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Hot and Cold Issues in Neonatal Resuscitation

Hot and Cold Issues in Neonatal Resuscitation. Jeffrey M Perlman MB Ch B Professor of Pediatrics Weill Cornell Medical College New York, NY. I have no Conflicts to Disclose. What Will be Covered.

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Hot and Cold Issues in Neonatal Resuscitation

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  1. Hot and Cold Issues in Neonatal Resuscitation Jeffrey M Perlman MB Ch B Professor of Pediatrics Weill Cornell Medical College New York, NY

  2. I have no Conflicts to Disclose

  3. What Will be Covered • Introduce some of the “Hot Issues” in 2010 • Stress the Importance of Pulse Oximetry • Indicate that Room air is superior to O2 • Chest compressions to ventilation ratios should remain unchanged in neonatal resuscitation • Therapeutic hypothermia should be offered to infants at risk for evolving brain injury

  4. Major New Recommendations - Hot Issues • Initial evaluation of an infant in the DR is now defined by the simultaneous assessment of Two Vital Characteristics i.e. heart rate and respirations. • Oximetry should be used for evaluation of oxygenation because assessment of color is unreliable. • For babies born at term it is best to Initiate Resuscitation with Air rather than 100% O2. • Administration of supplementary O2 should be regulated by blending O2 and air, and the concentration of O2 delivered should be guided by Oximetry. • The chest compression-ventilation ratio should remain at 3:1 for neonates unless the arrest is known to be of cardiac etiology, in which case a higher ratio should be considered. • Therapeutic hypothermia should be considered for infants born at term or near-term with evolving moderate to severe HIE encephalopathy, with protocol and follow-up coordinated through a regional perinatal system.

  5. The Basic Tenet of Delivery Room Resuscitation • Effective Ventilation is the principle and critical intervention in restoring cardio-respiratory status in a bradycardic infant in the DR • Bradycardia in the DR and in the neonatal period invariably reflects an asphyxial process rather than a cardiac cause • The most important clinical indicator of adequate ventilation at birth is a rapid  in Heart Rate i.e. within 20 seconds to > 100 beats/minute • DR approach to resuscitation remains ABC Palme-Kilander C et al Arch Dis Child 1993; 68: 11

  6. Why the Importance of Ventilation ? • In-utero the placenta acts as the “respiratory system” providing oxygen and eliminating CO2 • Interruption of placental blood flow with progressive O2 pCO2  pH may have significant effects on cardio respiratory adaptation • The lungs are fluid filled and respiratory adaptation at birth is in part dependent upon changes in fluid dynamic balance within the lungs • Production of lung fluid has to stop prior to or at birth, if an adequate functional residual capacity is to established

  7. Consequences of Asphyxia on Respirations, Heart Rate and Blood Pressure Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968.

  8. Why the Importance of Ventilation ? • In-utero the placenta acts as the respiratory system providing oxygen and eliminating CO2 • Interruption of placental blood flow may have significant consequences on cardio respiratory adaptation • The lungs are fluid filled and respiratory adaptation at birth is in part dependent upon changes in fluid dynamic balance within the lungs • Production of lung fluid has to stop prior to or at birth, if an adequate functional residual capacity is to established

  9. Ventilating an Apneic Baby at Birth - Importance of Establishing Functional Residual Capacity Passive Inflation – air circulates in the large airways and will not establish FRC =Initiation Of Respiratory Effort which is critical to establishing FRC so critical to effective breathing

  10. Neonatal Algorithm - NRP

  11. Differences Between ILCOR and Neonatal NRP Algorithm NRP ILCOR Note the NRP Algorithm stresses the importance of ventilation

  12. Assessing the Efficacy of Resuscitation -How to Measure Heart Rate • Heart rate remains the primary vital sign by which to judge the need for and efficacy of resuscitation. • Auscultation of the precordium should remain the primary means of assessing heart rate. • Palpation of the umbilical pulse has a high likelihood of underestimating the heart rate, but is preferable to other palpation locations. • For babies requiring ongoing resuscitation and/or respiratory support, the goal should be to use pulse oximetry. • Because of concerns regarding the ability to consistently obtain accurate measurements, pulse oximetry should be used in conjunction with, and not replace, clinical assessment of heart rate during newborn resuscitation.

