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Resucitation of newborn infants. Ola Didrik Saugstad Department of Pediatric Research Rikshospitalet, University of Oslo NORWAY. Facts. 6-10 out of 130 mill newborns need intervention at birth. 4 mill birth asphyxia. 1 mill die and a similar number

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Resucitation of newborn infants

Ola Didrik Saugstad

Department of Pediatric Research

Rikshospitalet, University of Oslo

NORWAY


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Facts

  • 6-10 out of 130 mill newborns

  • need intervention at birth

  • 4 mill birth asphyxia

  • 1 mill die and a similar number

  • develop sequels due to birth

  • asphyxia (CP, Epilepsia)

  • Most newborn infants

  • are born outside

  • hospitals without

  • health personel

  • attending



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Is newborn resuscitation

evidence based?

AHA and AAP in their last guidelines (2000)

summarised the literature and tried to determine

what is and what is not evidence based

If a procedure is not evidence based

evidenced based information should be collected

before the procedure in case is changed


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Resuscitation of Newborn Infants

WHO: Basic Newborn Resuscitation

(WHO, Geneva 1998)

ILCOR: An Advisory Statement From the Pediatric Working Group of the International Liason Committee on Resuscitation.

(Pediatrics, April 1999)

AHA/AAP: International Guidelines for Neonatal Resuscitation. (Pediatrics September 2000)


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WHO guidelines

Anticipate

  • Be prepared for every birth by having skill to resuscitate and by knowing the institutions policy on resuscitation

  • Review the risk factors for birth asphyxia

  • Clearly decide on the responsibilities of each health care provider during resuscitation

  • Remember that the mother is also at risk of complications


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WHO Guidelines

Risk factors for birth asphyxia

maternal illness traumatic delivery

sexually transmitted diseases prolapsed cord

malaria mec stained amniot fluid

eclampsia congenital anomaly

maternal bleeding prolonged labour

maternal sedation breech/other abn presnt

fever during labour PROM


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WHO Guidelines 1998

Prepare for birth

  • two clean towels for thermal protection and small)

  • a suction device ( mucus extractor)

  • a radiant heater (if available

  • a draught-free delivery room > 25oC

  • clean delivery kit for cord care, gloves

  • two infant masks (normal)

  • a blanket

  • a clock

  • an additional set of equipment in reserve for multiple births or in case of failure of the first set

  • inform mother

  • open the airway - clear the airway by suctioning first the mouth and then the nose

  • ventilate with appropriate mask (size 1 for a normal weight and 0 for a small newborn)

  • observe the rise of the chest

  • ventilate 40 (30-60) breaths/min

  • stop an look for spontaneous breathing after about 1 min


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AHA/AAP 2000

  • Recommendations resulting from collaboration among

    • AHA Pediatric Subcommittee

    • ILCOR Pediatric Working Group

    • AAP Neonatal Resuscitation Program

Textbook and video is available

www.aap.org


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Newborn ResuscitationAHA/AAP Guidelines

  • Summary of changes from 1992

  • Meconium -stained amniotic fluid: endotracheal suctioning of the depressed - not the vigorous child

  • Hyperthermia should be avoided

  • 100% oxygen is still recommended, however if supplemental oxygen is unavailable room air should be used

  • Chest compression: Initiated if heart rate is absent or remains < 60 bpm despite adequate ventilation for 30 sec

  • Medications: Epinephrine 0.01-0.03 mg/kg if heart rate < 60 bpm in spite of 30 seconds adequate ventilation and chest compression

  • Volume: Isotonic crystalloid solution or 0-neg blood




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Perinatal asphyxia – some basic facts

  • Primary to 2nd apnea lasts 8-10 min.

  • Auto resuscitation possible

  • Secondary apnea about 10 min asphyxia. Auto resuscitation not possible

  • pCO2 10 mm Hg (1.3 kPa) /min

  • Serum potassium 15 mmol/L after 10 min

  • Base deficit  2/5 mmol/L/min in 8% O2

  •  2/3 mmol/L/min in 6% O2


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Newborn Resuscitation

Clinical sequences


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Resair 2

Median (5-95percentile)


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Resair 2

Median (5-95percentile)




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SaO2 during resuscitation related to 1 min heart rate

1

70 (39-82)

60 (40-75)

45 (40-99)

3

85 (41-94)

85 (60-93)

76 (60-94)

5

90 (72-96)

90 (69-95)

80 (60-93)

10

93 (70-97)

90 (80-97)

90 (74-9)

Min 1’HR >80 1’min HR <80 1’min HR < 60

Median , 5-95 percentiles


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Newborn Resuscitation

How to carry out?


