Updates in Neonatal Resuscitation

1. Updates in Neonatal Resuscitation Stacie Bennett, M. D. East Bay Newborn Specialists Children’s Hospital Oakland

2. Overview • Every year ~ 5-10% of infants require neonatal resuscitation. • Yet there are many areas where we don’t have evidence for the best resuscitation approach. • Right Amount of Oxygen to use • ? Right Bag and Mask • ? Correct pressures • Intubation for Meconium

3. Pulse oxymetry • All other areas of resuscitation use monitors except the DR. • May be able to avoid hypoxia and hyperoxia • Difficult to correlate saturations and color

4. Infant Color • O’Donnell et al looked at 20 infants with video reviewed by 27 observers and compared to pulse ox readings. • 1 infant was thought to be pink by all and his highest sat was 87%, 10 infants whose sats were >95% were never thought to be pink ~ 20% of the time. • The mean sats when infants were perceived to be pink by all observers was 69% (range 10-100%)

5. Current NRP Guidelines for Saturation Monitoring • To reduce excessive tissue oxygenation if a very preterm baby (<32weeks) is being delivered use an oxygen blender and a pulse oximeter during resuscitation. • Begin PPV with O2 concentration between RA and 100%. Adjust O2 up or down to achieve a saturation that gradually increased toward 90% and decreased O2 as saturations rise over 95%. • If HR does not respond rapidly to >100 BPM correct any ventilation problems and use 100% O2.

6. Pulse oxymetry Pre vs Post ductal • Mariani et al J Peds April 07. • Looked at pre/post ductal sats simultaneously in healthy term infants born via SVD or c/s. Resuscitator was blinded to sat values. • 110 infants, median time to accurate readings was 3 minutes. • At 5 min median sats when baby perceived to be pink was 86%. The mean time to reach preductal sat of 90% was 5.5min. (5.2 min SVD, 6.3 min in c/s) • No infants admitted to NICU.

8. O2 sat trends • Rabi et al. J Peds May 2006 • Masimo pulse ox preductally. 165 infants “code pink” del, 49 excluded d/t O2 supplementation, all >35 weeks, 115 infants analyzed. • Median time to stable sat readings 82 sec • Median Sats at 5 min for vag del was 87% (80-95%) and c/s was 81% (75-83%), by 8min 91% in vag and 90% in c/s.

9. O2 sat trends • Kamlin et al Jpeds May 2006 • 175 infants, median sat values: • 1min 63% (53-68%), 2min 70% (58-78), 3 min 76% (64-87%), 4 min 81% (71-91%) and 5 min 90% (76-91). • Kamlin et al J Peds June 2006 Heart rate was accurate even in infants requiring resuscitation using pulse Ox.

10. Saturation Monitor • When applying place preductally • Once on infant turn on machine for fastest reading • Currently recommended for preterm infants • Future probably recommended for all deliveries.

11. Current Oxygen Guidelines for Resuscitation • Current evidence is insufficient to resolve all questions regarding supplemental O2. • Term: Recommend 100% O2 when infant is cyanotic or when PPV is required. • However research suggest that resuscitation with something less then 100% may be just as successful. • If resuscitation is started with less then 100% O2 supplemental O2 up to 100% should be administered if there is no appreciable improvement within 90sec after birth.

12. Room Air Vs 100% Oxygen in the DR • In multiple studies and meta-analysis comparing resuscitation with RA vs 100% O2- decreased risk of neonatal mortality in infants resuscitated with RA (Mortality was 4.6% higher in O2 group) • Trend toward reduction in Stage 2 to 3 HIE in those infants resuscitated in RA. • Onset of respirations was faster in RA in some studies. • Lower 5 minute apgar scores and heart rate in several studies in infants resuscitated with O2. • Exposure to O2 decreased cerebral blood flow.

13. RA vs O2

15. RA vs O2 • 2 studies suggesting increased risk of childhood leukemia's if exposed to O2. • A case-control study using the Swedish Cancer Register looking at 97% of Cancer patients and controls from birth registry (99% of births). Looking at those who were resuscitated with 100% O2 there was a OR of 2.57 to have childhood lymphatic leukemia. It increased to an OR of 3.54 if manual ventilation lasted longer then 3 minutes. (Children with Down’s were excluded)

16. RA vs O2 • Several animal studies have shown: • Increased brain injury when exposed to O2 • O2 induces inflammation in the lung, heart and brain • Increased pulmonary resistance and reactivity • Increased oxidative stress

17. RA vs O2 • Medbo et al found that PVR increased with induced hypoxia in piglets but fell equally with both RA or 100% O2. • Wang et al Peds 6/2008 looked at preterm infants resuscitated with RA vs 100%. • In RA group all infants required increased FiO2 due to bradycardia or failure of saturation criteria. • Escrig et al in abstract 2007 at PAS suggested no difference in reaching saturation goals between 100% and <40%FiO2 at ~8 minutes of age • For preterm infants starting at FiO2 of 30-40% may be appropriate.

