Rescuer Fatigue Using Two Thumb Versus Two Finger Method During Simulated Neonatal Cardiopulomnary Resuscitation
Condition: Cardiac Output, High
MeSH terms: Cardiac Output, High
Study type: Interventional

Summary: 
      The majority of newborns transition successfully from intrauterine to extrauterine life
      without any assistance. Less than 1% of all newborns will require extensive neonatal
      resuscitation involving chest compressions (CC) and medications at birth 1. Chest
      compressions are indicated for those newborns whose heart rate remains less than 60 beats per
      minute despite adequate ventilation 1. The American Heart Association (AHA) identifies two
      different methods of delivering chest compressions; a) the two-thumb (TT) method and b) the
      two-finger (TF) method. The two-thumb method is favoured by the AHA as it results in higher
      blood pressure and coronary perfusion pressures and can also be delivered from the head of
      the bed during umbilical catheter insertion 1.

      The quality of CC plays a vital role in delivering effective cardiopulmonary resuscitation
      (CPR). Solevag et al. report that high-quality CC requires (A) optimal
      compression:ventilation (C:V) ratio, (B) adequate CC rate, (C) depth of CC as well as (D)
      full recoil between compressions 2. The American Heart Association (AHA) recommend delivering
      chest compressions on the lower third of the sternum to a depth of one third the
      anterior-posterior (AP) chest diameter. The recommended C:V ratio is 3:1 (90 compressions and
      30 breaths per minute) 1.

      A number of studies have highlighted the effects of rescuer fatigue on quality of chest
      compressions. One study reported adverse effects on CC quality when performed without
      interruption over a 3 minute period 6. It has therefore been recommended to rotate rescuers
      every 2-3 minutes in order to avoid rescuer fatigue and to ensure high quality CC6-7. As well
      as duration of CC, other factors can contribute to greater levels of rescuer fatigue. A
      number of studies have looked at the effect of different CC to ventilation methods on rescuer
      fatigue. Bodingh et al investigated this during simulated infant CPR. They reported greater
      levels of rescuer fatigue during simulated CPR in CCaV (continuous CC with asynchronous
      ventilation) at 120 CC per min compared to the recommended 3:1 C:V CPR 3. A similar study was
      performed by Li et al where rescuer fatigue was assessed during (i) 3:1 C:V ratio, (ii) CCaV
      at 90 CC per min and (iii) CCaV at 120 CC per min. However, unlike Bodingh et al, they found
      both 3:1 C:V and CCaV CPR to be equally fatiguing 4. Different CC techniques (TT vs TF
      method) can also cause varying levels of rescuer fatigue. In a recent study, Jiang et al
      compared the TT and TF chest compression techniques on infant mannequins and found that the
      TF method caused greater levels of rescuer fatigue compared with the TT method 5. We
      therefore set out to investigate whether different CC techniques cause different levels of
      rescuer fatigue during neonatal CPR. We hypothesize that performing TF method on neonatal
      mannequins will produce greater levels of rescuer fatigue. The results of this study would
      have significant implications in terms of choice of CC technique in new-born resuscitation.

      The purpose of this study is to compare rescuer fatigue during simulated neonatal chest
      compressions using two different CC methods; the two-finger (TF) method vs two-thumb (TT)
      method. This will be performed on both preterm and term mannequins by neonatologists and
      level of fatigue will be assessed by measuring change in cardiac output during chest
      compressions.

      Hypothesis: Performing CC using the two-finger (TF) method produces higher levels of rescuer
      fatigue compared with the two-thumb (TT) method during 5 minutes of simulated neonatal CPR.
    

Detailed description: 
      Inclusion criteria

        1. Neonatology NCHD's from CUMH

        2. Participants must have completed Neonatal Resuscitation Programme (NRP)

        3. Participants must be working as doctors in the area of neonatology Exclusion criteria

      1. Any history of cardiac or respiratory disorder 2. Physicians who are post-call/sleep
      deprived

      Intervention:

      This will be a crossover trial. Each participant will be assigned to performing ether TT or
      TF chest compressions. The participant will each perform 5 minutes of simulated chest
      compressions either a term or preterm mannequin using 3:1 C:V CPR. Each participant will have
      NICOM leads attached to their body which will record HR and cardiac output. One week later
      the participant will cross over and perform the alternate CC technique. The trial will
      initially be performed on a term mannequin for the first 2 weeks before being repeated on a
      preterm mannequin.

      Data Collection:

      Recorded data will include: Age, gender, ethnicity, weight, height, BMI, HR and cardiac
      output. Participants will have an allocated study number, ensuring that the data collected
      will be anonymised. The list of study numbers and data will be stored in a secure password
      protected database in the Neonatal Unit. Only people involved in the study and other
      authorised persons will have access to this information.

      Outcome Measures:

      Primary Outcome Measure:

      Percentage change in cardiac output after 5 minutes of simulated neonatal CPR using two
      different chest compression methods (2-finger method vs. 2-thumb method) on term and preterm
      mannequins.

      Secondary Outcome Measure:

      Perceived level of fatique. At the end of the study session each subject will complete a
      Likert scale-based questionnaire on subjective feeling of fatigue.
    

Intervention name(s): Two Finger technique; Two Thumb Technique
Intervention type(s): Behavioral; Behavioral
Intervention description(s): two finger method for chest compression provuision; Two thumb technique
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Single (Participant)
Primary purpose: Diagnostic