Updates in Updates in Neonatal Neonatal

ResuscitationResuscitationStacie Bennett, M. D.Stacie Bennett, M. D.

East Bay Newborn SpecialistsEast Bay Newborn Specialists

Children’s Hospital OaklandChildren’s Hospital Oakland

OverviewOverview

Every year ~ 5-10% of infants Every year ~ 5-10% of infants require neonatal resuscitation.require neonatal resuscitation.

Yet there are many areas where we Yet there are many areas where we don’t have evidence for the best don’t have evidence for the best resuscitation approach.resuscitation approach. Right Amount of Oxygen to useRight Amount of Oxygen to use ? Right Bag and Mask? Right Bag and Mask ? Correct pressures? Correct pressures Intubation for MeconiumIntubation for Meconium

Pulse oxymetryPulse oxymetry

All other areas of resuscitation use All other areas of resuscitation use monitors except the DR.monitors except the DR.

May be able to avoid hypoxia and May be able to avoid hypoxia and hyperoxiahyperoxia

Difficult to correlate saturations and Difficult to correlate saturations and colorcolor

Infant ColorInfant Color

O’Donnell et al looked at 20 infants with O’Donnell et al looked at 20 infants with video reviewed by 27 observers and video reviewed by 27 observers and compared to pulse ox readings.compared to pulse ox readings.

1 infant was thought to be pink by all and 1 infant was thought to be pink by all and his highest sat was 87%, 10 infants his highest sat was 87%, 10 infants whose sats were >95% were never whose sats were >95% were never thought to be pink ~ 20% of the time. thought to be pink ~ 20% of the time.

The mean sats when infants were The mean sats when infants were perceived to be pink by all observers was perceived to be pink by all observers was 69% (range 10-100%)69% (range 10-100%)

Current NRP Guidelines for Current NRP Guidelines for Saturation MonitoringSaturation Monitoring

To reduce excessive tissue oxygenation if a To reduce excessive tissue oxygenation if a very preterm baby (<32weeks) is being very preterm baby (<32weeks) is being delivered use an oxygen blender and a delivered use an oxygen blender and a pulse oximeter during resuscitation.pulse oximeter during resuscitation.

Begin PPV with O2 concentration between Begin PPV with O2 concentration between RA and 100%. Adjust O2 up or down to RA and 100%. Adjust O2 up or down to achieve a saturation that gradually achieve a saturation that gradually increased toward 90% and decreased O2 as increased toward 90% and decreased O2 as saturations rise over 95%.saturations rise over 95%.

If HR does not respond rapidly to >100 If HR does not respond rapidly to >100 BPM correct any ventilation problems and BPM correct any ventilation problems and use 100% O2.use 100% O2.

Pulse oxymetry Pre vs Pulse oxymetry Pre vs Post ductalPost ductal

Mariani et al J Peds April 07.Mariani et al J Peds April 07. Looked at pre/post ductal sats simultaneously Looked at pre/post ductal sats simultaneously

in in healthy term infantshealthy term infants born via SVD or c/s. born via SVD or c/s. Resuscitator was blinded to sat values.Resuscitator was blinded to sat values.

110 infants, median time to accurate readings 110 infants, median time to accurate readings was 3 minutes.was 3 minutes.

At 5 min median sats when baby perceived to At 5 min median sats when baby perceived to be pink was 86%. The mean time to reach be pink was 86%. The mean time to reach preductal sat of 90% was 5.5min. (5.2 min preductal sat of 90% was 5.5min. (5.2 min SVD, 6.3 min in c/s)SVD, 6.3 min in c/s)

No infants admitted to NICU.No infants admitted to NICU.

O2 sat trendsO2 sat trends

Rabi et al. J Peds May 2006Rabi et al. J Peds May 2006 Masimo pulse ox preductally. 165 infants Masimo pulse ox preductally. 165 infants

“code pink” del, 49 excluded d/t O2 “code pink” del, 49 excluded d/t O2 supplementation, all >35 weeks, 115 supplementation, all >35 weeks, 115 infants analyzed.infants analyzed.

Median time to stable sat readings 82 secMedian time to stable sat readings 82 sec Median Sats at 5 min for vag del was 87% Median Sats at 5 min for vag del was 87%

(80-95%) and c/s was 81% (75-83%), by (80-95%) and c/s was 81% (75-83%), by 8min 91% in vag and 90% in c/s.8min 91% in vag and 90% in c/s.

