• Aucun résultat trouvé

Summary Cardiovascular Care Science With TreatmentRecommendations 2017 International Consensus on Cardiopulmonary Resuscitation andEmergency Resuscitation

N/A
N/A
Protected

Academic year: 2021

Partager "Summary Cardiovascular Care Science With TreatmentRecommendations 2017 International Consensus on Cardiopulmonary Resuscitation andEmergency Resuscitation"

Copied!
14
0
0

Texte intégral

(1)

ContentslistsavailableatScienceDirect

Resuscitation

j o ur na l h o me pa g e:ww w . e l s e v i e r . c o m / l o c a t e / r e s u s c i t a t i o n

ILCOR

Summary

Statement

2017

International

Consensus

on

Cardiopulmonary

Resuscitation

and

Emergency

Cardiovascular

Care

Science

With

Treatment

Recommendations

Summary

Theresa

M.

Olasveengen,

Allan

R.

de

Caen,

Mary

E.

Mancini,

Ian

K.

Maconochie,

Richard

Aickin,

Dianne

L.

Atkins,

Robert

A.

Berg,

Robert

M.

Bingham,

Steven

C.

Brooks,

Maaret

Castrén,

Sung

Phil

Chung,

Julie

Considine,

Thomaz

Bittencourt

Couto,

Raffo

Escalante,

Raúl

J.

Gazmuri,

Anne-Marie

Guerguerian,

Tetsuo

Hatanaka,

Rudolph

W.

Koster,

Peter

J.

Kudenchuk,

Eddy

Lang,

Swee

Han

Lim,

Bo

Løfgren,

Peter

A.

Meaney,

William

H.

Montgomery,

Peter

T.

Morley,

Laurie

J.

Morrison,

Kevin

J.

Nation,

Kee-Chong

Ng,

Vinay

M.

Nadkarni,

Chika

Nishiyama,

Gabrielle

Nuthall,

Gene

Yong-Kwang

Ong,

Gavin

D.

Perkins,

Amelia

G.

Reis,

Giuseppe

Ristagno,

Tetsuya

Sakamoto,

Michael

R.

Sayre,

Stephen

M.

Schexnayder,

Alfredo

F.

Sierra,

Eunice

M.

Singletary,

Naoki

Shimizu,

Michael

A.

Smyth,

David

Stanton,

Janice

A.

Tijssen,

Andrew

Travers,

Christian

Vaillancourt,

Patrick

Van

de

Voorde,

Mary

Fran

Hazinski,

Jerry

P.

Nolan,

On

behalf

of

the

ILCOR

Collaborators

a

r

t

i

c

l

e

i

n

f

o

Keywords:

AHAScientificStatements Cardiopulmonaryresuscitation Heartmassage

a

b

s

t

r

a

c

t

TheInternationalLiaisonCommitteeonResuscitationhasinitiatedanear-continuousreviewof car-diopulmonaryresuscitationsciencethatreplacestheprevious5-yearcyclicbatch-and-queueapproach process.ThisisthefirstofanannualseriesofInternationalConsensusonCardiopulmonaryResuscitation andEmergencyCardiovascularCareScienceWithTreatmentRecommendationssummaryarticlesthat willincludethecardiopulmonaryresuscitationsciencereviewedbytheInternationalLiaisonCommittee onResuscitationinthepreviousyear.Thereviewthisyearincludes5basiclifesupportand1 paedi-atricConsensusesonCardiopulmonaryResuscitationandEmergencyCardiovascularCareScienceWith TreatmentRecommendations.Eachoftheseincludesasummaryofthescienceanditsqualitybasedon GradingofRecommendations,Assessment,Development,andEvaluationcriteriaandtreatment recom-mendations.InsightsintothedeliberationsoftheInternationalLiaisonCommitteeonResuscitationtask forcemembersareprovidedinValuesandPreferencessections.Finally,thetaskforcemembershave pri-oritisedandlistedthetop3knowledgegapsforeachpopulation,intervention,comparator,andoutcome question.

©2017EuropeanResuscitationCouncilandAmericanHeartAssociation,Inc.PublishedbyElsevier B.V.Allrightsreserved.

Untilrecently,theInternationalLiaisonCommitteeon Resusci-tation(ILCOR)cardiopulmonaryresuscitation(CPR)sciencereview process has been undertaken in 5-year cycles, the last being

夽 ThisarticlehasbeencopublishedinCirculation:CardiovascularQualityand Out-comes.

published in 2015.1,2 This batch-and-queue approach has the advantageofenabling a well-plannedand systematicupdateof guidelinesand training materials,butit couldpotentiallydelay theimplementationofneweffectivetreatments.In2016,ILCOR adoptedanewprocessthatwouldenableanear-continuousreview ofresuscitationsciencebyusingtaskforce–prioritisedpopulation, intervention, comparator,and outcome (PICO) questions. There willbe2distinct pathwaysfor evidenceevaluation.Knowledge

https://doi.org/10.1016/j.resuscitation.2017.10.021

(2)

synthesisunits(KSUs),organisationswithexpertiseinsearching scientificdatabasesandperformingsystematicreviewsand meta-analyses,willaddressPICOsthatarelargeandcomplicatedortopics forwhichseveralPICOscanbegroupedtogetherandaddressed throughsensitivityorsubgroupanalyses.Contractedsystematic reviewerswillundertakesimplesystematicreviewsinvolving typi-callysinglePICOquestions.Bothpathwaysinvolvecontentexperts, andcriticalstepsduringevidenceevaluationarediscussedwith relevanttaskforceswhenneeded.

TheGradingofRecommendations,Assessment,Development, andEvaluation(GRADE)processthatwasadoptedfortheILCOR “2015 International Consensus on Cardiopulmonary Resuscita-tionandEmergencyCardiovascularCareScienceWithTreatment Recommendations”(CoSTR)willalsobeusedforthecontinuous review of CPRscience.3 In theGRADE approach, thequality of evidencesupportinginterventioneffects(definedbythePICO ques-tion)israted as high,moderate, low, or verylow. Randomised controlledtrials(RCTs)startashigh-qualityevidence,and observa-tionalstudiesstartaslow-qualityevidence.Fivefactorsmaylead todowngradingofthequalityofevidence,and3factorsmayenable anupgradeofthequalityofevidence(Table).4–9Thequality assess-mentsforeachoutcomearesummarisedinGRADEevidenceprofile tables,whichalsoincludeasummaryoffindingsintheformofthe numbersofpatients,therelativerisk(RR),andanindicationofthe absoluterisk(describedastheriskdifference[RD]).

ThisisthefirstofaseriesofannualILCORCoSTRsummary arti-clesthatwillincludetheCPRsciencereviewedbyILCORinthe previousyear.Thereviewthisyearincludes5basiclifesupport (BLS)CoSTRsand1paediatricCoSTR.TheCoSTRswereproduced aftera systematic review bythe KSUat St. Michael’sHospital, Toronto,ON,Canada,incollaborationwithILCORcontentexperts andmembersoftheILCORBLSandPaediatricTaskForces.Allthe evidenceprofiletablesandmeta-analyseswereproducedbythe KSUandreviewedbyILCORBLSandPaediatricTaskForces.The CoSTRshavebeensubjectedtorigorousevaluation,peerreview, andpubliccomment.Weanticipatethatby2018,≈20PICO ques-tionswillbeaddressedperyear,andeachquestionwillgeneratea draftCoSTRthatwillbepublishedontheILCORwebsite.10Thedraft CoSTRspublishedonlinewillprovidethedatafortheannualCoSTR summaryarticlethatwillbepublishedeachyear.Thesummary articlediffersinseveralrespectsfromthedraftCoSTRspublished ontheILCORwebsite:Thelanguageusedtodescribethescience isnotrestrictedtostandardGRADEterminology,whichmakesit moreaccessibletoawideraudience;thevaluesandpreferences havebeenexpandedtoprovidegreaterinsightintotherationalefor treatmentrecommendations,particularlywhenhigh-quality evi-denceislacking;andthetop3knowledgegapsforeachtopichave beenprioritisedandrankedbythetaskforcemembers.

TableGRADEQualityAssessmentCriteria

StudyDesign Qualityof Evidence Lowerif Higherif Randomised trial High Moderate Riskofbias Inconsistency Largeeffect Doseresponse Observational study Low Verylow Indirectness Imprecision Publicationbias Allplausible confounding:would reduceademonstrated effectorwouldsuggest aspuriouseffectwhen resultsshownoeffect

TheCoSTRsarebasedonthedatasummarisedintheGRADE evidenceprofiletablesforeachofthekeyoutcomesforeachofthe clinicalscenarios.Thepertinentoutcomedataarelistedforeach statementasRR(with95%confidenceinterval[CI])andRD(with 95%CI).TheRDistheabsolutedifferencebetweentherisksand iscalculatedbysubtractingtheriskinthecontrolgroupfromthe

riskintheinterventiongroup.Thisabsoluteeffectenablesamore clinicallyusefulassessment ofthemagnitudeoftheeffectofan interventionandenablescalculationofthenumberneededtotreat (=1/RD).

