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Newborn-02 - Paper Draft CC
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RECOVER 2.0 Worksheet
QUESTION ID: Newborn-02
PICO Question:
In newborn dogs and cats that require resuscitation in which PPV has been initiated (P), how does starting chest compressions below any other heart rate (I), compared with less than 60 bpm (C) improve outcome (O).
Outcomes:
Histopathologic damage; Surrogate marker(s) of perfusion; Hospital length of stay; Favorable neurologic outcome; Survival to Discharge
Prioritized Outcomes (1= most critical; final number = least important):
- Favorable neurologic outcome
- Survival to discharge
- Surrogate markers of perfusion
- Hospital length of stay
- Histopathologic damage
Domain chairs: Christopher Byers, final edits by Manuel Boller
Evidence evaluators: Steven Berkowitz, Deborah Silverstein
Conflicts of interest: Byers: Founder, CriticalCareDVM.com
Search strategy: See attached document
Evidence Review:
Add rows to the table to incorporate all outcomes evaluated as part of the evidence review and all study types. You can use this template to add a new outcome by copying and pasting it to the end of the table. Once you have completed your review, please delete this template from the document.
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Outcome: |
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Study Design |
Reduced Quality Factors
0 = no serious, - = serious,
- - = very serious |
Positive Quality Factors
0 = none, + = one, ++ = multiple |
Dichotomous Outcome Summary |
Non-Dichotomous Outcome Summary
Brief description |
Overall Quality
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Indirectness |
Imprecision |
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Confounder |
# Intervention with Outcome |
# Control with Outcome |
RR (95% CI) |
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Outcome: Survival to discharge, No evidence identified |
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0 |
NA |
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None |
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Outcome: Favorable neurologic outcome, No evidence identified |
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NA |
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None |
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Outcome: Surrogate markers of perfusion, No evidence identified |
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NA |
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None |
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Outcome: Hospital length of stay, No evidence identified |
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NA |
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None |
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Outcome: Histopathologic damage, No evidence identified |
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NA |
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PICO Question Summary
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Introduction |
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Intrapartum fetal asphyxiation leads to a reduction in HR at birth, and this bradycardia can further exacerbate vital organ hypoxia (Polgase, 2016). Positive pressure ventilation and oxygen administration are expected to increase HR in many cases, but where these interventions fail to increase the HR above a critical threshold, chest compressions might increase tissue blood flow and tissue oxygen delivery. However, once effective PPV and oxygen supplementation have been started in newborn dogs or cats, the ideal HR below which to initiate chest compressions is unknown. The current recommendation in newborn infants is to initiate chest compressions if the heart rate drops below 60 beats/min.( Wyckoff, 2020) |
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Consensus on science |
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We found no evidence relevant to this PICO question for the outcomes of favorable neurologic outcome, survival to discharge, surrogate markers of perfusion, hospital length of stay, and histopathologic damage. |
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Treatment recommendation |
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In very severely bradycardic newborn dogs and cats that have received effective PPV and oxygen supplementation for at least 30 seconds, we recommend initiating chest compressions (strong recommendation, expert opinion).
We suggest using a heart rate below 50 beats/minute as the threshold for initiating chest compressions in newborn dogs and cats that have received effective PPV and oxygen supplementation for at least 30 seconds (weak recommendation, expert opinion).
