 9; 50%) 0% (P < .001). CONCLUSIONS: Children with anesthesia induction in the ICU represent a high-risk population for POCA and POCA-associated mortality. POCA classification should be based on the individual cause (respiratory versus circulatory) rather than on the perioperative phase or the responsible specialty.

How does the side of approach impact the force delivered during external chest compression?

BACKGROUND: We investigated the biomechanics of four external chest compression (ECC) approaches involving different sides of approach and hand placement during cardiopulmonary resuscitation (CPR). METHODS: A total of 60 participants (30 women and 30 men) with CPR certification performed standard continuous 2-min ECC on a Resusci Anne manikin with real-time feedback in four scenarios: rescuer at the manikin's right side with right hand chest contact (RsRc), rescuer at the manikin's right side with left hand chest contact (RsLc), rescuer at the manikin's left side with left hand chest contact (LsLc), and rescuer at the manikin's left side with right hand chest contact (LsRc). Pressure distribution maps of the palm, peak compression pressure, and compression forces were analysed. RESULTS: The participants' mean age, height, and weight was 24.8 ± 4.8 years, 165.8 ± 8.7 cm, and 62.7 ± 13.5 kg, respectively. Of the participants, 58 and 2 were right- and left-handed, respectively. Significant between-scenario differences were observed in ulnar-side palm pressure. Ulnar-radial pressure differences were higher in the LsLc and RsRc groups than in the LsRc and RsLc groups (0.69 ± 0.62 and 0.73 ± 050 kg/cm2 vs. 0.49 ± 0.49 and 0.50 ± 0.59 kg/cm2; respectively; p < 0.05). Ulnar-radial force differences were higher in the LsLc and RsRs groups than in the sLsLc and RsRs groups. CONCLUSIONS: The higher differences in pressure and force under the LsLc and RsRc approaches may lead to higher risks of potential injury. When performing standard-quality ECC, the LsRc and RsLc approaches, in which compression pressure and force are better distributed, may be more suitable than RsRc or LsLc.

CPR by foot. An alternative in special circumstances? A randomized simulation study.

OBJECTIVE: To assess the differences in the quality and self-perception of CPR performed with foot technique compared to the standard technique with the hands in nursing students. METHODS: 65 university nursing students participated in a randomized simulation crossover design study. The participants randomly performed two CPR tests: CPR by foot and CPR by hands techniques. The compression-only protocol with a 2-min test was used with the Resusci Anne QCPR® manikin and Wireless Skill Reporter® software, both from Laerdal. RESULTS: Participants had lower quality when doing CPR by foot (72%) than when doing standard CPR (91%) (p = 0.006). 95% of the participants indicated standard CPR as the technique of choice, while 92% indicated that they would use CPR by foot if it was not possible to perform standard technique. CONCLUSIONS: CPR quality was lower when performing foot technique, although with positive results. It would be advisable for people with acquired CPR skills to know that they can do foot compressions in situations where they cannot use their hands.

Chest compressions during ventilation in out-of-hospital cardiopulmonary resuscitation cause fragmentation of the airflow.

INTRODUCTION: When a patient suffers an out-of-hospital cardiac arrest, ventilation and chest compressions are often given simultaneously during cardiopulmonary resuscitation. These simultaneous chest compressions may cause a fragmentation of the airflow, which may lead to an ineffective ventilation. This study focusses on the occurrence and quantification of this fragmentation and its effect on ventilation. MATERIALS AND METHODS: This study is a single-center observational study, held at Ghent University Hospital. A custom-built bidirectional flow sensor was used to quantify the volumes of ventilation. Adult cardiac arrest patients who were prehospitally intubated and resuscitated by the medical emergency team were eligible for inclusion. Data of the patients who were ventilated and received simultaneous chest compressions, was used to calculate the volumes of ventilation and the amount and volumes of fragmentation. All data in this study is reported as mean (standard deviation; range). RESULTS: Data of 10 patients (7 male) with a mean age of 71 years (14;51-87) was used in this study. The mean ventilation frequency was 12/min (2;9-16), the mean minute volume and tidal volume were respectively 6.21 L (1.51;3.79-8.15) and 514 mL (99;422-682). Fragmentation of the airflow was observed in all patients, with an average of 3 (1;2-5) fragments per inspiration and a mean volume of 214 mL (65;112-341) per fragment. DISCUSSION AND CONCLUSION: Chest compressions during ventilation caused fragmentation of the airflow in all patients. There was wide variation in the number and volume of the fragments between patients. The importance of quantification of airflow volumes and the effect fragmentation of the airflow on the efficacy of ventilation can be essential in improving cardiopulmonary resuscitation techniques and therefore needs further investigation.