CPRStrategies:Background

Oneoftheprimarymeasurestakentoimprovesurvivalafter car-diacarresthasbeenfocusedeffortstoimprovethequalityofCPR. Althoughtheimpactofhigh-qualitychestcompressionshasbeen studiedextensively,11–14theroleofventilationandoxygenationis lessclear.Effortstosimplifyresuscitationbydelayingventilation orbyprovidingpassiveoxygenationhavebeenimplementedfor bothlayandprofessionalrescuers.Thesestrategieshavebeen con-sistentlyassociatedwithincreasedbystanderCPRratesandfewer pausesinchestcompressions,buteffectsonsurvivalhavebeenless clear.15–18

Duringthedevelopmentofthe2015CoSTR,severalPICO ques-tionswerededicatedtoreviewingevidenceofcontinuouschest compressionstrategiesforbothlayand professionalrescuersin variouspopulations(adult,paediatric)andforvarioussettings(in hospital,out of hospital).19–22 Shortlyafter thesereviewswere completed,a 23711-patient RCTevaluating theeffectiveness of continuous chest compressionsin the emergency medical ser-vices(EMS)settingwaspublished.23Inparallel,developmentsof largenationalandregionalregistriesarecontinuallyprovidingnew insights into the epidemiology of cardiac arrest and bystander CPR.24Theseemergingpublicationsgeneratedanurgentneedto reviewallavailableevidenceoncontinuouscompressionstrategies toprovideupdatedevidenceevaluationsthatincludedthelatest scienceavailable.Thesystematicreviewandmeta-analysisofthis topicundertakenbySt.Michael’sHospitalKSUandILCORhasbeen publishedseparately.25

ThePopulation,Intervention,Comparator,Outcome,Study Designs,andTimeFrame

Thefollowing wasusedby St.Michael’s HospitalKSUwhen undertakingthesystematicreview:

• Population:Patientsofallages(eg,neonates,children,adults) withcardiacarrestfromanycauseandacrossallsettings(in hos-pitalandoutofhospital)wereincluded.Studiesthatincluded animalswerenoteligible.

• Intervention:AllmanualCPRmethods,including compression-onlyCPR,continuouscompressionCPR,andCPRwithdifferent compression-to-ventilation(CV)ratios,wereused. Compression-onlyCPRincludedcompressionswithnoventilations;continuous compressionCPRincludedcompressionswithasynchronous ven-tilationsorminimallyinterruptedcardiacresuscitation.Studies thatmentionedtheuseofamechanicaldeviceduringCPRwere consideredonly if the same device wasused acrossall rele-vantinterventionarmsand wouldthereforenotconfoundthe observedeffect.

• Comparators:Studieshad tocompare atleast2differentCPR methodsfromtheeligibleinterventions;studieswithouta com-paratorwereexcluded.

• Outcomes:The primaryoutcome wasfavourableneurological outcomes, measured by cerebral performance or a modified RankinScale.Secondaryoutcomesweresurvival,returnof spon-taneouscirculation,andqualityoflife.

• Study designs: RCTs and nonrandomised studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohortstudies)wereeligibleforinclusion.Studydesigns

(3)

with-outacomparatorgroup(eg,caseseries,cross-sectionalstudies), reviews,andpooledanalyseswereexcluded.

• Timeframe:PublishedstudiesinEnglishsearchedonJanuary15, 2016,wereincluded.

Dispatch-AssistedCompression-OnlyCPRComparedWith Dispatch-AssistedConventionalCPR(Adults):Consensuson Science

Dispatch-assistedcompression-onlyCPR wascompared with dispatch-assistedconventionalCPR(ratioof15compressionsto 2ventilations)in1RCTthatgeneratedlow-qualityevidencefor favourableneurologicalfunction.16 Thequality ofevidencewas downgradedforseriousimprecisionbecauseonly2ofthe3sites provided data onneurological outcome. In this study, instruc-tionstogivecontinuouschestcompressionshadnodemonstrable benefit for favourable neurological function (RR, 1.25 [95% CI, 0.94–1.66];RD,2.86percentagepoints[95%CI,−0.80to6.53]) com-paredwithinstructionstogivecompressionsandventilationsata ratioof15:2.

Dispatch-assisted compression-only CPR compared with dispatch-assistedconventionalCPR(ratioof15compressionsto 2ventilations) in 3RCTsprovided low-qualityevidenceforthe criticaloutcomeofsurvivaltohospitaldischarge.15–17Thequality ofevidenceforthesestudieswasdowngradedbecauseofserious riskofbias: All3studiesexcludedpatientsafterrandomisation andincludedaninterventionthatcouldnotbeblinded,andinat least1study,manyoutcomedataweremissing.17Inapreviously publishedmeta-analysis of thesestudies, there appeared tobe asmallbenefitinsurvivaltohospitaldischargeinfavourofthe groupinstructedtogivecontinuouschestcompressionscompared withthegroupinstructedtogivecompressionsandventilations ataratioof15:2(RR,1.22[95%CI,1.01–1.46];RD,2.4percentage points[95%CI,0.1–4.9];fixed-effectmodel;P=0.04).26This meta-analysisusedsurvivaltohospitaldischargeforall3studies,15–17 althoughtheSwensonstudywasmissing 55%oftheseoutcome data.Inameta-analysisusingarandom-effectmodeltocombine survivaltohospitaldischarge15,16and30-daysurvival17outcomes tocapturethemaximumamountofdata,survivalwasnolonger significantly different between the 2 groups. Continuous chest compressionshad anRR forsurvivalof1.20 (95%CI, 1.00–1.45; RD,1.88percentagepoints[95%CI,−0.05to3.82])comparedwith conventional15:2CPR.

TreatmentRecommendation

We recommend that dispatchers provide chest compression–only CPR instructions to callers for adults with suspected out-of-hospitalcardiacarrest (OHCA) (strong recom-mendation,low-qualityevidence).

ValuesandPreferences

In making these recommendations, we recognise that the evidenceinsupportoftheserecommendationscomesfrom ran-domisedtrialsofvariablequalityperformedatatimewhenthe ratioofchestcompressionstoventilationswas15:2,whichleads togreaterinterruptionstochestcompressionsthanthecurrently recommendedratioof30:2.However,thesignalfromeverytrial is consistently in favourof telephoneCPR protocols thatuse a compression-onlyCPR instructionset.Reviewing thetotalityof availableevidenceandconsideringcurrentcommonpractice, train-ing, and quality assuranceexperiences, theBLS Task Force has keptthestrong recommendationfor compression-only CPR for dispatch-assisted CPR despite low-quality evidence. In making theserecommendations,weplacedahighervalueontheinitiation

ofbystandercompressionsandalowervalueonpossibleharmsof delayedventilation.Thetaskforcerecognisesthattherearemany unansweredquestionswhenbalancingpossiblebenefitsandharms frombystanderventilation.Mostnotably,althoughsomecardiac arrestpathogeneses(eg,asphyxialcardiacarrest)mightbe depen-dentonearlyventilationtoincreasesurvival,bystanders’abilityto learnhowtoperformmouth-to-mouthventilationsoverthephone is notknown.Possible harmfuleffects ofincorrectly performed ventilations(gastricinflation)andfewercompressionsperformed beforeambulancearrivalbecauseofmorecomplexinstructionsand pausesforventilationwereweightedmoreheavilythanpotential benefitsfromearlyventilation.

Thisdocumentreferstodispatch-assistedCPR.Inadoptingthis terminology,weacknowledgethatthedispatchingofemergency medicalresourcesisalimiteddescriptionofthetasksperformedby multiprofessionalteamsworkinginemergencymedicaldispatch centres,andperhapsmoresuitableoptionsarebeingused world-wide.Theyincludetelecommunicators,ambulancecommunication officers,emergencymedicalcommunicators,andcallhandlers,as wellasothertermsmorecloselyrelatedtotheiractualtask descrip-tion.

KnowledgeGaps

Severalknowledgegapswereidentifiedinthereviewofthis topic.AmorecomprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3arethefollowing:

1Whatistheoptimalinstructionsequenceforcoachingcallersin dispatch-assistedCPR?

2Whataretheidentifyingkeywordsusedbycallersthatare asso-ciatedwithcardiacarrest?

3Whatistheimpactofdispatch-assistedCPRinstructionson car-diacarrestsfromnoncardiaccausessuchasdrowning,trauma, orasphyxiainadultandpaediatricpatients?

BystanderCompression-OnlyCPRComparedWith BystanderCPRUsingCompressionsandVentilations (Adults):ConsensusonScience

BystanderCPR usingchestcompressionsonlywascompared withbystanderCPRusingaCVratioof15:2or30:2in6cohort studies that generated very-low-quality evidence for the crit-ical outcome of favourable neurological function.24,27–31 In a meta-analysis of 2 studies, there was no significant difference in favourable neurological function in patients who received compression-onlyCPRcomparedwithpatientswhoreceivedCPR ataCVratioof15:2(RR,1.34[95%CI,0.82–2.20];RD,0.51 per-centagepoints[95%CI,−2.16to3.18]).27,29Thequalityofevidence wasdowngradedforseriousindirectnessandimprecisionbecause ofvaryingresultsacrossstudies,becausethecontrolgrouphad a different CV ratio from the intervention group, and because therewasvariablepostarrestcare.In ameta-analysisof3 stud-ies,therewasnosignificantdifferenceinfavourableneurological function in patientswho receivedcompression-only CPR com-paredwithpatientswhoreceivedcompressionsandventilations during a period when theCV ratiochanged from15:2 to30:2 (RR,1.12[95%CI,0.71–1.77];RD,0.28percentagepoints[95%CI, −2.33to2.89]).28,30,31Thequalityofevidencewasdowngraded forseriousindirectnessandimprecisionbecausethecontrolgroup had a differentCVratiofromtheintervention groupand there wasvariablepostarrestcare.Onestudyexaminedtheinfluenceof nationwidedisseminationofcompression-onlyCPR recommenda-tionsforlayrescuersandshowedthat,althoughbystanderCPR

(4)

ratesand nationwide survival improved, patientswhoreceived compression-onlyCPRhadlowersurvivalcomparedwithpatients whoreceivedchestcompressionsandventilationsataCVratioof 30:2(RR,0.72[95%CI,0.69–0.76];RD,−0.74percentagepoints[95% CI,−0.85to0.63]).24Thequalityofevidencewasdowngradedfor seriousindirectnessbecausethestudydidnotdirectlycompare compression-onlyCPRwithCPRwithchestcompressionsand ven-tilationsbutrathercomparedcompression-onlyandCPRwithchest compressionsandventilationswithnoCPR.Theevidencewasalso consideredindirectbecausemultipleaspectsofresuscitationwere likelytohavechangedovertimeinthisbefore-and-afterstudy.

