Neonatal cardiopulmonary resuscitation project in Japan

In July 2007, the Neonatal Cardiopulmonary Resuscitation (NCPR) program in Japan was launched to ensure that all staff involved in perinatal and neonatal medicine can learn and practice NCPR based on the Consensus on Science with Treatment Recommendations developed by the International Liaison Committee on Resuscitation. In 1978 in North America, a working group on pediatric resuscitation was formed by the American Heart Association Emergency Cardiac Care Committee and concluded that the resuscitation of newborns required a different strategy than the resuscitation of adults. The original first edition of the Neonatal Resuscitation Program textbook was published in 1987. The NCPR program consists of three courses for health‐care providers and two courses for instructors. A course and B course are for newly certified health‐care providers and course S is for health‐care providers who are renewing their certification. As of 31 March 2019, 3,227 advanced instructors (I instructor) and 1,877 basic instructors (J instructor) were trained to teach A, B, and S courses to health‐care providers on the basis of their license. In total 7,075 A courses and 4,012 B courses were held; 131 651 people attended A course or B course of the NCPR program, and 77 367 were certified. A total of 1,865 S courses, which were developed in 2015, were held and 12 875 people attended this course. Here, we introduce the background, purpose, history, and content of the development of the NCPR program in Japan.     

Electrocardiogram shows reliable heart rates much earlier than pulse oximetry during neonatal resuscitation

Background: The aim of this study was to determine the usefulness of the three‐lead electrocardiogram (ECG) during neonatal resuscitation. Methods: Both pulse oximetry (PO) and ECG were applied immediately after delivery to measure heart rate (HR). We reviewed video recordings of the respective monitors, and checked the time at which each monitor started to display reliable rate values. Results: In 20 deliveries, ECG showed HR much earlier than PO (median 38 s vs 122 s after delivery). ECG displayed reliable HR throughout resuscitation. We were able to confirm the effectiveness of the initial respiratory support from the elevation in HR. Conclusions: ECG was a safe and reliable method for showing HR, and was used to determine the initiation and the effectiveness of resuscitation in the delivery room.     

新生儿困难复苏相关危险因素分析

目的分析新生儿困难复苏的相关危险因素。方法以2011年1月至2015年10月分娩的活产满28周窒息儿(1分钟Apgar评分0~7分)为研究对象,经复苏后,以5分钟Apgar评分8~10分新生儿为5分钟复苏顺利组,0~7分新生儿为5分钟复苏困难组,进行相关危险因素的分析;5分钟复苏困难新生儿继续复苏后,20分钟Apgar评分8~10分的新生儿列为20分钟复苏顺利组,0~7分新生儿为20分钟复苏困难组,再进行危险因素分析。结果纳入1分钟窒息新生儿743例,其中5分钟复苏困难新生儿130例,另外613例复苏顺利,早产、低出生体质量、1分钟Apgar评分0~3分、产时感染性发热、胎盘异常、妊娠后期阴道出血、双胎输血综合征、胎儿畸形与5分钟复苏困难有明显的相关性(P均0.05)。5分钟复苏困难新生儿继续复苏后,20分钟复苏困难新生儿32例,与复苏顺利组新生儿98例比较,两组在1分钟Apgar评分0~3分、5分钟Apgar评分0~3分方面比较差异均有统计学意义(P均0.05)。1分钟窒息新生儿中的2例前置血管和8例胎儿水肿新生儿,在5分钟和20分钟仍复苏困难。结论窒息新生儿复苏影响因素较多,其中前置血管、胎儿水肿所致窒息复苏困难。     

Use of naloxone during neonatal resuscitation in Australia: compliance with published guidelines

AIMS: The aims of this study were to describe the use of naloxone during neonatal resuscitation in Australia, and to assess this against the published guidelines for use. METHODS: The states of Queensland, South Australia and the Australian Capital Territory record the administration of naloxone in their statutory state perinatal database collections, covering all deliveries within each state. Relevant information was extracted from these databases. In addition, we interrogated the perinatal database from a single tertiary perinatal centre in Western Australia and conducted a chart review of the 100 most recent infants identified as receiving naloxone. RESULTS: A total of 531 058 liveborn infants from 1994 through 2004 were assessed. The administration of naloxone fell from 4% to 1% of liveborn infants during this period. There was inconsistent compliance with published guidelines. Forty-two per cent of infants received naloxone without documentation of prior ventilatory support, 14% of infants received naloxone without prior administration of maternal narcotics and 80% of infants were not monitored following naloxone administration. The prevalent route of administration was intramuscular. CONCLUSIONS: Despite a steady decrease in the use of naloxone for neonatal resuscitation, there is a considerable lack of compliance with published guidelines for use. Given the scant evidence supporting naloxone use during neonatal resuscitation and increasing documentation of potential deleterious effects, perhaps it is time to remove naloxone from our resuscitaires.     