Do manual chest compressions provide substantial ventilation during prehospital cardiopulmonary resuscitation?

INTRODUCTION: Chest compressions have been suggested to provide passive ventilation during cardiopulmonary resuscitation. Measurements of this passive ventilatory mechanism have only been performed upon arrival of out-of-hospital cardiac arrest patients in the emergency department. Lung and thoracic characteristics rapidly change following cardiac arrest, possibly limiting the effectiveness of this mechanism after prolonged resuscitation efforts. Goal of this study was to quantify passive inspiratory tidal volumes generated by manual chest compression during prehospital cardiopulmonary resuscitation. MATERIALS AND METHODS: A flowsensor was used during adult out-of-hospital cardiac arrest cases attended by a prehospital medical team. Adult, endotracheally intubated, non-traumatic cardiac arrest patients were eligible for inclusion. Immediately following intubation, the sensor was connected to the endotracheal tube. The passive inspiratory tidal volumes generated by the first thirty manual chest compressions performed following intubation (without simultaneous manual ventilation) were calculated. RESULTS: 10 patients (5 female) were included, median age was 64 years (IQR 56, 77 years). The median compression frequency was 111 compression per minute (IQR 107, 116 compressions per minute). The median compression depth was 5.6 cm (IQR 5.4 cm, 6.1 cm). The median inspiratory tidal volume generated by manual chest compressions was 20 mL (IQR 13, 28 mL). CONCLUSION: Using a flowsensor, passive inspiratory tidal volumes generated by manual chest compressions during prehospital cardiopulmonary resuscitation, were quantified. Chest compressions alone appear unable to provide adequate alveolar ventilation during prehospital treatment of cardiac arrest.

Impact of personal protective equipment on the effectiveness of chest compression - A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: To assess the impact of personal protective equipment (PPE) on different aspects of chest compression (CC) during cardiopulmonary resuscitation, we conducted this study. METHODS: This systematic review was performed according to the PRISMA. We searched PubMed, EMBASE and Web of Science from inception to June-6, 2020, limiting to the studies that reported the comparison of the effectiveness of CC in terms of CC rate, CC depth, the proportion of adequate CC rate, the proportion of adequate CC depth or proportion of adequate recoil; in study arms with or without PPE. Risk of bias was assessed by the ROB-2 and ROBINS-I tool. Quantitative data synthesis was done using the generic inverse variance method and the fixed-effects model. RESULTS: Five simulation-based studies were finally included. A Significant decrease in CC rate (SMD: -0.28, 95%CI: -0.47 to -0.10) and CC depth (SMD: -0.26, 95%CI: -0.44 to -0.07) were observed in the PPE arm as compared to the no-PPE arm. The difference in CC rate was more prominently seen in adult CPR than in paediatric CPR. Without PPE, the proportion of adequate CC rate delivered was 0.74, which reduced significantly to 0.60 after use of PPE (p - 0.035). Similarly, the proportion of adequate CC depth was significantly lesser (p - 0.001) in PPE arm (0.55), as compared to that of the no-PPE arm (0.78). CONCLUSION: The use of PPE compromises the quality of CC during CPR significantly, and newer ways to deliver chest compression has to be investigated. This study was prospectively registered in PROSPERO (CRD42020192031).

Leg-heel chest compression as an alternative for medical professionals in times of COVID-19.

