What

1
Whats new in Neonatal Resuscitation?Qué hay
de nuevo en reanimación neonatal?

• N. Ambalavanan MD
• Division of Neonatology,
• University of Alabama at Birmingham
• May 2003

2
Overview

• The new NRP
• Outline
• Rationale for new guidelines
• Controversies and new concepts

3
The new NRP Algorithm (4rd Edition, 2000)

• Birth

• Clear of meconium?
• Breathing or crying?
• Good tone?
• Color pink?
• Term gestation?

• Routine care
• Provide warmth
• Clear airway
• Dry

YES
30 sec
NO

• Provide warmth
• Position clear airway (as necessary)
• Dry, stimulate, reposition
• Give O2 (as necessary)

4
The new NRP Algorithm (contd.)
Breathing HRgt100 and pink

• Evaluate respirations,
• heart rate, and color

Supportive care
Apnea or HRlt100
30 sec

• Provide positive-pressure
• ventilation

HRlt60 HRgt60
30 sec
Ventilating HRgt100 and pink

• Provide positive-pressure ventilation
• Administer chest compressions

Ongoing care
HRlt60

• Administer epinephrine

ET intubation may be considered at Several steps
5
Objectives

• Review the new guidelines for neonatal
  resuscitation and understand the rationale
  underlying these new guidelines
• Review current controversies regarding neonatal
  resuscitation

6
New Guidelines

1. Management of meconium stained infants
2. Emphasis of ventilation as the primary concern
   for effective resuscitation
3. Indications for chest compressions
4. Indications for epinephrine
5. Others
6. Impact
7. New changes

7
New Guidelines

1. Management of meconium stained infants
2. Emphasis of ventilation as the primary concern
   for effective resuscitation
3. Indications for chest compressions
4. Indications for epinephrine
5. Others
6. Impact
7. New changes

8
Management of Meconium Stained Infants

• 1. Perform endotracheal suction of
  meconium-stained infants if any of the following
  is present
• A. Absent or depressed respirations
• B. Decreased muscle tone or
• C. HR lt 100/min
• 2. If the HR remains below 100/min or respiration
  is severely depressed, PPV is indicated following
  initial suctioning(s).

9
RCT of Endotracheal Suctioning in Vigorous
Meconium-Stained Infants

• Intubation Expectant Rx p
• n1051 n1043
• MAS () 3.2 2.7 NS
• Other respiratory
• distress () 3.8 4.5 NS
• All causes 7.0 7.2 NS
• 61 (6) of the infants developed respiratory
  distress and were suctioned.

Wiswell, et al. Pediatrics 1051, 2000
10
New Guidelines

1. Management of meconium stained infants
2. Emphasis of ventilation as the primary concern
   for effective resuscitation
3. Indications for chest compressions
4. Indications for epinephrine
5. Others
6. Impact
7. New changes

11
Emphasis on Ventilation as the Most Important and
Effective Action for Resuscitation

1. Initial steps and ventilation are effective in
   establishing normal vital signs in over 99.8 of
   infants (Perlman and Risser. Arch Pediatr Adolesc
   Med 14920, 1995)
2. Chest compressions may interfere with ventilation
   and should not be initiated until adequate
   ventilation is established

12
New Guidelines

1. Management of meconium stained infants
2. Emphasis of ventilation as the primary concern
   for effective resuscitation
3. Indications for chest compressions
4. Indications for epinephrine
5. Others
6. Impact
7. New changes

13
Indications for Chest Compressions

1. Chest compressions are rarely indicated in the
   resuscitation of the newly born
2. Chest compressions are recommended if HR is less
   than 60 after 30 sec of adequate ventilation
3. Because of ease of teaching and skill retention,
   chest compressions are now recommended only if HR
   is less than 60/min

14
New Guidelines

• Management of meconium stained infants
• Emphasis of ventilation as the primary concern
  for effective resuscitation
• Indications for chest compressions
• Indications for epinephrine
• Others
• Impact
• New changes

15
Indications for Epinephrine

1. Epinephrine is rarely indicated in the
   resuscitation of the newly born
2. Epinephrine is indicated if HR remains less than
   60/min after a minimum of 30 seconds of adequate
   ventilation and chest compressions
3. Endotracheal route is faster, but may not be as
   effective as the intravenous route
4. Administration of higher dose epinephrine in
   neonates is not supported by adequate studies

16
New Guidelines

1. Management of meconium stained infants
2. Emphasis of ventilation as the primary concern
   for effective resuscitation
3. Indications for chest compressions
4. Indications for epinephrine
5. Others
6. Impact
7. New changes

