evidence based newborn resuscitation - university of · pdf fileresuscitation history...
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Evidence Based Newborn Resuscitation
David Burchfield, MDProfessor of Pediatrics
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Resuscitation History
But one day the woman’s son became sick and died...”Give him to me,” Elijah replied...and he stretched himself upon the child three times ...and the spirit of the child returned, and he became alive again.
1 Kings 17:17-24
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Resuscitation History
When Elisha arrived, the child was indeed dead, lying there upon the prophet’s bed...then he lay upon the child’s body, placing his mouth upon the child's mouth, and his eyes upon the child’s eyes, and his hands upon the child’s hands. And the child’s body began to grow warm again!
2 Kings 4:32-35
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Resuscitation History
“If the child does not breathe immediately upon Delivery, which sometimes it will not, especially when it has taken Air in the womb; wipe its Mouth, and press your Mouth to the Child’s, at the same time pinching the Nose with your Thumb and Finger, to prevent the Air escaping; inflate the lungs; rubbing it before the Fire; by which Method I have saved many.”
Benjamin Pugh, 1754
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Incidence for Neonatal Resuscitation
01020304050607080
<750 751-1000
1001-1500
1500-2000
2000-2500
>2500
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Prevalence of Neonatal Resuscitation
020406080100120140160
<750 751-1000
1001-1500
1501-2000
2001-2500
>2500
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Need for CPR in the Delivery Room
• 30,839 consecutive deliveries– 39 with CPR ± epinephrine (0.12%)– 1/3 with severe fetal acidemia– If no fetal acidemia, correction of ventilation
improved heart rate
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Neonatal Resuscitation Program (NRP)
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NRP--Has it done any good?
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Pathophysiology of Adult Cardiac Arrest
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Mechanisms of Cardiac Arrest in Neonates
Blood pressure trends upward during the asphyxial process
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Neurophysiology of Resuscitation
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Artificial Respiration Class 1930’s
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Ventilation in Neonatal Resuscitation
• 1950’s, investigators showed hypopharyngeal structures occluded airway, making chest compressions ineffective for ventilation--this was not the case with mouth to mouth
• 1958, the self-inflating bag introduced
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Physiological Impediments to Artificial Ventilation in the Newborn
Bag-Mask Ventilation
Airway Closure
Alveolar Opening Pressure
Establishment of FRC
Neural Reflexes
Lung Liquid Clearance
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Artificial Ventilation
Breathing
CardioaccelerationStretch Receptors
Oxygenation
Bradycardia
Trigeminal Reflex (pressure from face mask)
Apnea
Hering-Breuer (overinflation)
Effects of Artificial Ventilation on Resuscitation
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Airway Closure
Opens Larynx
Closes Larynx
Airflow
ECoG
CBF
Airway Pressure
Diaphram
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Alveolar Opening Pressure
• Spontaneously Breathing– Not present... that is,
some flow for any change in pressure
• Asphyxiated, BVM ventilated– 13-32 cm H2O in
asphyxiated neonates receiving PPV
Inspiratory pressure that must be overcome to begin delivering a tidal volume
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Establishment of FRC• Spontaneously
breathing– 1st few breaths are
exhaled against closed glottis, generating 71 cm H2O pressure
• Asphyxiated, BVM Ventilated– Difficult to mimic this
with BVM ventilation
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Lung Liquid Clearance• Spontaneously
breathing– Negative pressure
breathing rapidly clears lung liquid
• Asphyxiated, BVM Ventilated– Median pressure to
move chest during first 10 breaths is 40 cm H2O
• Pop-off valves set at 30-35 cm H2O
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Ventilation During Cardiac Arrest
0
10
20
30
40
pCO2
pCO2 before and during CPR
PrearrestDuring CPR
Angelos 1992
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Ventilation During Cardiac Arrest
010203040506070
Arterial Mixed Venous
pCO2 before and during CPR
BaselineCPR 2 minCPR 4 minCPR 8 minResus 2 min
Grundler 1986
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• 1891, Bonnaire first gave oxygen to a “blue baby” and concluded:“Whenever there is insufficient pulmonary haematosis, either from obstruction of the respiratory passages or from weak action of the mechanical apparatus of respiration, or from want of excitation of the respiratory nerve-centre, oxygen administration is indicated. Apparent death in the newborn is, therefore, the first indication…”
Oxygen in Newborn Resuscitation
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Advantages of 100% Oxygen
• Overcome diffusion barriers– lung liquid– lung disease
Normal Diffusion Barrier
