Criteria
Judgements
Research evidence
2010 American Heart Association recommended compression depths during pediatric
in-hospital resuscitations are associated with survival. Sutton et al. Resuscitation
May 16 2014.
Single centre study of 89 events in children > 1 yr of age requiring cardiac
compression's, 87 with quantitative data available. AHA depth compliant events (>
51mm) were associated with a higher 24 hr survival compared to shallower
compression depths, even after accounting for confounding factors.
Problem
Is there a
problem
priority?
○ No
○ Probably no
○ Uncertain
● Probably
yes
○ Yes
○ Varies
Benefits &
harms of
the options
○
What is the
No included
overall certainty
studies
of this evidence?
Very low
●
Only one paper able to be included in this GRADE table.
Two very small papers analysed in a separate GRADE table (Maher 2009 662: 6
infants post cardiac surgery and Sutton 2013 168: 9 children and adolescents in a
second paper) for chest compression depths and physiological end point (blood
pressure) as part of same worksheet. Analyzed in a separate table as outcome was
not initially part of PICO question but was felt to be of importance and had advice to
do it this way.
The relative importance or values of the main outcomes of interest:
Additional considerations
- Adult worksheet on this topic.
- Worksheet from 2010 - which
also included radiological studies
which were specifically excluded
from this worksheet.
- There are many mannequin
studies which consider depth of
chest compressions as part of
quality of CPR. They have also
been excluded from this
worksheet as they do not have
outcome data. The main findings
of these papers were that the
quality of CPR can be improved
upon.
- The other whole area that is
not covered by this worksheet
but is related to the topic is the
question of mattress deflection
and the surface upon which CPR
is performed which is also
intimately related to chest
compression depth. It is touched
upon in the worksheet as one
paper compensates for mattress
deflection and another does
not.
Criteria
Judgements
○ Low
○ Moderate
○ High
○ Important
uncertainty or
variability
○ Possibly
Is there
important
uncertainty
about how much
people value the
main outcomes?
important
uncertainty or
variability
○ Probably no
important
uncertainty of
variability
Research evidence
Survival with good neurological
outcome
CRITICAL
Survival to discharge
CRITICAL
24 hour survival
IMPORTANT
Return of spontaneous
circulation
IMPORTANT
Outcome
○ No known
undesirable
Are the
desirable
anticipated
effects large?
○ No
○ Probably no
Certainty of the evidence
(GRADE)
⨁◯◯◯
VERY LOW
⨁◯◯◯
VERY LOW
⨁◯◯◯
VERY LOW
⨁◯◯◯
VERY LOW
Summary of findings: chest compression depth < 50mm
● No
important
uncertainty of
variability
Relative
importance
Outcome
Additional considerations
Survival with
good
neurological
outcome
Survival to
Without AHA
compliant chest
compression
depths > 51mm
With AHA
compliant chest
compression
depths > 51mm
47 per 1000
0 per 1000
(0 to 0)
63 per 1000
0 per 1000
Difference
(95% CI)
not estimable
not estimable
Relative
effect
(RR)
(95% CI)
not
estimable
not
Criteria
Judgements
○ Uncertain
○ Probably
yes
● Yes
○ Varies
Are the
undesirable
anticipated
effects small?
Are the
desirable effects
large relative to
undesirable
effects?
○ No
○ Probably no
○ Uncertain
● Probably
yes
○ Yes
○ Varies
○ No
○ Probably no
○ Uncertain
● Probably
yes
○ Yes
Research evidence
Additional considerations
discharge
(0 to 0)
24 hour
survival
156 per 1000
656 per 1000
(337 to 878)
500 more per
1000 (from
181 more to
722 more)
OR 10.3
(2.75 to
38.8)
313 per 1000
657 per 1000
(379 to 857)
344 more per
1000 (from
66 more to
545 more)
OR 4.21
(1.34 to
13.2)
Return of
spontaneous
circulation
estimable
Criteria
Judgements
Research evidence
Additional considerations
○ Varies
No out of hospital evidence.
Are the
resources
required small?
○ No
○ Probably no
● Uncertain
○ Probably
yes
○ Yes
○ Varies
Resource
use
Is the
incremental cost
small relative to
the net benefits?
○ No
○ Probably no
● Uncertain
○ Probably
yes
○ Yes
Problem is more complex than
question initially appears.
Sutton 2014 1179 One in-hospital prospective observational study with 89 cardiac
Guidelines of compressing chest
compression (CC) events where AHA compliant CC depths were associated with
to a depth of 1/3 AP diameter or
higher 24 hr survival even after accounting for potential confounding patients and
> 50 mm in or out of hospital
event factors.
are fine, but how to we actually
teach and measure this? In
hospital when we often have
Two very small studies Maher 2009 662 and Sutton 2013 168 (6 infants and 9
children and adolescents) looking at physiological endpoints suggesting compressions physiological endpoints (intrathat are AHA compliant are associated with improved blood pressure parameters.
arterial line) should we be
aiming for an approximate depth
or a physiological guideline, or
should we be recommending
that chest compression depth be
measured ( QCPR) which does
require resources. I am not
sure if we are asking the right
questions for the right groups of
patients.
