A Babies First 5 Minutes: Delivery Room Resuscitation Dave Dewar January 31, 2011

Review of Physiology

First Breaths Trigger via mechanical and chemical stimuli “Squeeze” from delivery has less role in fluid clearance than previously thought  Process of mobilizing lung fluid begins with the onset of labor and is gradual  Occurs primarily via active transport across interstitial with drainage via pulm veins Peak inspiratory pressure  Low opening pressure (-5) Very high expiratory pressure  Aids in removal of fluid  Homogeneous distribution of air Development of a FRC

Lungs Expansion of lungs trigger surfactant release  Reduces surface tension and increases compliance  Helps develop a stable FRC Removal of fluid decrease hydrostatic pressure on capillaries  Decreased PVR Gas exchange starts  Increase in O2 and pH  more decrease PVR

Circulation With first breaths decrease in PVR With chord clamping increased SVR Adult circulation begins  Decreased R  L shunting across PDA  Increased blood flow to pulm vasculature  Increased LA pressure  closure of Foramen Ovale

Asphyxia/Hypoxia pH pAO2 decreases  PVR stays high  Shunts stay open  Blood bypasses the lungs  BP and HR stay OK until mycardial hypoxia decrease cardiac output Respirations  Initially Gasping respirations May be in utero Primary apnea follows  If Asphyxia continues then gasping breaths will resume Followed by secondary apnea

Neonatal Resuscitation

In the beginning… National Academy of Science published national guidelines for resuscitation of adults Work group on Pediatric resuscitation formed Concluded newborns required different emphasis than adults Primarily respiratory not cardiac in nature AAP and AHA formed joint goal to develop program to teach delivery room resuscitation First NRP course published Written primarily by Ron Blood and Cathy Cropley Current (5 th edition) NRP PublishedIn Spring th Edition will be released

Early NRP Initially nearly all recommendations were expert opinions Concerted effort to back recommendations up with evidence  Have discovered many have little/no evidence Formal review process established Current Edition (5 th ) based on 2005 review

Review process Currently a 5 yr evaluation process  Define the issues for consideration in the new cycle  Conduct an in-depth review of the literature  Debate the evidence through a series of Internation Liason Committee on Resuscitation (ILCOR) meetings  Reach Consensus on Science and Treatment Recommendation (COSTR) with ILCOR  Reach consensus within the NRP Steering Committee (NRPSC) on the appropriate application of the science to define appropriate treatment recommendations for NRP  Publish COSTR and Treatment Recommendations documents and a new edition of the NRP Textbook

Review Process begin ~6 mo after publication of previous edition Questions which will improve outcomes agreed upon  Done via survey of Neo’s, NNP’s, and educators Each question assigned to at least 2 experts  Independent review of literature Each expert then meets to presents review  Hope is that both will be able to negotiate unified recommendations

Assessment of need for and measures of efficacy of resuscitation: Anticipation (accuracy of risk factors, role of gestation) How accurate are clinical/physical findings (HR, Resp effort, color) for assessing the need for and efficacy of resuscitation What adjunct measures are there that might improve clinical findings (pulse ox, exhales CO2, rhythm strip)

Assessment of need for and measures of efficacy of resuscitation: Review of human and animal study still supports HR as most sensitive indicator of efficacy  Auscultation is preferred method for assessment  Palpation of umbilical pulse more likely underestimates May be misleading or inaccurate This and need to control O2 use led to strong recommendation for pulse ox use Newer machines will get HR and O2 Sats  Except in severe bradycardia/hypoxia

Assessment of the need for and management of supplemental oxygen: What is the reliability of oximeters (type, probe placement, timing of achieving signal, limitations)? How much oxygen should be used (room air versus 100% versus blended O2)? What are the appropriate indications for supplemental oxygen use (eg, color versus SpO2; CO2 production)?

Assessment of the need for and management of supplemental oxygen: Since last review 6 RCT have shown no benefit to starting resuscitation with 100% vs. 21% FiO2 2 meta analyses suggested decreased mortality and fewer investigation when starting with 21%  Likely due to decrease in proinflamatory cytokines

Assessment of the need for and management of supplemental oxygen: Every delivery area should have an oximeter readily available (not necessarily present at every delivery) Supplimental O2 should be given by blender, and titrated to keep in range for normal babies NRP advocates FT babies to be started out at 21% and preterms to be>21% but < 100% Use of oximeter whenever supplemental O2, PPV, or CPAP is used  Color should no longer be used to evaluate newborn

Normal O2 ranges Mariani et al, 2007

Ventilation How should functional residual capacity (FRC) be established with positive-pressure ventilation (PPV) (eg, long inflations, positive end- expiratory pressure [PEEP], pressure guidelines)? Is pressure the appropriate parameter to consider in PPV or should we measure and display volume? Is continuous positive airway pressure (CPAP) preferable to intubation and PPV in the delivery room? What are the alternative airway interfaces to intubation (masks, prongs, laryngeal mask airway)? What are the alternatives to PPV devices (eg, mouth-to-mouth, mouth-to-tube, mouth-to-mask)?

