Time needed to achieve changes in oxygen concentration at the T-Piece resuscitator during respiratory support in preterm infants in the delivery room

OBJECTIVE:

To measure the time needed to achieve changes in fraction of inspired oxygen concentration (FiO₂) from the oxygen blender to the facemask during simulated neonatal resuscitation.

METHOD:

Two oxygen analyzers were placed at each end of the T-Piece. During simulated ventilation, the duration to achieve the set oxygen concentration at the facemask was measured. This was repeated at different gas flow rates (5 L/min, 8 L/min or 10 L/min) and different FiO₂ changes (0.21 to 1.0 to 0.21, with stepwise increases and decreases in 0.05, 0.1 and 0.2 increments).

RESULTS:

A total of 1134 measurements (378 measurements for each flow) were recorded. Overall, the mean (± SD) time required to achieve FiO₂ changes at 5 L/min, 8 L/min and 10 L/min was 36±15 s, 31±14 s and 28±14 s, respectively.

CONCLUSION:

There was a lag time of approximately 30 s to achieve the FiO₂ at the facemask. This delay needs to be considered when making serial adjustments to FiO₂ during neonatal resuscitation.     

The use of oxygen for delivery room resuscitation of newborn infants in non-Western countries

Background

Using pure oxygen (PO) in neonatal resuscitation increases oxidative stress and mortality in full-term hypoxic infants. International neonatal resuscitation guidelines recommend air or blended oxygen for resuscitation regardless of gestational age but this requires education and equipment that may not be globally available.

Objective

To determine current neonatal resuscitation practices and availability of oxygen blending equipment in non-Western hospitals.

Design

196 email addresses were obtained through perinatal societies representing 45 hospitals in 14 countries in Asia, Africa and the Middle East.

Results

68 (34.6%) responses were received from all 14 countries. The majority (90%, n = 61) of respondents were aware of recent guideline changes but continued to resuscitate with PO because of the lack of equipment and uncertainty about international guidelines (61%, n = 41 for term, 44%, n = 30 for preterm). Most (81%, n = 55) believed that PO caused adverse effects in term neonates. The availability of oxygen blending equipment correlated significantly with the country's gross domestic product.

Conclusion

The majority of the practitioners we surveyed in non-Western countries are aware of the most recent recommendations regarding oxygen use in neonatal resuscitation. However, lack of oxygen blending equipment remains a hindrance to the use of blended gas at resuscitation in low resource, non-western countries. Global guidelines from developed countries must take into account the resource limitations and implementation difficulties faced by countries with restricted resources, where the majority of the high-risk infants are born.     

Percentiles of oxygen saturations in healthy term newborns in the first minutes of life

The aim of this study was to establish the reference values of preductal oxygen saturation (SpO₂) in healthy infants immediately after birth. SpO₂ recordings of 200 term neonates (vaginal group;n=150 and cesarean group;n=50) with regular respiratory pattern were evaluated. The median SpO₂ values in the first, fifth and tenth minutes were 71, 92, and 98% in vaginal deliveries and 70, 79, and 96% in cesarean deliveries, respectively. SpO₂ was significantly lower in the cesarean group at any time after the first minute of life (p<0.0001). The time needed to reach a SpO₂>90% was three times longer in cesarean deliveries. Healthy neonates are poorly saturated immediately after birth. The duration to reach a SpO₂>90% was longer in infants born by cesarean deliveries. This study was supported by The Marmara University Scientific Research Committee (SAG-TUS-200906-0165). Presented as a poster in Hot Topics in Neonatology 2006, Washington, DC, 2–5 December 2006.     

Delivery room emergencies: Respiratory emergencies in the DR

The majority of newborns transition to extra uterine life without support. However, respiratory emergencies in the delivery room are a common occurrence. Whilst some situations are predictable e.g. the anticipated birth of an extremely preterm infant, others are less so. In this chapter we address the most frequent scenarios that result in delivery room respiratory emergencies and discuss the latest recommendations for their management. We outline the need for a trained resuscitation team and appropriate equipment to provide respiratory support at every birth. We address the basic care that all infants should receive, the detailed application of non–invasive ventilation and the use of advanced airway techniques. We discuss the unique challenges presented by extreme prematurity including umbilical cord management, use of supplemental oxygen, initial modes of respiratory support and surfactant delivery. We will explore optimal techniques in the management of infants with lung hypoplasia, pneumothorax and meconium aspiration.     

