International Liaison Committee On Resuscitation Research Articles

Brain Hypothermic Therapy Dramatically Decreases Elevated Blood Concentrations of High Mobility Group Box 1 in Neonates with Hypoxic-Ischemic Encephalopathy

Background. According to the Consensus 2010 of the International Liaison Committee on Resuscitation (ILCOR), children with moderate to severe hypoxic-ischemic encephalopathy (HIE) should receive brain hypothermic therapy (BHT) after successful resuscitation. Elevated high mobility group box 1 (HMGB1) in the blood at the early stage of brain ischemia-reperfusion injury has been suggested to be involved in the release of various inflammatory cytokines. Methods. In total, 21 neonates plasma HMGB1 concentration was measured. These neonates included 8 with HIE in whom BHT was indicated, 5 controls diagnosed as having HIE but who were not suitable candidates for BHT, and 8 normal controls. Results. The umbilical artery HMGB1 (UA-HMGB1) level before undergoing BHT significantly exceeded reference values. The UA-HMGB1 level in the BHT (−) group did not differ significantly from reference values, but was significantly increased 24 hours after birth. Repeated measure ANOVA showed a significant difference in time course changes between the BHT (+) and BHT (−) groups (P = 0.0002). Conclusions. This study demonstrated hypothermic therapy to significantly decrease HMGB1. Furthermore, HMGB1 is a useful index of the inhibition of early stage inflammation.

Consenso sobre manejo integral del neonato con encefalopatía hipóxico isquémica

Neonatal encephalopathy secondary to birth asphyxia,the hypoxic ischemic encephalopathy, remains a major cause of postnatal death and neurological sequelae worldwide. Supportive therapy has been the mainstay of treatment. Recently series of multicenter clinical trials show the benefits of therapeutic hypothermia in this high risk population. The International Liaison Committee on Resuscitation (ILCOR) has recommended hypothermia as a standard of care and a beneficial therapy using the protocols followed in large clinical trials. Our objective was to develop a practical guide to be used at a national level in Chile, compatible with published protocols and standardized on an international basis, practical and compatible with the country's situation, and considering an integral management of the asphyxiated neonates, rescue and neuroprotective therapies. In summary, to establish rescue therapies, with the aim objective of support measures that promote cerebral and systemic oxygenation/perfusion, ensuring optimal cellular homeostasis, which are the basis of the rescue measures in asphyxiated neonates. Along with these rescue therapies, the objective is to perform the more beneficial neuroprotective therapy known today, hypothermia. Hypothermia should be conducted in a level 3 Neonatal Intensive Care Unit, with multidisciplinary care and standardized protocols and also multidiscipli nary follow-up and rehabilitation therapies.

Drugs in Newborn Resuscitation: The More We Learn the Least We Use

Temperature control, airway management and support of circulation remain the gold-standards for the majority of neonates requiring resuscitation at birth. For the minority of neonates in which the basic steps of resuscitation fail to reverse an adverse situation, drug administration is justifiable. The 2010 International Liaison Committee on Resuscitation (ILCOR) guidelines for newborn resuscitation state: "Drugs are rarely indicated in resuscitation of the newly born infant. Bradycardia in the newborn infant is usually caused by inadequate lung inflation or profound hypoxia, and establishing adequate ventilation is the most important step to correct it. However, if the HR remains less than 60 min-1 despite adequate ventilation and chest compressions, it is reasonable to consider the use of drugs. These are best given via an umbilical venous catheter". Even though drugs have been used in neonatal resuscitation for long, their doses, order and route of administration have been issues of debate among neonatologists, mainly due to the lack of data in human studies. This review will examine existing evidence behind the medications currently used in neonatal resuscitation.