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Justification of treatment recommendation |
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As in human medicine, we identified no studies that investigate the heart rate threshold at which to initiate chest compressions in asphyxiated newborn puppies and kittens.( Ramachandran, 2022) During asphyxiation in newborns, the HR drops and the cardiac output declines.[ Dawson 2010, ] While this is initially compensated by counterregulatory mechanisms to maintain blood flow to heart and brain, severe global tissue hypoxia and end-organ injury, including hypoxic-ischemic encephalopathy, eventually ensues.( Polglase, 2016) Although we did not identify any direct evidence to inform at which HR chest compressions should be initiated in any species, a reduction to a median HR of 46 beats/min in an experimental asphyxia model in newborn lambs demonstrated a reduction of cerebral blood flow to 25% of baseline, with a linear reduction of cerebral blood flow and HR.( Alhassen, 2021) Another study in asphyxiated newborn lambs found no improvement of cerebral and coronary blood flow when chest compressions were administered during bradycardia with a HR of 63±8 beats/min.( Chandrasekharan, 2022) There are some physiological concerns that chest compressions in newborns with bradycardia could be harmful.( Agrawal, 2019) In addition, the concurrent administration of chest compressions and PPV is challenging and may compromise the ability of the rescuer to effectively provide PPV, which is likely the most beneficial intervention in asphyxiated newborns. Given that compressions started at a HR of approximately 60 beats/min did not improve cerebral and coronary blood flow and that a HR of approximately 46 beats/min led to severe reduction in cerebral blood flow, the committee suggests starting chest compression only when the HR falls below 50 beats/min. Below that HR, vital organ blood flow is likely less than what is generated by chest compressions. With effective PPV, experimental evidence from asphyxiate piglets suggests that HR will start to increase with PPV alone after 15-30 seconds in those animals that are able to respond.( Espinoza 2019) We therefore considered PPV for 30 seconds to be a reasonable first step before escalating resuscitation to include chest compressions in animals that fail to respond at that time. We suggest that chest compressions are administered when the HR remains below 50 beats/min after 30 seconds of effective PPV and oxygen administration have been delivered. If there is no heart beat identified, chest compressions should be started immediately. |
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Knowledge gaps |
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There is no clinical or experimental evidence to assess harm or benefit for chest compressions in newborn puppies and kitten when initiated at any HR cut-off. An initial study could explore whether in newborn puppies and kitten with severe bradycardia (HR |
References:
● Z. Alhassen, p. vali, A. Lesneski, M. Hardie, P. Chen, D. Sankaran, et al. What Is the Optimal Heart Rate Cut-Off For Initiating Chest Compressions In Neonatal Bradycardia? Pediatrics 2021 Vol. 147 Issue 3_MeetingAbstract Pages 753-753
● Agrawal V, Lakshminrusimha S, Chandrasekharan P. Chest Compressions for Bradycardia during Neonatal Resuscitation-Do We Have Evidence? Children (Basel). 2019 Oct 29;6(11):119. doi: 10.3390/children6110119. PMID: 31671867; PMCID: PMC6915497
● P. Chandrasekharan, S. Gugino, C. Koenigsknecht, J. Helman, N. Bradley, M. Rawat, et al. Chest Compressions During Neonatal Bradycardia Do Not Enhance Flow to Vital Organs but Reduce Inherent Cardiac Activity. Pediatrics 2022 Vol. 149 Issue 1 Meeting Abstracts February 2022 Pages 654-655
● Dawson, J.A.; Kamlin, C.O.F.; Wong, C.; te Pas, A.B.; Vento, M.; Cole, T.J.; Donath, S.M.; Hooper, S.B.; Davis, P.G.; Morley, C.J. Changes in heart rate in the first minutes after birth. Arch. Dis. Child.- Fetal Neonatal Ed. 2010, 95, F177–F181.
● Polglase GR, Ong T, Hillman NH. Cardiovascular Alterations and Multiorgan Dysfunction After Birth Asphyxia. Clin Perinatol. 2016 Sep;43(3):469-83. doi: 10.1016/j.clp.2016.04.006. Epub 2016 Jun 22. PMID: 27524448; PMCID: PMC4988334.
● Ramachandran S, Bruckner M, Wyckoff MH, et al. Chest compressions in newborn infants: a scoping review. Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 01 December 2022. doi: 10.1136/archdischild-2022-324529
● Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, Kim HS, Liley HG, McKinlay CJD, Mildenhall L, Perlman JM, Rabi Y, Roehr CC, Schmölzer GM, Szyld E, Trevisanuto D, Velaphi S, Weiner GM; Neonatal Life Support Collaborators. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020 Oct 20;142(16_suppl_1):S185-S221. doi: 10.1161/CIR.0000000000000895. Epub 2020 Oct 21. PMID: 33084392.
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