17
Other Important Guidelines Changes and
Revisions

1. Resuscitation algorithm
2. Scientific contents
3. Supplies and equipment
4. Program contents
5. Administrative

18
New Guidelines

1. Management of meconium stained infants
2. Emphasis of ventilation as the primary concern
   for effective resuscitation
3. Indications for chest compressions
4. Indications for epinephrine
5. Others
6. Impact
7. New changes

19
Impact of Training in NRP Controlled Trial

• Setting 14 teaching hospitals in India
• Design Historic controls
• 7,000 control group in 3 months pre-intervention
• 25,713 experimental group in 12 months
  post-intervention
• Outcome Birth asphyxia (apnea/gasping at 1 and 5
  min)

Deorari et al. Ann Trop Paed 2129, 2001
20
Impact of Training in NRP Controlled Trial
Results Incidence of Asphyxia

• Pre-intervention Post-intervention p
  Apnea/gasping
• 1 min 2.8 3.8 lt0.001
• 5 min 1.0 1.4 lt0.01
• 10 min 0.6 0.7 NS

Deorari et al. Ann Trop Paed 2129, 2001
21
Pre-intervention Post-intervention plt0.001
Deorari et al. Ann Trop Paed 2129, 2001
22
Impact of Training in NRP Controlled Trial
Results Mortality

• Pre-intervention Post-intervention p All
  causes 3.7 3.5 NS
• Hypoxia 1.6 1.1 lt0.01

Deorari et al. Ann Trop Paed 2129, 2001
23
New Guidelines

1. Management of meconium stained infants
2. Emphasis of ventilation as the primary concern
   for effective resuscitation
3. Indications for chest compressions
4. Indications for epinephrine
5. Others
6. Impact
7. New changes

24
Oro- and Nasopharyngeal Suction in MSF Infants

• Design Multi-center RCT
• Inclusive criteria Any consistency of MSF
• GA gt 37 weeks
• Cephalic presentation
• No major congenital anomaly
• Outcome Incidence of MAS

Vain et al. Pediatr Res 51379, 2002
25
Oro- and Nasopharyngeal Suction in MSF Infants
Results n2514 infants in 12 centers

• Suction No Suction p
• MAS 3.6 3.5 NS
• Mech vent (MAS) 1.1 1.1 NS
• Mortality 0.4 0.2 NS

Vain et al. Pediatr Res 51379, 2002
26
Areas of Controversy/Conflict But Insufficient
Data

• Who should be present at the delivery of an
  infant at low risk for need of resuscitation?
• Who should be present at the delivery of an
  infant at high risk for need of resuscitation?

27
Areas of Controversy/Conflict But Insufficient
Data

• 2. Should the simultaneous assessment of a
  newborn during resuscitation include the parts of
  the Apgar scores not currently used (tone,
  reflex)?
• 3. Is nasopharyngeal and oral suction necessary
  in the infant with clear amniotic fluid?

28
Areas of Controversy/Conflict But Insufficient
Data

• 4. Is the use of PEEP necessary during PPV?
• 5. Should air or an air-oxygen blender (mixer) be
  used during neonatal resuscitation?
• 6. What is the recommended saturation level that
  should be maintained during resuscitation?

29
Areas of Controversy/Conflict But Insufficient
Data

• 7. Can adjunctive airways (e.g. laryngeal mask)
  be effective in neonatal resuscitation?
• 8. Is high-dose epinephrine effective when the
  normal dose of epinephrine is not?

30
Areas of Controversy/Conflict But Insufficient
Data

• 9. Is THAM better than NaHCO3 in the treatment of
  metabolic acidosis?
• 10. Should hypothermia be used during and/or
  after neonatal resuscitation?

31
Summary

• New guidelines emphasize ventilation as the most
  effective aspect of neonatal resuscitation
• Further evidence of efficacy is needed
• Many areas of controversy translates into many
  research opportunities

32
Controversies

1. Room air or 100 O2 resuscitation Room air may
   be equivalent or better
2. Hypothermia or normothermia following
   resuscitation trials in progress
3. Crystalloid and albumin for hypovolemia no
   benefit for albumin
4. High vs standard epinephrine for resuscitation
   no benefit for higher doses?
5. NaHCO3 or not for prolonged resuscitation no
   benefit in human studies

33
Additional slides
34
Effect of Resuscitation Gas on Room Air 100 O2

• Room air 100 O2 p value
• Mod/severe asphyxia (n) 304 526 -
• Overall mortality (n) 1 17 NS
• Mortality in severe
• asphyxia (n, ) 1/16, 7 6/14, 43 0.053
• (OR 0.003- 1.023)