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AAP/AHA

Neonatal Resuscitation

The following questions should be answered after

every birth:

  • Is the amniotic fluid clear of meconium?

  • Is the baby breathing or crying?

  • Is there a good muscle tone?

  • Is the color pink?

  • Was the baby born at term?

Ifthe answer is no to any of these consider resuscitation

Be prepared: every newborn baby might need resuscitation!


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Neonatal Resuscitation

AHA/AAP (2000)

Four Categories

  • Basic steps including rapid assessments and initial steps of stabilisation

  • Ventilation, including bag-mask or bag -tube ventilation

  • Chest compression

  • Administration of medications or fluids


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The most important is to get air into the lungs

Facts About Newborn Resuscitation


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Bag and mask

Ventilate for 30 seconds:

Rate: 40-60 /min

Pressure: Visible rise and fall of chest

HR < 60

HR 60-100

HR >100

Continue ventilation

Initiate chest compression

Consider intubation

HR > 100 bpm:

Check for spontaneous

respirations

Continue ventilation

Consider intubation



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Expiratory tidal exchange resuscitation

Milner A, et al


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Ventilation resuscitation

Even a few (6) blows with a too high tidal volume (35-40 mL/kg) before surfactant destroys the lungs of premature lambs

A too high or a too low tidal volume triggers inflammatory changes in the lungs leading to influx of phagocytes, proinflammatory cytokines increase


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Neonatal Resuscitation resuscitationChest compressions - indication

Chest compressions should be performed if the heart rate is < 60 beats/minute, despite adequate ventilation with 100% oxygen for 30 seconds. [ILCOR 1999 Advisory Statement],AHA- AAP 2000


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Chest compression resuscitation

  • If:

  • HR < 60 after 30 seconds ventilation and stimulation

  • Thumb technique: Place your thumbs side by side or, on a small baby,

  • one over the other, immediately above xyphoid. The other fingers provide

  • support needed for the back

  • Pressure so that you depress the sternum to a depth of approximately

  • 1/3 of the anterior/posterior diameter of the chest. Then release.

  • The downward stroke should be somewhat shorter than duration of the release.

  • Your thumbs should remain in contact with the chest at all times

  • 90 compressions + 30 breaths per min

  • ”One and two and three and breath, and one and two and three and breath …”


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Heart rate < 60 per min resuscitation

%

seconds

Resair 2 – Pediatrics, 1998


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Chest compression 19% resuscitation

But needed in only 1-2% …

RESAIR 2


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Neonatal Resuscitation resuscitationRoom air vs. 100% Oxygen

If assisted ventilation is required, 100% oxygen should be delivered by positive pressure ventilation … If supplemental oxygen is not available, resuscitation of the newly born infant should be initiated with positive pressure ventilation and room air.

AAP/AHA 2000:

Not sufficient data to change present guidelines

(grandfather principle)


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RESAIR 2 resuscitation

Room air vs 100% oxygen

Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics, 1998; 102:e1


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Median time (min) to first cry resuscitation

Saugstad et al 1998 Ramji et al 2003

21% O2 1.6 2.0

100% O2 2.0 3.0

p 0.005 0.008

  • Duration of ventilation significantly shorter ( 2 min)

  • in room air group. Saugstad et al, 1998, Vento et al, 2001

  • Oxygen resuscitated received 350 ml more O2 than

  • room air resuscitated. Vento et al, 2003


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0 1 2 3 resuscitation

Odds Ratio

..............

..............

:

Favoring 21% Favoring 100%

Ramji et al

Saugstad et al

1737 newborn in 5 studies randomized to 21 or 100% O2

21% 100% O2

Total % 8 13

Spain % 0.5 3.5

Vento et al

Neonatal mortality

Ramji et al

0.58 (95% CI 0.43-0.80)

Typical estimate


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0 1 2 odds ratio resuscitation

Neonat mortality

Term

Preterm

Apgar 1min < 4

All infants

A 5% reduction in mortality

indicates approx 200,000 saved

lives worldwide

A 3% reduction in mortality

indicates approx 6000 saved

lives in both North America

and Western Europe

Favoring 21% Favoring 100%


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Clinical data resuscitation

Adverse effects of resuscitation with 100% O2

  • Prolonges time to first breath

  • Prolonges duration of positive pressure ventilation

  • Elevates oxidative stress (at least 4 weeks)

  • Increases neonatal mortality

  • 3% in industrialised, 5% in developing countries

  • Associated with acute lymphatic leukemia

Experimental data

\

  • Inflammation in brain, myocardium and lungs

  • Increases neuronal damage?

