296 - Optimal position of the compressor for high-quality chest compressions on infants

Publication Number: 296.5732

Nicole Neveln, Baylor College of Medicine, Houston, TX, United States; Mona Khattab, Baylor College of Medicine, Houston, TX, United States; Regine Fortunov, Baylor College of Medicine, Houston, TX, United States; Sharada H. Gowda, Baylor College of Medicine, Houston, TX, United States; Joseph Hagan, Baylor College of Medicine, Houston, TX, United States; Nathan C. Sundgren, Baylor College of Medicine, Houston, TX, United States

Background: The Neonatal Resuscitation Program states compressions in the delivery room should be performed from the infant’s head using the two-thumb encircling hands technique. The Pediatric Advanced Life Support program recommends two-thumb encircling hands as the preferred two-rescuer technique for infants but does not specify compressor positioning. Both resuscitation programs recommend two-thumb compressions on infants, but positioning of the compressor outside of the delivery room is not standardized. Differences in compressor positioning may affect the ability to perform quality compressions.

Objective: To determine the optimal position of the compressor when performing two-thumb chest compressions on infants.

Design/Methods: Using a 10% non-inferiority margin and paired analysis with 206 participants, we compared two-thumb compressions delivered from the head of the manikin to those from the side and foot of the manikin. The primary outcome was the percentage of high-quality compressions, defined as compressions meeting goal rate, depth, and recoil. Secondary outcomes included individual compression metrics and compressor fatigue. We also analyzed compression metrics during clinical resuscitations of infants using data from Zoll R series defibrillators.

Results: Percentage of high-quality compressions delivered from the side and foot of the manikin was not non-inferior to the head (Figure 1A). Full recoil from the side was inferior to head, while foot was not non-inferior (Figure 1B). Rate and depth were non-inferior from side and foot compared to head. A significantly lower percentage of compressors were able to complete 10 minutes from the side or foot compared to the head (Figure 2). From clinical data, 19 infants received 33,783 compressions of which 22,638 had both a known provider position and technique. One infant received two-finger compressions from the foot (34 total compressions); all others received compressions from the side using varying techniques (Table 1). Full recoil was the metric with the poorest performance.

Conclusion(s): Less than 50% of simulated and clinical compressions were high quality. Manikin data clearly shows that positions other than the head, especially the side, do not meet the standard of non-inferiority. The same comparison cannot be made from clinical data as nearly all compressions were performed from the side, but it should be noted that the percentage of high-quality compressions from this position was very poor. This study suggests that compressions on all infants are best done from the infant’s head regardless of the resuscitation program followed or location of event.

Figure 1. Compression Quality – Manikin
A 10% non-inferiority margin was used. (A) Compressions from the side (35.1±2.0%, mean difference -12.0, 95%CI [-16.4, -7.6]) or foot (37.8±1.9%, mean difference -9.3, 95%CI [-13.9, -4.8]) of the manikin were not non-inferior to compressions from the head (47.1±2.1%). (B) Full recoil from the side (66.5±2.1%, mean difference -15.5, 95%CI [-19.1, -11.7]) was inferior to head (82.0±1.7%) while foot (71.2±2.0%, mean difference -10.8, 95%CI [-14.3, -7.2]) was not non-inferior.

Figure 2. Compressor Fatigue
Each of the 206 participants performed a 10-minute compression session in all three positions. 82 (39.8%) quit before the end of the session in the head position compared to 96 (46.6%, p=0.025) in the foot position and 122 (59.2%, p<0.001) in the side position. Participants performing sessions in the foot position (hazard ratio 1.220, 95%CI [1.032,1.443], p=0.020) and side position (hazard ratio 2.001, 95%CI [1.672, 2.393], p<0.001) had a significantly greater instantaneous risk of quitting compared to sessions performed in the head position.

Table 1. Compression Quality – Clinical