Cardiac arrest management: any news? When the literature does not meet clinical practice

The percentage of patients transported alive to hospital after an out-of-hospital cardiac arrest has increased in recent years thanks to growing population education. In 2010 the International Liaison Committee on Resuscitation (ILCOR) has published new guidelines for the management of cardiac arrest. These guidelines present several new features, but cardiac compression remains the mainstay of optimal cardiopulmonary resuscitation. Use of atropine and endotracheal drugs are no longer recommended, and early ultrasound evaluation and intraosseous vascular access are new methods now standardized. The best chances of improving patient prognosis are in the period immediately after return of spontaneous circulation (ROSC). It is well known that most patients who experience cardiac arrest without an obvious extra-cardiac cause, show significant underlying coronary artery disease. Hence, the importance of widespread and early use of primary percutaneous coronary intervention. An early percutaneous coronary intervention was found to be crucial not only in increasing survival, but also in improving neurological outcome at discharge. The ILCOR consensus statement suggests that therapeutic hypothermia should be considered as the standard treatment for comatose patients resuscitated from cardiac arrest. This was supported by the evidence that moderate hypothermia is the only treatment for post-ROSC as it is associated with a significant increase in survival. For this reason, it should be started as early as possible, preferably in the pre-hospital setting. Despite the bulk of available literature on the early treatment of cardiac arrest, the studies carried out in Italy indicate that most post-ROSC patients are undertreated or untreated. This results in poor resource utilization with a high social and personal impact that involves both the patients and their families. Teamwork activities addressing the chain of survival become a fundamental tool for the treatment of resuscitated patients. Given the crucial importance of the time elapsing from collapse to cardiopulmonary resuscitation in terms of final prognosis, efforts should be made to promote the "culture of cardiopulmonary resuscitation" not only among health professionals, but also among the general population.

The Effect of the AED and AED Programs on Survival of Individuals, Groups and Populations

The automated external defibrillator (AED) is a tool that contributes to survival with mixed outcomes. This review assesses the effectiveness of the AED, consistencies and variations among studies, and how varying outcomes can be resolved. A worksheet for the International Liaison Committee on Resuscitation (ILCOR) 2010 science review focused on hospital survival in AED programs was the foundation of the articles reviewed. Articles identified in the search covering a broader range of topics were added. All articles were read by at least two authors; consensus discussions resolved differences. AED use developed sequentially. Use of AEDs by emergency medical technicians (EMTs) compared to manual defibrillators showed equal or superior survival. AED use was extended to trained responders likely to be near victims, such as fire/rescue, police, airline attendants, and casino security guards, with improvement in all venues but not all programs. Broad public access initiatives demonstrated increased survival despite low rates of AED use. Home AED programs have not improved survival; in-hospital trials have had mixed results. Successful programs have placed devices in high-risk sites, maintained the AEDs, recruited a team with a duty to respond, and conducted ongoing assessment of the program. The AED can affect survival among patients with sudden ventricular fibrillation (VF). Components of AED programs that affect outcome include the operator, location, the emergency response system, ongoing maintenance and evaluation. Comparing outcomes is complicated by variations in definitions of populations and variables. The effect of AEDs on individuals can be dramatic, but the effect on populations is limited.

They think it’s all over-managing post cardiac arrest syndrome

Return of spontaneous circulation (ROSC) is the first stage in the successful management of the cardiac arrest patient. The care that the patient receives during the immediate post-ROSC period, has a major impact on subsequent survival from out of hospital cardiac arrest (OHCA), particularly in terms of surviving to hospital discharge neurologically intact. For the first time, the 2010 Resuscitation Council (UK) ( Nolan, 2010 ) guidelines incorporates a section specifically relating to the mangement of OHCA. This review will outline the guidance from the Resuscitation Council (UK) and the International Liaison Committee On Resuscitation (ILCOR) on the management of post cardiac arrest syndrome (PCAS) and how this can be practically implemented in the pre-hospital environment. interventions directly applicable to the pre-hospital phase until handover at the emergency department (ED) will be considered. In addition, specific guidance relating to the management of the ROSC patient in the pre-hospital phase of their care will be provided.

CPR compression depth and rate in relation to physical exertion in paramedic students

The International Liaison Committee on Resuscitation (ILCOR) guidelines suggest rescuers deliver cardiopulmonary resuscitation (CPR) in cycles of 30 chest compressions and 2 ventilations (30:2) at a rate of 100 compressions per minute with a compression depth of 4-5 cm. Given this increase from the previous CPR cycle of 15:2, there is now also greater emphasis on pushing faster and deeper with minimal interruption. This has led to speculation surrounding rescuer fatigue and compression inefficiency. The purpose of this pilot study was to assess the level of work intensity and fatigue among undergraduate students during simulated CPR, including the quality of chest compressions. Methods: this was an observational pilot study investigating second year undergraduate paramedic students’ fatigue levels and quality of chest compressions following 20 minutes of simulated CPR. Data were collected at baseline and after every 2 minutes until conclusion of twenty minutes. Measurements of work intensity and fatigue included heart rate, rating of perceived exertion (Borg), compression depth and compression frequency. Results: a total of 7 subjects participated (2 male, 5 female), with five students aged 21-25 years. Male subjects showed a significantly slower compression rate when compared to females (108.0 vs 125.6 chest compressions per minute, P=0.006). Heart rate was significantly higher than rest (prior to commencing CPR) after 14 minutes of CPR (P=0.045). Perceived exertion was significantly higher than at rest at 2, 6, 10, 14, and 18 minutes, (P<0.01). Conclusion: this pilot study suggests that high levels of fatigue and perceived exertion are present early when undertaking CPR in a controlled setting, with some fatigue attributed to the faster than recommended chest compression rates.

What’s new in pediatric resuscitation? A practical update for the anesthesiologist

The International Liaison Committee on Resuscitation (ILCOR) has members from the world’s major resuscitation councils, including the Heart and Stroke Foundation of Canada and the American Heart Association. ILCOR engages with resuscitation science experts to perform systematic reviews of the world’s resuscitation literature, and from these appraisals, it produces its Consensus on Science and Treatment Recommendations for Resuscitation (the CoSTR document) every five years. Individual resuscitation councils then work from this document to create resuscitation guidelines and educational programs specific to their local context, including Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program. The publication of the 2010 Resuscitation Guidelines was particularly notable as it marked the 50 anniversary of the introduction of modern cardiopulmonary resuscitation (CPR). The guidelines for the Neonatal Resuscitation Program are applicable to neonates being cared for in the delivery room. After discharge from the newborn nursery (whether it be to home or to hospital wards), emergent care for neonates is provided using Pediatric Advanced Life Support guidelines. Adolescents with signs of secondary sexual development should be resuscitated using Advanced Cardiac Life Support guidelines. Much of the 2010 Heart and Stroke Foundation of Canada/American Heart Association Resuscitation Guidelines are relevant to the perianesthetic setting and are important for anesthesiologists to know. Anesthesiologists should recognize particular patients at higher risk of cardiac arrest, including those requiring emergency surgery, American Society of Anesthesiologists’ physical status class III-V, pulmonary hypertension, and congenital heart disease. Prevention of cardiac arrest is dependent on healthcare providers’ early recognition of the infant or child at risk of imminent collapse. The creation of medical emergency teams or rapid response teams is an attempt to address this problem. An abundance of historical control (‘‘pre/ post’’) pediatric studies suggests possible benefit associated with their implementation, but there is an absence of well-controlled prospective randomized studies that conclusively support their use. Cardiac arrest can be surprisingly difficult to diagnose quickly, even for resuscitation experts. Anesthesiologists should recognize that the pulse check performed by pediatric healthcare providers may be inaccurate, with a pulse being mistakenly detected up to 25% of the time when none is actually present. A maximum of ten seconds should be taken to feel for a pulse in a patient without signs of life (unresponsive and with apnea or agonal respirations), and chest compressions should be initiated if a pulse cannot be felt or if its presence is uncertain. A sudden profound fall in end-tidal CO2 (EtCO2) or the absence of an EtCO2 waveform may assist in diagnosing intraoperative cardiac arrest. Conversely, a progressive significant rise in EtCO2 while chest compressions are ongoing may suggest the return of a spontaneous circulation (ROSC). Pediatric cardiac arrest is typically asphyxial and follows a prolonged period of respiratory failure or shock. The rhythm immediately preceding cardiac arrest is frequently sinus bradycardia with a pulse of 60 beats min. While A. de Caen, MD (&) Pediatric Critical Care Medicine, Stollery Children’s Hospital, University of Alberta, 8440 – 112 Street, Edmonton, AB T6G 2B7, Canada e-mail: allan.decaen@albertahealthservices.ca

