Transcript Slide 1

Newborn Resuscitation: latest guidelines
Ola Didrik Saugstad MD, PhD, FRCPE
Professor of Pediatrics
Director
Department of Pediatric Research
Oslo University Hospital, Rikshospitalet
University of Oslo
NORWAY
Kiev, November 30th, 2011
5-10% need help to breathe
within «the golden minute»
Maternal, and intrapartum related deaths
Black RE, et al. Lancet. 2010 Jun 5;375(9730):1969-87. Global, regional, and national causes of child mortality in 2008: a systematic analysis.
Interventions in term or near term newborn in the delivery room
NUMBER
INTERVENTION
136 mill
Assess baby’s
response to birth
All
136 mill
Keep baby warm
Position, clear airway, stimulate to breathe by drying
All
4-6 mill
1 mill
1 mill
1 mill
0.1 mill
Establish effective ventilation
• bag & mask ventilation
Start with air
• endotracheal intubation
• Provide chest compressions
• Adrenaline
Volume
expansion
FREQUENCY
B
A
S
I
C
3 – 5/100
1/100-1/700
< 1/1000
0.6/1000
1/12000
A
D
V
A
N
C
E
D
ILCOR/AHA 2000
Neonatal Resuscitation
The following questions should be answered after
every birth:
• XXXXXXXXXXXXXXXXXXXXXXXXX
Is the amniotic fluid clear of AHA/ILCOR: 2010
XXXXXXXXXXX
meconium?
• Is the baby breathing or
crying?
• Is there a good muscle tone?
AHA/ILCOR: 2005
• XXXXXXXXXXXXXX
Is the color pink?
• Was the baby born at term?
If the answer is no to any of these consider resuscitation
ILCOR Guidelines Newborn Resuscitation
Changes from 2005 -2010
•Timing the first 60 seconds only
•Progression to the next step following initial evaluation is
defined by heart rate and respiration
•For babies born at term it is best to begin resuscitation with
air rather than 100% oxygen
• Evidence does not support or refute routine endotracheal
suctioning of infants born through meconium-stained
amniotic fluid, even when the newborn is depressed
• Chest compression- ventilation ratio 3:1 unless the arrest is
known to be of cardiac etiology. Then higher ratio should
be considered (15:2)
•Hypothermia in moderate to severe HIE
•Cord clamping late, in asphyxia not known
ILCOR Neonatal Resuscitation Guidelines 2010
3 questions:
Term, Breathing, Tone
Timing: First 60 seconds only
Start with air, consider SpO2
Start Ventilation:
Heart rate < 100 bpm
and or apnea/insufficent
breathing
Perlman J et al, Circulation 2010;122 (Suppl 2) S516-538
Treatment Recommendation
In term infants receiving resuscitation at birth with positive
pressure ventilation, it is best to begin with air rather than
100% oxygen. If despite effective ventilation there is no
increase in heart rate or if oxygenation (guided by oximetry)
remains unacceptable, use of a higher concentration of
oxygen should be considered.
American Academy of Pediatrics 2010
Kattwinkel J et al Pediatrics, 2010
Development of SaO2 first 10 min of life
Dawson et al, Pediatrics 2010
Need of Oxygen According to SpO2 – USA Guidelines
X
X
X
X
X
X
X
ILCOR/AHA 2005
Four Categories
A
Airways
• Initial steps of stabilisation (assess the airways,
positioning, stimulating, dry and provide warmth)
B
• Ventilation (including bag-mask or bag -tube ventilation)
C
• Chest compressions
Breathing
Circulation
D
Drugs
• Medications or volume expansion
A: Airways
Stabilisation and suctioning
Suctioning of upper airways
Routine intrapartum oropharyngeal and
nasopharyngeal suctioning for infants
born with clear or meconium stained
amniotic fluid is no longer
recommended
ILCOR 2010
•A vigorous newborn who starts to breath within 10-15
seconds does not need suctioning routinely
•Deep suctioning should be avoided especially the first 5
min of life. It may induce apnea, bradycardia and
bronchospasm
•If suctioning, always suction the mouth before through
the nose to minimize risk of aspiration
B: ventilation
The most important is to ventilate the lungs. Training is needed
Increasing heart rate is the
primary sign of effective
ventilation during resuscitation
What is an adequate heart rate?
Observe also:
•Improving color
•Spontaneous breathing
•Improving muscle tone
50 percentile for heart rate
is 99 bpm at one min
Dawson et al, 2010
Check these signs of improvement
after 30 seconds of PPV.
This requires the assistance of
another person
The 10th, 25th, 50th, 75th and 90th heart rate centiles for all infants with no medical
intervention after birth. bpm, beats per minute.
Dawson J et al. Arch Dis Child Fetal Neonatal Ed
2010;95:F177-F181
©2010 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health
Assessment if resuscitation is stepped up
3 vital characteristics
•Heart rate
•Respirations
•State of oxygenation
”The most sensitive indicator of
successful response to each
step is an increase in heart rate”
Initial breaths and pressures
• Initiation of intermittent positivepressure ventilation at birth can
be accomplished with either
shorter
or
Heart rate increase is more
longer inspiratory times. Important to observe than chest rise
• Initial peak inflating pressures needed are
variable- start with 20 cm H2O may be
effective but 30-40 Cm H2O may be
needed.
• PEEP is likely to be beneficial
Basic Newborn Resuscitation, WHO 1998
Sustained inflation (SI) ?
●
●
●
In babies with GA < 29 weeks SI is tested
out
Different models for instance 5 seconds x 3
or 15 seconds with increasing PIP
Still experimental
Self inflating (Laerdal) bag and mask with a manikin
P
No PEEP
F
V
Neopuff and mask with a mannequin
P
PEEP
F
V
C: Circulation
Neonatal Resuscitation
Chest compressions - indication
Chest compressions should be performed if the
heart
rate is < 60 beats/minute, despite adequate
ventilation
start with a 3:1 ratio - that is 90:30
0.8 per 1000 term or near term infants
2-10% in preterm infants
No human data have identified an optimal compression to
ventilation
ratio for cardiopulmonary resuscitation in any age
Goals: Reperfuse the heart (obtain diastolic pressure)
Reperfuse the Brain
Wyckoff
et al, Pediatrics 2005:115:950-955
Finer et al Pediatrics 1999;104:428-34
Wyckoff and Berg Seminars Fetal and Neonatal
Med 2008;13:410-415
The two-thumb technique is superior to the two-finger method for
administering chest compressions in a manikin model of neonatal
resuscitation
Depth of compressions and coefficient of variation
(COV) utilising a 3:1 compression to ventilation ratio
for 2 min using the two-thumb compared with the
two-finger technique
Depth (mm)
Variability (COV)
0.00002
Two-thumb 3:1 (2 min) Two-finger 3:1 (2 min) p Value
29±5.4
23.7±5.8
0.0009
6.1±2.9
9.8±3.1
C Christman, RJ Hemway, MH Wyckoff,JM Perlman Arch Dis Childhood 2010
Fact sheet
Chest compressions
If no signs of life beyond 10 min:
83% mortality
of survivors:
77% suffer severe disability
15% suffer moderate disability
8% mild disability
No reported normal survivors
Harrington et al Am J Obstet Gynecol 2007;196:463 e1-5
Newborn hypoxic piglets with cardiac arrest:
Time to return of spontaneous circulation
after cardiac arrest
ROSC in seconds
200
150
100
50
0
3:1
9:3
Chest compressions:ventilation
Solevaag A et al Neonatology 2010
Return of Spontaneous Circulation after Cardiac Arrest
ROSCseconds
400
P< 0.001
300
200
100
Median and IQR
0
30
60
90
seconds from cardiac arrest to chest compression
Solvaag A et al, Resuscitation 2010
D: Drugs
Neonatal Resuscitation
Adenaline/Epinephrine dose
If adequate ventilation and chest compressions
have failed to increase heart rate to > 60 bpm,
then it is reasonable to use adrenaline despite
the lack of human neonatal data.