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• Pulmonary Vasodilation
Advantages of 100% Oxygen
In-Utero Fluid Distention
Nitrogen Distention
Oxygen Distention
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Physiology of 100% Oxygen
Alveolar Gas Equation with FiO2 = 1.0 and pCO2 = 40
PAO2 = (713 x 1.0) - 40 = 673 torr
PAO2 = (713 x 0.21) - 40 = 110 torr
Alveolar Gas Equation with FiO2 = 0.21 and pCO2 = 40
Assume 0.45 aA gradient, pO2 = 50 torr
Assume 0.45 aA gradient, pO2 = 300 torr
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Physiology of 100% OxygenOxygen Content = (1.34 x Hb x O2 saturation) + 0.003 x pO2
For pO2 of 300 torr and Hb 17:
Oxygen Content = 22.8 + 0.9 = 23.7
For pO2 of 25 torr and Hb 17:
Oxygen Content = (1.34 x 17 x 0.63) + 0.003 x 25 14.3 + 0.1 = 14.4
45%
13%
For pO2 of 50 torr and Hb 17: Oxygen Content = 21.7 + 0.15 = 20.9
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Room Air vs 100% in Resuscitation of Lambs
Room Air100%
Baseline Hypopnea IMV 45 s 2 minn 3 minn
Vt
(mL/kg/min)
Hutchison, 1987
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Room Air100% Oxygen
Hypoxemia Reoxygenation Rootwelt et al, 1992
Blood Pressure During Resuscitation in Intact Animals
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Heart Rate During Resuscitation in Intact Animals
Hypoxemia ReoxygenationRootwelt et al, 1992
Room Air100% Oxygen
Hea
rt R
ate
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PEDIATRICS Vol. 102 No. 1 July 1998, p. e1
ELECTRONIC ARTICLE:Resuscitation of Asphyxiated Newborn InfantsWith Room Air or Oxygen: An InternationalControlled Trial: The Resair 2 Study
Ola Didrik Saugstad*, Terje Rootwelt*, and Odd Aalen
From the * Department of Pediatric Research, National Hospital, Oslo, Norway,and the Section of Medical Statistics, University of Oslo, Oslo, Norway.
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Resair 2 Study
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Resair 2 Study
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Resair 2 Study
*
*p<0.05
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Resair 2 Study
100%
RA
Proportion Not Breathing
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TABLE 3Number of Registered Infants With Adverse Outcome
Event RA O2
Death within 7 da 35/288 (12.2%) 48/321 (15.0%)Death within 28 da 40/288 (13.9%) 61/321 (19.0%)Death within 7 d
orHIE grade II or IIIa 61/288 (21.2%) 76/321 (23.7%)HIE grade II or IIIa 47/288 (16.3%) 55/321 (17.1%)
Resair 2 Study
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Room Air vs 100%
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Results of Trials
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Meta-analysis
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O2 Use in Premies
PEDIATRICS 128:Issue 2, 2011
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O2 Use in Premies
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Origin of Present Dosage of Epinephrine• Redding and Pearson originally used 1 mg
in dogs weighing approximately 10 kg– Equates to 0.1 mg/kg
• Adult recommendations are 0.5-1.0 mg, possibly based on the dose used by Redding– In a 70 kg patient, this would equate to
0.007-0.014 mg/kg.• Current dosage recommendation in
neonates is 0.01-0.03 mg/kg, probably extrapolated from adult dosing guidelines.
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ProblemIf the dose of epinephrine used by
Redding et al has merit, then the current recommendations may lead
to serious underdosing in adults and, by extrapolation, in children.
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“Optimum” Dose of Epinephrine
0
10
20
30
40
No Epi Epi
Diastolic BP (mmHg)
0.0150.030.0450.09
Epi dose (mg/kg)
Linder et al: Am J Emerg Med 1991; 9:27-31
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“Optimum” Dose of Epinephrine
-2
0
2
4
6
8
10
1 mg High dose
Coronary Perfusion Pressure(change from baseline mmHg)
1 min2 min3 min4 min5 min
Paradis et al; JAMA 1991
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“Optimal” Dose of Epinephrine
0
10
20
30
40
50
60
ROSC DC Home
Return of Spontaneous Circulation (percentage)
1 mg5 mg
Linder et al: 1991 Acta Anaesthesiol Scand
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“Optimal” Dose of Epinephrine
0
50
100
150
200
BP CO
Blood Pressure and Cardiac Output During Resuscitation with Epi
011050100
Burchfield et al Resuscitation 1993
dose, mg/kg
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Complications of Epinephrine in Neonatal Resuscitation
• Myocardial necrosis• Mechanical injury to the mitral valve.• Subendocardial hemorrhage• Pulmonary edema• Ischemic necrosis of the liver• Cortical hemorrhage in the kidney• Ischemic enterocolitis
Karch SB: Am J Forensic Med Path 1990
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Present Recommendations for Epinephrine Use
• Heart rate <60 beats per min despite 30 sec of CPR.
• Heart rate =0.– IV: 0.1-0.3 mL/kg of 1:10,0000 (0.01-0.03 mg/kg)
• Endotracheally, 1 mL/kg (max of 3 mL)• Repeat every 3-5 min
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Sodium Bicarbonate in Resuscitation
Graf et al, Science 227:745-756, 1985
Saline
No Treatment
HCO3
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CO2
CO2
CO2
CO2
CO2
HCO3-
Intracellular Space
HCO3-
Lung
HCO3-
CO2
arteryvein HCO3- CO2
HCO3-
H+ + HCO3- ