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Chest Compression Coordination

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Yesterday I was conducting code in NICU and one fellow was assigned to chest compression and other was providing PPV via ETT. but they were not coordinating in 3:1 ratio. He argued that once ETT inserted then coordination is not required, which was new to me. He based his logic on PALS where coordination between chest compression and PPV is not required.

Can someone further elaborate this point, what is your practice in your unit, do you do coordinating chest compression? and also when to switch to PALS in NICU at what gestational age. As far as I know, recent NRP 7th edition tells us chest compression to PPV via ETT ratio is 3:1.



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Hi Rehman

Yes there is often confusion between paediatric and neonatal resuscitation.

The Australian Resuscitation Council (ARC) Guidelines https://resus.org.au/guidelines/ provide different guidelines for compression and ventilation in neonates and paediatric patients. 

For paediatric patients it states in ANZCOR Guideline 12.2 point 5.3:

  • Chest compressions should not be interrupted if ventilation is given via endotracheal tube. Ventilation should be given just after a compression. This will minimise but not eliminate simultaneous ventilation and chest compression [Class A, Expert Consensus Opinion]

For neonatal patients it states in ANZCOR Guideline 13.6 

  • ANZCOR suggests that inflations and chest compressions should be performed with a 3:1 ratio of 90 compressions per minute and a half second pause after each 3rd compression to deliver an inflation (CoSTR 2015, weak recommendation, very low quality of evidence).2 Compressions and inflations should be coordinated to avoid simultaneous delivery of a compression and a breath [extrapolated evidence7]. 

I have provided a link to this website for your perusal.

Hope this helps :)

Cheers Trish

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Thanks @gayle-omansky and @trish 

Interesting to know wide variation in practice across the globe on such issue. Evidence in NICU is not an evidence in ER when same patient arrive at different location.

Do we know what is the logic behind this, " not to pause between compression and ventilation". when the ETT is not in, then may be tracheal compression with chest compression make it compulsory to pause for ventilation, but when ETT is in then no pause between two. 

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Neonatal Resuscitation program, the one of the >International Liaison Committee on Resuscitation (ILCOR) in 2015, which is followed in Mexico indicates a 3:1 ratio which gives 90 compressions and 30 ventilations. 

You can find more here: 

From the American Academy of Pediatrics
Chest Compressions and Ventilation in Delivery Room Resuscitation
Anne Lee Solevåg, Po-Yin Cheung, Georg M. Schmölzer
("Continuous CCs and asynchronous ventilation have been shown to have improved outcomes in adults and older children after cardiac arrest, and current evidence suggests that it is as good as a 3:1 C:V ratio in neonatal resuscitation.")
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17 hours ago, gayle omansky said:

NICU= NRP, we do not switch gears

I think that context matters.  In the DR, of course there is only NRP.  However, depending on where you practice there may be good physiologic reasons to use PALS.  You mention the ED where (I assume) you're being called for a neonate and the ED should probably be switching over to NRP (politically fraught suggestion, I know).  Our local practice has been that if the ED is calling the NICU down for more than 'advice' (ie asking us to touch the patient, intubate, place lines etc), NICU takes over as code team leader.  However, there are at least two scenarios where we switch to PALS (and for this reason, outside of the DR, one of the first things we try to establish after team leadership is what algorithm we are in). 1) Older kids in our Level 4 NICU who can be over a year old and 2) Cardiac ICU patients whom we co-manage with the CICU service and whom our fellows cover during the day.

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There is some research on these issues:

Different practices for infant resuscitation: https://www.ncbi.nlm.nih.gov/pubmed/27787506

Possibly it doesnt make any difference if you interrupt for ventilations or not: https://www.ncbi.nlm.nih.gov/pubmed/24161768 but that may only count for piglets 🙂

A free readibly review on the issue can be found here https://www.ncbi.nlm.nih.gov/pubmed/28168185 #FOAMNeo

One more review from the same group on ventilation strategies: https://www.frontiersin.org/articles/10.3389/fped.2018.00018/full #FOAMNeo

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3:1 is correct. It would be advised for the resusitator to attend NRP basic training which is clearly different from PALS. Since the patient is a neonate it would be advisable to follow NRP. Not questioning the care givers ability in PALS but the patient is a neonate. 

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The NRP Committee and PALS oversight committee recommend that newborns who require CPR while in the nursery or NICU receive CPR according to NRP.

However, it is reasonable to resuscitate a newborn in the NICU that has a primary cardiac problem (e.g., arrhythmia after heart surgery) using PALS.

Outside of the nursery and NICU settings, it is reasonable to provide CPR according to PALS in order to simplify provider training.

In either case, optimal CPR for newborns and infants includes both ventilation and compressions.

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17 hours ago, Dr Jubara Alallah said:

The NRP Committee and PALS oversight committee recommend that newborns who require CPR

I think the issue here (as evidenced by the several excellent articles Francesco posted) is what age to switch over from NRP to PALS (or maybe it doesn't matter).  ie when is a baby in the NICU no longer a 'newborn' for purposes of this recommendation.  I'm unsure what the practice is in other countries, but in the US it is increasingly common for quaternary level NICUs with complex surgical patients and severe BPD requiring chronic ventilation to have patients several months or even over a year old.  The physiologic rational for synchronization seems less plausible the older/bigger the patient gets, but the exact timing or patient characteristics that define the optimal transition point remain unknown (to me at least)

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Thanks for all the respectable members about great ideas and references.

To summarize and close the loop, PALS vs NRP use depends on the type of ICU the child is, doesn't matter the chronological age or corrected age.  It is all dependent on provider expertise and it makes sense as PICU, CICU are more trained in PALS while NICU providers are trained in NRP.

BUT very important to mention is that at the start of CPR, the team leader has to mention ( especially when the code is in ER) that we will follow NRP or PALS guidelines and all members should follow it irrespective of the differences so that everyone is on the same pitch. 



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