Oxygenation and ventilation in spontaneously breathing very preterm infants with nasopharyngeal CPAP in the delivery room

AIM: To provide data on ventilation, oxygenation and acid-base state from birth to 48 h in very preterm infants treated with lung recruitment manoeuvre and nasopharyngeal continuous positive airway pressure in the delivery room. METHODS: Subjects of this prospective observational cohort study were 48 of 61 infants enrolled in a randomised controlled trial to test two lung recruitment manoeuvres after birth. The infants had received an arterial line in the delivery room. The outcome measures were data on oxygenation, ventilation and acid-base state during spontaneous breathing. RESULTS: Data are presented as (n [%]; median [minimum-maximum]). 22 of 48 (46%) infants (gestational age, 26.4 [25.0-28.9] weeks; birth weight 870 [540-1310] g) were never intubated during the study. The FiO(2) of these infants was low (0.4 [0.21-0.45] at 45 min and 0.21 [0.21-0.5] at 48 h). PCO(2) reached its maximum at 24 (11-44) min (8 [6.4-10.8] kPa) and decreased below 6.7 kPa (median) within 3 h. The incidence of intracranial haemorrhage/periventricular leukomalacia did not increase with hypercapnia (pCO(2) > 8 kPa). CONCLUSION: A transient period of hypercapnia after birth may occur in spontaneously breathing very preterm infants supported with nasopharyngeal continuous positive airway pressure in the delivery room. The incidence of cerebral damage was not increased in infants with hypercapnia.     

Improving the delivery room setting in developing countries: the opinion of local health caregivers

OBJECTIVE: Neonatal mortality has remained steady or increased in many developing countries. A pragmatic approach to the organization of the delivery room setting, where a large part of neonatal deaths occurs, could detect the priorities for potential ameliorative interventions. We evaluated the local health caregivers' opinions regarding the priority areas for improving the hospital delivery room setting in developing countries. METHODS: Twenty-eight participants to a World Health Organization (WHO) workshop were asked to fill out an anonymous, written questionnaire regarding the priorities that could significantly improve their hospital delivery room setting. RESULTS: The three most important interventions for improving the delivery room setting were classified as following: education of all staff in newborn care (28%), optimize doctor-nurse/patient ratio (15%), equipment (14%), maternal-antenatal care (13%), role and responsibilities (8%), salary (8%), neonatal intensive care unit facilities (6%), availability of a specialized team for neonatal resuscitation (5%) and improve the building (3%). CONCLUSION: Education of health staff in newborn care, personnel organization and equipment availability are valued as high priorities by local health caregivers for improving the delivery room setting in developing countries. The opinion of operators involved in maternal and neonatal health may contribute to better design interventions in setting with limited resources.     

腹裂患儿Silo袋内肠管血供监测的方法探讨

目的介绍一种针对无法一期回纳的严重新生儿腹裂患儿放置silo袋后监测袋内肠管血供的方法及其临床意义。方法对先天性腹裂患儿施行手术时,在Slio袋放置完毕后,将外周血氧饱和度监测仪的条带状探头紧贴硅胶袋壁包绕,监测硅胶袋内肠管血氧饱和度。结果5例无法一期回纳的新生儿腹裂患儿放置免缝Silo袋后成功应用外周血氧饱和度监测仪监测袋内肠管血供情况。结论外周血氧饱和度监测仪可安全应用于对Silo袋内肠管血供的监测,改变了以往仅仅依靠裸眼观察判断袋内肠管血供的欠准确科学的现状,避免了因袋内肠管嵌顿、缺血导致肠管缺血坏死的可能。     

新生儿及婴儿发育性髋关节异常早期筛查及早期治疗的探讨

目的通过对新生儿及婴儿发育性髋关节异常的早期筛查,结合临床检查与超声检查诊断的评价,推动新生儿及婴儿发育性髋关节异常的早期诊治。方法对本院出生的1213例新生儿及866例年龄6个月以下婴儿进行临床及超声早期筛查（Graf方法）,以明确诊断,及时治疗。结果新生儿早期疑诊45例,最终确诊5例,婴儿确诊3例,经用Pavlik吊带治疗6例痊愈,1例6个月后行闭合复位石膏固定治疗。结论新生儿期超声检查髋关节不稳定率偏高（Graflla型髋）,发育性髋关节异常的早期筛查,特别是低于6个月的超声检查检出率高,各科医师合作有利于DDH的早期诊治。     