O2 sat trendsO2 sat trends

Kamlin et al Jpeds May 2006Kamlin et al Jpeds May 2006 175 infants, median sat values:175 infants, median sat values: 1min 63% (53-68%), 2min 70% (58-1min 63% (53-68%), 2min 70% (58-

78), 3 min 76% (64-87%), 4 min 81% 78), 3 min 76% (64-87%), 4 min 81% (71-91%) and 5 min 90% (76-91).(71-91%) and 5 min 90% (76-91).

Kamlin et al J Peds June 2006 Heart Kamlin et al J Peds June 2006 Heart rate was accurate even in infants rate was accurate even in infants requiring resuscitation using pulse requiring resuscitation using pulse Ox.Ox.

Saturation MonitorSaturation Monitor

When applying place preductallyWhen applying place preductally Once on infant turn on machine for Once on infant turn on machine for

fastest readingfastest reading Currently recommended for preterm Currently recommended for preterm

infantsinfants Future probably recommended for Future probably recommended for

all deliveries.all deliveries.

Current Oxygen Guidelines Current Oxygen Guidelines for Resuscitationfor Resuscitation

Current evidence is insufficient to resolve all Current evidence is insufficient to resolve all questions regarding supplemental O2.questions regarding supplemental O2.

Term: Recommend 100% O2 when infant is Term: Recommend 100% O2 when infant is cyanotic or when PPV is required.cyanotic or when PPV is required.

However research suggest that resuscitation However research suggest that resuscitation with something less then 100% may be just with something less then 100% may be just as successful.as successful.

If resuscitation is started with less then If resuscitation is started with less then 100% O2 supplemental O2 up to 100% 100% O2 supplemental O2 up to 100% should be administered if there is no should be administered if there is no appreciable improvement within 90sec after appreciable improvement within 90sec after birth.birth.

Room Air Vs 100% Room Air Vs 100% Oxygen in the DROxygen in the DR

In multiple studies and meta-analysis In multiple studies and meta-analysis comparing resuscitation with RA vs 100% O2- comparing resuscitation with RA vs 100% O2- decreased risk of neonatal mortality in infants decreased risk of neonatal mortality in infants resuscitated with RA (Mortality was 4.6% resuscitated with RA (Mortality was 4.6% higher in O2 group)higher in O2 group)

Trend toward reduction in Stage 2 to 3 HIE in Trend toward reduction in Stage 2 to 3 HIE in those infants resuscitated in RA.those infants resuscitated in RA.

Onset of respirations was faster in RA in some Onset of respirations was faster in RA in some studies.studies.

Lower 5 minute apgar scores and heart rate in Lower 5 minute apgar scores and heart rate in several studies in infants resuscitated with O2.several studies in infants resuscitated with O2.

Exposure to O2 decreased cerebral blood flow.Exposure to O2 decreased cerebral blood flow.

RA vs O2RA vs O2

RA vs O2RA vs O2

2 studies suggesting increased risk of 2 studies suggesting increased risk of childhood leukemia's if exposed to O2.childhood leukemia's if exposed to O2.

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

RA vs O2RA vs O2

Several animal studies have shown:Several animal studies have shown: Increased brain injury when exposed Increased brain injury when exposed

to O2to O2 O2 induces inflammation in the lung, O2 induces inflammation in the lung,

heart and brainheart and brain Increased pulmonary resistance and Increased pulmonary resistance and

reactivityreactivity Increased oxidative stressIncreased oxidative stress

RA vs O2RA vs O2 Medbo et al found that PVR increased with Medbo et al found that PVR increased with

induced hypoxia in piglets but fell equally with induced hypoxia in piglets but fell equally with both RA or 100% O2.both RA or 100% O2.

Wang et al Peds 6/2008 looked at preterm infants Wang et al Peds 6/2008 looked at preterm infants resuscitated with RA vs 100%.resuscitated with RA vs 100%.

In RA group all infants required increased FiO2 In RA group all infants required increased FiO2 due to bradycardia or failure of saturation due to bradycardia or failure of saturation criteria.criteria.

Escrig et al in abstract 2007 at PAS suggested no Escrig et al in abstract 2007 at PAS suggested no difference in reaching saturation goals between difference in reaching saturation goals between 100% and <40%FiO2 at ~8 minutes of age 100% and <40%FiO2 at ~8 minutes of age

For preterm infants starting at FiO2 of 30-40% For preterm infants starting at FiO2 of 30-40% may be appropriate.may be appropriate.

