Neonatal Resuscitation: Evidence for the RecommendationsNeonatal Resuscitation: Evidence for the...

Neonatal Resuscitation:

Evidence for the Recommendations

Adriann Combs, RN, BSN

Neonatal Care Today

9/18/2015

I have no conflicts of interest to disclose

American Heart Association (AHA)/

International Liaison Committee on Resuscitation

(ILCOR)

Scientific Evidence Evaluation and Review System (SEERS)

Dallas 2015, Seven Taskforces: Acute Coronary Syndrome

(ACS); Advanced Life Support (ALS); Basic Life Support

(BLS); Education, Implementation and Teams (EIT); First

Aid; Neonatal Resuscitation (NRP); and Pediatric Life

Support (Peds)

Evidence from literature reviewed and posted for public

comment through February 2015

https://volunteer.heart.org/apps/pico/pages/default.aspx

Literature reviewed by NRP Taskforce

to be Discussed

Babies born to mothers who are hyperthermic or hypothermic in labor

Temperature Maintenance in the Delivery Room

Delivery Room Assessment <25 weeks and Prognostic Score

Tracheal Intubation for Suctioning in non-vigorous infants born through meconium stained amniotic fluid

Two thumb vs. two fingers for cardiac compressions

Devices to provide positive pressure ventilation

The use of the Laryngeal Mask Airway Delayed Cord Clamping in Preterm Infants requiring resuscitation

Apgar Score 0 or 1 for > 10 minutes

Format

Discuss the topic

Present evidence

Describe the SEERs recommendation

Does Alteration in Maternal Body Temperature

Change Outcomes for the Newborn?:

Hyperthermia

1218 nulliparous women, singleton pregnancies at term

Categorized maximum intrapartum temperature as:

<100.4˚F, (afebrile), ≥100.4˚F and >101˚F.

Of the 1218 women, 123 developed a body temperature

> 100.4˚F.

% newborns afebrile ≥100.4˚F >101˚F

I minute Apgar <7 8 22.8

hypotonia 0.5 4.8

Bag mask ventilation 3.0 11.5

Oxygen therapy in the

nursery

1.3 8.2

Seizures 0.2 3.3*

n=4 babies total included both elevated body temperature ranges



Hyperthermia

Lieberman, E., Lang, J., & Richardson, D. (2000). Intrapartum Maternal Fever and Neonatal Outcome. Pediatrics, 8-13.

Conclusions: elevated intrapartum maternal temperature is associated with transient

adverse events in the newborn. Larger studies are required to investigate the association

between intrapartum fever and to identify lasting injury to the fetus.



Hypothermia

Baker, B., & Lawson, R. (2012). Maternal and Newborn Outcomes Related to Unplanned Hypothermia

in Scheduled Low-Risk cesarean Delivery Births. Newborn and Infant Nursing Reviews, 75-77.

Study of women undergoing scheduled, low risk c-sections

N=143

Maternal hypothermia, n=27 (21%)

Neonatal hypothermia, n=46 (36.5%)

-In hypothermic infants, 5 were hypoglycemic 12 had respiratory instability

-An elevated maternal BMI was protective against hypothermia in the newborn,

For every 1 unit increase in maternal BMI the odds of a newborn being

hypothermic are .90,10% less likely to be hypothermic


Change Outcomes for the Newborn?

SEERS recommendation (draft):

“Although maternal hyperthermia is associated with adverse

neonatal outcomes there is insufficient evidence to make a

recommendation on the management of maternal

hyperthermia.

With regard to maternal hypothermia, there is insufficient

evidence to make a recommendation about maternal

hypothermia.

There are no randomized controlled trials of the important or

critical neonatal outcomes after interventions to keep mothers

normothermic.”

Temperature Maintenance in the

Delivery Room

Neonatal hypothermia is associated with higher mortality

and morbidity.

Thermal management and awareness of its impact on

outcome is a critical component of neonatal care.

