New guidelines for newborn resuscitation

The new guidelines from the International Liaison Committee on Resuscitation and American Heart Association/American Academy of Pediatrics for newborn resuscitation underline that efficient ventilation is the key to a successful resuscitation of the newly born infant. Compared with the former guidelines published in 1999, the major changes are (i) less emphasis on using supplemental oxygen when initiating resuscitation, (ii) no need for routine intrapartum oropharyngeal and nasopharyngeal suctioning for vigorous infants born to mothers with meconium staining of amniotic fluid, (iii) occlusive wrapping of very low birth weight infants <28 weeks to reduce heat loss is recommended, (iv) preference for the intravenous versus endotracheal route for adrenaline and (v) more emphasis on parental autonomy at the threshold of viability. A number of gaps in newborn resuscitation have been identified and discussed. CONCLUSION: The new guidelines for newborn resuscitation are more evidence-based than previously ones. However, still there is a need for further research and modifications.     

Adaptación de las recomendaciones internacionales en estabilización y reanimación neonatal 2015

The International Liaison Committee on Resuscitation (ILCOR) recommendations provide a universal guide of measures to support the transition and resuscitation of newborn after their birth. This guide is expected to be adapted by local groups or committees on resuscitation, according to their own circumstances.The objective of this review is to analyse the main changes, to discuss several of the controversies that have appeared since 2010, and contrasting with other national and international organisations, such as European Resuscitation Council (ERC), American Heart Association (AHA), or the Australian-New Zealand Committee on Resuscitation (ANZCOR). Thus, the Neonatal Resuscitation Group of the Spanish Society of Neonatology (GRN-SENeo) aims to give clear answers to many of the questions when different options are available, generating the forthcoming recommendations of our country to support the transition and/or resuscitation of a newborn after birth, safely and effectively.     

Anticipation and preparation for every delivery room resuscitation

A majority of babies initiate spontaneous respirations shortly after birth. Up to 10%, however, require resuscitative measures to make the transition from fetus to newborn. Ideally, the need for resuscitation at birth would be predicted before delivery, and a skilled neonatal resuscitation team would be available and ready. This is not always possible. Therefore, neonatal resuscitation teams must be prepared to provide lifesaving resuscitation at every delivery. In this report, we examine risk factors for resuscitation at birth, discuss the importance of communication between obstetric and newborn teams, review key questions to ask before delivery, and investigate antenatal counseling methods. We also investigate ways to prepare for newborn deliveries, including personnel and equipment preparation, and pre-delivery team briefing. Finally, we explore ways in which neonatal resuscitation teams can improve their preparedness through the use of simulation and post-resuscitation debriefing. This report will help neonatal resuscitation teams to anticipate and prepare for every delivery room resuscitation.     

Pneumomediastinum in newborns induced by the Elder CPR/demand valve during resuscitation

Two term and one post-term newborn infants with pneumomediastinum associated with the use of an Elder CPR (cardiopulmonary resuscitation)/demand valve during resuscitation are described. Because of apnea or irregular gasping respiration after vaginal delivery, they received repetitive positive-pressure ventilation with this resuscitator, which is designed to provide 100% oxygen with a limited pressure of up to 40 cmH₂O. Following resuscitation, the infants had tachypnea and diminished breath sounds. Roentgenograms and computed tomography of the chest revealed pneumomediastinum in all three and cervical subcutaneous emphysema in one. They required 25–30% oxygen for 3–14 days until they recovered spontaneously. Thus, pressures as low as 40 cmH₂O can cause barotrauma, and the Elder resuscitator, even when functioning properly, may injure the lungs of newborn infants.     

Hyperoxia in the term newborn: more evidence is still needed for optimal oxygen therapy

It took more than 30 years from the first observations that oxygen may be toxic during resuscitation till international guidelines changed to recommend that term and near term newborn infants should be resuscitated with air instead of 100% oxygen. There are still a number of unanswered questions related to oxygen therapy of the newborn infant. The newborn brain, lungs and other organs are susceptible to oxygen injury, and newborns still develop injury caused by hyperoxia.     