Potential Future O2 Potential Future O2 guidelinesguidelines

RA for term deliveries, avoid 100% RA for term deliveries, avoid 100% unless hypoxicunless hypoxic

? 30-40% for preterm deliveries.? 30-40% for preterm deliveries. Saturation monitoring and O 2 Saturation monitoring and O 2

blenders in ALL delivery rooms to blenders in ALL delivery rooms to guide O2 needsguide O2 needs

Bag and MaskBag and Mask

All types are acceptable including: T-All types are acceptable including: T-piece resuscitators, flow inflating piece resuscitators, flow inflating and self-inflating bags.and self-inflating bags.

T-piece can give consistent PEEP T-piece can give consistent PEEP and PIPand PIP

Self-inflating can’t deliver consistent Self-inflating can’t deliver consistent PEEP or PIP.PEEP or PIP.

NeopuffNeopuff

CO2 detectorsCO2 detectors Now recommended for confirming ETT Now recommended for confirming ETT

placement. As confirms faster and more placement. As confirms faster and more accurately.accurately.

May not change color if low HR, may need to May not change color if low HR, may need to visualize ETT, will get color change with visualize ETT, will get color change with adequate chest compressions.adequate chest compressions.

If ETT right mainstem-may not change colorIf ETT right mainstem-may not change color If have not established FRC may not changeIf have not established FRC may not change If give epinephrine down ETT will stay yellow, If give epinephrine down ETT will stay yellow,

need to replace CO2 detector.need to replace CO2 detector. May also be used with bag and mask to indicate May also be used with bag and mask to indicate

airway obstruction.airway obstruction.

Current statement Current statement regarding Therapeutic regarding Therapeutic

hypothermiahypothermia Hypothermia may reduce the extent of brain Hypothermia may reduce the extent of brain

injury following hypoxia-ischemiainjury following hypoxia-ischemia There is insufficient data to recommend There is insufficient data to recommend

routine use of selective and/or systemic routine use of selective and/or systemic hypothermia after resuscitation of infants hypothermia after resuscitation of infants with suspected asphyxia.with suspected asphyxia.

Hyperthermia may worsen the extent of brain Hyperthermia may worsen the extent of brain injury following hypoxia-ischemia.injury following hypoxia-ischemia.

The goal should be to achieve normothermia The goal should be to achieve normothermia and to avoid iatrogenic hyperthermia in and to avoid iatrogenic hyperthermia in resuscitated newborns.resuscitated newborns.

HypothermiaHypothermia 2 large randomized trials: 1. Cool-cap trial-234 2 large randomized trials: 1. Cool-cap trial-234

infants in 25 centers, >36 weeksinfants in 25 centers, >36 weeks Maintain rectal temps of 34-35 C. Subgroup Maintain rectal temps of 34-35 C. Subgroup

analysis showed that infants with moderate analysis showed that infants with moderate encephalopathy had significantly better outcomes at encephalopathy had significantly better outcomes at 18months (OR 0.46), no effect on infants with 18months (OR 0.46), no effect on infants with severe encephalopathy or seizures at time of severe encephalopathy or seizures at time of enrollment.enrollment.

2. Whole Body cooling: 208 infants >36 weeks, 2. Whole Body cooling: 208 infants >36 weeks, esophageal temp to 33.5 C. Significantly reduced esophageal temp to 33.5 C. Significantly reduced death or moderate-to-severe disability at 18-22 death or moderate-to-severe disability at 18-22 months (44% vs 62%) On subgroup analysis no months (44% vs 62%) On subgroup analysis no improvement in the severely encephalopathic improvement in the severely encephalopathic infants.infants.

HypothermiaHypothermia

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

Cerebral Cooling CriteriaCerebral Cooling Criteria

GA GA >> 36 weeks, can started on cooling within 6 hrs of 36 weeks, can started on cooling within 6 hrs of age, if received passive cooling at referral hospital and age, if received passive cooling at referral hospital and can be started on active cooling within 8 hrs of age.   can be started on active cooling within 8 hrs of age.   

History compatible with HIE, meaning at least one of History compatible with HIE, meaning at least one of the following:the following: Apgar score of Apgar score of << 5 at 10 minutes 5 at 10 minutes Continued need for resuscitation, including ETT or mask Continued need for resuscitation, including ETT or mask

ventilation at 10 minutes ventilation at 10 minutes Acidosis present within 60 minutes of birth, defined as Acidosis present within 60 minutes of birth, defined as

either an umbilical cord gas (arterial or venous) pH or either an umbilical cord gas (arterial or venous) pH or post-natal arterial pH < 7.00 post-natal arterial pH < 7.00