Y, L., Shah, P., Ye, X., & Warre, R. (2015). Association Between Admission Temperature and Mortality and Major

Morbidity in Preterm Infants Born at Fewer than 33 Weeks Gestation. JAMA Pediatrics, 169(4)e150277.

Association Between Admission Temperature and Mortality

and Major Morbidity in Preterm Infants Born

at Fewer than 33 Weeks Gestation

Canadian Neonatal

Network

29 NICUs

n=9833

Inborns <33 weeks

gestation

January 1, 2010-December

31, 2012

Admit

Temperature

%

<34.5˚C 1

34.5-34.9˚C 1

35.0-35.4˚C 3

35.5-35.9˚C 7

36.0-36.4˚C 24

36.5-36.9˚C 38

37.0-37.4˚C 19

37.5-37.9˚C 5

38.0˚C or greater 2

Results: After adjusting for maternal and newborn characteristics, the rates of composite

outcome, severe neurological injury, severe ROP, NEC, BPD and nosocomial infection

were at the lowest with an admit temperature ranging from 36.5˚C to 37.2˚C.

U Shaped relationship:

Lowest rates of

Adverse outcomes

were associated with admit

temp 36.5-37.2˚C

>40% of admit temps

outside the identified range

of 36.5-37.2˚C

Temperature Maintenance in the

Delivery Room


“We recommend that the temperature of newly born infants

be maintained above 36.5˚C after birth through admission

temperature check”.

Delivery Room Assessment <25 weeks and

Prognostic Score

The Apgar Score is > 50 years old

Its purpose (as initially described by Dr. Apgar) is to:

be used as a basis for discussion and comparison of the results

of obstetric practices, types of maternal pain relief and the

effects of resuscitation

The design of the Apgar score is not optimal for use in

prognostic models

including its potential lack of reliability

each of the five components carries different clinical

significance despite having the same weight in scoring.

Lee, H., ;Subeh, M. G. & Gould JB. (2010). Low Apgar Score and Mortality in Extremely Preterm

Neonates Born in the United States. Acta Paediatr, 99(12): 1785-1789.

Delivery Room Assessment <25 weeks

and Prognostic Score

A joint statement from AAP/ACOG:

“Because there are no consistent data on the significance of

the Apgar score in preterm infants, in this population the score

should not be used for any purpose other than ongoing

assessment in the delivery room.”

The Apgar score. Obstet Gynecol. 2006;107:1209–12. ACOG Committee

Opinion. Number 333, May 2006 (replaces No. 174, July 1996)



An investigation of the relationship between low Apgar

score and mortality in preterm neonates

n=690,933 neonates 24-36 weeks gestation, birth and death

certificate data (2001-2002)

Primary outcome was 28 day mortality

Mortality rates calculated for each combination of gestational

age and five minute Apgar.

RR calculated of mortality based on high (7-10) vs. (low 0-3)

for each GA

Study Results and Conclusions Results:

Distribution of Apgar Score depends on GA

The lower the GA, the greater the proportion of low Apgar scores

The RR of death was significantly higher at Apgars 0-3 vs. 7-10

Conclusions:

Low Apgar score was associated with increased mortality in preterm neonates

It may be a useful tool for clinicians and researchers as a risk prediction variable

Limitations:

No breakdown of the individual components of the Apgar or its contribution to the score




“There is no evidence that addresses the clinical prospective

use of prognostic scoring (the use of composite survival data

using GA and other parameters) in infants.”

http://www.dailymail.co.uk/news/article-1255657/Meet-worlds-premature-baby-

Doctors-release-image-incredible-infant-weighed-cup-coffee-birth.html












Tracheal Intubation for Suctioning in Non-

vigorous Infants Born through Meconium

Stained Amniotic Fluid

Meconium stained amniotic fluid (MSAF) occurs in 7-20%

of term births

MSAF is associated with fetal acidosis, abnormalities in

FHR tracings and low Apgar scores

Meconium aspirated into the tracheobronchial tree can

lead to hypoxia, inflammation and infection sometimes

resulting in meconium aspiration syndrome.