Vento et al. Biol Neonate 79261, 2001.
35
Time of Onset of Breathing
Vento et al. Biol Neonate 79261, 2001
36
Effect of O2 Resuscitation on Oxidative Stress
Room air 100 O2 p value n51 n55 Ventilation
for resuscitation 5.31.5 6.81.2 lt0.05 (in
minutes) PO2 12622 727 lt0.05 GSSG (oxidised
glutathione) At end of resuscitation
8310 10214 lt0.05 Clinical stabilization 8313
11121 lt0.05
Vento et al. J Pediatr 142240, 2003.
37
RCT of Room Air Resuscitation

• Setting 11 centers, 6 countries
• Entry BW gt 999 grams
• Design Randomized by birth date, not masked
• Primary outcome Death by 1 week and/or HIE
• Enrolled 703 from 11 centers, 94 patients
• Excluded 94 patients from one center

Saugstad et al. Pediatrics 102e1, 1998
38
RCT of Room Air Resuscitation

• Room Air Oxygen OR CI
• Gestational age (wks) 38 38
• Birthweight (gm) 2600 2560
• 7 day mort/HIE () 21 24 0.94 0.53-1.40
• 7 day mortality () 12 15 0.82 0.50-1.35
• 28 day mortality () 12 19 0.72 0.45-1.15
• Resuscitation failure () 26 35 0.81 0.56-1.19

Saugstad et al. Pediatrics 102e1, 1998
39
SummaryRoom Air vs 100 O2

• Room air resuscitation results in comparable
  (maybe better) survival and less oxidant injury
• Further research is necessary, but room air
  resuscitation can be an alternative for neonatal
  resuscitation

40
Controversies In Neonatal Resuscitation

1. Room air or 100 O2 resuscitation
2. Hypothermia or normothermia following
   resuscitation
3. Crystalloid and albumin for hypovolemia
4. High vs standard epinephrine for resuscitation
5. NaHCO3 or not for prolonged resuscitation

41
Head Cooling in Neonates

• Study 10 control, 12 head cooling infants
• Mild selective head cooling is a safe and
  convenient method of quickly reducing cerebral
  temperature (masopharyngeal temperature 34.5
  0.3ºC)

Gunn et al. Pediatrics 102885, 1998
42
Body Cooling in Neonates

• Mild hypothermia (33.2 0.6ºC) resulted in
• Mild metabolic acidosis/high lactate
• Low potassium (3.9 mmol/L)
• Lower heart rate
• Higher blood pressure
• But was well tolerated

Azzopardi et al. Pediatrics 106684, 2000
43
Summary Hypothermia in Neonatal Resuscitation

1. Experiments demonstrated benefits of hypothermia
2. Small studies reveal mild physiologic
   abnormalities
3. RCTs of hypothermia in neonates following
   resuscitation are needed

44
Controversies In Neonatal Resuscitation

1. Room air or 100 O2 resuscitation
2. Hypothermia or normothermia following
   resuscitation
3. Crystalloid and albumin for hypovolemia
4. High vs standard epinephrine for resuscitation
5. NaHCO3 or not for prolonged resuscitation

45
RCT of Colloid Infusion in Hypotensive Infants
(62 infants 24-36 weeks)

• Infusion BP Change
• 5 ml/kg of 20 albumin ? 9
• 15 ml/kg of 4.5 albumin ? 17
• 15 ml/kg of FFP ? 19
• Volume rather than oncotic load affects BP

Emery et al. Arch Dis Child 571185, 1982
46
RCT of Albumin in Hypoalbuminemic Infants (2534
week infants)

• Design
• 5 ml/kg of 20 albumin vs 5 ml/kg of maintenance
  fluids
• Results
• Albumin infusion increased albumin levels, but
  did not improve the cardiorespiratory status

Greenough et al. Eur J Pediatr 2157, 1993
47
RCT of Albumin vs Crystalloid in Hypothermic
Infants (63 infants 23-34 weeks)

• Design
• 10 mL/kg 5 albumin vs 10 mL/kg NSS
• Results
• Albumin group required more volume expander (27
  vs 10 ml/kg) to maintain normal blood pressure

So et al. Arch Dis Child 76F43, 1997
48
RCT of Prophylactic FFP/Gelatin in Infants (776
infants lt 32 weeks)

• FFP Gelatin Control p
• (glucose)
• Death or IVH 23 27 23 NS
• Death by 2 year 21 25 20 NS
• Death or disability 32 36 36 NS

Greenough et al. Eur J Pediatr 155580, 1996
Lancet 348229, 1996
49
Volume Expansion in Normothermic Infants (940
stable infants lt32 weeks or lt 1500g)

• Volume vs no treatment
• RR CI
• Mortality 1.11 0.9-1.4
• Severe disability 0.80 0.5-1.2
• Mortality or disability 1.00 0.8-1.2

Osborn and Evans. Cochrane Data Syst Rev
2CD002055, 2001
50
Summary Albumin in Neonatal Resuscitation