Use of oxygen for delivery room neonatal resuscitation in non-tertiary Australian and New Zealand hospitals: A survey of current practices, opinions and equipment

Background: Delivery room resuscitation of hypoxic newborn infants with pure or 100% oxygen causes oxidative toxicity and increases mortality. Current international resuscitation guidelines therefore recommend that oxygen be used judiciously. However, this requires staff education and special equipment that may not be available in non-tertiary maternity hospitals where the majority of births occur. Aim: To determine current attitudes, practices and available equipment for the use of air and blended oxygen for newborn delivery room resuscitation in non-tertiary maternity hospitals of Australia and New Zealand (ANZ). Methods: Structured questionnaires sent by mail and e-mail after personal phone contact. A total of 203 eligible hospitals in ANZ were identified. A second mailing was conducted a month later for non-responders. Responders: Final response rate was 64% (n= 130: 70% physicians, 30% midwives). The majority (121, 93%) of respondents were aware of Australian Resuscitation Council recommendations, but only one in five hospitals had the capacity to deliver blended oxygen and 38% used pulse oximeters at delivery. Only 24 (18.5%) hospitals had guidelines. Air would be used by 68 (57%) hospitals to resuscitate term infants compared to 35 (31%) for preterm infants. Most (111, 91%) advocated the use of blended oxygen despite the lack of facilities. Conclusion: Only one in five ANZ non-tertiary maternity hospitals had the capacity to resuscitate newborn infants with air or blended oxygen. Most are aware of current recommendations and agreed that the use of less oxygen would be beneficial for this purpose. Further study into the necessary infrastructure required to implement these guidelines are recommended.     

Summary of Japanese Neonatal Cardiopulmonary Resuscitation Guidelines 2015

The Japan Resuscitation Council joined the International Liaison Committee on Resuscitation (ILCOR) as a member of the Resuscitation Council of Asia in 2006. In 2007, the Japan Society of Perinatal and Neonatal Medicine (JSPNM), which is a member of an affiliated body, launched the Neonatal Cardiopulmonary Resuscitation (NCPR) program as an authorized project to ensure that all staff involved in perinatal and neonatal medicine can learn and practice neonatal cardiopulmonary resuscitation based on the Consensus on Science with Treatment Recommendations developed by ILCOR. The content of courses in the NCPR program is based on the NCPR guidelines. These guidelines are revised by the Japan Resuscitation Council according to the Consensus on Science with Treatment Recommendations, which is updated by ILCOR every 5 years. The latest updated edition in Japanese was published in 2016 and we translated these Japanese guidelines to English in 2018. Here, we introduce a summary of the NCPR guidelines 2015 in Japan. The NCPR 2015 algorithm has two flows, “lifesaving flow” and “stabilization of breathing flow” at the first branching point after the initial step of resuscitation.     

A randomized trial comparing oxygen delivery on intermittent positive pressure with nasal cannulae versus facial mask in neonatal primary resuscitation

AIM: To compare, in a prospective clinical trial, oxygen delivery on intermittent positive pressure with nasal cannulae versus facial mask in primary resuscitation of the newborn with moderate asphyxia. METHODS: 617 neonates with moderate asphyxia at birth were randomized: 303 were resuscitated by oxygen on intermittent positive pressure with nasal cannuale and 314 neonates by mask. Resuscitation followed the Neonatal Resuscitation Program guidelines of the American Academy of Pediatrics, 3rd edition. RESULTS: Resuscitation through the nasal route less frequently requires chest compressions and intubations (26 neonates needed chest compression and 20 needed intubation out of 314 resuscitated by mask; five neonates needed chest compression and two needed intubation out of 303 resuscitated by nasal cannulae). Apgar scores, admission rates to neonatal intensive care units, air-leak syndromes, birthweight, gestational age, use of prenatal steroids and deaths did not differ between groups. CONCLUSION: Oxygen delivery on intermittent positive pressure with nasal cannulae in primary resuscitation of the newborn with moderate asphyxia is a less aggressive and potentially advantageous alternative to the traditional oral route.     

