Transcript Updates in Neonatal Resuscitation

Updates in Neonatal
Resuscitation
Stacie Bennett, M. D.
East Bay Newborn Specialists
Children’s Hospital Oakland
Overview
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Every year ~ 5-10% of infants require neonatal
resuscitation.
Yet there are many areas where we don’t have
evidence for the best resuscitation approach.
Right Amount of Oxygen to use
 ? Right Bag and Mask
 ? Correct pressures
 Intubation for Meconium
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Pulse oxymetry
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All other areas of resuscitation use monitors
except the DR.
May be able to avoid hypoxia and hyperoxia
Difficult to correlate saturations and color
Infant Color
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O’Donnell et al looked at 20 infants with video
reviewed by 27 observers and compared to pulse ox
readings.
1 infant was thought to be pink by all and his highest
sat was 87%, 10 infants whose sats were >95% were
never thought to be pink ~ 20% of the time.
The mean sats when infants were perceived to be pink
by all observers was 69% (range 10-100%)
Current NRP Guidelines for
Saturation Monitoring
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To reduce excessive tissue oxygenation if a very
preterm baby (<32weeks) is being delivered use an
oxygen blender and a pulse oximeter during
resuscitation.
Begin PPV with O2 concentration between RA and
100%. Adjust O2 up or down to achieve a saturation
that gradually increased toward 90% and decreased O2
as saturations rise over 95%.
If HR does not respond rapidly to >100 BPM correct
any ventilation problems and use 100% O2.
Pulse oxymetry Pre vs Post ductal
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Mariani et al J Peds April 07.
Looked at pre/post ductal sats simultaneously in
healthy term infants born via SVD or c/s.
Resuscitator was blinded to sat values.
110 infants, median time to accurate readings was 3
minutes.
At 5 min median sats when baby perceived to be pink
was 86%. The mean time to reach preductal sat of 90%
was 5.5min. (5.2 min SVD, 6.3 min in c/s)
No infants admitted to NICU.
O2 sat trends
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Rabi et al. J Peds May 2006
Masimo pulse ox preductally. 165 infants “code pink”
del, 49 excluded d/t O2 supplementation, all >35
weeks, 115 infants analyzed.
Median time to stable sat readings 82 sec
Median Sats at 5 min for vag del was 87% (80-95%)
and c/s was 81% (75-83%), by 8min 91% in vag and
90% in c/s.
O2 sat trends
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Kamlin et al Jpeds May 2006
175 infants, median sat values:
1min 63% (53-68%), 2min 70% (58-78), 3 min
76% (64-87%), 4 min 81% (71-91%) and 5 min
90% (76-91).
Kamlin et al J Peds June 2006 Heart rate was
accurate even in infants requiring resuscitation
using pulse Ox.
Saturation Monitor
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When applying place preductally
Once on infant turn on machine for fastest
reading
Currently recommended for preterm infants
Future probably recommended for all deliveries.
Current Oxygen Guidelines for
Resuscitation
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Current evidence is insufficient to resolve all questions
regarding supplemental O2.
Term: Recommend 100% O2 when infant is cyanotic
or when PPV is required.
However research suggest that resuscitation with
something less then 100% may be just as successful.
If resuscitation is started with less then 100% O2
supplemental O2 up to 100% should be administered if
there is no appreciable improvement within 90sec after
birth.
Room Air Vs 100% Oxygen in the
DR
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In multiple studies and meta-analysis comparing
resuscitation with RA vs 100% O2- decreased risk of
neonatal mortality in infants resuscitated with RA
(Mortality was 4.6% higher in O2 group)
Trend toward reduction in Stage 2 to 3 HIE in those
infants resuscitated in RA.
Onset of respirations was faster in RA in some studies.
Lower 5 minute apgar scores and heart rate in several
studies in infants resuscitated with O2.
Exposure to O2 decreased cerebral blood flow.
RA vs O2
RA vs O2
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2 studies suggesting increased risk of childhood
leukemia's if exposed to O2.
A case-control study using the Swedish Cancer Register
looking at 97% of Cancer patients and controls from
birth registry (99% of births). Looking at those who
were resuscitated with 100% O2 there was a OR of
2.57 to have childhood lymphatic leukemia. It
increased to an OR of 3.54 if manual ventilation lasted
longer then 3 minutes. (Children with Down’s were
excluded)
RA vs O2
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Several animal studies have shown:
Increased brain injury when exposed to O2
O2 induces inflammation in the lung, heart and
brain
Increased pulmonary resistance and reactivity
Increased oxidative stress
RA vs O2
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Medbo et al found that PVR increased with induced
hypoxia in piglets but fell equally with both RA or
100% O2.
Wang et al Peds 6/2008 looked at preterm infants
resuscitated with RA vs 100%.
In RA group all infants required increased FiO2 due to
bradycardia or failure of saturation criteria.