  13. Use of Pulse Oximetry • Pulse Oximeters display heart rate, SpO2 updated every 2 seconds, as well as a continuous display of the arterial plethysmographic waveform • The heart rate is accurate as long as the signal quality is good • To obtain the fastest signal the oximeter should be switched on, the sensor placed on the infant’s right arm or wrist , covered to reduce extraneous light, and then plugged into the oximeter cable. O'Donnell CP a, Arch Dis Child Fetal Neonatal Ed. 2005 90(1):F84-5

  14. Changes in Oxygen Saturation at Birth -Importance of Pulse Oximetry

  15. Balance between oxygen delivery and tissue demand Neither PaO2 and O2 saturation can provide this information O2 is transport from lung to tissues almost exclusively bound to hemoglobin (97%) with 3% dissolved in plasma (determines PaO2) There is minimal PaO2 contribution to O2 delivery Oxygen toxicity correlates with PaO2 not saturation (SaO2 ) What Constitutes Adequate Oxygenation?

  16. Oxygen Hemoglobin Dissociation Curve 27 50 200 B A Note when Saturation values are > 95% the PaO2 can be extremely high

  17. Oxygen Saturation Changes Around Birth

  18. SpO2 values for the first 5 minutes of life 2009 DR CPAP Fetal Saturation At Birth The PaO2 in the umbilical artery at birth is ~ 27mmHg The P50 for fetal hemoglobin is 19mmHg

  19. Comparison of Sp02 Values 1 to 10 Minutes After Birth for Preterm and Term Infants Saturation values are lower at each minute in preterm versus term infants Dawson et al Pediatrics 2010;125:e1341

  20. Comparison of Sp02 Values 1 to 10 Minutes After Birth for Vaginal and CS Births Saturation values are lower at each minute following CS versus Vaginal Delivery Dawson et al Pediatrics 2010;125:e1341

  21. Time for Infants to Reach Specific Sp02 Targets Dawson et al Pediatrics 2010;125:e1341

  22. Summary • There is clear evidence that an increase in oxygenation and improvement in color may take many minutes to achieve, even in uncompromised babies. • Furthermore, there is increasing evidence that exposure of the newly born to hyperoxia is detrimental to many organs at a cellular and functional level. • For this reason color has been removed as an indicator of oxygenation or resuscitation efficacy. • The oximeter can be used to adjust the increase in oxygenation to that of the uncompromised baby born at term.

  23. Room Air versus Oxygen During Delivery Room Resuscitation-Which is Superior?

  24. Potential Consequences of Using 100% Oxygen During Resuscitation • 100% O2 depresses ventilation – has been associated with lower Apgar scores • 100% O2 produces more oxygen free radicals which are damaging to cells throughout the body • However newborn asphyxiated piglets resuscitated with room air versus 100% O2 have significantly  levels of excitatory amino acids in striatum, lower mean ABP, and greater degree of hypoperfusion in cerebral cortex.

  25. Resuscitation in Room Air versus 100% O2 - Effect on Mortality  Mortality with RA vs O2 Relative Risk and 95% Confidence Intervals (CI) Neonatology 2008 Saugstad, Ramji, Stoll, Vento

  26. Room Air versus O2 in the Premature Infant – Using the Target Saturation range of 85-95% to Titrate Delivered O2

  27. Mean SpO2 at Each Minute of Life Using Room air vs 90% O2 During Resuscitation Wang, C. L. et al. Pediatrics 2008;121:1083-1089

  28. Proportion of Infants with SpO2 > 95% for Each Minute of Life Note the % of Babies with saturation values > 95% Wang, C. L. et al. Pediatrics 2008;121:1083-1089

