An Update on Neonatal Resuscitation

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An Update on Neonatal Resuscitation

• Dr. Ezzedin A Gouta
• Consultant Paediatrician, BHNFT, UK
• Honorary Senior Lecturer, Sheffield University,
  UK
• RCPCH (UK) Director to the Middle East

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Objectives

• A brief history of neonatal resuscitation
• Neonatal Resuscitation Guidelines
• Evidence based recommendations
• ILCOR

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Schultze Method Of Neonatal Resuscitation
Since ancient times many different methods have
been used to revive newborns ( From Schultze BS.
Der Scheintod Neugeborener. Jenna Maukes
Verlag, 1871.)
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Techniques Advocated and Used to Resuscitate
Newborns 18501950

• Squeezing the chest (Prochownich method)
• Raising and lowering the arms while an assistant
  compressed the chest (Sylvester method)
• Rhythmic traction of the tongue (Laborde method)
• Tickling the chest, mouth, or throat
• Dilating the rectum by a ravens beak or a corn
  cob
• Immersion in cold water, sometimes alternating
  with immersion in hot water
• Yelling, Shaking , Rubbing, Slapping, and
  Pinching
• Electric shocks
• Nebulisation of brandy mist
• Insufflation of tobacco smoke into the rectum

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History of Neonatal Resuscitation

• Artificial respiration has been accepted as the
  mainstay of neonatal resuscitation for about the
  last 40.
• Formal teaching programmes have evolved over the
  last 20 years.
• The last 10 years have seen international
  collaboration, which has resulted in careful
  evaluation of the available evidence and
  publication of recommendations for clinical
  practice.

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The International Liaison Committee on
Resuscitation (ILCOR, 1992)

• Formed in 1992 to provide a forum for liaison
  between resuscitation organisations in the world
• ILCOR 1997 made recommendations for Basic Life
  support for the newly born. It noted that
• "the paucity of pediatric and newborn
  clinical resuscitation outcome data makes
  scientific justification of recommendations
  difficult". Discussion of advanced life support
  for newborns was considered beyond the scope of
  the document.

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ILCOR 2000-2005

• ILCOR 2000 Guidelines- Identified controversial
  neonatal resuscitation issues.
• The Neonatal Subcommittee of ILCOR reconvenes
  approximately every five years to evaluate
  available evidence that may support a change in
  the recommendations.
• ILCOR 2005 Guidelines -The literature was
  researched and a consensus was reached on those
  issues.

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How Often is Resuscitation Necessary?

• The vast majority of newborn infants do not
  require intervention to make the transition from
  intrauterine to extrauterine life
• Approximately 10 of newborns require some
  assistance to begin breathing at birth
• About 1 require extensive resuscitation

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The Size of The Problem

• 100, 000 newborn, Sweden, Acta Paediatr 1992
  81739-44
• Babies weighing 2.5 kg
• 10 babies per 1000 received mask inflation or
  ventilation. Of these
• 8 responded to mask inflation alone
• 2 required intubation at birth

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No Resuscitation is Needed

• Newborn infants who are born at term, have had
  clear amniotic fluid, and are breathing or crying
  and have good tone must be dried and kept warm
  and given to mother

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Other Who Need Resuscitation

• May receive one or more of the following
  actions in sequence
• Initial steps (Dryingwrapping, Assessment)
• A. Positioning, clearing the airway
• B. Ventilation-inflation breaths
• C. Chest compressions
• D. (medications or volume expansion)
• Progression to the next step is based on
  simultaneous assessment of three vital signs
  Respirations, Heart Rate, and Colour
• Progression occurs only after successful
  completion of the preceding step (30Seconds)

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ILCOR-EB Guidelines 2005

• Role of supplementary oxygen
• Peri-partum management of meconium
• Ventilation strategies
• Devices to confirm placement of an advanced
  airway (e.g. ET tube or LMA)
• Medications
• Maintenance of body temperature
• Post-resuscitation management
• Withholding discontinuing resuscitation.

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Supplementary Oxygen/Air

• There are concerns about potential adverse
  effects of 100 oxygen on breathing physiology,
  cerebral circulation, and potential tissue damage
  from oxygen free radicals.
• There is growing evidence that air is as
  effective as 100 oxygen for the resuscitation of
  most infants at birth, and is associated with
  less mortality and no evidence of harm.