Australian and New Zealand Committee on Resuscitation Neonatal Resuscitation guidelines 2016

New Australian and New Zealand Neonatal Resuscitation guidelines reflect recent advances in neonatal resuscitation science, as critically appraised by the International Liaison Committee on Resuscitation. Substantial changes since the 2010 guidelines include: (i) updates to the Newborn Resuscitation Flowchart to include a greater emphasis on maintaining normal body temperature, and to emphasise the importance of beginning assisted ventilation by 1 min in infants who have absent or ineffective spontaneous breathing; (ii) updates to the physiology of the normal perinatal transition that resuscitation is trying to restore; (iii) recommendations for more frequent reinforcement of training, and for structured feedback for resuscitation training instructors; (iv) new guidance in relation to the timing of cord clamping for preterm newborn infants; (v) recommendation to monitor body temperature on admission to newborn units as a resuscitation quality indicator; (vi) suggestion to consider electrocardiographic (ECG) monitoring (as an adjunct to oximetry) to obtain more rapid and accurate estimation of heart rate during resuscitation; (vii) removal of previous suggestions to intubate meconium‐exposed, non‐vigorous term infants to suction the trachea; and (viii) suggestion to establish vascular access to enable administration of intravenous adrenaline (epinephrine) as soon as chest compressions are deemed to be needed.     

Newborn resuscitation: from necessity of continous practice to professional liability

The immediately postbirth extra uterine adaptation is the most important cause of death in the first two hours of life. In all risky cases, it is necessary to effect efficient and on time techniques of newborn resuscitation, because dubitation or delay may be very dangerous for the infant. In Italy courses of equipment in newborn resuscitation are regularly performed, but an excellent level of technique can be obtained only with continuous daily practice. Then, particularly in little hospitals where it is unusually necessary to act resuscitation on a newborn, courses of simulation for medical and nursering staff would be opportune to prevent neonatal handicap and to deal with the professional liability in the best way. The Italian current jurisprudence, in fact, has slowly confined the application of 2236 article of Civil code about professional liability in particularly difficult efforts. The Italian law asserts that a professional specialist is trained to be able resolve any type of problem among those of his specialistic competence, even if technically very difficult. It should be opportune to train health staff with practical exercises, in order to obtain complete technical skills in all neonatal centers.     

A consideration of neonatal resuscitation

There are currently two major areas of resuscitation of the newborn which have come into question: the use of intermittent positive pressure ventilation and the use of oxygen. There is evolving evidence that volutrauma associated with IPPV, especially in the premature infant, may induce changes in the lung which can lead to chronic lung disease. There is reason to believe that the use of continuous positive airway pressure in premature infants who are making respiratory efforts may be less harmful than the use of IPPV. With regard to the use of oxygen, it is clear that most infants can be successfully resuscitated with room air. Although we can identify markers for oxidative stress in newborns when resuscitated with 100% oxygen, the clinical importance of these markers remain an open issue. If the presence of these markers after resuscitation is shown to relate to clinical problems, then the use of oxygen may need to be considered.     

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.     

Monitoring the resuscitation of preterm infants in the delivery room using pulse oximetry

The first few minutes after birth are a critical time of adaptation of the newborn infant to extrauterine life. The adequacy of that adaptation has been evaluated by means of the summed Apgar score. In preterm infants, Apgar score may correlate less with adequacy of cardiopulmonary function because of developmental immaturity. Measurement of arterial oxygen saturation by means of pulse oximetry offers a physiologic, real time method of monitoring the progress of cardiopulmonary adaptation by which the clinician can evaluate the need for and success of resuscitative efforts. Four preterm infants are reported in whom pulse oximetry was useful in assessing the changes in oxygen saturation during resuscitation.     

Versorgung und Reanimation des Neugeborenen

Based on a rigorous scientific appraisal by the International Liaison Committee on Resuscitation (ILCOR), the European Resuscitation Council (ERC) issued and published new treatment recommendations for resuscitation in October 2010. These guidelines incorporate new scientific insights where appropriate. In areas for which evidence-based data are still lacking since the 2005 guidelines, the recommendations remain the same. The most notable change for newborn resuscitation is certainly the recommendation to use 21% oxygen at the beginning of newborn life support. The most important and often only necessary step in successful newborn resuscitation is ensuring adequate ventilation. In addition to the medical content the guidelines emphasize the importance of implementing the recommendations in daily practice through regular training not only to apply algorithms but also non-technical skills such as teamwork and communication. This article summarizes the new guidelines for the care of newborns in a concise and practical fashion.     