BystanderCPRusingcompression-onlyCPRwascomparedwith bystanderCPRusingaCVratioof15:2or30:2in7cohortstudies thatgeneratedvery-low-qualityevidenceforthecriticaloutcome of survival.24,27,29,32–35 In a meta-analysis of 6 studies, there wasnosignificantdifferenceinsurvivalinpatientswhoreceived compression-onlyCPRcomparedwithpatientswhoreceivedCPR ataCVratioof15:2(RR,0.88[95%CI,0.74–1.04];RD,−0.83 per-centagepoints[95%CI,−1.85to0.19]).27,29,32–35 Thequalityof evidencewasdowngradedfor seriousrisk ofbias and indirect-ness.Riskofbiaswasrelatedtothecomparabilityofthecohorts becausethe majority did not adjust for potential confounders. Thestudieswerealsodowngradedforindirectnessbecausethey eitherwereinvestigatingCPRguidelinechangesordidnot explic-itlyreporttheCVratioamongincludedcases.In1study,patients receivingcompression-onlyCPRhadworsesurvivalcomparedwith patientswho receivedCPRat aCVratio of30:2(RR, 0.75[95% CI, 0.73–0.78]; RD, −1.42 percentage points [95% CI, −1.58 to −1.25]).24 Thequality of evidencewasdowngraded for serious indirectnessasdescribedearlier.Inameta-analysisof3 observa-tionalstudies,28,30,31therewasnosignificantdifferenceinsurvival when patientswho received compression-only CPR were com-paredwithpatientswhoreceivedCPRduringaperiodwhenthe CVratiochangedfrom15:2to30:2(RR,1.16[95%CI,0.64–2.09]; RD,1.27percentagepoints[95%CI,−3.70to6.23]).Thequalityof evidencewasdowngradedforseriousinconsistency,indirectness, andimprecisionasdescribedearlier.

TreatmentRecommendations

Wecontinuetorecommendthatbystandersperformchest com-pressionsforallpatientsincardiacarrest(goodpracticestatement). Inthe2015CoSTR,thiswascitedasastrongrecommendationbut basedonvery-low-qualityevidence.19,20

Wesuggestthatbystanderswhoaretrained,able,andwilling togiverescuebreathsandchestcompressionsdosoforalladult patientsincardiacarrest(weakrecommendation,very-low-quality evidence).

ValuesandPreferences

Inmakingtheserecommendations,thetaskforceplacedhigh valueonthe2010and 2015CoSTRs thatshowed thatrescuers should perform chest compressions for all patients in cardiac arrest.19,20,36,37Giventhatthe2017systematicreviewdidnotseek datacomparinganyCPRwithnoCPRandinkeepingwithGRADE recommendations,ourrecommendationforperformingchest com-pressionsforallpatientsincardiacarresthasbeencitedasagood practicestatement(seeAppendixes1and2).38Wealsoplacedhigh valueontheadvantagederivedfromthesimplicityof teaching orprovidinginstructionsforcompression-onlyCPR.This recom-mendationreflectsthevalueplacedonthedatathatindicateno apparentdownsideinpatientswithtruearrestwithsimilar sur-vivalratesfromadultcardiacarrestsofcardiacoriginbothwith andwithoutventilations.39,40Wealsoacknowledgedthe poten-tialadditionalbenefitsofCPRwithcompressionsandventilations

whendeliveredbytrainedlaypeople,particularlyinsettingswhere EMSresponseintervalsarelongorwhenthecauseofcardiacarrest isasphyxia.

KnowledgeGaps

Severalknowledgegapswereidentifiedinthereviewofthis topic.Amore comprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3arelistedhere:

1.Theeffectofdelayedventilationversus30:2high-qualityCPR. 2.The impact of continuous chest compressions on outcomes

forcardiacarrestsfromnoncardiaccausessuchas drowning, trauma,orasphyxiainadultandpaediatricpatients.

3.Theabilityofbystanderstoperformcorrectmouth-to-mouth ventilations.

EMS-DeliveredCPR:ConsensusonScience

High-qualityCPRincludesminimalinterruptionstochest com-pressions.ThreedistincttechniquesareusedbyEMS todeliver continuouschestcompressionCPRduringOHCA:(1)continuous chestcompressionswithpositive-pressureventilation(PPV)ofthe lungswithabag-maskdevicetypicallyatarateof10breathsper minute,(2)continuouschestcompressionsandPPVofthelungs viaatrachealtubeorsupraglotticairway,and(3)continuouschest compressionswithpassiveoxygenationtypicallywithan oropha-ryngealairway and simpleoxygenmask (a strategy sometimes referredtoasminimallyinterruptedcardiacresuscitation). Stud-iesinvolvingthesetechniqueshavetypicallydelayedinsertionof anadvancedairwayuntilafterreturnofspontaneouscirculationor 3cyclesofCPR.

For thecritical outcome offavourable neurologicalfunction, weidentifiedhigh-qualityevidencefrom1RCT23and very-low-qualityevidencefrom2cohortstudies.18,41IntheRCT,patients whowererandomisedtoPPVdeliveredwithabag-maskdevice withoutpausingchestcompressionshadnodemonstrablebenefit forfavourableneurologicalfunction(RR,0.92[95%CI,0.84–1.00]; RD,−0.65percentagepoints[95%CI,−1.31to0.02])comparedwith patientsrandomisedtoconventionalCPRwithaCVratioof30:2.23 In1cohortstudy,patientswhoreceivedcontinuouschest compres-sionsandpassiveventilationfor3cycleshadimprovedfavourable neurologicalfunction(RR,2.58[95%CI,1.5–4.47];RD,24.11 per-centagepoints[95%CI,11.58–36.63])comparedwiththosewho receivedcompressionsandventilationsatatimewhentheCVratio changedfrom15:2to30:2.41Thequalityofevidencewas down-gradedforseriousriskofbiasandindirectness.Riskofbiasincluded moderateriskthatthecontinuouschestcompressioncohortwas notrepresentativeandhighriskthattherewereconfounding fac-tors between the cohorts for which there was no adjustment. Thestudywasconsideredindirectbecauseofitsbefore-and-after designincludingaperiodwithchangingguidelines.Intheother cohortstudy,18minimallyinterruptedcardiacresuscitation (ini-tialseriesof3 cyclesof200uninterruptedchest compressions, passiveventilation,before-and-afterrhythmanalysiswithshock ifappropriate)inpatientswithwitnessedshockablecardiacarrest hadnodemonstrablebenefitforfavourableneurologicalfunction (RR,0.81[95%CI,0.57–1.13];RD,−11.30percentagepoints[95% CI,−28.48to5.87])comparedwithconventionalCPR(mixtureof CVratiosof15:2and30:2).Thequalityofevidencewas down-gradedforseriousriskofbias,indirectness,andimprecision.Risk ofbiasincludedmoderateriskthatthecontinuouschest compres-sioncohortwasnotrepresentativeandunclearriskofinadequate follow-up.Thestudywasconsideredindirectbecauseofits

(5)

before-and-afterdesignincludingaperiodwithchangingguidelinesand imprecisebecausetheCIsforRDcrossedfromappreciableharm (0.75)toappreciablebenefit(1.25).

Forthecriticaloutcomeofsurvival,weidentifiedhigh-quality evidence from 1 RCT23 and very-low-quality evidence from 1 cohortstudy.18IntheRCT,therewasnosignificantdifferencein survivaltodischargeofpatientsrandomisedtocontinuouschest compressionscomparedwithpatientsrandomisedtoconventional CPRwithaCVratioof30:2(RR,0.92[95%CI,0.85–1.00];RD,−0.76 percentagepoints[95%CI,−1.51to0.02]).23Inthecohortstudy,18 patientswith witnessed shockablecardiac arrest who received minimallyinterruptedcardiacresuscitationhadimprovedsurvival (RR,2.37[95%CI,1.69–3.31];RD,5.24percentagepoints[95%CI, 2.88–7.60])comparedwithconventionalCPRusingamixtureof 30:2and15:2CVratios.Thequalityofevidencewasdowngraded forseriousindirectnessandimprecisionasdescribedearlier. TreatmentRecommendations

WerecommendthatEMSprovidersperformCPRwith30 com-pressionsto2ventilationsorcontinuouschestcompressionswith PPVdeliveredwithoutpausingchestcompressionsuntilatracheal tubeorsupraglotticdevicehasbeenplaced(strong recommenda-tion,high-qualityevidence).

WesuggestthatwhenEMSsystemshaveadoptedminimally interruptedcardiacresuscitation,thisstrategyisareasonable alter-nativetoconventionalCPRforwitnessedshockableOHCA(weak recommendation,very-low-qualityevidence).