Escrig et al in abstract 2007 at PAS suggested no
difference in reaching saturation goals between 100%
and <40%FiO2 at ~8 minutes of age
For preterm infants starting at FiO2 of 30-40% may be
appropriate.
Potential Future O2 guidelines
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RA for term deliveries, avoid 100% unless
hypoxic
? 30-40% for preterm deliveries.
Saturation monitoring and O 2 blenders in ALL
delivery rooms to guide O2 needs
Bag and Mask
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All types are acceptable including: T-piece
resuscitators, flow inflating and self-inflating
bags.
T-piece can give consistent PEEP and PIP
Self-inflating can’t deliver consistent PEEP or
PIP.
Neopuff
CO2 detectors
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Now recommended for confirming ETT placement.
As confirms faster and more accurately.
May not change color if low HR, may need to visualize
ETT, will get color change with adequate chest
compressions.
If ETT right mainstem-may not change color
If have not established FRC may not change
If give epinephrine down ETT will stay yellow, need to
replace CO2 detector.
May also be used with bag and mask to indicate airway
obstruction.
Current statement regarding
Therapeutic hypothermia
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Hypothermia may reduce the extent of brain injury
following hypoxia-ischemia
There is insufficient data to recommend routine use of
selective and/or systemic hypothermia after
resuscitation of infants with suspected asphyxia.
Hyperthermia may worsen the extent of brain injury
following hypoxia-ischemia.
The goal should be to achieve normothermia and to
avoid iatrogenic hyperthermia in resuscitated newborns.
Hypothermia
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2 large randomized trials: 1. Cool-cap trial-234 infants
in 25 centers, >36 weeks
Maintain rectal temps of 34-35 C. Subgroup analysis
showed that infants with moderate encephalopathy had
significantly better outcomes at 18months (OR 0.46),
no effect on infants with severe encephalopathy or
seizures at time of enrollment.
2. Whole Body cooling: 208 infants >36 weeks,
esophageal temp to 33.5 C. Significantly reduced death
or moderate-to-severe disability at 18-22 months (44%
vs 62%) On subgroup analysis no improvement in the
severely encephalopathic infants.
Hypothermia
Future: Hypothermia whether total body or cerebral
cooling is now considered the standard of care.
Anticipate recommendations will change in future
guidelines.
Cerebral Cooling Criteria
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GA > 36 weeks, can started on cooling within 6 hrs of age, if received
passive cooling at referral hospital and can be started on active cooling
within 8 hrs of age.
History compatible with HIE, meaning at least one of the following:
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Apgar score of < 5 at 10 minutes
Continued need for resuscitation, including ETT or mask ventilation at 10
minutes
Acidosis present within 60 minutes of birth, defined as either an umbilical
cord gas (arterial or venous) pH or post-natal arterial pH < 7.00
Base deficit >16 mmol/L in umbilical cord gas (arterial or venous)
or patient blood gas (arterial, venous, or capillary) obtained within 60
minutes of birth
Cerebral Cooling Con’t
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Physical exam compatible with encephalopathy, meaning at
least one of the following:
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Lethargy, stupor, or coma
Hypotonia
Abnormal reflexes, including oculomotor or pupillary abnormalities
Absent or weak suck
Clinical seizures
At CHO:
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CFM (Cerebral Function Monitor, also known as
aEEG),showing moderately or severely abnormal
background (score 2-3) and/or seizures at any time < 6 hrs
from birth.
Cerebral Cooling Con’t
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Exclusion Criteria
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< 36 weeks gestation
< 1800 grams
Coagulopathy with active bleeding
Severe congenital anomalies/syndromes/known metabolic disorders
ECMO
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Potential Exclusion Criteria
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Severe PPHN
Passive Cooling
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If neonatologist and Pediatrician agree: To begin passive cooling:
Turn table warmer off and monitor rectal temperatures every 15 minutes.
Check rectal temperatures by gently inserting a clean, lubricated digital thermometer
into the rectum approximately ½ inch or 2cm. Wipe thermometer with alcohol
between uses.
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The desired temperature range is 34°C- 35°C (rectal) or 93°F- 95°F.
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Keep TABLE WARMER OFF unless rectal temperature < 34.5°C or 94°F
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If patient’s rectal temperature falls below 34.5oC or 94°F, begin table warmer on
lowest setting or “preheat.”
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If patient’s rectal temperature is greater than 35°C or 95°F, continue passive cooling
and do not attempt active cooling.
Passive Cooling Con’t
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Maintain all other aspects of routine post-resuscitation care.
Maintain oxygenation and ventilation
Monitor blood pressure, heart rate, and perfusion
Obtain IV access
Provide IV fluids
Monitor glucose, electrolytes, CBC
Consider antibiotics
Avoid hyperthermia
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Treat clinical or electrographic seizures with 20 mg/kg Phenobarbital.