• Several randomized controlled trials do not
  demonstrate benefits of albumin administration in
  neonates

51
Controversies In Neonatal Resuscitation

1. Room air or 100 O2 resuscitation
2. Hypothermia or normothermia following
   resuscitation
3. Crystalloid and albumin for hypovolemia
4. High vs standard epinephrine for resuscitation
5. NaHCO3 or not for prolonged resuscitation

52
Effect of High (HDE) vs Standard Dose Epinephrine
(SDE) in In-Hospital Pediatric CPR
Carpenter and Stenmark. Pediatrics 99403, 1997
53
Effect of High (HDE) vs Standard Dose Epinephrine
(SDE) in Out of Hospital Pediatric CPR

• HDE SDE p
• Median age 0.25 y 0.25 y
• Male/female 27/13 8/5
• Asystole 88 62 0.055
• ROSC 2.5 8 0.43
• Return electrical rhythm 10 20
  0.59
• Survival 2.5 2.5 0.43

Dieckmann and Vardis. Pediatrics 95901, 1995
54
Summary Epinephrine in Neonatal Resuscitation

• High dose epinephrine is no more effective than
  standard dose epinephrine in infant (not newly
  born) resuscitation

55
Controversies In Neonatal Resuscitation

1. Room air or 100 O2 resuscitation
2. Hypothermia or normothermia following
   resuscitation
3. Crystalloid and albumin for hypovolemia
4. High vs standard epinephrine for resuscitation
5. NaHCO3 or not for prolonged resuscitation

56
NaHCO3 in Neonatal Resuscitation

1. Recommendations based on animal data
2. Older neonatal trials failed to show benefits
3. Risks are IVH, hypervolemia, local injury

57
Other Controversies

1. HR below which chest compressions are indicated
2. Optimal technique for ventilation
3. Limits of viability

58
The Laryngeal Mask Airway

• Latex-free, silicone rubber tube connected to an
  elliptical mask with an inflatable outer rim
• Standard 15 mm male adaptor
• Pilot tube and balloon attached to the inflatable
  outer rim
• Bars cover the connection between the tube and
  the mask
• Re-useable up to 40 times (Autoclave)

59
Advantages Disadvantages

• Advantages
• Hands free
• No laryngoscopy
• Less traumatic
• Quick
• Disadvantages
• Leak pressure
• Risk of gastric aspiration
• Cant reliably suction trachea for meconium

60
LMA in Place
61
LMA Placement

• Size 1.0 Classic LMA
• Neonates up to 5 kg
• Several case reports in neonates 1000-1500 grams
• Single case report of 800 gm neonate for
  resuscitation(Brimacombe, Paediatric
  Anaesthesia, 1999)
• In general, the lower limit has been considered
  1.0 kg
• Size 1.5 Classic LMA
• Infants 5-10 kg
• Most useful in infants who are difficult to
  intubate infants with micrognathia, upper airway
  malformations.
• May also be useful for people who do not intubate
  often

62
Search results

• No randomized trials
• 2 aborted RCTs
• 9 Letters to the Editor
• 8 Case series/reports describing a total of 172
  newborns
• 1 Study using resuscitation mannequins

63
Case Series 1 LMA in DR

• University of Alberta
• Included all gt 2.5 kg, gt 35 wk EGA requiring PPV
  in the DR
• n 21
• Weight range 2235-4460 gm
• Gestation range 35-41 wk EGA
• All had LMA successfully placed on 1st attempt
• 2 with MSAF had ETT for suction, then LMA
• 1 had LMA, then ETT placed for epinephrine
• Patterson SJ et al, Anesthesiology, 1994

64
Paterson, cont.
Time to Insert (sec) 8.6 (7-12)
Duration of PPV (sec) 80 (30-300)
Audible Leak cm H2O 22 (17-29)
Peak Pressure cm H2O 37 (31-42)

• In 20/21, HR gt 100 within 30 seconds
• One pneumothorax noted 90 minutes after birth
• No airway, oropharyngeal, or feeding complications

65
Case Series 2 LMA in DR

• Queensland, Australia
• LMA used as PPV standard since 1994
• Single resuscitators experience
• Excluded if evidence of meconium aspiration
• Gandini and Brimacombe, Anesth Analg, 1999

66
Gandini, cont.
Normal (n75) LBW (n29)
Weight (kg) 3.7 2.0 6 lt 1500 gm
Gestation (wk) 37 32
Success w/ 1 attempt () 75 29
Time to chest expansion (sec) 10 10
Time to HR gt 100 (sec) 13 14
PPV gt 15 minutes, ETT 1 5
LMA Revoval (sec) 42 42
Leak Pressure (cm H2O) 22 24