Base deficit Base deficit >>16 mmol/L in umbilical cord gas (arterial or 16 mmol/L in umbilical cord gas (arterial or venous) or  patient blood gas (arterial, venous, or venous) or  patient blood gas (arterial, venous, or capillary) obtained within 60 minutes of birth capillary) obtained within 60 minutes of birth

Cerebral Cooling Con’tCerebral Cooling Con’t Physical exam compatible with Physical exam compatible with

encephalopathy, meaning at least one of the encephalopathy, meaning at least one of the following:following:

Lethargy, stupor, or coma Lethargy, stupor, or coma Hypotonia Hypotonia Abnormal reflexes, including oculomotor or pupillary Abnormal reflexes, including oculomotor or pupillary

abnormalities abnormalities Absent or weak suck Absent or weak suck Clinical seizures Clinical seizures

  At CHO:At CHO: CFM (Cerebral Function Monitor, also known CFM (Cerebral Function Monitor, also known

as aEEG),showing moderately or severely as aEEG),showing moderately or severely abnormal background (score 2-3) and/or abnormal background (score 2-3) and/or seizures at any time < 6 hrs from birth.   seizures at any time < 6 hrs from birth.   

Cerebral Cooling Con’tCerebral Cooling Con’t Exclusion CriteriaExclusion Criteria  

< 36 weeks gestation < 36 weeks gestation < 1800 grams < 1800 grams Coagulopathy with active bleeding Coagulopathy with active bleeding Severe congenital anomalies/syndromes/known metabolic Severe congenital anomalies/syndromes/known metabolic

disorders disorders ECMO ECMO   

Potential Exclusion CriteriaPotential Exclusion Criteria  

Severe PPHNSevere PPHN   

      

Passive CoolingPassive Cooling If neonatologist and Pediatrician agree: To begin passive cooling:If neonatologist and Pediatrician agree: To begin passive cooling: Turn table warmer off and monitor rectal temperatures every 15 Turn table warmer off and monitor rectal temperatures every 15

minutes. minutes. 

Check rectal temperatures by gently inserting a clean, lubricated Check rectal temperatures by gently inserting a clean, lubricated digital thermometer into the rectum approximately ½ inch or 2cm.  digital thermometer into the rectum approximately ½ inch or 2cm.  Wipe thermometer with alcohol between uses. Wipe thermometer with alcohol between uses. 

The desired temperature range is 34°C- 35°C (rectal) or The desired temperature range is 34°C- 35°C (rectal) or 93°F- 95°F.  93°F- 95°F.    

Keep TABLE WARMER OFF unless rectal temperature < 34.5°C or Keep TABLE WARMER OFF unless rectal temperature < 34.5°C or 94°F 94°F 

If patient’s rectal temperature falls below 34.5oC or 94°F, begin If patient’s rectal temperature falls below 34.5oC or 94°F, begin table warmer on lowest setting or table warmer on lowest setting or “preheat.”“preheat.”  

If patient’s rectal temperature is greater than 35°C or 95°F, If patient’s rectal temperature is greater than 35°C or 95°F, continue passive cooling and continue passive cooling and do not attempt active cooling. do not attempt active cooling.   

Passive Cooling Con’tPassive Cooling Con’t Maintain all other aspects of routine post-resuscitation care.Maintain all other aspects of routine post-resuscitation care. Maintain oxygenation and ventilationMaintain oxygenation and ventilation Monitor blood pressure, heart rate, and perfusionMonitor blood pressure, heart rate, and perfusion Obtain IV accessObtain IV access Provide IV fluidsProvide IV fluids Monitor glucose, electrolytes, CBCMonitor glucose, electrolytes, CBC Consider antibioticsConsider antibiotics Avoid hyperthermiaAvoid hyperthermia  

Treat clinical or electrographic seizures with 20 mg/kg Treat clinical or electrographic seizures with 20 mg/kg Phenobarbital.   Phenobarbital.   

If the patient is hemodynamically unstable and/or has an oxygen If the patient is hemodynamically unstable and/or has an oxygen requirement of 50% FiO2 in order to maintain oxygen saturations requirement of 50% FiO2 in order to maintain oxygen saturations of of >> 95%, it may be determined by the attending neonatologist and 95%, it may be determined by the attending neonatologist and referral pediatrician that passive cooling should not be initiated referral pediatrician that passive cooling should not be initiated due to the patient’s instability.  Hyperthermia should however be due to the patient’s instability.  Hyperthermia should however be avoided.  The patient’s temperature should be kept at 36 avoided.  The patient’s temperature should be kept at 36 ++ 0.5°C or 0.5°C or 97°F.97°F.