Adrenaline for newborn resuscitation
•
•
•
•
6:10 000 newborns
0.1-0.3 mL/kg 1:10 000 adrenaline solution
1st dose at earliest at 4-5 min of life
IV recommended
Barber et al Pediatrics 2006;118:1028-1034
Neonatal Resuscitation
Volume expansion
Volume expansion may be accomplished with (1)
isotonic crystalloid such as normal saline or
Ringer’s lactate or (2) O-negative blood. 10ml
per kg, can be repeated
Needed in 1:12000 term or near term infants
(Perlman et al)
Insufficient evidence to support routine use
In infants with no blood loss.
Air versus Oxygen
Defining the reference range for oxygen saturation
for infants after birth.
Dawson JA, Kamlin COF, Vento M, Wong C, Cole TJ, Donath SM, Davis PG, Morley CJ.
PEDIATRICS 2010
0
10 20 30 40 50 60 70 80 90
100
Term Neonates > 37 weeks gestation
1
2
3
4
5
6
minutes from birth
10-90th centile
7
8
9
10
median
Dawson Ja et al Pediatrics 2010
0
10 20 30 40 50 60 70 80 90
100
Preterm < 37 weeks gestation
1
2
3
4
5
6
minutes from birth
10-90th centile
7
8
9
10
median
Dawson Ja et al Pediatrics 2010
SpO2 polynomial adjustment curve (± SD) in “control” ELGA neonates
(≤ 28 weeks gestation (n=29).
95
Preductal SpO2 (%)
85
75
65
Optimal FiO2 for ELBWI
Is not known !
55
45
35
25
0
2
4
6
8
Time after birth (min)
10
12
14
16
Vento M, Saugstad OD SFNM 2010
18
How could SpO2 centiles be used to inform decision
making in the DR?
100
90
80
70
60
50
40
30
20
10
Suggested level for administration of oxygen
0
0
1
2
3
4
5
6
7
8
9
Minutes after birth
10th
25th
50th
75th
90th
Dawson, Vento, Finer, Rich, Saugstad, Morley, Davis J Pediatrics 2011
10
TRANSITIONAL OXYGEN TRACKING SYSTEM
Allowing to individualize FiO2 avoiding hyper/hypoxia
50%
10%
Rich W et al unpublished data, 2010
Guidelines for optimizing oxygenation after birth
in ELBW infants



Place preductal SPO2 sensor (60-90 sec)
Start in 21%-30% FiO2 with adequate flow (4-8 l/min)
and always use an O2/air blender.
Aerate lungs to promptly achieve Functional Residual
Capacity (FRC)
Dawson, Vento, Finer, Rich, Saugstad, Morley, Davis J Pediatrics 2011
Guidelines for optimizing oxygenation after birth
in ELBW infants


At 90s review the infants HR, SpO2 and breathing efforts
 If the baby is breathing, or is well ventilated, and HR is
rising, and the SpO2 > 10th  O2 is not required
 If O2 is needed, FiO2 should be titrated against SpO2 to
keep it >10th and < 90th
 SpO2 < 10th and or HR is not rising or continues to fall
increase FiO2 until the SpO2 >10th and < 90th
 Wait at least 30 sec after each change until HR improves and
SpO2 between 10 to 90th
 If SpO2 > 90th reduce FiO2
Continue titrating FiO2 according to infant’s response
Dawson, Vento, Finer, Rich, Saugstad, Morley, Davis J Pediatrics 2011
Do we need a new Apgar Score ?
Virginia Apgar
0_______1__________
Heart rate
Respiration
Reaction*
Colour
Tone
0
0
0
Blue or pale
Limp
* Reaction to suctioning
2_____
<100
Weak, irregular
Slight
>100
Good cry
Good
All pink, limbs blue
Some movement
Body pink
Active movements
limbs well flexed
What about PCO2 ?
• PCO2 is high in asphyxia
• Hypercapnia restores cerebral circulation
faster than normocapnia
• Hypocapnia increases risk of brain injury
• Perhaps we need to be more careful in
the DR ventilating even term babies?
• Routine monitoring of PCO2 is needed
Newborn resuscitation
Current challenges
•
•
•
•
•
•
•
Optimal heart rate response not established
Ratio ventilation:chest compession not established
Sustained inflation?
Optimal PEEP not established
Optimal pCO2 not established
Optimal adrenaline dose not established
Optimal FiO2 and other procedures for ELGANS not
established
Thank you for your attention!
Comments – Questions?