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Treatment Recommendation 1
R

• Once adequate ventilation is established with
  lung inflation/ventilation , if the heart rate
  remains low, the priority should be to support
  cardiac output with chest compressions and
  coordinated ventilations.
• Supplementary oxygen should be considered for
  babies with persistent central cyanosis.

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Treatment Recommendation 2
R

• There is currently insufficient evidence to
  specify the concentration of oxygen to be used at
  initiation of resuscitation.
• Excessive tissue oxygen may cause oxidant injury
  and should be avoided, especially in the
  premature infant.

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Peripartum Management of Meconium

• Prevention of MAS
• Intrapartum Suctioning Suctioning of the
  meconium from the infants airway after delivery
  of the head but before delivery of the shoulders
  
• Tracheal Suctioning Suctioning of
  the trachea
• immediately after birth.

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Intrapartum suctioning

• A large multicenter randomised trial found that
  intrapartum suctioning of meconium does not
  reduce the incidence of meconium aspiration
  syndrome
• Routine intrapartum oropharyngeal and
  nasopharyngeal suctioning for infants born with
  meconium-stained amniotic fluid is no longer
  recommended.

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Tracheal Suctioning

• A RCT showed that tracheal intubation and
  suctioning of meconium-stained but vigorous
  infants at birth offers no benefit and
  accordingly is no longer indicated
• No studies in Meconium-stained, depressed
  infants. These should receive tracheal suctioning
  immediately after birth and before stimulation,
  presuming the equipment and expertise is
  available.

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Initial Breaths

• The optimum pressure, inflation time, and flow
  required to establish an effective FRC has not
  been determined.
• Average initial peak inflating pressures of
  30-40 cm water used successfully to ventilate
  unresponsive term infants
• Ventilation rates of 30-60 breaths min-1
  commonly used, but the relative efficacy of
  various rates has not been investigated

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Treatment Recommendation 1
R

• Establishing effective ventilation is the primary
  objective in the management of the apnoeic or
  bradycardic newborn in the delivery room.
• Positive-pressure ventilation alone is effective
  for resuscitating almost all apnoeic or
  bradycardic newborn infants
• Prompt improvement in HR is the primary measure
  of adequate initial ventilation chest wall
  movement should be assessed if heart rate does
  not improve.

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Treatment Recommendation 2
R

• If pressure is being monitored, an initial
  inflation pressure of 20 cm H2O may be effective,
  but a pressure 3040 cm H2O may be necessary in
  some term babies.
• If pressure is not being monitored, the minimal
  inflation required to achieve an increase in
  heart rate should be used.
• There is insufficient evidence to recommend
  optimal initial or subsequent inflation times.

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Assisted Ventilation Devices

• A self-inflating bag, a flow-inflating bag, or a
  T-piece mechanical device designed to regulate
  pressure as needed can be used to provide mask
  ventilation to a newborn.
• Target inflation pressures and long inspiratory
  times are achieved more consistently when using
  T-piece devices than when using bags.

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Laryngeal Mask Airway (LMA)

• LMA can provide effective ventilation during
  resuscitation of term preterm babies at birth
• May enable effective ventilation during
  resuscitation if bag-mask ventilation is
  unsuccessful and tracheal intubation is
  unsuccessful or not feasible.
• There is insufficient evidence to recommend use
  of LMA as the primary airway device during N.
  resuscitation.

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Ventilation for Preterm Infants

• Studies indicate that preterm lungs are more
  easily injured by large-volume inflations
  immediately after birth
• Avoid creation of excessive chest wall movement
  during ventilation of preterm infants immediately
  after birth.
• If positive-pressure ventilation is required, an
  initial inflation pressure of 2025 cm H2O is
  adequate for most preterm infants, consider
  higher pressure if no prompt improvement in heart
  rate or no chest movement is obtained.

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Use of CPAP or PEEPDuring Resuscitation

• Excessive CPAP, can overdistend the lung,
  increase the work of breathing, and reduce
  cardiac output and regional blood flow.
• In the sick neonate CPAP helps stabilise and
  improve lung function
• A small underpowered feasibility trial of
  delivery room CPAP/PEEP versus no CPAP/PEEP did
  not show a significant difference in immediate
  outcomes

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Treatment Recommendation
R

• There are insufficient data to support or refute
  the routine use of CPAP during or immediately
  after resuscitation in the delivery room.
• In preterm baby-Start resuscitation with CPAP of
  at least 56 cm water via mask or nasal prongs to
  stabilize the airway and establish functional
  residual volume (D).It is not clear at present if
  delivery room CPAP will reduce the need for
  subsequent surfactant treatment or mechanical
  ventilation

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Exhaled CO2 Detectors to Confirm Tracheal Tube
Placement

• A positive test confirms tracheal placement of
  the tube, whereas a negative test strongly
  suggests oesophageal intubation.
• Exhaled CO2 detection is a reliable indicator of
  tracheal tube placement in infants
• Identify oesophageal intubations faster than
  clinical assessments
• Poor or absent pulmonary blood flow may give
  false-negative results may lead to unnecessary
  extubation.