  29. SpO2 values in the first 20 minutes after birth in ELBW Infants randomly assigned to lowO2 (Lox) group (30%) or HighO2 (Hox) group (FIO2 90%) Note using the saturation range as a guide O2 delivery can be titrated Escrig, R. et al. Pediatrics 2008;121:875-881

  30. Heart Rate and FiO2 Used to Attain a Target SpO2 of 85% at 10 Minutes After Cord Clamping in VLBW Infants Resuscitated with 30% or 90% O2 Escrig, R. et al. Pediatrics 2008;121:875-881

  31. Effect of Change in Practice on Starting FiO2 in the DR and Initial FiO2 on Admission Using the Target of 85-95% 0.70±0.03 0.38±0.02 0.42±0.06 0.28±0.07* *RA 14/53 (26%) Period 1 (June-Aug) Period 2 (Sept-Nov) Period 3 (Dec-Feb) Period 4 (Mar-June) Stola et al Journal of Perinatology 2009;29: 548

  32. Oxygen - Treatment Recommendation • In term infants receiving resuscitation at birth with positive pressure ventilation, it is best to begin with air as opposed to 100% oxygen. If, despite effective ventilation there is no increase in heart rate or oxygenation (guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered  • As many preterm babies less than 32 weeks gestation will not reach target saturations in air, blended oxygen and air may be given judiciously and ideally guided by pulse oximetry. Both hyperoxemia and hypoxemia should be avoided. If a blend of oxygen and air is not available, resuscitation should be initiated with air

  33. Chest Compressions

  34. Chest Compressions- Consensus on Science • Cardiac arrest in neonates is invariably secondary to an asphyxial process. • In animal studies of asphyxial models of cardiac arrest, piglets resuscitated with a combination of chest compressions and ventilations had better outcomes than those resuscitated with ventilations or compressions alone • Manikin studies confirm that the 3:1 compression-ventilation ratio provides more ventilations per minute when compared with higher ratios. • Evidence from randomized studies in swine models, manikin studies, small case series and cadavers support the current practice of favoring the 2 thumb–encircling hands technique of chest compressions when compared with the 2-finger technique.

  35. Treatment Recommendations – ILCOR 2010 • There is no evidence from quality human, animal, manikin or mathematical modeling studies to warrant a change from the current compression to ventilation ratio of 3:1. • The two thumb technique is the preferred method of administering compressions • Strategies for optimizing the quality of the compressions and ventilations with as few interruptions as possible should be considered. • Because ventilation is critical to reversal of newborn asphyxial arrest, any higher ratio that decreases minute ventilation should be introduced with caution. • If the arrest is known to be of cardiac etiology, a higher ratio should be considered.  

  36. Therapeutic Hypothermia A large body of evidence from 3 large randomized studies and 2 small randomized trials demonstrated that induced hypothermia (33.5 to 34.5C) implemented within 6 hours of birth in term infants at highest risk for brain injury (as defined by specific protocols) and with further treatment in neonatal intensive care units is associated with significantly fewer deaths and less neurodevelopmental disability at 18-month follow-up. The number needed to treat is 9

  37. Meta-Analysis of Major Studies Edwards et al BMJ 2010; 10: 340

  38. ILCOR 2010- Treatment Recommendation • Newly born infants born at or near-term with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia. • Whole body cooling and selective head cooling are both appropriate strategies. • Cooling should be initiated and conducted under clearly defined protocols with treatment in neonatal intensive care facilities and with the capability for multidisciplinary care. • Treatment should be consistent with the protocols used in the randomized clinical trials (ie, begin within 6 hours of birth, continue for 72 hours after birth, and rewarm over at least 4 hours). • Carefully monitor for known adverse effects of cooling, eg, thrombocytopenia and hypotension. • All treated infants should be followed up longitudinally.

  39. Conclusions • Based on the rigorous ILCOR process, the NRP treatment recommendations presented reflect the best available scientific evidence. • This rigorous process has stimulated neonatal resuscitation research and as a consequence clinicians are delivering more targeted and enhanced therapy in the delivery room

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