Neonatal resuscitation: In pursuit of evidence gaps in knowledge

Guidelines for the techniques of resuscitating newly born infants have undergone major revisions over the past 25 years. The International Liaison Committee on Resuscitation (ILCOR) is committed to “periodically developing and publishing a consensus on resuscitation science” every five years with the most recent Consensus on Science and Treatment Recommendations (CoSTR) statement published in 2010. The CoSTR document is used as a basis for developing specific resuscitation guidelines felt to be appropriate for implementation in respective countries. A “gaps in knowledge” summary is created at the conclusion of a cycle. It is a goal that identification of these knowledge gaps will stimulate investigators to pursue more targeted studies to help close the gaps. The current document is based on the “gaps in knowledge” summary for neonatal resuscitation that was created at the conclusion of the 2005–2010 ILCOR cycle.

Abstract 262: Slight Therapeutic Hypothermia (35°C to 36°C) for Post--Cardiac Arrest Syndrome Due to Ventricular Fibrillation with Low Left Cardiac Function Is a Feasible and Safe Possibility

Background: Mild therapeutic hypothermia (32-34°C, 24-48 hours: mild TH) for post cardiac arrest syndrome (PCAS) due to ventricular fibrillation (VF) had been recommended in the American Heart Association (AHA) Guidelines 2005 (class IIa) and the International Liaison Committee on Resuscitation (ILCOR). In the AHA guidelines 2010, it has been recommended more strongly (class I). But it is still unknown what temperature is best for low cardiac function patients including acute myocardial infarction (AMI) cases. Sometimes executing mild TH for patients with severe left ventricular dysfunction are not so easy and safe because of hypotension, arrhythmias, unstable vital signs and so on. So we studied whether slight therapeutic hypothermia (35-36°C: Slight TH) was effective and safe compare with mild TH for PCAS due to VF. Methods: Consecutive PCAS patients who were witnessed, done by-stander cardiopulmonary resuscitation (CPR), confirmed VF caused by cardiac or coronary events and introduced therapeutic hypothermia for the latest 45 months were sorted into the GroupM (Mild TH, 34°C, 24-72 hours) and the GroupS (Slight TH, 35-36°C, 24-72 hours).The primary end point was a favorable neurologic outcome (cerebral performance category: CPC 1 or 2) in 28th days after cardiac arrest. Secondary end points were the changes of cardiac index (CI) after introducing therapeutic hypothermia, the time required to reach target temperature and the rate of complications (infections, bleeding, arrhythmias etc.) within fourteen days. Results: Thirty-five patients (twenty AMI cases) were studied (GroupM 20 patients and GroupS 15 patients). The rate of favorable neurologic outcome was available and did not differ significantly between the two groups (50% vs. 53%, p=0.85). The time to reach target temperature was significantly shorter in the GroupS (5.9h vs. 0.9h, p<0.01). The decrease of CI was remarkable in the groupM (before TH/during TH, GroupM 2.8/2.2, GroupS 1.9/2.1, the changes of them were Δ32% vs. +0.05%, p<0.01). The rate of complications did not differ significantly between them and there were no major complications. Conclusion: Slight therapeutic hypothermia for PCAS due to VF with low cardiac function is possibility feasible and safe.

Evidence Based Neonatal Resuscitation

For the past 50 years, the practice of neonatal resuscitation has been based largely on expert opinion and evidence from animal models. The 2010 International Liaison Committee on Resuscitation (ILCOR) guidelines contain recommendations derived from an accumulating body of higher quality evidence. This presentation will summarise some of the studies underpinning changes to the guidelines. Changes include: □ Colour is no longer recommended as a sign of oxygenation. Pulse oximetry is recommended for infants receiving respiratory support □ PEEP is beneficial for preterm infants receiving positive pressure ventilation □ Both CPAP and ventilation via an endotracheal tube are reasonable methods of respiratory support for preterm infants Mask ventilation remains the cornerstone of neonatal resuscitation. Clinical signs, including chest wall movement poorly measure the effectiveness of ventilation. Mask leak and airway obstruction are common, often unrecognized factors that lead to ineffective ventilation. Respiratory function monitoring is a potentially useful way of improving treatment in the delivery room. The strengths and limitations of novel monitoring techniques will be discussed.Evidence emerging since publication of the 2010 guidelines will be presented and the most important gaps in our knowledge outlined.