Laryngeal Mask Airway Laryngeal Mask Airway (LMA)(LMA)

1-5% of newborns require PPV in DR.1-5% of newborns require PPV in DR. LMA may provide alternative for facemask LMA may provide alternative for facemask

ventilation or endotracheal intubationventilation or endotracheal intubation Advantages: high rate of successful first-time Advantages: high rate of successful first-time

placement, short time for placement, less placement, short time for placement, less training and practice needed, no training and practice needed, no instrumentation.instrumentation.

Disadvantages: gastric distension, potentially Disadvantages: gastric distension, potentially inadequate alveolar ventilation due to inadequate alveolar ventilation due to limitation of peak pressure due to leak, limitation of peak pressure due to leak, difficulty with suctioning of the airway or difficulty with suctioning of the airway or giving intra-tracheal emergency medications.giving intra-tracheal emergency medications.

LMALMA Many case control studies, limited Many case control studies, limited

randomized studies. randomized studies. Limited studies using endotracheal Limited studies using endotracheal

epinephrine or surfactant with LMA.epinephrine or surfactant with LMA. Can be used for difficult airwaysCan be used for difficult airways Few complications including soft tissue Few complications including soft tissue

damage.damage. Used for short term airway support.Used for short term airway support. Current recommendations: can be used in Current recommendations: can be used in

some newborns who have failed bag and some newborns who have failed bag and mask ventilation or endotracheal intubation.mask ventilation or endotracheal intubation.

LMALMA

MeconiumMeconium Meconium stained amniotic fluid (MSAF) occurs in Meconium stained amniotic fluid (MSAF) occurs in

7-20% of births. Probably due to in-utero hypoxia 7-20% of births. Probably due to in-utero hypoxia and acidosis.and acidosis.

MAS occurs in 2-9% of infants born through MSAFMAS occurs in 2-9% of infants born through MSAF Management: 1. Current recommendations are for Management: 1. Current recommendations are for

Intrapartum amnioinfusion for moderate to thick Intrapartum amnioinfusion for moderate to thick MSAF (meta-analysis showed benefit, though recent MSAF (meta-analysis showed benefit, though recent large multicenter study did not show benefit, may large multicenter study did not show benefit, may change recommendation in up coming guidelines.change recommendation in up coming guidelines.

2. Suctioning on the perineum or abdomen prior to 2. Suctioning on the perineum or abdomen prior to delivering the shoulders is no longer recommended.delivering the shoulders is no longer recommended.

3. Post delivery suctioning for those infants who are 3. Post delivery suctioning for those infants who are not vigorous.not vigorous.

ETT vs IV epinephrineETT vs IV epinephrine ETT not as effective possibly secondary to ETT not as effective possibly secondary to

decreased blood flow, pulmonary decreased blood flow, pulmonary vasoconstriction from acidosis, persistent vasoconstriction from acidosis, persistent alveolar fluid that dilutes the epi, possible alveolar fluid that dilutes the epi, possible right to left intracardiac shunts that bypass right to left intracardiac shunts that bypass pulmonary circulation all together.pulmonary circulation all together.

In animal data ETT epi needed to be 5-30x In animal data ETT epi needed to be 5-30x the recommended dose for effect.the recommended dose for effect.

In 2005 recommendations: Epinephrine In 2005 recommendations: Epinephrine should be delivered via IV if not the ETT dose should be delivered via IV if not the ETT dose should be 0.3-1ml/kg (0.03-0.1mg/kg), iv is should be 0.3-1ml/kg (0.03-0.1mg/kg), iv is still 0.1-0.3ml/kg.still 0.1-0.3ml/kg.

I usually start with 1ml if term infant via ETT.I usually start with 1ml if term infant via ETT.

SummarySummary

Possible future changes:Possible future changes: Preductal pulse ox monitoring all deliveries Preductal pulse ox monitoring all deliveries

requiring resuscitationrequiring resuscitation Blended O2 in all deliveriesBlended O2 in all deliveries RA resuscitation for term infants, 30-40% O2 RA resuscitation for term infants, 30-40% O2

for preterm resuscitation as a starting point.for preterm resuscitation as a starting point. Therapeutic hypothermia for moderate to Therapeutic hypothermia for moderate to

severe hypoxic-ischemic encephalopathysevere hypoxic-ischemic encephalopathy ? Management for Meconium, use of CPAP ? Management for Meconium, use of CPAP

in DR, recommended starting pressures, in DR, recommended starting pressures, LMA’s, etc.LMA’s, etc.

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