18. Potential Future O2 guidelines • RA for term deliveries, avoid 100% unless hypoxic • ? 30-40% for preterm deliveries. • Saturation monitoring and O 2 blenders in ALL delivery rooms to guide O2 needs

19. Bag and Mask • All types are acceptable including: T-piece resuscitators, flow inflating and self-inflating bags. • T-piece can give consistent PEEP and PIP • Self-inflating can’t deliver consistent PEEP or PIP.

20. Neopuff

21. CO2 detectors • Now recommended for confirming ETT placement. As confirms faster and more accurately. • May not change color if low HR, may need to visualize ETT, will get color change with adequate chest compressions. • If ETT right mainstem-may not change color • If have not established FRC may not change • If give epinephrine down ETT will stay yellow, need to replace CO2 detector. • May also be used with bag and mask to indicate airway obstruction.

25. Current statement regarding Therapeutic hypothermia • Hypothermia may reduce the extent of brain injury following hypoxia-ischemia • There is insufficient data to recommend routine use of selective and/or systemic hypothermia after resuscitation of infants with suspected asphyxia. • Hyperthermia may worsen the extent of brain injury following hypoxia-ischemia. • The goal should be to achieve normothermia and to avoid iatrogenic hyperthermia in resuscitated newborns.

26. Hypothermia • 2 large randomized trials: 1. Cool-cap trial-234 infants in 25 centers, >36 weeks • Maintain rectal temps of 34-35 C. Subgroup analysis showed that infants with moderate encephalopathy had significantly better outcomes at 18months (OR 0.46), no effect on infants with severe encephalopathy or seizures at time of enrollment. • 2. Whole Body cooling: 208 infants >36 weeks, esophageal temp to 33.5 C. Significantly reduced death or moderate-to-severe disability at 18-22 months (44% vs 62%) On subgroup analysis no improvement in the severely encephalopathic infants.

29. Hypothermia Future: Hypothermia whether total body or cerebral cooling is now considered the standard of care. Anticipate recommendations will change in future guidelines.

30. Cerebral Cooling Criteria • GA > 36 weeks, can started on cooling within 6 hrs of age, if received passive cooling at referral hospital and can be started on active cooling within 8 hrs of age.    • History compatible with HIE, meaning at least one of the following: • Apgar score of < 5 at 10 minutes • Continued need for resuscitation, including ETT or mask ventilation at 10 minutes • Acidosis present within 60 minutes of birth, defined as either an umbilical cord gas (arterial or venous) pH or post-natal arterial pH < 7.00 • Base deficit >16 mmol/L in umbilical cord gas (arterial or venous) or  patient blood gas (arterial, venous, or capillary) obtained within 60 minutes of birth

31. Cerebral Cooling Con’t • Physical exam compatible with encephalopathy, meaning at least one of the following: • Lethargy, stupor, or coma • Hypotonia • Abnormal reflexes, including oculomotor or pupillary abnormalities • Absent or weak suck • Clinical seizures •  At CHO: • CFM (Cerebral Function Monitor, also known as aEEG),showing moderately or severely abnormal background (score 2-3) and/or seizures at any time < 6 hrs from birth.   

32. Cerebral Cooling Con’t • Exclusion Criteria • < 36 weeks gestation • < 1800 grams • Coagulopathy with active bleeding • Severe congenital anomalies/syndromes/known metabolic disorders • ECMO Potential Exclusion Criteria • Severe PPHN

33. Passive Cooling • If neonatologist and Pediatrician agree: To begin passive cooling: • Turn table warmer off and monitor rectal temperatures every 15 minutes.  • Check rectal temperatures by gently inserting a clean, lubricated digital thermometer into the rectum approximately ½ inch or 2cm.  Wipe thermometer with alcohol between uses.  • The desired temperature range is 34°C- 35°C (rectal) or 93°F- 95°F.  • Keep TABLE WARMER OFF unless rectal temperature < 34.5°C or 94°F  • If patient’s rectal temperature falls below 34.5oC or 94°F, begin table warmer on lowest setting or “preheat.” • If patient’s rectal temperature is greater than 35°C or 95°F, continue passive cooling and do not attempt active cooling.

34. Passive Cooling Con’t • Maintain all other aspects of routine post-resuscitation care. • Maintain oxygenation and ventilation • Monitor blood pressure, heart rate, and perfusion • Obtain IV access • Provide IV fluids • Monitor glucose, electrolytes, CBC • Consider antibiotics • Avoid hyperthermia • Treat clinical or electrographic seizures with 20 mg/kg Phenobarbital.    • If the patient is hemodynamically unstable and/or has an oxygen requirement of 50% FiO2 in order to maintain oxygen saturations of > 95%, it may be determined by the attending neonatologist and referral pediatrician that passive cooling should not be initiated due to the patient’s instability.  Hyperthermia should however be avoided.  The patient’s temperature should be kept at 36 + 0.5°C or 97°F.