ValuesandPreferences

Inmakingtheserecommendations,thetaskforcetookinto con-siderationthat althoughthere wasrelative homogeneityinthe bodyofevidencearoundEMScontinuouschestcompressionsand adjunctivetherapies(eg,bundlesofcareinthecommunitysuch asimprovedbystanderCPRstrategiesandhospitalsystemsofcare suchastransferstoresuscitationcentres),therewas heterogene-ityinthecontinuousCPRventilationstrategies(ie,passiveversus PPV strategies) and in the comparatorgroups. The recommen-dationsreflect high-qualityevidence forthesafety ofCPR with compressionsandventilations(CVratio,30:2)byEMSproviders whileacknowledgingthelackof datasupportingsuperior func-tionalorsurvivaloutcomes.Thetaskforcealsoplacedarelatively highvalueontheimportanceofprovidinghigh-qualitychest com-pressionsandsimplifyingresuscitationlogisticsforEMSsystems andnotedthesupportfortheclinicalbenefitofbundlesofcare involvingminimallyinterruptedcardiacresuscitation.Inmaking aweakrecommendationinsupportofsystemsthathave imple-mentedminimallyinterruptedcardiacresuscitation,thetaskforce alsoacknowledgesthelackofRCTsevaluatingpassiveoxygenation strategiessuchasthosedescribedinminimallyinterruptedcardiac resuscitation.

KnowledgeGaps

Severalknowledgegapswereidentifiedinthereviewofthis topic.Amore comprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3follow:

1.Whatistheeffectofdelayedventilationversus30:2high-quality CPR?

2.Whichelementsofthebundledcare(compressions,ventilations, delayeddefibrillation)aremostimportant?

3.Howeffectiveis passiveoxygeninsufflation(applyinga flow ofoxygenviaafacemaskorasupraglotticairwaybutwithout PPV)?

In-HospitalCPR:ConsensusonScience

Only1cohortstudyevaluatingtheeffectofcontinuouschest compressionsinthein-hospital setting wasidentified.42In this study, PPV without interruption of chest compressions after trachealintubationwascomparedwithinterruptionofchest com-pressionsfor1ventilationaftereveryfifthchestcompression(a CVratioof5:1)amongpatientsadmittedtoahospitalemergency departmentafterOHCA.Chestcompressionsweredeliveredbya mechanicaldeviceknownastheThumperMechanicalCPRMachine (MichiganInstruments,GrandRapids,MI)inallpatients,adevice thatisnotcommonlyusedclinicallyandthatdelivereddifferent averagecompressionrates(70versus100perminute)betweenthe studyperiods.Thestudycomparedcontinuouschestcompressions andventilationsdeliveredafterevery10thcompression(without pausingcompressions)witha5:1CVratio(withpausesfor venti-lation)thatresultedinmorefrequentpausesincompressionsand higheroverallventilationratesthantheconventional30:2CVratio recommendedbythe2015CoSTR.19,20 Itwasconductedwitha before-and-afterdesignthat,althoughadjustedfordemographic and cardiac arrest characteristics,didnot account for potential temporal differencesinresuscitation efficienciesbetweenstudy periods.

Very-low-quality evidence was identified for the critical outcome of favourable neurological function.42 There was no differenceinfavourableneurologicaloutcomebetweenthe unin-terrupted10:1CPRandinterrupted5:1CPRcohorts(RR,1.18[95% CI,0.32–4.35];RD,0.29percentagepoints[95%CI,−2.05to2.64]). Thequalityofevidencewasdowngradedtoveryserious impreci-sionbecausetheCIsforRDcrossedfromappreciableharm(0.75) toappreciablebenefit(1.25).

Low-qualityevidencewasidentifiedforthecriticaloutcomeof survival.42Theuninterrupted10:1CPRcohorthadahighersurvival ratetohospitaldischargecomparedwiththeinterrupted5:1CPR cohort(RR,2.38[95%CI,1.22–4.65];RD,5.86percentagepoints [95%CI,1.19–10.53]).

TreatmentRecommendation

Whenever tracheal intubation or a supraglottic airway is achievedduringin-hospitalCPR,wesuggestthatproviders per-formcontinuouscompressionswithPPVdeliveredwithoutpausing chestcompressions(weakrecommendation,very-low-quality evi-dence).

ValuesandPreferences

Inmakingthisrecommendation,thetaskforcenotedthatthere is noprospectivestudyof in-hospitalCPR thatcompares deliv-eryofventilationsduringcontinuousmanualchestcompressions withventilationsdeliveredduringpausesinmanualchest com-pressions.Thetaskforceplacedvalueinthatdeliveringcontinuous chestcompressionsisacommonpracticeinmanysettingsafter trachealintubationorplacementofasupraglotticairway.Theonly studytohaveaddressedthisspecificquestioninanin-hospital set-tinghaslimitedapplicabilityinthatitwasperformedafterOHCA andinthecontextofmechanicalchestcompressions,alongwith otherlimitations.However,thefindingsofthisstudysupportthe treatmentrecommendation.

(6)

KnowledgeGaps

Severalknowledgegapswereidentifiedinthereviewofthis topic.AmorecomprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3areasfollows:

1.Noprospectivestudyofin-hospitalCPRcomparesdeliveryof ventilationsduringcontinuousmanualchestcompressionswith ventilationsdeliveredduringpausesinmanualchest compres-sions.

2.Whatistheeffectofdelayedventilationversus30:2high-quality CPR?

3.Whatistheoptimalmethodforensuringapatentairway? ChestCVRatio(Adults):ConsensusonScience

The30:2CVratiowascomparedwithadifferentCVratioin 2 observational cohort studies that generated very-low-quality evidence for the critical outcome of favourable neurological function.43,44Inameta-analysisofthesestudies,the30:2CVratio demonstratedbenefitforfavourableneurologicalfunction(RR,1.34 [95%CI,1.02–1.76];RD,1.72percentagepoints[95%CI,0.52–2.91]) compared with the CV ratio of 15:2. The quality of evidence wasdowngradedfor serious indirectnessbecausethesestudies werebefore-and-afterinvestigationsthatevaluatedthe bundle-of-careinterventionsimplementedafterthe“2005International ConsensusonCardiopulmonaryResuscitationandEmergency Car-diovascularCareScienceWithTreatmentRecommendations,”45,46 inwhichthechangeinCVratiowasjust1aspect.

Sevenobservationalcohortstudiesprovidedvery-low-quality evidenceforthecriticaloutcomeofsurvival.43,44,47–51The qual-ityofevidencewasdowngradedforseriousindirectnessbecause theCVratiowasnottheonlyaspectevaluatedinthesestudies.In ameta-analysisof6cohortstudies,thesurvivalratewashigher inthegroupof patientswhoreceived30:2CPRcomparedwith thegroupwhoreceived15:2CPR(RR,1.37[95%CI,1.19–1.59]; RD,2.48percentagepoints[95%CI,1.57–3.38]).43,44,47,49–51One retrospectivecohortshowedimprovedsurvivalwiththe50:2CV ratiocomparedwiththe15:2ratio(RR,1.96[95%CI,1.28–2.99]; RD,21.48percentagepoints[95%CI,6.90–36.06]).48Thequalityof evidencewasdowngradedforseriousriskofbiasandindirectness. Riskofbiasincludedhighriskthatthecohortswerenotcomparable onthebasisofdesignoranalysisandmoderateriskofinadequate follow-up.Thestudywasalsoconsideredindirectbecauseofits before-and-afterdesignpotentiallyevaluatingseveralchangesto practice.

TreatmentRecommendation

WesuggestaCVratioof30:2comparedwithanyotherCVratio inpatientswithcardiacarrest(weakrecommendation, very-low-qualityevidence).

ValuesandPreferences

Inmakingthisrecommendation,thetaskforceacknowledged thattherewouldlikelybesubstantialresourceimplications(eg, reprogramming,retraining)associated withachangein recom-mendation related to the CVratio. In theabsence of any data addressing the critical outcomes, the task force placed a high valueonmaintainingconsistencywiththe2005,2010,and2015 CoSTRs.19,20,36,37,45,46Wealsoplacedhighvalueonfindingsthat suggestthatabundleofcare(whichincludedaCVratioof30:2) resultedinmorelivesbeingsaved.

KnowledgeGaps

Severalknowledgegapswereidentifiedinthereviewofthis topic.Amore comprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3follow:

1.ThepossiblebenefitofhigherCVratios(morecompressionsper ventilations).

2.TheabilityofCPRproviderstodeliver2effectiveventilations duringtheshortpauseinchestcompressionsduringCPR. 3.Is there a ratio-dependent critical volume of air movement

requiredtomaintaineffectiveness?

BystanderCPRforPaediatricOHCA:ConsensusonScience Arecentsystematicreviewcomparedoutcomesassociatedwith bystander compression-only CPR with those of bystander CPR thatincludedchestcompressionsplusventilationfor paediatric OHCA.25Thereviewidentified2largeobservationalcohortstudies, bothusingdatafromJapan’snationwideAll-JapanUtsteinOHCA registry.52,53 This largemandatory registry includes all cardiac arrestsinpeopleofallagesinJapanandbothcardiacand non-cardiac(eg,trauma,hanging,drowning,drugoverdose,asphyxia, respiratorydiseases,cerebrovasculardiseases,malignanttumours) causesofarrest.Asof2017,itcontainsdatafrom>1millioncardiac arrests.

