An Update on Neonatal Resuscitation

1. 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

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

4. Schultze Method Of Neonatal Resuscitation Since ancient times many different methods have been used to revive newborns ( From Schultze BS. Der Scheintod Neugeborener. Jenna: Mauke’s Verlag, 1871.)

5. Techniques Advocated and Used to Resuscitate Newborns 1850–1950 • 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 raven’s 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

6. 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.

7. 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.”

8. 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.

9. 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

10. The Size of The Problem • 100, 000 newborn, Sweden, ActaPaediatr 1992; 81:739-44 • 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

12. 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

13. Other Who Need Resuscitation May receive one or more of the following actions in sequence: • Initial steps (Drying&wrapping, 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)

14. 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.

15. Supplementary Oxygen/Air • There are concerns about potential adverse effects of 100% oxygenon 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.

16. R Treatment Recommendation 1 • 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.

17. R Treatment Recommendation 2 • 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.

18. Peripartum Management of Meconium • Prevention of MAS • Intrapartum Suctioning Suctioning of the meconium from the infant’s airway after delivery of the head but before delivery of the shoulders • Tracheal Suctioning Suctioning of the trachea • immediately after birth.

19. 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.

20. Tracheal Suctioning • A RCT showed that tracheal intubation and suctioning of meconium-stained but vigorous infantsat 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.

21. 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

22. R Treatment Recommendation 1 • 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.

23. R Treatment Recommendation 2 • If pressure is being monitored, an initial inflation pressure of 20 cm H2O may be effective, but a pressure ≥30—40 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.

25. 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.

26. 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.

27. 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 20—25 cm H2O is adequate for most preterm infants, consider higher pressure if no prompt improvement in heart rate or no chest movement is obtained.

28. 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

29. R Treatment Recommendation • 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 5–6 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

30. 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.

31. 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.

32. 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 >60 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.

33. 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.

34. 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.

35. 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)

36. 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 <28 weeks gestation • Consider the use of plastic bags or plastic wrapping under radiant heat as well as standard techniques to maintain temp.

37. Hyperthermia • Babies born to febrile mothers (temp. >38 ◦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.

38. 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.

39. Induced Hypothermia • In a multicenter trial involving newborns with suspected asphyxia, selective head cooling (34–35°C) 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.

40. R Treatment Recommendation • 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.

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

42. An Update on Neonatal Resuscitation Any Questions