Attitudes of neonatal clinicians towards resuscitation of the extremely premature infant: an exploratory survey

OBJECTIVE: This study aims to explore the current attitudes of Australian neonatologists and nurses towards the resuscitation of extremely preterm infants. METHODOLOGY: An anonymous questionnaire regarding resuscitation of infants of less than 28 weeks gestation was sent to all neonatologists and three registered nurses in each perinatal centre in Australia. RESULTS: One hundred and thirty-three questionnaires were sent. A return rate of 93% and 73% was obtained from neonatologists and nurses, respectively. Twenty-two per cent of neonatologists would 'occasionally' resuscitate at 22 weeks while none of the nurses would. A considerable proportion of neonatologists (23%) but only a few nurses (6%) would 'quite often' resuscitate 23-week infants. The majority of neonatologists (85%) and nurses (88%) would 'almost always' resuscitate 24 week infants. More than half of the respondents would 'occasionally' resuscitate a 400-499 g infant and most would resuscitate infants weighing more than 500 g. Clinicians were not as optimistic of long-term outcome as they were for survival. Typically, only 52% of neonatologists and 38% of nurses thought babies of 25 weeks gestation had a greater than 50% chance of survival without major handicap. Parental wishes and the presence of congenital abnormalities were major influences on decision to resuscitate. Hypothetically, most respondents, more doctors than nurses, would consider initiating resuscitation without parental consent at a median gestation of 25 weeks. CONCLUSIONS: The majority of Australian clinicians would resuscitate at a gestation of 24 weeks or greater or at a birth weight of over 500 g despite conservative estimates of intact survival. This survey has brought to light the importance of communication with parents prior to extreme premature birth.     

Neonatal resuscitation capacity in Nepal

Aim: Perinatal asphyxia is a major contributor to the nearly 4 million neonatal deaths worldwide each year in resource‐limited settings. Neonatal resuscitation, a proven method for preventing newborn deaths, is effective only when local caregivers have proper training and access to essential supplies. There are few published data describing neonatal resuscitation capacity in Nepal, where neonatal mortality rates are high. The goal of this study was to quantify neonatal resuscitation capacity at birthing sites in urban and rural Nepal. Methods: Seventeen birth centres ranging from tertiary care hospitals to rural health posts were evaluated. Assessments included standardised interviews of health‐care workers and evaluation of newborn resuscitation areas. The availability of essential resuscitation tools was recorded. Results: Eleven of the 17 health centres conducted deliveries on‐site. Of those, 45% had posted and visible resuscitation algorithms; 72% had infant warmers; 91% had mechanical suction machines; 36% had bulb suctions and 82% had bag‐mask ventilation devices available. Tertiary hospitals were much better equipped compared with smaller health centres. None of the health‐care workers who attended home deliveries had access to algorithms, warming devices, suction or bag‐mask ventilation devices. Conclusions: Availability of appropriate resuscitation supplies was variable in health centres providing delivery services on‐site and was severely deficient among health staff attending to home deliveries. Limited availability of resuscitation equipment may contribute to the high neonatal mortality rates seen in Nepal. Sustainable training programmes and distribution of neonatal resuscitation equipment are critical priorities in this region.     

Expiratory CO2 as the first sign of successful ventilation during neonatal resuscitation

Three‐lead electrocardiography and expired CO₂ monitoring were used during positive pressure ventilation of seven non‐intubated newborns (gestational age, 31–37 weeks; birthweight, 1503–2885 g). In all cases, adequate CO₂ (>15 mmHg) was detected prior to the achievement of stable heart rate (>100 beats/min). The delay between detection of adequate CO₂ and improvement of bradycardia ranged from 8 to 73 s (median, 15 s). Inadequate expired CO₂ during positive pressure ventilation indicates airway obstruction or poor aeration of the newborn lungs. Thus, positive expiratory CO₂ can be the first recognizable sign of successful ventilation during neonatal resuscitation.     

Retention of skills in neonatal resuscitation

OBJECTIVES:

To evaluate the impact of a neonatal resuscitation course on the theoretical knowledge and practical skills of birthing room personnel, and to evaluate the performance of skills at different times after the course.

DESIGN:

A program evaluation using a before and after cohort study.

SETTING:

Seven level II perinatal centres in the central-east region of Ontario.

PARTICIPANTS:

Seven hundred thirty-seven individuals (medical staff, nurses and respiratory technologists) who worked in birthing rooms.

INTERVENTION:

During an eight-month period, a course in neonatal resuscitation was presented at the perinatal centres. A cohort of 108 (15%) participants received testing before and after the course; the theoretical knowledge and practical performance of 62 of these participants were retested after six and 12 months.