TheKitamuraetal52studyincludes5170eventsinchildren≤17 yearsofage,including2439eventsinwhichbystanderCPRwas performed,capturedfrom2005through2007.Atthetimeofthe study,resuscitationguidelinesinJapanweretransitioningfroma CVratioof15:2to30:2forpaediatricOHCA.TheGotoetal53study includes5056eventsinchildren18yearsofage,including2722 eventsinwhichbystanderCPRwasperformed,capturedfrom2008 through2010.Atthetimeofthestudy,paediatricCPRguidelinesin JapanrecommendedCPRthatincludedventilationwithaCVratio of30:2.Inaddition,nationalimplementationofadispatch-assisted CPRprogramwasoccurring.

Thequalityofevidencewasdowngradedtoverylowforthe critical outcome of favourable neurological function (Paediatric Cerebral PerformanceCategory [PCPC]1 or 2)at 1 month.52,53 Thequalityofevidenceforthesestudieswasdowngradedbecause ofseriousriskofbias(eg,potentialvariabilitybetween compari-songroups,single-country/healthcaresystemregistry,variability in protocolsamongfire/EMS departments),seriousindirectness (ie,the CVratioprovided was notspecifically described inthe publicationsandhad tobededucedfromthedescriptionofthe guidelinesandrecommendationsthatwerereportedtobeusedat thetimeofdatacollection),andseriousimprecision(wideCIs).In thefirststudy,inallchildren,survivalwithfavourable neurologi-calfunction(PCPC1or2)waslesslikelyamongchildrenreceiving chest compression–only CPR (RR, 0.46 [95% CI, 0.29–0.73]; RD, 3.02percentagepoints[95%CI,1.47–4.57]).52Afterfurther sub-groupanalysisbyage,patients1to17yearsofagewithbystander chestcompression–onlyCPRhadworseoutcomes(RR,0.46[95% CI,0.28–0.75];RD,4.34percentagepoints[95%CI,1.95–6.73]).In infants,outcomewasuniformlypoor,andtherewasno demon-strable difference in favourable neurological function whether bystandersprovidedchestcompression–onlyCPRorCPRwith ven-tilation(RR,0.39[95%CI,0.11–1.36];RD,1.31percentagepoints [95%CI,−0.17to2.80]).Thesecondstudydidnotreportresults divided by agesubgroups but identified fewer patients overall withfavourableneurologicalfunction(PCPC1or2)inthechest compression–onlyCPRgroupthaninthosereceivingCPRwitha CVratioof30:2,(RR,0.45[95%CI,0.31–0.66];RD,3.30

(7)

percent-agepoints[95%CI,1.71–4.88]).53Thesedatawerenotpublished intheoriginalarticlebutwereprovidedviae-mailfromthe cor-respondingauthorofthestudy(Y.Goto,MD,PhD,personale-mail communication,unpublisheddata,May2,2014).

Thequalityofevidencewasverylowforthecriticaloutcomeof survivalto1month.52,53Thequalityofevidenceforthesestudies wasdowngradedbecauseofseriousriskofbias,serious indirect-ness,andseriousimprecision(seereasonsfordowngradinggiven previously).IntheKitamuraetal52study,outcomeswereworsefor allchildrenwhoreceivedbystanderchestcompression–onlyCPR comparedwiththosewhoreceivedCPRwithventilation(RR,0.76 [95%CI,0.60–0.97];RD,2.98percentagepoints[95%CI,0.45–5.51]). Afterfurthersubgroupanalysisbyage,patients1to17yearsofage whoreceivedchestcompression–onlyCPRhad worseoutcomes (RR,0.70[95%CI,0.53–0.93];RD,4.74percentagepoints[95%CI, 1.17–8.31]).Ininfants,therewasnodemonstrabledifferencein sur-vivalto1month(RR,0.90[95%CI,0.56–1.45];RD,0.74percentage points[95%CI,−2.61to4.09]).IntheGotoetal53study,survivalwas worseamongchildrenwhoreceivedchestcompression–onlyCPR comparedwiththosewhoreceivedCPRwithventilation(RR,0.56 [95%CI,0.45–0.69];RD,7.04percentagepoints[95%CI,4.50–9.58]). Therewasnosubgroupanalysisfordifferentagesinthisstudy. TreatmentRecommendations

Wesuggestthat bystandersprovideCPRwithventilationfor infantsandchildren18yearsofagewithOHCA(weak recom-mendation,very-low-qualityevidence).

We continue to recommend that if bystanders cannot pro-viderescuebreathsaspartofCPRforinfantsandchildren18 yearsofagewithOHCA,theyshouldatleastprovidechest com-pressions(goodpracticestatement).Inthe2015CoSTR,thiswas citedasastrongrecommendationbutbasedonvery-low-quality evidence.21,22

AdditionalSciencePublishedSincetheSystematicReview WasCompleted

Afterthesystematicreviewwascompleted,2additional rel-evantobservationalstudies werepublished,54,55 and theyhave informedthetaskforcedecisioninitstreatmentrecommendation. Very-low-qualityevidencewasidentifiedforthecritical out-comeoffavourableneurologicalfunction(PCPC1or2)athospital discharge.54The GRADEquality forthis studywasdowngraded forseriousriskofbias(observationalstudywithpossible variabil-itybetweencomparisongroups)andseriousindirectness(specific CPRCVrationotlisted)from1cohortstudy.Thisstudyisfroma voluntaryAmericanOHCAregistryofnontraumaticcardiacarrest thatrepresentsacatchmentareaof>90millionpeoplein37states. Thisstudyincluded3900eventscapturedfrom2013through2015 andcomparedtheoutcomesofchildrenreceivingeitherbystander chestcompression–onlyCPRorbystanderCPRwithventilationfor the1411children forwhomdatawereavailableonthetypeof CPRprovided.DatafromFigure4ofthisstudyindicatethatthere wasnodifferenceinfavourableneurologicalfunctionwheninfants whoreceivedchestcompression–onlyCPRwerecompared with thosewhoreceivedCPRwithventilation(P=0.083),aswellasno differenceamongchildren(1–17yearsofage)whoreceivedchest compression–only CPRcompared withthose who receivedCPR withventilation(P=0.117).54

Very-low-qualityevidencehasbeenidentifiedforthecritical outcomeof favourableneurologicalfunction (PCPC1or 2)at1 month.55Thisstudywasanotherobservationalstudyfromthe all-Japanregistry.Thelevelofevidenceforthisstudywasdowngraded forseriousriskofbias(observationalstudywithpossible

variabil-itybetweencomparisongroups),seriousindirectness(specificCPR CVrationotlisted),andveryseriousimprecision(verywideCI). ThisJapanese OHCAregistry study(including traumaticcardiac arrest)reported2157eventsinchildren>1year(ie,noinfants) and18yearsofage,capturedfrom2011through2012,and com-paredtheoutcomesofchildrenreceivingeitherbystanderchest compression–onlyCPRorbystanderCPRwithventilationforthe 1150children forwhomdatawereavailableonthetypeofCPR provided. The studywas performedat a time when JapanCPR guidelinesrecommendeda CVratioof30:2,andan established nationaldispatch-assistedCPRprotocolexisted.Favourable neu-rologicalfunctionwasnodifferentamongchildrenwhoreceived chestcompression–onlyCPRandthosewhoreceivedCPRwith ven-tilation(adjustedoddsratio,1.52[95%CI,0.93–2.49]).

Very-low-quality evidence has been identified for the criti-cal outcome of survival to1 month.55 The quality of evidence for this cohort study was downgraded for serious risk of bias, seriousindirectness,andveryseriousimprecision(see explana-tionsgivenpreviously).Inthisstudy,1-monthsurvivalinchildren (age,1–18years) wasnodifferentwhethertheyreceivedchest compression–onlyCPRorCPRwithventilation(adjustedoddsratio, 1.38[95%CI,0.98–1.96]).

Very-low-qualityevidencehasbeenidentifiedforthecritical outcome ofsurvival tohospital discharge.54 Thequality of evi-denceforthiscohortstudywasdowngradedforseriousriskofbias (observationalstudywithpossiblevariabilitybetweencomparison groups).IninfantswithOHCA,survivaltohospitaldischargewas worseinthosereceivingchestcompression–onlyCPRcompared withthosereceivingCPRwithventilation(P=0.002).Conversely, forchildren≥1yearofage,therewasnodifferenceinsurvivalto hospitaldischargeinacomparisonofthosewhoreceivedbystander chestcompression–onlyCPRandthosewhoreceivedCPRwith ven-tilation(P=0.258).

ValuesandPreferences

BystanderCPRimprovessurvival, andCPR treatment recom-mendationsshouldstrivetoenhanceeaseofCPRimplementation andCPReffectiveness.Mostpaediatriccardiacarrestsareasphyxial inorigin,soeffectiveCPRislikelytorequireventilationinaddition tochestcompressions.Inmakingtheserecommendations,thetask forceplacedahighervalueontheimportanceofrescuebreathsas partofpaediatricCPRoverastrategythatdeemphasisesventilation tosimplifyCPRinstructionsandskills.The2(observational)articles publishedsincethecompletionofthesystematicreviewsuggest thatsurvivalandneurologicaloutcomemaynotdifferamong chil-dren(ie,≥1yearofage)whoreceivebystandercompression-only CPRorCPRwithventilation.54,55Thisconclusiondiffersfrom previ-ousevidencethatsuggestedthesuperiorityofCPRwithventilation forpaediatricpatientsofallageswithOHCA.21,22,56Availabledata arenowinconsistentandsomewhatcontradictoryforthe compar-isonofbystandercompression-onlyCPRandCPRwithventilation forinfant(1yearofage)OHCA.Thesediscrepanciesinfindings, especiallythosecomingfromthemorerecentpublications,helped informtaskforcedecisionswithrespecttothebystanderCPRwith ventilationversuscompression-onlyCPRtreatment recommenda-tionsand explaintherationale behindthetaskforce’s decision todowngradethestrengthofthetreatmentrecommendationto theweakerterminologyofsuggestsinsteadofthestrongerterm recommends.Thisrelativeclinicalequipoiseshouldstimulatethe developmentofprospectiveclinicaltrialstodefinitivelydetermine theoptimalbystanderCPRtechniqueforinfants(1yearofage) andchildren(≥1yearofage).