OBJECTIVE: To evaluate leg-heel chest compression without previous training as an alternative for medical professionals and its effects on distance to potential aerosol spread during chest compression. METHODS: 20 medical professionals performed standard manual chest compression followed by leg-heel chest compression after a brief instruction on a manikin. We compared percentage of correct chest compression position, percentage of full chest recoil, percentage of correct compression depth, average compression depth, percentage of correct compression rate and average compression rate between both methods. In a second approach, potential aerosol spread during chest compression was visualized. RESULTS: Our data indicate no credible difference between manual and leg-heel compression. The distance to potential aerosol spread could have been increased by leg-heel method. CONCLUSION: Under special circumstances like COVID-19-pandemic, leg-heel chest compression may be an effective alternative without previous training compared to manual chest compression while markedly increasing the distance to the patient.

[Improvement in breathing mechanics by plate osteosynthesis of the ribs after cardiac massage : Case report and review of the literature]. / Verbesserung der Atemmechanik durch Plattenosteosynthese der Rippen nach Herzdruckmassage : Fallbericht und Literaturübersicht.

This article reports the case of a 69-year-old patient with multiple rib fractures and sternal fracture after repetitive cardiopulmonary resuscitation (CPR). Because of secondary respiratory failure due to an unstable thorax, rib fixation was performed 10 days after CPR. Subsequently, ventilation improved resulting in successful extubation 4 days after rib plating. A review of the literature revealed only five documented cases of rib osteosynthesis after CPR. Although flail chest occurs in up to 15% of patients after CPR, there is little evidence of the effect of rib fixation. The benefit of this procedure after chest trauma is reduced pain, shortened intensive care unit stay, lower rates of ventilation-associated pneumonia and lower costs for the healthcare system. Further clinical research is needed and interdisciplinary treatment should be kept in mind when dealing with patients resuscitated with prolonged mechanical ventilation.

Possibilities of using open chest cardiac massage in sudden, non-traumatic cardiac arrest.

Cardiopulmonary resuscitation is one of the most studied procedures in medicine. Over the years, despite numerous scientific studies, changes in guidelines, refining algorithms, expanding the availability of resuscitation equipment and educating the public, it has not been possible to improve the results of treatment of patients after cardiac arrest. Only 10% of them survive until hospital discharge. There is a well-tested medical procedure, wide application of which could improve results of resuscitation. This procedure is open chest cardiac massage (OCCM). OCCM is not a new technique, its use dates back to the nineteenth century, now it is reserved for patients sustaining trauma and those after surgical procedures. A number of experimental and clinical studies have proven its advantage over the currently preferred indirect massage (CCCM) also in the group of non- traumatic patients. Of course, OCCM is an invasive method with a number of possible complications accompanying surgical procedures, and its wide implementation would require a long-term training program, but it seems that it could be an impulse that would significantly improve survival in this group of patients.

Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes.