Design of the RINSE Trial: The Rapid Infusion of cold Normal Saline by paramedics during CPR

BackgroundThe International Liaison Committee on Resuscitation (ILCOR) now recommends therapeutic hypothermia (TH) (33°C for 12-24 hours) as soon as possible for patients who remain comatose after resuscitation from shockable rhythm in out-of-hospital cardiac arrest and that it be considered for non shockable rhythms. The optimal timing of TH is still uncertain. Laboratory data have suggested that there is significantly decreased neurological injury if cooling is initiated during CPR. In addition, peri-arrest cooling may increase the rate of successful defibrillation. This study aims to determine whether paramedic cooling during CPR improves outcome compared standard treatment in patients who are being resuscitated from out-of-hospital cardiac arrest.Methods/DesignThis paper describes the methodology for a definitive multi-centre, randomised, controlled trial of paramedic cooling during CPR compared with standard treatment. Paramedic cooling during CPR will be achieved using a rapid infusion of large volume (20-40 mL/kg to a maximum of 2 litres) ice-cold (4°C) normal saline.The primary outcome measure is survival at hospital discharge. Secondary outcome measures are rates of return of spontaneous circulation, rate of survival to hospital admission, temperature on arrival at hospital, and 12 month quality of life of survivors.DiscussionThis trial will test the effect of the administration of ice cold saline during CPR on survival outcomes. If this simple treatment is found to improve outcomes, it will have generalisability to prehospital services globally.Trial RegistrationClinicalTrials.gov: NCT01172678

Therapeutic hypothermia for neonatal encephalopathy: JSPNM & MHLW Japan Working Group Practice Guidelines: Consensus Statement from the Working Group on Therapeutic Hypothermia for Neonatal Encephalopathy, Ministry of Health, Labor and Welfare (MHLW), Japan, and Japan Society for Perinatal and Neonatal Medicine (JSPNM)

Neonatal encephalopathy (NE) secondary to intrapartum asphyxia remains a major cause of post-natal death and permanent neurological deficits worldwide. Supportive therapy has been the mainstay of the treatment until recent series of large clinical trials demonstrating benefit of therapeutic hypothermia (TH) in this high risk population. Now the International Liaison Committee on Resuscitation (ILCOR) recommends TH as a standard of care with the protocols used in the large clinical trials as tentative standard protocols. Our goal is to develop a nationwide consensus practice guideline not only consistent with the international standard protocols but also practical and compatible with the current medical system in Japan. In summary, TH should be offered to newborn infants born ⩾36 weeks gestational age and birth weight ⩾1800 g exhibiting clinical signs of moderate to severe NE as well as evidence of hypoxia–ischemia, i.e. 10 min Apgar score ⩽5, a need for resuscitation at 10 min, blood pH < 7.00, or base deficit ⩾16 mmol/L. TH should be conducted in the NICUs capable of multidisciplinary care and under the standard protocols, i.e. utilization of cooling device, target (rectal or esophageal) temperatures at 33.5 ± 0.5 and 34.5 ± 0.5 °C for whole body and selective head cooling respectively, duration of TH for 72 h, gradual rewarming not exceeding the rate of 0.5 °C/h. Long term follow-up with multidisciplinary approach including standardized psychological assessment is warranted.

Past, present and future of hypothermic neuroprotection for neonatal encephalopathy in Japan: Time to say good-by to the old remedies

In October 2010, International Liaison Committee on Resuscitation (ILCOR) released its revised statement on neonatal resuscitation recommending therapeutic hypothermia (TH) in the tertiary care setting as a standard of care in term or near-term infants with moderate to severe neonatal encephalopathy. It states TH should be conducted under clearly defined protocols and treatment should be consistent with those used in the randomized clinical trials [1]. However, in Japan, TH has been applied to various types of brain injury with originally-developed protocols.