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Adrenaline-Route and Dose

• A paediatric study studies in newborn animals
  showed no benefit and a trend toward reduced
  survival rates and worse neurological status
  after administration of high-dose IV adrenaline
  (100gkg-1) during resuscitation.
• Animal adult human studies show that when given
  tracheally, considerably higher doses of
  adrenaline than currently used are required to
  show a positive effect.

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Adrenaline-Route and Dose

• Lack of human data.
• Reasonable to continue to use adrenaline when
  adequate ventilation and chest compressions have
  failed to ? the HR to gt60 beats/min.
• Use the IV route for adrenaline.
• The recommended IV dose is 0.01-.03 mg kg-1.
• Do not give higher doses of intravenous
  adrenaline.
• If the tracheal route is used, give a higher dose
  (0.1 mg kg-1).The safety of these not studied.

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Sodium Bicarbonate (SB)Infusion During
Resuscitation

• At birth babies who do not respond to initial
  resuscitative efforts have acidosis
• IV SB common practice for over 30 years- no good
  evidence
• Only 1 high quality study of 55 babies that
  compared SB treatment with no treatment, did not
  show any benefit nor any adverse effects.
• There is insufficient evidence that SB reduces
  mortality morbidity in infants receiving
  resuscitation at birth.

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Volume ExpansionCrystalloids and Colloids

• Three RCT in neonates showed that isotonic
  crystalloid is as effective as albumin for the
  treatment of hypotension
• In consideration of cost and theoretical risks,
  an isotonic crystalloid solution rather than
  albumin should be the fluid of choice for volume
  expansion in neonatal resuscitation.

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Maintenance of Body Temperature

• Studies showed an association between hypothermia
  and increased mortality in premature newborns.
• Premature infants continue to be at risk for
  hypothermia when treated according to current
  recommendations (dry the infant, remove wet
  linens, place the infant on a radiant warmer)

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Plastic Bags/Wrapping

• Studies confirm the efficacy of plastic bags or
  plastic wrapping (food-grade, heat-resistant
  plastic) in addition to the radiant heat in
  significantly improving admission temp. of
  premature babies of lt28 weeks gestation
• Consider the use of plastic bags or plastic
  wrapping under radiant heat as well as standard
  techniques to maintain temp.

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Hyperthermia

• Babies born to febrile mothers (temp. gt38 ?C)
  have an increased risk of death, perinatal
  respiratory depression, neonatal seizures, and
  cerebral palsy
• The goal is to achieve normo-thermia and to avoid
  iatrogenic hyperthermia in babies who require
  resuscitation.

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Glucose

• Both low and high blood glucose may have adverse
  effects
• Based on available evidence, the optimal range of
  blood glucose concentration to minimise brain
  injury following asphyxia and resuscitation
  cannot be defined.
• Infants requiring resuscitation should be
  monitored and treated to maintain glucose in the
  normal range.

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Induced Hypothermia

• In a multicenter trial involving newborns with
  suspected asphyxia, selective head cooling
  (3435C) was associated with a non-significant
  reduction in the overall number of survivors with
  severe disability at 18 months but a significant
  benefit in the subgroup with moderate
  encephalopathy.
• A second large trial of asphyxiated newborns
  treatment with systemic hypothermia (33.5 C)
  following moderate to severe encephalopathy was
  associated with a significant (18) decrease in
  death or moderate disability at 18 months.

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Treatment Recommendation
R

• There is insufficient data to recommend routine
  use of modest systemic or selective cerebral
  hypothermia after resuscitation of infants with
  suspected asphyxia.
• Further clinical trials are needed to determine
  which infants benefit most and which method of
  cooling is most effective.
• Avoidance of hyperthermia (elevated body
  temperature) is particularly important in infants
  who may have had a hypoxic-ischemic event.

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Summary

• A brief history of neonatal resuscitation
• Neonatal Resuscitation Guidelines
• Evidence based recommendations
• ILCOR

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An Update on Neonatal Resuscitation
Any Questions