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

COI Disclosure (specific to this systematic review) EVREV 1 COI 107 Commercial/industry Nil Potential intellectual conflicts EVREV 2 COI

2010 CoSTR Topic not reviewed in 2010

C2015 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 time 9-Critical improve perfusion 8-Critical decrease time to ROSC 8-Critical increase survival rates 7-Critical improve neurological outcomes

Inclusion/Exclusion & Articles Found Inclusions Neonatal / Infant / Animal / Manikins RCT, Observational Exclusions: Adult, V-Fib, Abstracts, Editorials Number of Articles initially identified 691 Included in Evidence Profile tables 5 (All ETCO2) RCTs 0 non-RCTs 5 Excluded 686

Draft 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).

Risk of Bias in studies

Key data from key studies Asphyxial Arrest (ETT clamped): 11 dogs HR = 0 All achieved ROSC Bhende MS et al Am J Emerg Med. 1996 Jul;14(4):349-50.

40 children (aged 1 week to 10 years): Easy-Cap (Nellcor) 15 - 38mmHg (< 2%) Yellow 4 - < 15mmHg Tan (0.5 – 2%) < 4mmHg (< 0.5%) Purple 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)

Key data from key studies 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)

Evidence profile table(s)

Proposed 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

Draft 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).

Knowledge Gaps (eg. ETT vs BVM) Other specific worksheets that would be helpful Relationship with training to ETT success Specific research required Adult ETT vs BVM Essential slide (one slide only). Estimated time <30 sec

Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date Essential slide (one slide only). Estimated time <30 sec