Despitetheavailabilityofonlyvery-low-qualityevidence (ana-lysed as part of the 2015 ILCOR evidence evaluation process), thetaskforceunanimouslyagreedtoreiterate the2015strong

(8)

treatment recommendation for providing any CPR (including compression-onlyCPR)overnoCPRforpaediatricOHCAbecause thepotentialbenefitoutweighsanypotentialharm.Giventhatthe systematicreviewdidnotseekdatacomparinganyCPRwithnoCPR andinkeepingwithGRADErecommendations,our recommenda-tionhasbeencitedasagoodpracticestatement(seeAppendixes1 and2).38

KnowledgeGaps

Inorderofpriority,thetopknowledgegapsforthistopicareas follows:

1.Morehigh-qualitystudiesareneededtocompare compression-onlyCPRandCPRwithventilationforinfantsandchildrenwith OHCA.

2.Data areneeded fromother resuscitationregistries that will enablecomparisonoftheroleofventilationwithCPRbecause thisvariesworldwide,largelyonthebasisofdifferencesinlocal resuscitationcouncilguidelines.Thisshouldalsoinclude sub-groupanalysisofdifferentpatientages(eg,infancy,1–8years, >8years)andcausesofcardiacarrest.

3.Cantelephonedispatcherscoachbystanderstoprovideeffective rescuebreaths/CPRwithventilationforinfantsandchildren? Acknowledgements

The authors thank the ILCOR Collaborators for their contri-butionstothis document:KarlB.Kern,MD, FAHA;KoenraadG. Monsieurs,MD,PhD,FERC,FAHA; RobertW.Neumar,MD, PhD, FAHA;CliftonW.Callaway,MD,PhD;andTzong-LuenWang,MD, PhD.

Appendix1.

GlossaryofTermsUsedinThisSummary

Advancedairway Trachealtubeorsupraglotticairway

Compression-onlyCPR Chestcompressionswithoutactiveventilation(eg, mouth-to-mouthventilation,bag-mask ventilation,orventilationviaanadvancedairway) CPRwithventilation ChestcompressionswithPPV;thisincludesa

varietyofchestCVratiosandcontinuouschest compressionswithventilationsdeliveredwithout pausingchestcompressions.

Continuouschest compressionCPR

Chestcompressionsdeliveredwithoutpausingfor ventilation.PPVmay(oftenat10breathsper minute)ormaynotbeprovided.Maintenanceof airwaypatencymayenablepassiveventilation.

Dispatch-assistedCPR AbystanderprovidesCPRundertelephone instructionbyanEMSdispatcher,mostoften compression-onlyCPR.Alternativeterminologyfor thesedispatchersincludestelecommunicators, ambulancecommunicationofficers,emergency medicalcommunicators,andcallhandlers. Appendix2.

GRADETerminology

Riskofbias Studylimitationsinrandomisedtrialsincludelack ofallocationconcealment,lackofblinding, incompleteaccountingofpatientsandoutcome events,selectiveoutcomereportingbias,and stoppingearlyforbenefit.Studylimitationsin observationalstudiesincludefailuretoapply appropriateeligibilitycriteria,flawed

measurementofexposureandoutcome,failureto adequatelycontrolconfounding,andincomplete follow-up.

Inconsistency Criteriaforinconsistencyinresultsincludethe following:pointestimatesvarywidelyacross studies;CIsshowminimalornooverlap;statistical testforheterogeneityshowsalowPvalue;andthe I2islarge(ameasureofvariationinpointestimates

resultingfromamong-studydifferences). Indirectness Sourcesofindirectnessincludedifferencesin

population(eg,OHCAinsteadofin-hospitalcardiac arrest,adultsinsteadofchildren),differencesin theintervention(eg,differentCVratios), differencesinoutcome,andindirectcomparison. Imprecision Loweventratesorsmallsamplesizeswill

generallyresultinwideCIsandtherefore imprecision.

Publicationbias Severalsourcesofpublicationbiasinclude tendencynottopublishnegativestudiesand influenceofindustry-sponsoredstudies.An asymmetricalfunnelplotincreasessuspicionof publicationbias.

Goodpractice statements

Guidelinepanelsoftenconsideritnecessaryto issueguidanceonspecifictopicsthatdonotlend themselvestoaformalreviewofresearch evidence.Thereasonmightbethatresearchinto thetopicisunlikelytobelocatedorwouldbe consideredunethicalorinfeasible.Criteriafor issuinganongradedgoodpracticestatement includethefollowing:overwhelmingcertainty thatthebenefitsoftherecommendedguidance willoutweighharmsandaspecificrationaleis provided;thestatementsshouldbeclearand actionabletoaspecifictargetpopulation;the guidanceisdeemednecessaryandmightbe overlookedbysomeprovidersifnotspecifically communicated;andtherecommendationsshould bereadilyimplementablebythespecifictarget audiencetowhichtheguidanceisdirected.

(9)

T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214 209 Disclosures

WritingGroupDisclosures

WritingGroup

Member

Employment ResearchGrant OtherResearch

Support

Speakers’ Bureau/Honoraria

ExpertWitness Ownership

Interest Consultant/Advisory Board Other TheresaM. Olasveengen OsloUniversity Hospital(Norway) LaerdalFoundation (unrestrictedresearch grant)*;South-Eastern RegionalHealth Authority(unrestricted researchgrant)

None None None None None None

RichardAickin StarshipChildren’s

Hospital(NewZealand)

None None None None None None None

DianneL.Atkins UniversityofIowa None None None None None None None

RobertA.Berg Children’sHospitalof

Philadelphia

None None None None None None None

RobertM.Bingham GreatOrmondStreet

HospitalNHS

FoundationTrust

(UnitedKingdom)

None None None None None None None

StevenC.Brooks Queen’sUniversity

(Canada)

HeartandStroke

FoundationofCanada

(researchoperating

granttostudyamobile

deviceapplication

designedtoincrease

bystanderresuscitation

forOHCA)

None None None None None None

MaaretCastrén HelsinkiUniversity

Hospital(Finland)

None None SMACCBerlin*;

EMS2017*

None None None None

SungPhilChung YonseiUniversity

CollegeofMedicine

(RepublicofKorea)

None None None None None None None

JulieConsidine DeakinUniversity

(Australia)

None None None None None None None

Thomaz Bittencourt Couto

HospitalIsraelita

AlbertEinstein(HIAE),

SãoPaulo,Brazil;

department:Centrode

Simulac¸ãoRealística

(CSR)ANDUnidadede

ProntoAtendimento

(UPA);Institutoda

Crianc¸adoHospitaldas

ClínicasdaFaculdade

deMedicinada

UniversidadedeSão

Paulo(ICr-HCFMUSP),

SãoPaulo,Brazil;

department:Pronto

Socorro

None None None None None None None

AllanR.deCaen UniversityofAlberta,

StolleryChildren’s

Hospital(Canada)

None None None None None None None

RaffoEscalante Inter-AmericanHeart

Foundation(Peru)

(10)

T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214

RaúlJ.Gazmuri RosalindFranklin

UniversityofMedicine andScience DePaul-Rosalind FranklinUniversity CollaborativePilot ResearchGrant

Program(basicscience

research:study mechanismsbywhich cyclophilin-D modulates transcriptionof mitochondrialgenes); DepartmentofDefense USArmyMedical

ResearchandMaterial

Command

(translationalresearch:

sustainedV1Areceptor

activationfor prolonged haemodynamic supportand neurologicalprotection afternoncompressible haemorrhageand traumaticbrain

injury);ZollMedical

Corp(translational

research:AMSAto

guideshockdeliveryin

aswinemodelof

ventricularfibrillation

andclosedchest

resuscitation);James

R.&HelenD.Russell

InstituteforResearch&

Innovation:Small

ResearchGrants

Program(basicscience

research:preventionof

oxidativeinjurytothe

neonatalheart)*

None None None None None None

Anne-Marie Guerguerian

TheHospitalforSick

Children(Canada)

None None None None None None None

TetsuoHatanaka KyotoPrefectural

UniversityofMedicine

(Japan)

None None None None None None None

MaryFranHazinski VanderbiltUniversity None None None None None AmericanHeart

AssociationECC

None

RudolphW.Koster AcademicMedical

Center(the

Netherlands)

PhysioControl

(fundingfordata

management, researchers,

equipment)

None None None None PhysioControl* None

PeterJ.Kudenchuk Universityof

WashingtonMedical

Center

(11)

T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214 211 (Canada)

SweeHanLim SingaporeGeneral

Hospital(Singapore)

None None None None None None None

BoLøfgren AarhusUniversity

Hospital(Denmark)

None None None None None None EuropeanResuscitation

Council,International

BLS/AEDCourse

Committee*

IanK.Maconochie St.Mary’sHospital

(UnitedKingdom)

None None None None None None None

MaryE.Mancini UniversityofTexasat

Arlington

None None None None None PhysioControl* None

PeterA.Meaney Children’sHospitalof

Philadelphia

None None None 2017,Defensewitness,

ICUcareofgraftvshost

disease*

None None None

WilliamH.