A multi- centre study of cardiopulmonary resuscitation by using the Hainan Utstein templates for resuscitation registries

Objective To study the Hainan Utstein templates used for cardiac arrest and resuscitation registries to evaluate the epidemiological characteristics and outcomes of the patients with CPR by multi-center study. Methods ccording to the Utstein templates for cardiac arrest and CPR set by International Liaison Committee on resuscitation in 2004, a Hainan Utstein CPR registry chart was designed and a prospective descriptive study was carried out to evaluate the epidemiological characteristics, impact factors and outcomes of the patients with resuscitation attempt in emergency departments of thirteen hospitals in Hainan Island between January 2007 and December 2010. Results Of 1125 patients with cardiac arrest, male accounted for 73. 8％ and female was 26. 2％. The mean ( ± S. D) age of the cardiac arrest patients was 53.9 ± 13. 1 years old. Coronary heart diseases and hypertension were the most common preexisting chronic diseases in the studied patients. The ROSC rate and discharge rates after survival in 1125 patients with CPR were 23. 8％ and 7.4％ respectively. The ROSC rate and discharge rates after survival were 36. 3％ and 11.6％ in the in-hospital cardiac arrest (IHCA) group, respectively whereas 11.5％ and 3. 3％ in out-hospital cardiac arrest (OHCA) group. Of 188 patients with ventricular fibrillation/Pulseless ventricular tachycardia, the ROSC rate and discharge rate after survival were 58.0％ and 21.8％,respectively. Of them, 448 (39. 8％ ) of the cardiac arrest patients had underlying cardiac causes, and the ROSC rate and discharge rate after survival were 36. 3％ and 11.5％ respectively in IHCA group whereas 11.6％ and 3. 3％ in OHCA group. The ROSC rate and discharge rate after survival were 69. 8％ and 7. 4％respectively in the tertiary hospitals whereas 30. 2％ and 7. 3％ in the secondary hospitals. Conclusions Patients experienced cardiac arrest were predominantly male. Coronary heart disease and hypertension were the two most common preexisting chronic diseases. The ROSC rate and discharge rate of patients with IHCA were higher than those with OHCA. ROSC rate and discharge rate after survival were higher in the ventriculat fibrillation/Pulseless ventricular tachycardia group than the other cardiac rhythms first witnessed groups. The time delayed of starting CPR after onset of cardiac arrest had a critical impact on survival and discharge rate in both IHCA and OHCA groups. Key words: Cardiac arrest; In-hospital cardiac arrest; Out of hospital cardiac arrest; Ventricularfibrillation; Pulseless ventricular tachycardia; Cardiopulmonary resuscitation; Utstein templates; Return ofspontaneous circulation; Survival to discharge

Assessment of Knowledge of Cardiopulmonary Resuscitation of Pregnant Women among Physician Obstetric Care Givers in the South-South of Nigeria

Background: Obstetricians are usually well prepared for and knowledgeable about the challenges of the birthing process. Cardiac arrest during pregnancy is uncommon, and many never encounter it throughout their practice. Objectives: The aim of this study was to evaluate the knowledge of maternal cardiopulmonary resuscitation of various cadres of physician obstetric care givers in five tertiary institutions in the south-south of Nigeria. Methodology: Questionnaires detailing years of experience of the physician caregivers, level of care involved in, previous experience with pregnant women requiring cardiopulmonary resuscitation, as well as formal training in cardiopulmonary resuscitation were distributed during Obstetrics Clinical Meetings in 5 tertiary hospitals. The questionnaire also evaluated knowledge of maternal resuscitation following cardiac arrest and awareness of Advanced Life Support in Obstetrics (ALSO) as well as International Liaison Committee on Resuscitation (ILCOR) guidelines. Data obtained were entered into Microsoft Excel and results expressed in simple percentages. Results: Out of 260 questionnaires distributed, 253 were returned (response rate 97.31%). There were 78 Consultant Obstetricians, 63 Senior Registrars, 70 Registrars and 42 House-Officers. Although 76% of the respondents have participated in the resuscitation of the pregnant woman, only 3 (1.19%) had formal training in cardiopulmonary resuscitation. Only 5 (1.98%) physician obstetric care givers were able to rank correctly the steps taken during maternal cardiopulmonary resuscitation following a cardiac arrest. The correlation between the knowledge of maternal resuscitation and the years of experience was not significant (r= - 0.314; p=0.143). Conclusion: Majority of Physician Obstetric care givers in tertiary hospitals in the south-south of Nigeria do not have appropriate knowledge of cardiopulmonary resuscitation of the pregnant woman following cardiac arrest. Keywords: Cardiopulmonary resuscitation, pregnant women, Physician Obstetric Care Givers, Knowledge

The 2010 Guidelines on Neonatal Resuscitation (AHA, ERC, ILCOR): Similarities and Differences – What Progress Has Been Made since 2005?