Vilaphi, S., & Vidyasagar, D. (2006). Intrapartum and Post Delivery Management of Infants born to Mothers with

Meconium Stained Amniotic Fluid: Evidence Based recommendations. Clinics in Perinatology, 29-42.

Summary of the Evidence:

Infants born through MSAF

Vilaphi, S., & Vidyasagar, D. (2006). Intrapartum and Post Delivery Management of Infants born to Mothers

with Meconium Stained Amniotic Fluid: Evidence Based recommendations. Clinics in Perinatology, 29-42.





“There is insufficient evidence to support the routine tracheal intubation for suctioning of meconium in non-vigorous infants born through meconium stained amniotic fluid as opposed to no tracheal intubation for suctioning. (weak recommendation, very low quality of evidence).

Comments: Routine suctioning of non-depressed infants is more likely to result in

delays in initiating ventilation, especially where the provider is unable to promptly intubate the infant or suction attempt is more than once.

Delay in initiating bag mask ventilation is associated with increased mortality (Ersdal, 2012). Therefore emphasis should be made on initiating ventilation within the first minute of life in non-breathing or ineffective breathing infants. Tracheal intubation for suctioning should be considered where there is no increase in heart rate and no chest movement with bag mask ventilation, as obstruction by meconium may be the cause of inadequate response to ventilation

Two Thumb vs. Two Fingers for

Cardiac Compressions

Currently, NRP guidelines endorse both two-thumb and

two-finger techniques.

Study to evaluate compress depth, variability, rate and

finger placement on both types compressions using

recommended 3:1 compressions to ventilations ratio.

Cristman, C., Hemway, R., & Wycoff, M. (2011). The two-thumb method is superior to the two finger method for administering

chest compressions in a manikin model of neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed, F99-F101.



-Physicians and neonatal nurses (n=25)

-Depth greater for two thumb (TT) vs. two finger (TF) method

-Variability was less, TT vs. TF

-Rate comparable

-Appropriate finger placement achieved more often TT vs. TF



Correct placement is necessary to generate higher

systolic and mean blood pressure.

Incorrect placement is associated with injury to the abdominal viscera.

Compared to proportion of correct placements between two finger (TF) and two thumb (TT) technique of chest compressions in neonates of varying gestational age (GA).

32 adult rescuers were compared with the inter-nipple to sterno-xiphoid junction in 39 neonates.

Correct placement was defined as TF/TT span was equal to or less than the inter-nipple line to the sterno-xiphoid junction distance.

-

Saini, S., Gupta, N., Bhalla, A., & Kaur, H. (2012). A comparison of two finger technique

and two-thumbs encircling hand technique of chest compressions in neonates. Journal of Perinatology, 690-694.



-

Saini, S., Gupta, N., Bhalla, A., & Kaur, H. (2012). A comparison of two finger technique

and two-thumbs encircling hand technique of chest compressions in neonates. Journal of Perinatology, 690-694.

Overall Preterm

TT 77 59

TF 6.7* 1.2**

TT. vs TF *p=<0.001, **p<0.001

Percent of Correct Finger Placements

n=1248



SEERS recommendation (draft): We suggest that chest

compressions in the newborn should be delivered by the

two thumb, hands encircling the chest as the preferred

option. Compressions should be performed on the lower

1/3 of the sternum.

Devices to Provide Positive Pressure

Ventilation

In newborns receiving positive pressure ventilation (PPV)

in the delivery room (DR) does the use of a t-piece

resuscitator vs. a self inflating bag with PEEP compared to

a self inflating bag without PEEP change survival to

discharge, air leak, development of spontaneous breathing

of bronchopulmonary dysplasia?