Montgomery

StraubClinicand

Hospital

None None None None None AmericanHeart

Association

None

PeterT.Morley Universityof

Melbourne(Australia)

None None None None None None None

LaurieJ.Morrison St.Michael’sHospital

(Canada)

CanadianInstitutefor

HealthResearch

(operatinggrantfor5

yearswithoutsalary

support);Heartand

StrokeFoundationof

Canada(operating

grantfor5years

withoutsalary

support)

None None None None None None

VinayM.Nadkarni Children’sHospitalof

Philadelphia

None None None None None None None

KevinJ.Nation NewZealand

ResuscitationCouncil

(NewZealand)

None None None None None None None

Kee-ChongNg KKHospital

(Singapore)

None None None None None None None

ChikaNishiyama KyotoUniversity

(Japan)

None None None None None None None

JerryP.Nolan RoyalUnitedHospital,

Bath(UnitedKingdom)

UKNationalInstituteof

HealthResearch(NIHR

researchgrantsfor

AIRWAYS-2and

PARAMEDIC-2

studies)*

None None Medicolegalreports

relatingto

resuscitation

None None None

GabrielleNuthall StarshipChildren’s

Hospital(NewZealand)

None None None None None None None

GeneYong-Kwang

Ong

KKWomen’sand

Children’sHospital

(Singapore)

None None None None None None None

GavinD.Perkins WarwickMedical

SchoolandHeartof

EnglandNHS

FoundationTrust

(UnitedKingdom)

None None None None None None None

AmeliaG.Reis Inter-AmericanHeart

Foundation(Brazil)

None None None None None None None

GiuseppeRistagno ItalianResuscitation

Council-Scientific

Committee(Italy)

(12)

T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214

TetsuyaSakamoto TeikyoUniversity

(Japan)

None None None None None None None

MichaelR.Sayre Universityof

Washington

None None None None None None Physio-ControlInc.

(FundsEMSMedicine

Fellowshipat

Universityof

Washington.Ihave

travelreimbursement

fromthosefunds.)*

StephenM.

Schexnayder

Universityof

Arkansas/Arkansas

Children’sHospital

None None None None None AmericanHeart

Association(course

developmentand

scientificediting

consultant)

None

NaokiShimizu TokyoMetropolitan

Children’sCenter

(Japan)

None None None None None None None

AlfredoF.Sierra Inter-AmericanHeart

Foundation(Mexico)

None None None None None None None

EuniceM.

Singletary

UniversityofVirginia None None None None None AmericanRedCross

(chair,FirstAid

Subcouncilofthe

ScientificAdvisory

Council)*

None

MichaelA.Smyth UniversityofWarwick

(UnitedKingdom)

None None None None None None None

DavidStanton ResuscitationCouncil

ofSouthernAfrica

(SouthAfrica)

None None None None None None Netcare911(head,

ClinicalLeadership)

JaniceA.Tijssen LondonHealthServices

Center(Canada)

HeartandStroke

FoundationofCanada

grantinaid(grant

recipientforresearch)*

None None None None None None

AndrewTravers EmergencyHealth

Services,NovaScotia

(Canada)

None None None None None None None

Christian Vaillancourt UniversityofOttawa, OttawaHospital ResearchInstitute (Canada)

CIHR(Grantforc-spine

ruleimplementation);

CIHRandHSFC

(CanROCSteering

CommitteeChair)

None None None None None None

PatrickVande

Voorde

(13)

ReviewerDisclosures

Reviewer Employment Research

Grant OtherResearch Support Speakers’Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ AdvisoryBoard Other

MioaraD.Manole UniversityofPittsburgh None None None None None None None

ArthurB.Sanders ArizonaHealthSciences Center

None None None None None None None

DemetrisYannopoulos UniversityofMinnesota None None None None None None None

References

1.HazinskiMF,NolanJP,AickinR,BhanjiF,BilliJ,CallawayCW,CastrénM,de CaenAR,FerrerJM,FinnJC,GentLM,GriffinRE,IversonS,LangE,LimSH, MaconochieIK,MontgomeryWH,MorleyPT,NadkarniVM,NeumarRW, Niko-laouNI,PerkinsGD,PerlmanJM,SingletaryEM,SoarJ,TraversAH,WelsfordM, WyllieJ,ZidemanDA.Part1:executivesummary:2015InternationalConsensus onCardiopulmonaryResuscitationandEmergencyCardiovascularCare Sci-enceWithTreatmentRecommendations.Circulation2015;132(suppl1):S2–39, http://dx.doi.org/10.1161/CIR.0000000000000270.

2.NolanJP,HazinskiMF,AickinR,BhanjiF,BilliJE,CallawayCW,CastrenM, deCaenAR,FerrerJM,FinnJC,GentLM,GriffinRE,IversonS,LangE,Lim SH,MaconochieIK,MontgomeryWH,MorleyPT,NadkarniVM,NeumarRW, NikolaouNI,PerkinsGD,PerlmanJM,SingletaryEM,SoarJ,TraversAH, Wels-fordM,WyllieJ,ZidemanDA.Part1:executivesummary:2015International ConsensusonCardiopulmonaryResuscitationandEmergencyCardiovascular CareScienceWithTreatmentRecommendations.Resuscitation2015;95:e1–31, http://dx.doi.org/10.1016/j.resuscitation.2015.07.039.

3.GuyattG,OxmanAD,AklEA,KunzR,VistG,BrozekJ,NorrisS,Falck-YtterY, GlasziouP,DeBeerH,JaeschkeR,RindD,MeerpohlJ,DahmP,SchünemannHJ. GRADEguidelines,1:introduction:GRADEevidenceprofilesandsummaryof findingstables.JClinEpidemiol2011;64:383–94,http://dx.doi.org/10.1016/j. jclinepi.2010.04.026.

4.GuyattGH,OxmanAD,VistG,KunzR,BrozekJ,Alonso-CoelloP,MontoriV,Akl EA,DjulbegovicB,Falck-YtterY,NorrisSL,WilliamsJrJW,AtkinsD,Meerpohl J,SchünemannHJ.GRADEguidelines,4:ratingthequalityofevidence:study limitations(riskofbias).JClinEpidemiol2011;64:407–15,http://dx.doi.org/10. 1016/j.jclinepi.2010.07.017.

5.GuyattGH,OxmanAD,MontoriV,VistG,KunzR,BrozekJ,Alonso-CoelloP, DjulbegovicB,AtkinsD,Falck-YtterY,WilliamsJrJW,MeerpohlJ,NorrisSL, AklEA,SchünemannHJ.GRADEguidelines,5:ratingthequalityofevidence: publicationbias.JClinEpidemiol2011;64:1277–82,http://dx.doi.org/10.1016/ j.jclinepi.2011.01.011.

6.GuyattGH,OxmanAD,KunzR,BrozekJ,Alonso-CoelloP,RindD,DevereauxPJ, MontoriVM,FreyschussB,VistG,JaeschkeR,WilliamsJrJW,MuradMH,Sinclair D,Falck-YtterY,MeerpohlJ,WhittingtonC,ThorlundK,AndrewsJ, Schüne-mannHJ.GRADEguidelines6:ratingthequalityofevidence:imprecision.JClin Epidemiol2011;64:1283–93,http://dx.doi.org/10.1016/j.jclinepi.2011.01.012. 7.GuyattGH,OxmanAD,KunzR,WoodcockJ,BrozekJ,HelfandM,Alonso-Coello

P,GlasziouP,JaeschkeR,AklEA,NorrisS,VistG,DahmP,ShuklaVK,HigginsJ, Falck-YtterY,SchünemannHJ;GradeWorkingGroupGRADEguidelines,7: rat-ingthequalityofevidence:inconsistency.JClinEpidemiol2011;64:1294–302, http://dx.doi.org/10.1016/j.jclinepi.2011.03.017.

8.GuyattGH,OxmanAD,KunzR,WoodcockJ,BrozekJ,HelfandM,Alonso-CoelloP, Falck-YtterY,JaeschkeR,VistG,AklEA,PostPN,NorrisS,MeerpohlJ,ShuklaVK, NasserM,SchünemannHJ;GradeWorkingGroupGRADEguidelines,8:rating thequalityofevidence:indirectness.JClinEpidemiol2011;64:1303–10,http:// dx.doi.org/10.1016/j.jclinepi.2011.04.014.

9.GuyattGH,OxmanAD,SultanS,GlasziouP,AklEA,Alonso-CoelloP,AtkinsD, KunzR,BrozekJ,MontoriV,JaeschkeR,RindD,DahmP,MeerpohlJ,VistG, BerlinerE,NorrisS,Falck-YtterY,MuradMH,SchünemannHJ;GradeWorking GroupGRADEguidelines,9:ratingupthequalityofevidence.JClinEpidemiol 2011;64:1311–6,http://dx.doi.org/10.1016/j.jclinepi.2011.06.004.

10.ILCOR.InternationalLiaisonCommitteeonResuscitationwebsite.http://www. ilcor.org.AccessedAugust25,2017.

11.ParadisNA,MartinGB,RiversEP,GoettingMG,AppletonTJ,FeingoldM,Nowak RM.Coronaryperfusionpressureandthereturnofspontaneouscirculationin humancardiopulmonaryresuscitation.JAMA1990;263:1106–13.