Cerebral excitatory amino acids and Na+, K+-ATPase activity during resuscitation of severely hypoxic newborn piglets

We tested the hypothesis that early brain recovery in hypoxic newborn piglets is improved by resuscitating with an O₂ supply close to the minimum level required by the newborn piglet brain. Severely hypoxic 2-5-d-old anaesthetized piglets were randomly divided into three resuscitation groups: hypoxaemic (n = 8), 21% O₂ (n = 8), and 100% O₂ groups (n = 8). The hypoxaemic group was mechanically ventilated with 12-18% O₂ adjusted to achieve a cerebral venous O₂ saturation of 17-23% (baseline; 45±1%, mean±SEM). During the 2h resuscitation period, extracellular aspartate and glutamate concentrations in the cerebral striatum were higher during hypoxaemic resuscitation (p = 0.044 and p = 0.055, respectively) than during resuscitation with 21% O₂ or 100% O₂, suggesting an unfavourable accumulation of potent excitotoxins during hypoxaemic resuscitation. The cell membrane Na⁺,K⁺-ATPase activity of cerebral cortical tissue after 2 h resuscitation was similar in the three groups (p = 0.30). In conclusion, hypoxaemic resuscitation did not normalize early cerebral metabolic recovery as efficiently as resuscitation with 21% O2 or 100% O₂. Resuscitation with 21% O₂ was as efficient as resuscitation with 100% O₂ in this newborn piglet hypoxia model.     

新生儿窒息复苏首选纯氧还是空气的Meta分析

目的收集现有比较采用空气或者纯氧复苏窒息新生儿效果的临床文献,对其进行系统评价,试图寻找比较合理的新生儿复苏气源。方法检索在美国医学索引（MEDLINE）,荷兰医学文摘（EMBASE）,中国生物医学文摘（CBMA）及Cochrane图书馆（CL）上收录的自1966年1月至2005年6月,有关窒息新生儿复苏气源比较的文献,对符合纳入要求的文献进行系统评价,比较空气或者纯氧作为复苏气源在窒息新生儿病死率,缺氧缺血性脑病发生率,以及复苏失败率等方面内容。结果6篇文献符合纳入标准,共包括1940个窒息新生儿,其中采用空气复苏窒息新生儿988个,采用纯氧复苏窒息新生儿952个。对上述内容进行系统评价,得出采用空气复苏窒息新生儿病死率8．7％,与采用纯氧复苏窒息新生儿病死率13．4％比较,两者差异有显著统计学意义（P〈0．001）。OR为0．64,其95％可信区间（95％confidence interval,95％CI）为0．44-0．94。我们对其中5篇文献的窒息足月儿和窒息早产儿病死率进行分层系统评价,得出空气复苏窒息足月新生儿病死率5．9％,与纯氧复苏9．8％比较,两者差异有显著统计学意义（P〈0．001）,两者OR为0．59,其95％CI为0．40-0．87,在对窒息早产新生儿病死率的分析中也得到相似结果。空气或者纯氧复苏后窒息新生儿的其他情况如2-3度缺氧缺血性脑病（hypoxia ischemia encephalopathy,HIE）的发生率,复苏失败率等,两组比较差异无统计学意义（P〉0．05）。结论进行窒息新生儿复苏,空气和纯氧比,空气能降低窒息新生儿病死率,且不增加新生儿2-3度的HIE发生率和复苏失败率。但研究纳入文献的数量有限,对此结论的运用和推广仍应谨慎。     

Controversies in neonatal resuscitation

OBJECTIVE: To describe the main controversies surrounding newborn resuscitation procedures. SOURCES: Systematic review of articles from MEDLINE, LILACS and Cochrane Library, and of abstracts published in Pediatric Research, using the keywords resuscitation, asphyxia neonatorum, and newborn infant. SUMMARY OF THE FINDINGS: The effectiveness of hypothermia and ambient air ventilation has been under study. The reduction of barotrauma and volutrauma in the ventilation of preterm infants is still a challenge. The indication of endotracheal intubation in preterm infants based only on their extremely low weight is not a general agreement, except if the use of exogenous surfactant is required. There is still some uncertainty about the ideal dosage of intravenous or endotracheal adrenaline and the need of sodium bicarbonate, mainly in preterm infants. The ethical dilemma includes the decision on whether or not resuscitation should be used in circumstances related to gestational age, birth weight and severe congenital anomalies. CONCLUSIONS: Only the results obtained through animal experiments and randomized controlled clinical trials, with a follow-up of the development of newborn infants submitted to certain resuscitation procedures, will allow changing currently used therapies.     