Devices to Provide

Positive Pressure Ventilation

PPV using a T-piece vs. self

inflating bag (SIB) without

PEEP

Total of 90 babies requiring

PPV in the DR

duration of PPV

intubation rates in DR

incidence of RDS,

need for mechanical

ventilation during 1st 48

hours and duration

surfactant replacement

mortality during NICU stay.

Devices to Provide Positive Pressure

Ventilation: RCT Results

The median duration of PPV in the delivery room was

significantly less in the t-piece 30(30-60)s vs. SIB group 60

(30-90)s, (p<0.001)

A larger percentage of the infants receiving PPV via SIB

required intubation compared to the t-piece group in the

DR, 34 vs. 15%, (p=0.04).

A higher proportion of the t-piece group were

resuscitated with RA vs. the SIB group 72.5 vs. 38%,

(p=0.001).

Thakur, A., Saluja, S., & Modi, M.-p. o. (2015). T-piece or self inflating bag for positive pressure ventilation

during resuscitation: An RCT. Resuscitation, 21-24.

Devices to Provide

Positive Pressure Ventilation

An single institution’s review of preterm infants (<35 weeks)

response to during two time epochs. Epoch I using SIB, n=135

Epoch II using T-piece, n=159.

Primary outcome Apgar score, air leaks, need for chest compressions/epinephrine, need for intubation and surfactant use.

No statistically significant differences in the primary outcome (Apgar score (rate of rise)) or the secondary outcomes.

Conclusion: Although some manikin studies favor T-piece for providing reliable and consistent pressures, our experience did not indicate significant differences in effectiveness of resuscitation between T-piece and SIB in preterm resuscitations.

Jayaram, A., & Sima, A. B. (2013). T-piece Resuscitator Versus Self-Inflating Bag for Preterm Resuscitation: An Institutional Experience.

Respiratory Care, 1233-1236

Devices to Provide Positive Pressure Ventilation:

Delivery Room Devices Trial Group

Evaluate the

effectiveness and

safety of a T-piece

resuscitator

compared with a

self inflating bag for

providing mask

ventilation to

newborns at birth.

n=1027 neonates,

≥26 weeks gestation

Szyld, E., Aguilar, A., & Musante, G. (2014). Comparison of Devices for Newborn Ventilation in the Delivery Room.

The Journal of Pediatrics, 234-239.

Delivery Room Devices Trial Group:

Subgroup VLBWs



Delivery Room Devices Trial Group:

T-piece, SIB with PEEP valve, SIB no PEEP valve



Devices to Provide Positive Pressure Ventilation:

Delivery Room Devices Trial Group

No statistically significant difference in HR ≥100 BPM at 2

minutes between the t-piece and SIB groups (primary

outcome).

In the t-piece group, 17% were intubated in the DR vs.

26% in the SIB group, (p=0.002).

Maximum PIP was statistically difference with the

maximum pressure in the t-piece group 26+2 cm H20 vs

28 +5 cm H20 in the SIB group, (p=<0.001).

Air leaks, uses of drugs/chest compressions, mortality,

days on mechanical ventilation did not differ between the

groups.



Devices to Provide Positive Pressure Ventilation

SEERS recommendation (draft): We suggest ventilation

can be performed comparably with a self-inflating bag

with PEEP, t-piece resuscitator, a self-inflating bag without

PEEP during delivery room resuscitation.

We recognize that the use of t-piece resuscitator shows

marginal but not statistically significant benefits of

outcome of achieving spontaneous breathing.

In making this suggestion, we also place a value on the

impact of resource utilization and feasibility in resource

limited setting.

The Use of the Laryngeal Mask Airway

The key to successful newborn resuscitation is

ventilation.

Traditionally ventilation has been provided by bag-valve-

mask (BVM) or endotracheal tube and bag.

Failed ventilation with a BVM leads to endotracheal

intubation.

Intubation requires technical expertise and skill.

What is the evidence for the LMA as a primary airway

device?