  • Poorer neurological outcome


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Is the highest Apgar score always best? resuscitation

Virginia Apgar

0_________ 1__________ 2_____

Heart rate 0 <100 >100

Respiration 0 weak, irregular good cry

Reaction 0 slight good

Colour blue or pale body pink limbs blueall pink

Tone limp some movement active movements

limbs well flexed


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Drugs needed for resuscitationNewborn Resuscitation


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Neonatal Resuscitation resuscitationEpinephrine dose

The recommended IV or endotracheal dose of epinephrine is 0.1 to 0.3 mL/kg of a 1:10,000 solution (0.01 to 0.03 mg/kg) repeated every 3 to 5 minutes as indicated.

Higher doses have been associated with increased risk of intracranial hemorrhage and myocardial damage.

No different dose for premature infants


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Neonatal Resuscitation resuscitationVolume expansion

Volume expansion may be accomplished with (1) isotonic crystalloid such as normal saline or Ringer’s lactate or (2) O-negative blood. [Class IIb, level 7 evidence]


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Neonatal Resuscitation resuscitationCerebral Hypothermia

Cerebral hypothermia cannot presently be recommended for newly born infants who have experienced severe perinatal asphyxia.

Hyperthermia appears to be injurious and should be avoided.


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Neonatal Resuscitation resuscitation Ethics

There are circumstances in which non-initiation or discontinuation of resuscitation in the delivery room may be appropriate…

AHA-AAP 2000


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Neonatal Resuscitation resuscitationEthics

Non-initiation of resuscitation in the delivery room may be appropriate in infants with:

  • confirmed gestation < 23 weeks

  • birthweight < 400 grams

  • anencephaly

  • confirmed trisomy 13 or 18 may be appropriate.

    Current data support that resuscitation of these newborns is very unlikely to result in survival or survival without severe disability.

AHA/AAP 2000


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Neonatal Resuscitation resuscitation Ethics

Incases of uncertain prognosis, including uncertain gestational age, a trial of therapy, non-initiation, or discontinuation of resuscitation remain options following assessment of the baby. Ongoing evaluation and discussion with the parents and the health care team should guide continuation vs. withdrawal of support.

AHA/AAP 2000


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Documentation resuscitation

Written documentation of

  • Personal involved

  • All procedures including drugs

  • Timing


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Post resuscitation care resuscitation

infants (especially preterm) who required resuscitation are at increased risk for all of the general post-resuscitation complications, especially:

  • Heat loss

  • Develop RDS due to immature lungs

  • Intracranial hemorrhage due to a fragile germinal matrix

  • Hypoglycemia

  • Necrotizing enterocolitis

  • Oxygen injury


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Resuscitation of Preterm Infants resuscitation

No specific guidelines. No clinical trials

WHO: principles are the same for preterm and term

ILCOR: No specific recommendations

AHA/AAP: ”Prematurity pointers”

Avoid rapid boluses of volume expanders or hyperosmolar solutions.

Avoid heat loss.

Handle with care in order to prevent ICH


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AHA-AAP 2000 resuscitation

Neonatal Resuscitation Meconium

  • Direct endotracheal suctioning may not be necessary in the apparently vigorous infant with meconium-stained fluid.

  • Direct endotracheal suctioning, using the endotracheal tube as a suction catheter, should be performed if the neonate is depressed.


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Newborn Resuscitation resuscitation

Some conclusions

  • preparation and teaching in the bottom of successful resuscitation

  • ventilation is the primary goal

  • oxygenation can in most cases be obtained by room air - more studies are needed

  • Chest compression and drugs are rarely needed

  • ethics should carefully be considered

  • each step should be assessed scientifically - more research


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WHO Guidelines resuscitation

Resuscitation practises not effective or even harmful

  • routine aspiration of babies mouth and nose

  • routine aspiration of stomach

  • stimulation by slapping or flicking the soles of its feet

  • postural drainage or slapping the back

  • squeezing the chest to remove secretions

  • routine giving sodium bicarbonate to newborns who are not breathing


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WHO Guidelines resuscitation

Care after successful resuscitation

  • do not separate mother and newborn- skin-to skin

  • examine the newborn (body temp, count breaths, observe indrawing and grunting, malformations, etc)

  • record the resuscitation and the problems, if any

  • clean the equipment and prepare for the next birth


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Neonatal Resuscitation resuscitation Confirmation of ETI

Expired CO2 detection can be useful in the secondary confirmation of endotracheal intubation in the newly born, particularly when clinical assessment is equivocal.

In newborns, data are limited and the frequent circumstances of

inadequate pulmonary expansion, decreased pulmonary blood flow

and small tidal volumes make extrapolation from other age groups

especially hazardous.


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