699 - Sustained inflation and chest compression versus 3:1 chest compression to ventilation ratio during cardiopulmonary resuscitation of asphyxiated newborns – a cluster randomized controlled trial

Monday, May 1, 2023

9:30 AM – 11:30 AM ET

Poster Number: 699
Publication Number: 699.445

Georg Schmoelzer, University of Alberta Faculty of Medicine and Dentistry, Edmonton, AB, Canada; Gerhard Pichler, Medical University of Graz, Graz, Steiermark, Austria; Anne Lee Solevåg, Oslo University Hospital, Oslo, Oslo, Norway; Brenda H. Law, University of Alberta Faculty of Medicine and Dentistry, Edmonton, AB, Canada; Souvik Mitra, Dalhousie University & IWK Health, Halifax, NS, Canada; Daniel Pfurtscheller, Medical University of Graz, Graz, Steiermark, Austria; Po-Yin Cheung, University of Alberta, Edmonton, AB, Canada; Michael Wagner, Medical University of Vienna, Vienna, Wien, Austria

Presenting Author(s)

GS

Georg Schmolzer, MD, PhD

Neonatologist
University of Alberta Faculty of Medicine and Dentistry
Edmonton, Alberta, Canada

Background:

Current neonatal resuscitation guidelines recommend a 3:1 compression to ventilation ratio (C:V) ratio during cardiopulmonary resuscitation (CPR). In piglets, continuous chest compression (CC) superimposed by sustained inflations (CC+SI) resulted in faster time to return of spontaneous circulation (ROSC), lower mortality, improved hemodynamics, and improved minute ventilation compared to 3:1 C:V. Similar in a pilot trial in preterm infants, CC+SI compared to 3:1 C:V had significant faster time to ROSC.

Objective:

In newborn infants receiving chest compression with CC+SI compared with 3:1 C:V the time to ROSC will be reduced.

Design/Methods:

Multicenter cluster randomized trial of CC+SI vs. 3:1 C:V in newborn infants receiving CPR who were eligible bradycardic with heart rate < 60/min or asystolic despite adequate ventilation. Hospitals were randomized to CC+SI or 3:1 C:V for 12 months and then switched to the 2^nd intervention for another 12 months.

CC+SI: Infants received continuous CC at a rate of 90/min. During CC, a sustained inflation was delivered continuously for 20sec, then interrupted for 1 second and then the next sustained inflation was delivered for a further 20sec. Opt-out-rule: At 5min, if heart rate remained < 60/min, the clinical team had to convert to the standard method of care using 3:1 C:V ratio.

3:1 C:V: Infants received CC at a rate of 90/min and ventilations at a rate of 30/min using a 3:1 C:V ratio. In both interventions, CC were continued until ROSC. The primary outcome was time to ROSC (heart rate >60 for one minute). Analysis was intention-to-treat. The trial was stopped to slow enrolment, pandemic, and funding constrains.

Results:

Four sites (Edmonton, Graz, Halifax, and Vienna) included infants, which were randomized to CC+SI (n=11) and 3:1 C:V (n=14). Demographics (table 1) and delivery room intervention (table 2) were balanced.

There was a significant reduction in time to ROSC with CC+SI with 90 (60-270) sec versus 615 (174-780) sec with 3:1 C:V (p=0.0367) (Figure 1).

Overall survival was 9/11 (82%) with CC+SI and 7/14 (50%) with 3:1 C:V [relative risk (RR) 0.36, 95% Confidence interval (CI) 0.094 to 1.42]. Survival rates for CC+SI and 3:1 C:V were in the delivery room [11/11 (100%) vs. 12/14 (86%)], (RR 0.25, CI 0.013 to 4.73) and in the Neonatal Intensive Care Unit [9/11 (82%) vs. 7/12 (58%)] (RR 0.523 CI 0.12 to 2.28), respectively.

There were no differences in secondary outcomes between groups.

Conclusion(s):

CC+SI resulted in a significant reduction in time to ROSC compared to 3:1 C:V. There was a trend towards higher survival rates with CC+SI compared to 3:1 C:V.