Evaluated the feasibility, efficacy and safety of using the

LMA in neonatal resuscitation.

n=369 neonates, GA ≥34 weeks gestation, expected BW

≥2.0 kgs.

Randomized to LMA, n=205, BVM, n=164

Zhu, X., & Lin, B. Z. (2011). A prospective evaluation of the laryngeal mask airway during neonatal resuscitation. Resuscitation, 1405-1409.


Successful resuscitation rate was higher in the LMA vs. BVM group, 99 vs 84%. (p<0.001).

Total ventilation time was shorter in the LMA vs. BVM group (p<0.001).

7/9 infants in the LMA group with Apgars of 2 or 3 at I minute were successfully resuscitated vs. 0/6 infants in the BVM group-all of these infants required intubation.

The LMA was successfully inserted on the first attempt in 98.5% of cases. Insertion time was 7.8s ±2.2s

In this study of neonates ≥ 34 gestation the author’s conclude that the LMA is safe, effective and easy to implement.

Zhu, X., & Lin, B. Z. (2011). A prospective evaluation of the laryngeal mask airway during neonatal resuscitation. Resuscitation, 1405-1409.

The Use of the Laryngeal Mask Airway:

Observational Trial

n=86 neonates, gestational age 34 0/7-36 6/7 weeks.

The use of PPV, the device used to provide PPV: BVM,

LMA or ETT.

The association of the device used with short term

neonatal outcomes.

Total infants 34 0/7-36 6/7 during study period=921 (4.9%

of their newborns).

Zanardo, V., Weiner, G., & Micaglio, M. (2010). Delivery room resuscitation of near-term infants: Role of the laryngeal mask airway.

Resuscitation, 327-330.

The Use of the Laryngeal Mask Airway:

Results/Conclusions

Zanardo, V., Weiner, G., & Micaglio, M. (2010). Delivery room resuscitation of near-term infants: Role of the laryngeal mask airway.

Resuscitation, 327-330.

PPV Device n(%) NICU Admission

BFM 34 (39.5%) 15 (44.1%)

LMA 36 (41.8%) 7 (19.5%)

ETT 16 (18.6%) 12 (75%)

Resuscitation with an ETT is associated with an increased rate of respiratory distress syndrome

when compared with BFM or LMA

Resuscitation with the LMA was associated with a lower rate of NICU admission and shorter

length of stay

The author’s conclude:

The LMA is an effective device for primary airway management for near term infants

and for secondary management among near term infants failing BFM or ETT

resuscitation.

Prospective randomized trials are needed to confirm the potential advantages of the LMA

in neonatal resuscitation of near term infants.


SEERS recommendation (draft): LMA compared to FM as a primary device for infants at term requiring positive pressure ventilation for resuscitation as feasible and safe, but there is not enough evidence to recommend it instead of face mask. There is limited evidence, however, to evaluate its use for preterm infants.

The LMA has not been evaluated in the setting of meconium stained amniotic fluid, during chest compressions, or for the administration of emergency intratracheal medications.

The LMA should be considered during resuscitation if face mask and/or endotracheal intubation is unsuccessful or not feasible.


SEERS recommendation (draft): LMA compared to ETT

as a secondary device for infants at term requiring

positive pressure ventilation for resuscitation:

“We suggest that the use of the laryngeal mask airway as

a secondary device for respiratory support in the delivery

room for newborns at term requiring positive pressure

ventilation during neonatal resuscitation as feasible and

safe, but there is not enough evidence to recommend it

instead of endotracheal intubation.

Delayed Cord Clamping in Preterm

Infants Requiring Resuscitation

Timing of cord clamping in

the preterm infant remains controversial.

Immediate cord clamping is defined as <20 seconds, delayed cord clamping is defined as 30 seconds or more after birth.

Benefits reported in infants not requiring extensive resuscitation include: less need for volume therapy and inotrope support, decrease blood transfusion and decreased incidence of intra-ventricular hemorrhage.