12.ChristensonJ,AndrusiekD,Everson-StewartS,KudenchukP,HostlerD, Pow-ellJ,CallawayCW,BishopD,VaillancourtC,DavisD,AufderheideTP,Idris A,StoufferJA,StiellI,BergR;andtheResuscitationOutcomesConsortium InvestigatorsChestcompressionfractiondeterminessurvivalinpatientswith out-of-hospitalventricularfibrillation.Circulation2009;120:1241–7,http://dx. doi.org/10.1161/CIRCULATIONAHA.109.852202.

13.StiellIG,BrownSP,NicholG,CheskesS,VaillancourtC,CallawayCW, Morri-sonLJ,ChristensonJ,AufderheideTP,DavisDP,FreeC,HostlerD,StoufferJA, IdrisAH;andtheResuscitationOutcomesConsortiumInvestigatorsWhatisthe optimalchestcompressiondepthduringout-of-hospitalcardiacarrest resus-citationofadultpatients?Circulation2014;130:1962–70,http://dx.doi.org/10. 1161/CIRCULATIONAHA.114.008671.

14.CheskesS,SchmickerRH,VerbeekPR,SalcidoDD,BrownSP,BrooksS,Menegazzi JJ,VaillancourtC,PowellJ,MayS,BergRA,SellR,IdrisA,KamppM,Schmidt T,ChristensonJ;ResuscitationOutcomesConsortium(ROC)InvestigatorsThe impactofperi-shockpauseonsurvivalfromout-of-hospitalshockablecardiac

arrestduringtheResuscitationOutcomesConsortiumPRIMEDtrial. Resuscita-tion2014;85:336–42,http://dx.doi.org/10.1016/j.resuscitation.2013.10.014. 15.HallstromA,CobbL,JohnsonE,CopassM.Cardiopulmonaryresuscitationby

chestcompressionaloneorwithmouth-to-mouthventilation.NEnglJMed 2000;342:1546–53,http://dx.doi.org/10.1056/NEJM200005253422101. 16.ReaTD,FahrenbruchC,CulleyL,DonohoeRT,HamblyC,InnesJ,

Blooming-daleM,SubidoC,RominesS,EisenbergMS.CPRwithchestcompressionalone orwithrescuebreathing.NEnglJMed2010;363:423–33,http://dx.doi.org/10. 1056/NEJMoa0908993.

17.SvenssonL,BohmK,CastrènM,PetterssonH,EngerströmL,HerlitzJ,Rosenqvist M.Compression-onlyCPRorstandardCPRinout-of-hospitalcardiacarrest.N EnglJMed2010;363:434–42,http://dx.doi.org/10.1056/NEJMoa0908991. 18.BobrowBJ,ClarkLL,EwyGA,ChikaniV,SandersAB,BergRA,RichmanPB,Kern

KB.Minimallyinterruptedcardiacresuscitationbyemergencymedicalservices forout-of-hospitalcardiacarrest.JAMA2008;299:1158–65,http://dx.doi.org/ 10.1001/jama.299.10.1158.

19.PerkinsGD,TraversAH,BergRA,CastrenM,ConsidineJ,EscalanteR, Gaz-muriRJ,KosterRW,LimSH,NationKJ,OlasveengenTM,SakamotoT,Sayre MR,SierraA,SmythMA,StantonD,VaillancourtC;fortheBasicLifeSupport ChapterCollaboratorsPart3:adultbasiclifesupportandautomatedexternal defibrillation:2015InternationalConsensusonCardiopulmonaryResuscitation andEmergencyCardiovascularCareScienceWithTreatmentRecommendations. Resuscitation2015;95:e43–69,http://dx.doi.org/10.1016/j.resuscitation.2015. 07.041.

20.TraversAH,PerkinsGD,BergRA,CastrenM,ConsidineJ,EscalanteR,Gazmuri RJ,KosterRW,LimSH,NationKJ,OlasveengenTM,SakamotoT,SayreMR,Sierra A,SmythMA,StantonD,VaillancourtC;onbehalfoftheBasicLifeSupport ChapterCollaboratorsPart3:adultbasiclifesupportandautomatedexternal defibrillation:2015InternationalConsensusonCardiopulmonaryResuscitation and Emergency Cardiovascular Care Science With Treatment Recommen-dations.Circulation2015;132(suppl1):S51–83,http://dx.doi.org/10.1161/CIR. 0000000000000272.

21.MaconochieIK,deCaenAR,AickinR,AtkinsDL,BiarentD,GuerguerianAM, KleinmanME,KloeckDA,MeaneyPA,NadkarniVM,NgKC,NuthallG,ReisAG, ShimizuN,TibballsJ,VelizPintosR;forthePediatricBasicLifeSupportand PediatricAdvancedLifeSupportChapterCollaboratorsPart6:pediatricbasic lifesupportandpediatricadvancedlifesupport:2015InternationalConsensus onCardiopulmonaryResuscitationandEmergencyCardiovascularCareScience WithTreatmentRecommendations.Resuscitation2015;95:e147–68,http://dx. doi.org/10.1016/j.resuscitation.2015.07.044.

22.deCaenAR,MaconochieIK,AickinR,AtkinsDL,BiarentD,GuerguerianAM, KleinmanME,KloeckDA,MeaneyPA,NadkarniVM,NgKC,NuthallG,ReisAG, ShimizuN,TibballsJ,VelizPintosR;onbehalfofthePediatricBasicLifeSupport andPediatricAdvancedLifeSupportChapterCollaboratorsPart6:pediatricbasic lifesupportandpediatricadvancedlifesupport:2015InternationalConsensus onCardiopulmonaryResuscitationandEmergencyCardiovascularCareScience WithTreatmentRecommendations[publishedcorrectionappearsinCirculation. 2016;134:e121].Circulation2015;132(suppl1):S177–203,http://dx.doi.org/10. 1161/CIR.0000000000000275.

23.NicholG,LerouxB,WangH,CallawayCW,SopkoG,WeisfeldtM,StiellI, Mor-risonLJ,AufderheideTP,CheskesS,ChristensonJ,KudenchukP,VaillancourtC, ReaTD,IdrisAH,ColellaR,IsaacsM,StraightR,StephensS,RichardsonJ,Condle J,SchmickerRH,EganD,MayS,OrnatoJP;onbehalfoftheROCInvestigators TrialofcontinuousorinterruptedchestcompressionsduringCPR.NEnglJMed 2015;373:2203–14,http://dx.doi.org/10.1056/NEJMoa1509139.

24.Iwami T, Kitamura T, Kiyohara K, Kawamura T. Dissemination of chest compression-onlycardiopulmonaryresuscitationand survivalafter out-of-hospital cardiac arrest. Circulation 2015;132:415–22, http://dx.doi.org/10. 1161/CIRCULATIONAHA.114.014905.

25.Ashoor HM,LillieE,ZarinW,PhamB,KhanPA, NincicV,YazdiF, Ghas-semiM,IvoryJ,CardosoR,PerkinsGD,deCaenAR,TriccoAC;ILCORBasic LifeSupportTaskForceEffectivenessofdifferentcompression-to-ventilation methodsforcardiopulmonaryresuscitation:asystematicreview.Resuscitation 2017;118:112–25,http://dx.doi.org/10.1016/j.resuscitation.2017.05.032. 26.HüpflM,SeligHF,NageleP.Chest-compression-onlyversusstandard

cardiopul-monaryresuscitation:ameta-analysis.Lancet2010;376:1552–7,http://dx.doi. org/10.1016/S0140-6736(10)61454-7.

27.SOS-KANTO Study Group. Cardiopulmonary resuscitation by bystanders withchestcompression only(SOS-KANTO):anobservationalstudy.Lancet 2007;369:920–6,http://dx.doi.org/10.1016/S0140-6736(07)60451–6. 28.OlasveengenTM,WikL,SteenPA.Standardbasiclifesupportvs.continuous

chestcompressionsonlyinout-of-hospitalcardiacarrest.ActaAnaesthesiol Scand2008;52:914–9,http://dx.doi.org/10.1111/j.1399-6576.2008.01723.x.

Figure

Table GRADE Quality Assessment Criteria

Références

Documents relatifs

Le but a donc ´et´e de travailler sur l’´etude du ph´enom`ene de pompage ´energ´etique pour l’acoustique, c’est-`a-dire sur l’utilisation d’un absorbeur non lin´eaire pour

Les mol´ ecules d’eau participent aussi ` a renforcer la compl´ ementarit´ e g´ eom´ etrique au niveau de l’interface ; ceci est valable autant pour les interactions prot´ eiques

Lorsqu’un théoricien de la vertu ne nous fournit pas une véritable psychologie des vertus, il y a trois cas de figure : (1) tout simplement, il laisse de côté la question, avec ou

Un capteur de luminance combinant une fibre optique et un photodétecteur a été installé sur un banc expérimental du laboratoire pour mesurer la température de surface

That is especially the case for complex systems such as ships where energy exists in many forms (thermal - steam, cooling water or lubrication oil, mechanical - engine shaft

Un survol de certains déterminants illustre de façon significative l 'écar t entre la santé des Inuit et celle de la population du Canada et des Québécois

Les cartes ont été pensées pour instaurer un langage commun entre les concepteurs de différents domaines et pour les aider à explorer les différentes dimensions, favoriser

d'apprentissage ... Synthèse de la coanalyse des situations de pratique issues de la huitième rencontre .... Synthèse des éléments méthodologiques .... La