35. Laryngeal Mask Airway (LMA) • 1-5% of newborns require PPV in DR. • LMA may provide alternative for facemask ventilation or endotracheal intubation • Advantages: high rate of successful first-time placement, short time for placement, less training and practice needed, no instrumentation. • Disadvantages: gastric distension, potentially inadequate alveolar ventilation due to limitation of peak pressure due to leak, difficulty with suctioning of the airway or giving intra-tracheal emergency medications.

36. LMA • Many case control studies, limited randomized studies. • Limited studies using endotracheal epinephrine or surfactant with LMA. • Can be used for difficult airways • Few complications including soft tissue damage. • Used for short term airway support. • Current recommendations: can be used in some newborns who have failed bag and mask ventilation or endotracheal intubation.

37. LMA

38. Meconium • Meconium stained amniotic fluid (MSAF) occurs in 7-20% of births. Probably due to in-utero hypoxia and acidosis. • MAS occurs in 2-9% of infants born through MSAF • Management: 1. Current recommendations are for Intrapartum amnioinfusion for moderate to thick MSAF (meta-analysis showed benefit, though recent large multicenter study did not show benefit, may change recommendation in up coming guidelines. • 2. Suctioning on the perineum or abdomen prior to delivering the shoulders is no longer recommended. • 3. Post delivery suctioning for those infants who are not vigorous.

40. ETT vs IV epinephrine • ETT not as effective possibly secondary to decreased blood flow, pulmonary vasoconstriction from acidosis, persistent alveolar fluid that dilutes the epi, possible right to left intracardiac shunts that bypass pulmonary circulation all together. • In animal data ETT epi needed to be 5-30x the recommended dose for effect. • In 2005 recommendations: Epinephrine should be delivered via IV if not the ETT dose should be 0.3-1ml/kg (0.03-0.1mg/kg), iv is still 0.1-0.3ml/kg. • I usually start with 1ml if term infant via ETT.

42. Summary • Possible future changes: • Preductal pulse ox monitoring all deliveries requiring resuscitation • Blended O2 in all deliveries • RA resuscitation for term infants, 30-40% O2 for preterm resuscitation as a starting point. • Therapeutic hypothermia for moderate to severe hypoxic-ischemic encephalopathy • ? Management for Meconium, use of CPAP in DR, recommended starting pressures, LMA’s, etc.

43. References • O’Donnell. Clinical assessment of infant colour at delivery. Arch Dis Child Fetal Neonatal Ed 2007; 92: F465-467 • Mariani et al. Pre-ductal and Post-ductal O2 Saturation in Healthy Term Neonate after birth. J. Peds April 2007 pg 418-421 • Rabi et al. Oxygen Saturation Trends Immediately After Birth. J Peds May 2006 590-594 • Kamlin et al. Oxygen Saturation in healthy infants immediately after birth. J. Peds May 2006; 148: 585-9. • Kamlin et all. Accuracy of Pulse Oxymetry Measurement of Heart Rate of Newborn infants in the Delivery Room. J. Peds, 2008; 152: 756-60 • O’Donnell et all. Feasibility of and Delay in Obtaining Pulse Oximetry During Neonatal Resuscitation. J. Peds 2005; 147: 698-9 • Perlman et al. The Science Behind Delivery Room Resuscitation. Clinics in Perinatology March 2006. • Saugstad et al. Resuscitation of Newborn Infants with 21% or 100% Oxygen Neonatology 2008;94: 176-182 • AAP/AHA Emergency Cardiovascular Care Guidelines for Neonatal Resuscitation. 2005. • Richmond et al. Refining the role of oxygen administration during delivery room resuscitation: What are the future goals? Seminars in Fetal and Neonatal Medicine 2008 : 13: 368-374. • Wang et all: Resuscitation of Preterm Neonates by Using Room Air or 100% Oxygen; Peds 2008: 121: 1083-1089 • Leone et al. Disposable colorimetric carbon dioxide detector use as an indicator of a patent airway during noninvasive mask ventilation. Peds 2006; 118 (1) • Kamlin et al. Colorimetric end-tidal Carbon Dioxide Detectors in the delivery Room strengths and limitations. A case report. J. Peds 2005;147:547-8 • Trevisanuto et al. The laryngeal mask airway: potential applications in neonates. Arch Dis Child Fetal Neonatal Ed 2004; 89:F485-489. • Hoehn et al. Therapeutic hypothermia in neonates. Resuscitation 2008 7, 7-12. • Vain et al. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomized controlled trial. Lancet 2004; 364: 597-602.