The history of neonatal resuscitation

Attempts at human resuscitation date back to ancient times. Most strategies for resuscitation focused on adults until the early 1800s, when newborn resuscitation captured the interest of noted practitioners. The most promising techniques and strategies for neonatal resuscitation were developed during the latter part of the twentieth century. This article examines the key components of neonatal resuscitation and the discoveries that stimulated the development of current neonatal resuscitation practices.     

Gestational ageism

Published guidelines for resuscitation of extremely premature infants emphasize the importance of the gestational age of the infant. However, some ethicists and pediatricians have questioned these guidelines, suggesting that this may represent a form of discrimination. A policy of nonresuscitation of elderly patients older than a certain age would constitute a form of ageism and would likely be unacceptable to the broader community. Are resuscitation decisions for premature newborn infants analogous to resuscitation of elderly patients? Are current neonatal resuscitation guidelines discriminatory? This article looks at the relationship between discrimination based on gestational age and chronological age. There are 2 levels of gestational ageism and 2 separate strands of argument against gestational age guidelines. I conclude that resuscitation decisions for premature infants share many features with those for elderly patients, although there are also some relevant differences. I propose the use of gestational age equivalence as an alternative framework for practice.     

Clinical risk management in newborn and neonatal resuscitation

This chapter aims to provide an overview of aspects of risk management as they might be applied to the practice of resuscitation of the newborn using general principles of risk management and specific standards where they apply. Section 1 considers the matter of hazard and risk and how they may be classified. Figures are presented to provide a clinical perspective on resuscitation with a discussion on the hierarchy of clinical risks operating upon the baby. Section 2 centres on a discussion of those aspects that operate to modify the risks to the baby during a resuscitation, including environmental considerations (location, clinical setting and equipment); staffing issues (establishment, competency, induction and training) and logistics (process, communication and documentation). Section 3 debates the place of cord gases in the context of the diagnosis of perinatal hypoxaemia.     

Standards zur Versorgung von reifen Neugeborenen in ?sterreich

Immediately after birth, the majority of full-term infants merely require heat loss prevention. However, approximately 10% of all newborn infants require respiratory support during fetal to neonatal transition. About 1% of all newborn infants will need neonatal resuscitation including positive pressure ventilation, cardiac massage and drugs. Adequately trained staff and appropriate equipment needs to be available for these situations. Standards have not been defined as yet for the resuscitation of full-term neonates in Austria. Therefore, a consensus paper by the Working Group for Neonatology and Pediatric Intensive Care Medicine of the Austrian Society for Pediatrics and Adolescent Medicine describes the recommended standards for the resuscitation of full-term neonates. The goal is the definition of Austria-wide standards regarding training requirements for staff and recommendations regarding standard requirements for equipment.     

浙江省49家医院新生儿窒息复苏及培训现状调查

目的对浙江省三级和二级医院新生儿窒息复苏及人员培训情况进行基线调查。方法采用分层随机抽样法在浙江省11个地级市中每个地级市以抽签法抽取5所医院参与调查,其中地级市医院2所,县级医院3所。自制调查问卷,内容包括新生儿复苏开展情况,人员培训,产房、手术室复苏设备情况,新生儿出生窒息发生和死亡情况。 结果10/11个地级市49家医院纳入分析,其中三级医院23家（46.9％）,二级医院26家。①49家医院均有开展新生儿窒息复苏抢救的能力,三级医院均定期举办新生儿复苏培训。三级医院NICU病房配备率高于二级医院(87.0％ vs 34.6%,P=0.001 8)。②必备设备的配备：三级和二级医院产房和手术室在新生儿复苏气囊、辐射保温台、喉镜、气管导管和新生儿面罩的配备率均超过90%。高级设备的配备：三级医院产房和手术室血氧饱和仪配备率较高（72.7%）,脐静脉导管、喉管、T组合复苏器和空氧混合器的配备率均低于50%。③无论是三级还是二级医院,儿科医生院内和院外培训率均最高,麻醉师培训率最低。除儿科医生外的其他各类接产人员院内和院外培训率在三级和二级医院间差异均有统计学意义（P均<0.05）。④2004至2010年的年活产数在三级和二级医院中均呈逐年增加趋势。三级和二级医院新生儿年死亡率和出生窒息病死率均呈下降趋势,但总体上三级医院高于二级医院。二级医院重度窒息占出生窒息的比例总体上高于三级医院。 结论需加强各类接产人员复苏培训,提高复苏人员的复苏技能及理论水平,购置必备的复苏设备,进一步改善各级医院现有的复苏条件。     

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.