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Ola Didrik Saugstad Department of Pediatric Research Rikshospitalet, University of Oslo NORWAY

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 NORWAY

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  1. Resucitation of newborn infants Ola Didrik Saugstad Department of Pediatric Research Rikshospitalet, University of Oslo NORWAY

  2. 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

  3. Newborn Resuscitation Guidelines

  4. 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

  5. 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)

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Newborn Resuscitation Physiology

  12. Secondary energy failure – an opportunity for treatment

  13. 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

  14. Newborn Resuscitation Clinical sequences

  15. Resair 2 Median (5-95percentile)

  16. Resair 2 Median (5-95percentile)

  17. Resair 2

  18. Oxygen saturation% during first minutes of life

  19. 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

  20. Newborn Resuscitation How to carry out?

  21. 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!

  22. 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

  23. The most important is to get air into the lungs Facts About Newborn Resuscitation

  24. 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

  25. Bag and mask the most important tool in newborn resuscitation

  26. Expiratory tidal exchange Milner A, et al

  27. Ventilation 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

  28. Neonatal 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

  29. Chest compression • 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 …”

  30. Heart rate < 60 per min % seconds Resair 2 – Pediatrics, 1998

  31. Chest compression 19% But needed in only 1-2% … RESAIR 2

  32. Neonatal Resuscitation Room 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)

  33. RESAIR 2 Room air vs 100% oxygen Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics, 1998; 102:e1

  34. Median time (min) to first cry 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

  35. 0 1 2 3 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

  36. 0 1 2 odds ratio 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%

  37. Clinical data 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

  38. Is the highest Apgar score always best? 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

  39. Drugs needed forNewborn Resuscitation

  40. Neonatal 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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