No evidence
Very difficult to teach or
measure chest compressions as
the guidelines stand, if QCPR or
other measuring and feedback
devices were recommended that
would have a cost implication.
but that is not the subject of this
worksheet question.
Criteria
Judgements
Research evidence
Additional considerations
○ Varies
○ Increased
○ Probably
Note that most of the data in this area comes out of one centre - a large US teaching
hospital with an excellent record of high quality CPR.
increased
Equity
What would be
the impact on
health
inequities?
● Uncertain
○ Probably
However if the outcome is no change to present guideline then there is no impact to
present health inequity, other than the already present inequities.
reduced
○ Reduced
○ Varies
Is the option
acceptable to
Acceptability
key
stakeholders?
○ No
○ Probably no
○ Uncertain
● Probably
yes
○ Yes
○ Varies
In relation to the 2014 Sutton paper of 89 events showing that AHA compliant events The lack of evidence, the fact
better 24 hr survival than non- compliant events.
more research is needed, more
research needed from other
centres and that the research
needs to broaden to look at
physiological endpoints with inAlso in relation to Maher and Sutton 2013, overall finding is still "pushing harder,
hospital cardiac events and at
pushing faster' and good quality CPR is what makes a difference.
how we measure quality CPR
with out of hospital events, will I
think all be acceptable to key
stakeholders. We think it will be
acceptable that the present
guidelines are not changing
given the lack of evidence to do
so.
Criteria
Feasibility
Judgements
Is the option
feasible to
implement?
○ No
○ Probably no
○ Uncertain
○ Probably
Research evidence
Additional considerations
In terms of continue with present guideline until more evidence is available, but
continue the present emphasis on teaching good quality CPR.
yes
● Yes
○ Varies
Recommendation
Should AHA compliant chest compression depths > 51mm vs. chest compression depth < 50mm be used for children
> 1 year who recieve cardiac compressions?
Balance of
consequences
Type of
recommendation
Undesirable consequences
clearly outweighdesirable
consequences in most settings
Undesirable consequences
probably outweigh desirable
consequences in most
settings
The balance between
desirable and undesirable
consequences is closely
balanced or uncertain
Desirable consequences
probably outweigh
undesirable consequences
in most settings
Desirable consequences
clearly outweigh
undesirable consequences
in most settings
○
○
○
●
○
We recommend against offering this
option
We suggest not offering this
option
We suggest offering this
option
We recommend offering this option
○
Recommendation
○
●
○
We suggest no change to 2010 guideline. Present evidence supports on-going emphasis on good quality CPR and that adherence to these
guidelines may result in improving outcomes and this should continue to be reflected in the guidelines. We suggest offering this option.
For the critical outcomes of "survival with good neurological outcome" and "survival to hospital discharge" we have identified very low quality
evidence (downgraded for indirectness and imprecision) from one observational study (Sutton 2014 1179) enrolling 89 cardiac arrest events,
showed AHA compliant events trended to better survival but did not reach significance.
Justification
For the important outcomes of "24 hour survival" and "ROSC" we have identified very low quality evidence (downgraded for indirectness and
imprecision and imprecision) from the same observational study showing AHA compliant chest compressions (>51 mm) are associated with
better survival 24 hr: aOR 10.3 CI (95%) 2.75-39.8 p< 0.001 and ROSC: aOR 4.21 CI (95%) 1.34-13.2 p=0.014.
For the important outcome of physiological endpoints we have identified very low quality evidence (Maher 2009 662 and Sutton 2013 168)
(downgraded for risk of bias, indirectness and imprecision) from two observational studies enrolling 6 and 9 patients, both finding a trend towards
AHA chest compression depth targets being associated with improved predefined BP targets.
Subgroup
considerations
There is so little evidence that it is not possible to comment upon subgroups. However it is important to note that that while there is an overall
lack of evidence, the little evidence there is applies to in-hospital cardiac arrest and no research has been done in the area of out of hospital
pediatric cardiac arrest. for technological reasons there is also a lack of knowledge in the infant group, and in those under 8 years of age.
Implementation
considerations
As the decision is no change to present guidelines there are no implementation considerations.
Monitoring and
evaluation
No change to present guideline therefor nothing new to be monitored, but on-going evaluation of quality of CPR and outcomes of cardiac arrest
are useful in on-going decision making processes for the future and are to be encouraged.
Many,
- research by more than one main centre
- mattress deflection and surface of CPR effect
Research
possibilities
- infant research and more information on those less than 8 years of age
- out of hospital research
- how quality CPR is taught in terms of chest compression depth, eg in Australia ambulance are using QCPR as routine, should that be standard,
should we use chest compression depth in ICU's or should we use physiological end points?