RESULTS:

A significant improvement in both theoretical knowledge and practical skills was seen immediately after the course. Throughout the study, no difference was observed in the performance of nursing staff compared with that of medical staff, nor among the institutions involved. No significant difference in the decline of either theoretical knowledge or practical skills was seen among those who scored well in the original pre-test compared with those who scored poorly.

CONCLUSIONS:

Neonatal resuscitation should be an integral part of continuing education for all personnel involved in obstetrical care because it improves both tested knowledge and performance. Practical skills appear to decline faster than theoretical knowledge. Inservice instruction is required, at least, every six months.     

新生儿窒息新法复苏技术在基层的推广应用

目的推广新生儿窒息新法复苏技术，减少新生儿摩息死亡，降低新生儿死亡率。方法对全市围产医务人员开展新生儿窒息新法复苏技术培训，重点在实际操作技能训练；比较复苏技术推广前后3年新生儿窒息死亡和新生儿死亡率下降情况。结果推广应用新法复苏技术3年后，全市新生儿窒息死亡发生率由10．06％。下降至4．79％。，下降了52．39％；新生儿死亡率由25．31‰下降至13．77‰，下降了45．51％。结论注重学员实际操作能力训练的新法复苏技术在基层的推广应用及产儿合作，可有效地降低新生儿窒息死亡的发生，从而降低新生儿死亡率。     

Neonatal resuscitation training program in Malaysia: results of the first 2 years

OBJECTIVES: To determine the number of providers and instructors trained by the initial 37 core instructors during the first 2 years following the launch of the Malaysian Neonatal Resuscitation Program (NRP). To identify remediable problems which interfered with the propagation of the NRP in Malaysia. METHODOLOGY: A prospective observational study carried out over a 2-year period between 2 September 1996 to 2 September 1998. For every training course conducted, the instructors completed a NRP course report form (Form A) that documented the instructors involved in the course. For every participant who attended the course and successfully completed it, the instructors submitted a record form (Form B) that contained the name, hospital address, department, profession, place of work, language used for training and the marks obtained by the individual participant. After each course, completed forms A and B were returned to the NRP secretariat for compilation. RESULTS: Of the 37 core instructors, 35 (94.6%) carried out training courses in their respective home states. A further 513 new instructors and 2256 providers were trained subsequently. A total of 2806 health personnel from all 13 states of Malaysia were NRP-certified during the first 2 years. However, 61.2% (n = 335) of the 550 instructors were inactive trainers, having trained less than four personnel per instructor a year. Most of the NRP-certified personnel were either doctors (32.0%) or nursing staff (64.4%). More than 60% of these worked either in the labour rooms, neonatal intensive care units or special care nurseries. At least one person from all three university hospitals and all general hospitals, 89.3% (92/103) of the district hospitals, 3.5% (73/2090) of the maternal and child health services, and 21% (46/219) of the private hospitals and maternity homes, were trained in the NRP. CONCLUSION: Dissemination of the NRP in Malaysia during the first 2 years was very encouraging. Further efforts should be made to spread the program to private hospitals and the maternal and child health services. In view of the large number of inactive instructors, the criteria for future selection of instructors should be more stringent.     

垂体后叶素在新生儿心肺复苏中的应用

目的探讨垂体后叶素在新生儿心肺复苏中的应用价值。方法收集我院2007年至2011年急诊科、NICU收治的73例心跳呼吸骤停新生儿的临床资料。经常规新生儿复苏流程“ABC”急救后未复苏成功的新生儿分为肾上腺素组47例（对照组）及垂体后叶素联合肾上腺素组26例（治疗组）。结果治疗组患儿的初步复苏成功率（23．1％,6／26）与对照组（34．O％,16／47）比较差异无统计学意义（x。=0．956,P〉0．05）。结论在新生儿复苏中垂体后叶素联合肾上腺素与单独使用肾上腺素的疗效相似。     

Perinatal Physiology and Principles of Neonatal Resuscitation

Occasionally, deliveries occur in extramural settings or in the ED. These newborn infants are often brought to the emergency physician for initial stabilization. Rapid decision making based on periodic evaluation of heart rate, respiration, and color will determine need for and appropriate steps of resuscitation. Ventilation of the lungs is the key and improvement in heart rate is the best sign of successful neonatal resuscitation. Emergency physicians should be familiar with the principles and basics of neonatal resuscitation and maintain these skills with frequent mock codes.