Rabe, H., Reynolds, G., & Diaz-Rossello, J. (2008). A systematic review and meta-analysis of a brief delay in clamping the

umbilical cord of preterm infants. Neonatology, 138-144.



A review of ten trials was performed.

454 preterm infants < 37 weeks were included.

Included studies of both vaginal and c-section deliveries,

maternal oxytocics, the number of infants randomized to

immediate or delayed clamping, the position of the infant

in relation to the placenta and outcomes.

Outcomes described included, initial hematocrit, blood

pressure, Apgar scores, peak bilirubins and the need for

phototherapy, transfusion, need for volume and inotropes,

intraventricular hemorrhage and necrotizing enterocolitis.





Major benefits of interventions:

Higher hematocrit (5 studies), (p=0.0007)

Less need for blood transfusions (4 studies), (p=0.0004).

Less incidence of intra-ventricular hemorrhage (7 studies)

(p=0.002).

No statistically differences in cord blood pH, Apgar scores,

death or temperature on admission.





Author’s conclusions:

Early clamping decreases initial blood volume.

Delayed cord clamping is possible and safe in appropriately

configured perinatal centers.

It seems reasonable to recommend a slight delay in cord

clamping of at least 30 seconds as a routine practice in

preterm infants.

The international perinatal community needs to support a

robust study to confirm or refute the benefits intimated by

smaller studies.





SEERS recommendation (draft): we suggest delayed umbilical

cord clamping over immediate cord clamping for infants not

receiving resuscitation after birth.

There is insufficient evidence to recommend the approach to

cord clamping for preterm infants who do receive

resuscitation immediately after birth.

Acceptability to staff at delivery is high when delayed cord

clamping is introduced in the context of a QI process.

Delayed cord clamping requires increased coordination

between obstetrical and neonatal providers. The intervention

requires real time assessment of the conditions at delivery.


Investigate outcomes who had Apgar score of zero at 10

minutes and were successfully resuscitated.

A literature review and a reported single institution’s

experience, 13 years, 1/1991-12/2004, total deliveries

evaluated =83, 065 > 24 weeks.

Apgar score at 10 minutes of zero=12. 9 successfully

resuscitated, 3 unsuccessful attempts.

Harrington, D., Redman, C., & Moulden, M. (2007). The long term outcome in surviving infants with Apgar zero at 10 minutes:

a systemic review of the literature and hospital based cohort. American Journal of Obstetrics and Gynecology, 463e1-463e5.

Apgar Score 0 or 1 for > 10 minutes:

Studies Reviewed



Apgar Score 0 or 1 for > 10 minutes:

Institutional Experience



Comparison of the effect of cerebral cooling in the fetal sheep started at

different times after reperfusion and continued until 72 hours on

microscopically assessed neuronal loss in the parasagittal parietal cortex

after 5 days' recovery from 30 minutes of cerebral ischemia

Gunn, A. J. et al. Neoreviews 2002;3:e116-e122


SEERS recommendation (draft): we suggest that the

decision to continue or withdraw resuscitative efforts

after 10 minutes of adequate resuscitation with effective

ventilation, chest compressions and IV epinephrine if the

heart rate remains undetectable should be individualized.

Variables to be taken into consideration may include

availability of neonatal care and therapeutic hypothermia,

and wishes expressed by the family.

Recent data included infants that have been treated with

therapeutic hypothermia may show modest improvement

in neurodevelopmental outcome over previous reports.

Conclusions

The science that supports newborn resuscitation continues to evolve.

Although we continue to improve outcome, interventions especially in the preterm population are dependent on improved antepartum management including; adequate PNC,17P, antenatal steroids and a delivery setting with the appropriate resources.

Continued evaluation of hypothermia therapy in near term and term infants is needed to facilitate conclusions about its benefits on long term neurodevelopmental outcomes.

Further improvement in outcome depends on enhanced communication and planning between obstetric and newborn care providers and the families we serve.

THANK YOU

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