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If the patient is hemodynamically unstable and/or has an oxygen requirement of 50%
FiO2 in order to maintain oxygen saturations of > 95%, it may be determined by the
attending neonatologist and referral pediatrician that passive cooling should not be
initiated due to the patient’s instability. Hyperthermia should however be
avoided. The patient’s temperature should be kept at 36 + 0.5°C or 97°F.
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Laryngeal Mask Airway (LMA)
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1-5% of newborns require PPV in DR.
LMA may provide alternative for facemask ventilation
or endotracheal intubation
Advantages: high rate of successful first-time
placement, short time for placement, less training and
practice needed, no instrumentation.
Disadvantages: gastric distension, potentially
inadequate alveolar ventilation due to limitation of peak
pressure due to leak, difficulty with suctioning of the
airway or giving intra-tracheal emergency medications.
LMA
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Many case control studies, limited randomized studies.
Limited studies using endotracheal epinephrine or
surfactant with LMA.
Can be used for difficult airways
Few complications including soft tissue damage.
Used for short term airway support.
Current recommendations: can be used in some
newborns who have failed bag and mask ventilation or
endotracheal intubation.
LMA
Meconium
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Meconium stained amniotic fluid (MSAF) occurs in 720% of births. Probably due to in-utero hypoxia and
acidosis.
MAS occurs in 2-9% of infants born through MSAF
Management: 1. Current recommendations are for
Intrapartum amnioinfusion for moderate to thick
MSAF (meta-analysis showed benefit, though recent
large multicenter study did not show benefit, may
change recommendation in up coming guidelines.
2. Suctioning on the perineum or abdomen prior to
delivering the shoulders is no longer recommended.
3. Post delivery suctioning for those infants who are
ETT vs IV epinephrine
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ETT not as effective possibly secondary to decreased
blood flow, pulmonary vasoconstriction from acidosis,
persistent alveolar fluid that dilutes the epi, possible
right to left intracardiac shunts that bypass pulmonary
circulation all together.
In animal data ETT epi needed to be 5-30x the
recommended dose for effect.
In 2005 recommendations: Epinephrine should be
delivered via IV if not the ETT dose should be 0.31ml/kg (0.03-0.1mg/kg), iv is still 0.1-0.3ml/kg.
I usually start with 1ml if term infant via ETT.
Summary
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Possible future changes:
Preductal pulse ox monitoring all deliveries requiring
resuscitation
Blended O2 in all deliveries
RA resuscitation for term infants, 30-40% O2 for
preterm resuscitation as a starting point.
Therapeutic hypothermia for moderate to severe
hypoxic-ischemic encephalopathy
? Management for Meconium, use of CPAP in DR,
recommended starting pressures, LMA’s, etc.
References
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O’Donnell. Clinical assessment of infant colour at delivery. Arch Dis Child Fetal Neonatal Ed 2007; 92: F465467
Mariani et al. Pre-ductal and Post-ductal O2 Saturation in Healthy Term Neonate after birth. J. Peds April
2007 pg 418-421
Rabi et al. Oxygen Saturation Trends Immediately After Birth. J Peds May 2006 590-594
Kamlin et al. Oxygen Saturation in healthy infants immediately after birth. J. Peds May 2006; 148: 585-9.
Kamlin et all. Accuracy of Pulse Oxymetry Measurement of Heart Rate of Newborn infants in the Delivery
Room. J. Peds, 2008; 152: 756-60
O’Donnell et all. Feasibility of and Delay in Obtaining Pulse Oximetry During Neonatal Resuscitation. J. Peds
2005; 147: 698-9
Perlman et al. The Science Behind Delivery Room Resuscitation. Clinics in Perinatology March 2006.
Saugstad et al. Resuscitation of Newborn Infants with 21% or 100% Oxygen Neonatology 2008;94: 176-182
AAP/AHA Emergency Cardiovascular Care Guidelines for Neonatal Resuscitation. 2005.
Richmond et al. Refining the role of oxygen administration during delivery room resuscitation: What are the
future goals? Seminars in Fetal and Neonatal Medicine 2008 : 13: 368-374.
Wang et all: Resuscitation of Preterm Neonates by Using Room Air or 100% Oxygen; Peds 2008: 121: 10831089
Leone et al. Disposable colorimetric carbon dioxide detector use as an indicator of a patent airway during
noninvasive mask ventilation. Peds 2006; 118 (1)
Kamlin et al. Colorimetric end-tidal Carbon Dioxide Detectors in the delivery Room strengths and limitations.
A case report. J. Peds 2005;147:547-8
Trevisanuto et al. The laryngeal mask airway: potential applications in neonates. Arch Dis Child Fetal Neonatal
Ed 2004; 89:F485-489.
Hoehn et al. Therapeutic hypothermia in neonates. Resuscitation 2008 7, 7-12.
Vain et al. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of
their shoulders: multicentre, randomized controlled trial. Lancet 2004; 364: 597-602.