In 2010, the American Heart Association (AHA), the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR) issued new guidelines on newborn resuscitation. The new recommendations include: (1) pulse-oximetry for patient assessment during newborn resuscitation; (2) to start resuscitation of term infants with an FiO (2) of 0.21; (3) cardio-respiratory resuscitation with a 3:1 chest compression/inflation ratio for a heart rate <60 beats/min; (4) regarding infants born from meconium stained amniotic fluid: no recommendation is given to suction the upper airways at the perineum (when the head is born), but it is recommended to inspect the oropharynx and trachea for obstruction and suction the lower airway before inflations are given when the infant is depressed; (5) for birth asphyxia in term or near term infants, to induce hypothermia (33.5-34.5°C) within 6 h after birth. AHA, ERC and ILCOR used nearly identical literature for their evidence evaluation process. While the AHA and ILCOR guidelines are almost identical, the ERC guidelines differ slightly from the latter with regards to (i) promoting sustained inflations at birth, (ii) promoting a wider range in applied inflations during resuscitation, and (iii) to suction the airways in infants born from meconium stained amniotic fluid, before inflations are given.

Adaptación de las recomendaciones internacionales sobre reanimación neonatal 2010: comentarios

Since previous publication in 2005, the most significant changes that have been addressed in the 2010 International Liaison Committee on Resuscitation (ILCOR) recommendations are as follows: (i) use of 2 vital characteristics (heart rate and breathing) to initially evaluate progression to the following step in resuscitation; (ii) oximetry monitoring for the evaluation of oxygenation (assessment of color is unreliable); (iii) for babies born at term it is better to start resuscitation with air rather than 100% oxygen; (iv) administration of supplementary oxygen should be regulated by blending oxygen and air; (v) controversy about endotraqueal suctioning of depressed infants born through meconium-stained amniotic fluid; (vi) chest compression-ventilation ratio should remain at 3/1 for neonates unless the arrest is known to be of cardiac etiology, in which case a higher ratio should be considered; (vii) use of therapeutic hypothermia for infants born at term or near term evolving to moderate or severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system (post-resuscitation management); (viii) cord clamping delay for at least 1 minute in babies who do not require resuscitation (there is insufficient evidence to recommend a time for clamping in those who require resuscitation) and, (ix) it is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, although many factors contribute to the decision to continue beyond 10 minutes. Under certain circumstances, non-initiation of resuscitation could be proposed taking into consideration general recommendations, own results and parents’ opinion.

Working together, nurses can make a difference in resuscitation outcomes: An update on the American Heart Association's 2010 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide a forum for resuscitation organizations worldwide. According to its mission, ILCOR provides a mechanism by which international science and knowledge that are relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) can be identified, reviewed, and evaluated. Every 5 years, based on a rigorous review of the published, peer-reviewed science, ILCOR develops a consensus on resuscitation science and carries that forward into internationally agreed-on treatment recommendations. As part of the 2010 evidence-evaluation process, ILCOR published an updated consensus on science and treatment recommendations (CoSTR). Based on the CoSTR, the American Heart Association (AHA) developed and disseminated guidelines for ECC and CPR. Nursing has unique responsibilities in the chain of survival. This article reviews the major elements of AHA's 2010 guidelines and discusses the critical role that nurses play in the development, dissemination, and implementation of resuscitation science. By making the connection in resuscitation science, nurses can help to save more lives.

