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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Ola Didrik Saugstad
Department of Pediatric Research
Rikshospitalet, University of Oslo
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
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)
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
Prepare for birth
Textbook and video is available
Min 1’HR >80 1’min HR <80 1’min HR < 60
Median , 5-95 percentiles
How to carry out?
The following questions should be answered after
Ifthe answer is no to any of these consider resuscitation
Be prepared: every newborn baby might need resuscitation!
Facts About Newborn Resuscitation
Ventilate for 30 seconds:
Rate: 40-60 /min
Pressure: Visible rise and fall of chest
HR < 60
Initiate chest compression
HR > 100 bpm:
Check for spontaneous
Bag and mask the most important tool in newborn resuscitation
Milner A, et al
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
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
Resair 2 – Pediatrics, 1998
Chest compression 19% resuscitation
But needed in only 1-2% …
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.
Not sufficient data to change present guidelines
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
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
0 1 2 3 resuscitation
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
Ramji et al
0.58 (95% CI 0.43-0.80)
0 1 2 odds ratio resuscitation
Apgar 1min < 4
A 5% reduction in mortality
indicates approx 200,000 saved
A 3% reduction in mortality
indicates approx 6000 saved
lives in both North America
and Western Europe
Favoring 21% Favoring 100%
Clinical data resuscitationAdverse effects of resuscitation with 100% O2
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
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
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]
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.
There are circumstances in which non-initiation or discontinuation of resuscitation in the delivery room may be appropriate…
Non-initiation of resuscitation in the delivery room may be appropriate in infants with:
Current data support that resuscitation of these newborns is very unlikely to result in survival or survival without severe disability.
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.
Written documentation of
infants (especially preterm) who required resuscitation are at increased risk for all of the general post-resuscitation complications, especially:
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
AHA-AAP 2000 resuscitationNeonatal Resuscitation Meconium
Resuscitation practises not effective or even harmful
Care after successful resuscitation
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