Pretreatment cortisol values may predict responses to hydrocortisone administration for the prevention of bronchopulmonary dysplasia in high-risk infants

OBJECTIVES: To investigate the effect of hydrocortisone treatment on survival without bronchopulmonary dysplasia (BPD) and to study whether serum cortisol concentrations predict the response. STUDY DESIGN: We performed a randomized, placebo-controlled trial on infants with gestation < or =30 weeks, body weight of 501 to 1250 g, and respiratory failure. Hydrocortisone was started before 36 hours of age and given for 10 days at doses from 2.0 to 0.75 mg/kg per day. Shortly before hydrocortisone treatment, basal and stimulated (ACTH, 0.1 microg/kg) serum cortisols were measured. RESULTS: The study was discontinued early, because of gastrointestinal perforations in the hydrocortisone group (4/25 vs 0/26, P = .05); 3 of the 4 had received indomethacin/ibuprofen. The incidence of BPD (28% vs placebo 42%, P = 0.28) tended to be lower, and patent ductus arteriosus (36% vs 73%, P = .01) was lower in the hydrocortisone group. The hydrocortisone-treated infants with serum cortisol concentrations above the median had a high risk of gastrointestinal perforation. In infants with cortisol values below the median, hydrocortisone treatment increased survival without BPD. CONCLUSIONS: Serum cortisol concentrations measured shortly after birth may identify those very high-risk infants who may benefit from hydrocortisone supplementation.     

Guidelines for the use of pulse oximetry in the non-invasive estimation of oxygen saturation in oxygen-dependent newborn infants

Abstract An Ohmeda Biox 3700 oximeter was evaluated during treatment of 12 patients with respiratory distress. The infants were of 27–33 weeks'gestation and between 2 days and 5 months postnatal age. Blood gases were taken from indwelling arterial catheters and were measured on an ABL 30 blood gas analyser. The study tested the accuracy of the oximeter in detecting hypoxia ( P ao₂<55 mmHg) and hyperoxia ( P ao₂>80 mmHg). Results are based on 175 paired observations. Guidelines are suggested for the use of the pulse oximeter under three conditions. In a newborn infant with acute respiratory distress without direct arterial access, the limits should be set at 85% (lower) and 90% (upper). In an older infant with chronic respiratory distress, the upper limit of use should be 95%. In order to avoid oxygen tensions <55 mmHg which would increase the risk of pulmonary vasoconstriction, however, the lower limit should be 87%. Infants with indwelling arterial lines during their first few weeks of treatment should have oxygen tension measurements and simultaneous oxygen saturation readings plotted on a graph at the bedside. The graph should be updated every 48 h to take into account changed levels of 2,3-diphosphoglycerate, haemoglobin F, and carboxyhaemoglobin and the recommended limits should be changed accordingly.     

Prediction of gross motor development and independent walking in infants born very preterm using the Test of Infant Motor Performance and the Alberta Infant Motor Scale

Background

One objective of a neonatal follow-up program is to examine and predict gross motor outcome of infants born preterm.

Aims

To assess the concurrent validity of the Test of Infant Motor Performance (TIMP) and the Alberta Infant Motor Scale (AIMS), the ability to predict gross motor outcome around 15 months corrected age (CA), and to explore factors associated with the age of independent walking.

Methods

95 infants, born at a gestational age < 30 weeks, were assessed around 3, 6 and 15 months CA. At 3 months CA, correlations of raw-scores, Z-scores, and diagnostic agreement between TIMP and AIMS were determined. AIMS-score at 15 months CA and parental-reported walking age were outcome measures for regression analyses.

Results

The correlation between TIMP and AIMS raw-scores was 0.82, and between Z-scores 0.71. A cut-off Z-score of − 1.0 on the TIMP had 92% diagnostic agreement (κ = 0.67) with an AIMS-score < P10. Neither TIMP- nor AIMS-scores at 3 months CA were associated with the gross motor outcome at 15 months CA. The AIMS-scores at 6 months CA predicted the AIMS-scores at 15 months CA with an explained variance of 19%. Median walking age was 15.7 months CA, with which only the hazard ratio of the AIMS at 6 months CA and ethnicity were significantly associated.

Conclusions

Prediction of gross motor development at 15 months CA and independent walking was not possible prior to 6 months CA using the AIMS, with restricted predictive value. Cultural and infant factors seem to influence the onset of independent walking.