Ventilation Insufficient evidence to recommend any one modality  Curriculum will discuss all of them  Long (10 sec) and short (5 sec) i-times both effective Will vary from changes in adult and child life support in emphasizing importance of ventilation over chest compressions and meds  Added 30 sec to algorithm Addresses need for adequate pressure  20 cm H20 normally adequate for preterms  cm H20 may be needed for full terms  Use enough pressure to get chest rise Adds LMA to recommendations for:  “when endotracheal intubation is unsuccessful or not feasible” (IIa)  Babies >2kg or 34+ wks

Suctioning Clear Fluid  No suctioning (including bulb) unless obvious obstruction or requiring support (IIb) Meconium Stained Fluid  Insufficient evidence to change current recs  Intubate for tracheal suctioning in unresponsive infants  If difficult/prolonged attempts abandon intubation and provide PPV

Chest Compressions What is the optimum technique (two- finger, two thumb-encircling, best chest placement; how deep)? What is the most effective compression:ventilation ratio (3:1, 15:2, 30:2, continuous compressions)?

Chest Compressions Two thumbs recommended as provides better coronary perfusion (IIb) ALS and PALS recommendations  Single Person: 15:2  Two Person: 30:2 NRP differs from above  3:1  Strongly encourage intubation prior to starting compressions to allow for better coordination Wait sec before checking HR  Animal studies have indicated at least that much time is needed to re-profuse coronaries

Drugs Which drugs (epinephrine, sodium bicarbonate, naloxone)? What route (endotracheal, intravenous, intraosseous)? What dose of epinephrine is appropriate according to route?

Drugs ET Epi unpredictable and in animal studies has limited utility Highlighting the importance of establishing access early (IIb)  Dose: mg/kg Higher doses resulted in hypertension, decreased myocardial functioning, worse neuro-dev outcomes. ET Epi should only be used while access is being established  Dose: mg/kg

Drugs Not recommended in delivery room  Nalaxone  Bicarb  Vasopressin

Access Intraosseous access is an acceptable route for volume and drugs  Unable to obtain other access  Provider is more confident with obtaining this Intravenous is still preferred  Peripheral vs Umbilical

New Algorithm

Mr. Sopa M Adjust Mask to assure good seal R Reposition airway S Suction nose/mouth (if needed) O Open mouth and move jaw forward P Increase Pressure until chest rises A Consider Airway Alternative (ET tube/LMA)

Chord Clamping Early versus late (routine versus with resuscitation)? Is there an advantage to milking of the cord?

Chord Clamping Studies support delaying clamping in uncomplicated births  Time in studies ranged from 1 min to cessation of pulsation of chord Preterm infants have been shown:  To have increased BP during stabilization  Decreased incidence of IVH Recommend delaying clamping for 1 min in children who don’t require resuscitation  Insufficient evidence to recommend delayed clamping in babies that do require resuscitation

Post Resuscitation Care How often should glucose be monitored and how managed? When, if, and how should asphyxiated babies be given therapeutic hypothermia?

Warming Infants <1500 g or <28 wks  Preheat room to 26 C  Wrap in plastic wrap (I)  Use of exothermic mattress (IIb)  Radiant warmer (IIb)  Any procedure should be performed with measures in place (IIb)

Glucose No specific number has been connected with poor outcome Increased levels after ischemia may be protective Hypoglycemia should be avoided Not enough data for any recommendations

Post Resuscitation Care Since 5 th edition significant evidence regarding role of cooling has emerged New edition recommends use of hypothermia as per local protocols  Should be done in coordination with center that can provide multidisciplinary follow-up

Ethics What are the appropriate indications for nonresuscitation? What are the thresholds of viability and the parents’ role? How long should one attempt resuscitation before stopping?

Withholding Initiation Consistent communication is key  Parents  Ob/MFM  Neo Non-initiation and withdrawal of support ethically equivalent  Should not be resistant to withdrawal if “functional survival is highly unlikely” Non-initiation  When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors Parental Choice  In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high Dates and EFW can be off; withhold firm plans until baby is assesed

Ethics Maintains that it is acceptable to stop efforts if no pulse is present at 10 min APGAR Acknowledges decision may be complicated by:  Presumed cause of arrest  EGA  Additional conditons  Previously expressed wishes of parents

Education Methodology Are debriefing sessions effective and are they different from briefings? Is simulation as effective as traditional teaching?

Education Methodology Simulation improves performances in staged as well as real life resuscitation Briefing and Debriefing have been shown to improve both knowledge and skill of all participants

Practical Changes in Course Online test prior to starting course  Self paced, adult centered learning Increased emphasis on high fidelity simulation Increased emphasis on team communication