Stayin’ alive: The 2010 Heart and Stroke Foundation of Canada/American Heart Association resuscitation guidelines for newborns and older children

Five years have transpired since the most recent set of paediatric and neonatal resuscitation guidelines were jointly released by the Heart and Stroke Foundation of Canada (HSFC) and the American Heart Association. The recent publication of the 2010 resuscitation guidelines (1–3) prompts the following questions: What process led to the creation of the guidelines? What is new since 2005? What is our role in implementation? Guideline development has evolved from using consensus of experts, to the use of an evidence-based approach. Starting in 2000, the International Liaison Committee on Resuscitation (ILCOR), consisting of resuscitation councils from around the world (including the HSFC), has conducted regular systematic reviews of the resuscitation literature. These reviews resulted in the Consensus on Science and Treatment Recommendations (CoSTR). After the release of ILCOR’s 2005 CoSTR document, the paediatric and neonatal task forces reconvened, with international (including Canadian) representation. Each task force identified key questions requiring evidence evaluation, and assigned each question to two or more international resuscitation experts. After a rigorous literature search, relevant articles were independently identified, analyzed and graded by each worksheet author. With the assistance of an evidence evaluation expert, the scientific information surrounding a specific question was summarized and treatment recommendations were drafted based on this summary. The worksheet summaries (without treatment recommendations) were made available to the wider scientific community through the ILCOR website. Each worksheet author then presented his/her findings one final time to the paediatric or neonatal task forces, who debated and finalized the CoSTR statements (published in October 2010 [4,5]). Since that time, regional resuscitation councils (such as the HSFC and American Heart Association) have released their own resuscitation guidelines that have contextualized the CoSTR documents for their respective health care systems. A significant challenge for the world’s paediatric and neonatal resuscitation community continues to be the paucity of high-quality studies in the basic science, clinical and educational domains. Many resuscitation science recommendations are based on extrapolation from adult (human) studies or even animal data, whereas educational science largely consists of low-level studies of learner outcomes rather than patient outcomes. There is a pressing need for further study regarding how best to translate resuscitation science into practice, and how best to improve knowledge acquisition and retention by both lay rescuers and health care professionals over time. Studies are needed to compare traditional instructor-led courses with newer innovative approaches to teaching including Internet- and computer-based training, and low- or high-fidelity simulation. The rapid attrition of cognitive and technical skills within months of initial instruction suggests that we need to consider other approaches to continuing education, potentially including more frequent refresher courses, training sessions or simulations. The introduction of simulation and debriefing to neonatal resuscitation training will result in substantial changes to Neonatal Resuscitation Program (NRP) courses, presenting new challenges for our instructors and learners. These new methodologies will help us recognize the importance of teamwork competencies, and individual knowledge, skills and behaviours. Fortunately, the clinical science recommendations reinforce and build on practices introduced to Canada in 2006 (6), and will require relatively minor modifications. Outside the newborn population, clearer, simpler and more consistent messaging to the public regarding how to provide cardiopulmonary resuscitation (CPR) to individuals of all ages will hopefully ensure that bystanders act promptly, in contrast to the majority of out-of-hospital cardiac arrests in Canada, where no intervention is provided by lay rescuers. Starting the first cycle of CPR with chest compressions (chest compressions, airway, breathing), as opposed to the traditional order (airway, breathing, chest compressions) will ensure that rescuers immediately ‘do something (ie, at least chest compressions) as opposed to doing nothing’ for all cardiac arrest victims. This will maximize coronary perfusion and delay the provision of rescue breaths by only a few seconds. The challenge for paediatric and neonatal health care providers is to recognize our collective role and responsibility in optimizing resuscitative care for Canada’s infants and children. Although maintaining up-to-date CPR certification and/or NRP registration is an essential first step, our role extends to advocating CPR education for our own children and families, and getting the “stayin’ alive” message out to the public through our patients, their families and the community. It is time for us, as paediatricians, to approach paediatric cardiac arrest as a preventable disease, in the same way that we successfully advanced seatbelt and bicycle helmet education programs. Similarly, perinatal teams should view newborn compromise as predictable in many circumstances and, therefore, assess risk and prepare for resuscitation before every delivery. Finally, it is incumbent on us to cultivate resuscitation-based scientific research to fill the knowledge gaps in basic, clinical and educational science, and inform future CoSTR cycles.