BACKGROUND: At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable gas exchange. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs. OBJECTIVES: To assess the benefits and harms of an initial sustained lung inflation (SLI) (> 1 second duration) versus standard inflations (≤ 1 second) in newborn infants receiving resuscitation with intermittent PPV. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3), MEDLINE via PubMed (1966 to 1 April 2019), Embase (1980 to 1 April 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 1 April 2019). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth. DATA COLLECTION AND ANALYSIS: We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data; and mean standard deviation (SD), and weighted mean difference (WMD) for continuous data. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS: Ten trials enrolling 1467 infants met our inclusion criteria. Investigators in nine trials (1458 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review: mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40 (I² not applicable); typical RD 0.00, 95% CI -0.02 to 0.02; I² = 0%; 5 studies, 479 participants); and mortality during hospitalisation (typical RR 1.09, 95% CI 0.83 to 1.43; I² = 42%; typical RD 0.01, 95% CI -0.02 to 0.04; I² = 24%; 9 studies, 1458 participants). The quality of the evidence was low for death in the delivery room because of limitations in study design and imprecision of estimates (only one death was recorded across studies). For death before discharge the quality was moderate: with longer follow-up there were more deaths (n = 143) but limitations in study design remained. Among secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; I² = 95%; 5 studies, 524 participants; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study at high risk of bias: when this study was removed from the analysis, the size of the effect was reduced (MD -1.71 days, 95% CI -3.04 to -0.39; I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. risk of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.91, 95% CI 0.79 to 1.04; I² = 65%; 5 studies, 811 participants); risk of surfactant administration during hospital admission (typical RR 0.99, 95% CI 0.91 to 1.08; I² = 0%; 9 studies, 1458 participants); risk of chronic lung disease (typical RR 0.99, 95% CI 0.83 to 1.18; I² = 0%; 4 studies, 735 participants); pneumothorax (typical RR 0.89, 95% CI 0.57 to 1.40; I² = 34%; 8 studies, 1377 infants); or risk of patent ductus arteriosus requiring pharmacological treatment (typical RR 0.99, 95% CI 0.87 to 1.12; I² = 48%; 7 studies, 1127 infants). The quality of evidence for these secondary outcomes was moderate (limitations in study design ‒ GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates ‒ GRADE). We could not perform any meta-analysis in the comparison of the use of initial sustained inflation versus standard inflations in newborns receiving resuscitation with chest compressions because we identified only one trial for inclusion (a pilot study of nine preterm infants). AUTHORS' CONCLUSIONS: Our meta-analysis of nine studies shows that sustained lung inflation without chest compression was not better than intermittent ventilation for reducing mortality in the delivery room (low-quality evidence ‒ GRADE) or during hospitalisation (moderate-quality evidence ‒ GRADE), which were the primary outcomes of this review. However, the single largest study, which was well conducted and had the greatest number of enrolled infants, was stopped early for higher mortality rate in the sustained inflation group. When considering secondary outcomes, such as rate of intubation, rate or duration of respiratory support, or bronchopulmonary dysplasia, we found no benefit of sustained inflation over intermittent ventilation (moderate-quality evidence ‒ GRADE). Duration of mechanical ventilation was shortened in the SLI group (low-quality evidence ‒ GRADE); this result should be interpreted cautiously, however, as it might have been influenced by study characteristics other than the intervention. There is no evidence to support the use of sustained inflation based on evidence from our review.

Closing the Gap: Optimizing Performance to Reduce Interruptions in Cardiopulmonary Resuscitation.

OBJECTIVES: The American Heart Association recommends minimizing pauses of chest compressions and defines high performance resuscitation as achieving a chest compression fraction greater than 80%. We hypothesize that interruption times are excessively long, leading to an unnecessarily large impact on chest compression fraction. DESIGN: A retrospective study using video review of a convenience sample of clinically realistic in situ simulated pulseless electrical activity cardiopulmonary arrests. SETTING: Johns Hopkins Children's Center; September 2013 to June 2017. PATIENTS: Twenty-two simulated patients. INTERVENTIONS: A framework was developed to characterize interruptions. Two new metrics were defined as follows: interruption time excess (the difference between actual and guideline-indicated allowable duration of interruption from compressions), and chest compression fraction potential (chest compression fraction with all interruption time excess excluded). MEASUREMENTS AND MAIN RESULTS: Descriptive statistics were generated for interruption-level and event-level variables. Differences between median chest compression fraction and chest compression fraction potential were assessed using Wilcoxon rank-sum test. Comparisons of interruption proportion before and after the first 5 minutes were assessed using the X test statistic. Seven-hundred sixty-six interruptions occurred over 22 events. Median event duration was 463.0 seconds (interquartile range, 397.5-557.8 s), with a mean 34.8 interruptions per event. Auscultation and intubation had the longest median interruption time excess of 13.0 and 7.5 seconds, respectively. Median chest compression fraction was 76.0% (interquartile range, 67.7-80.7 s), and median chest compression fraction potential was 83.4% (interquartile range, 80.4-87.4%). Comparing median chest compression fraction to median chest compression fraction potential found an absolute percent difference of 7.6% (chest compression fraction: 76.0% vs chest compression fraction potential: 83.4%; p < 0.001). CONCLUSIONS: This lays the groundwork for studying inefficiency during cardiopulmonary resuscitation associated with chest compression interruptions. The framework we created allows for the determination of significant avoidable interruption time. By further elucidating the nature of interruptions, we can design and implement targeted interventions to improve patient outcomes.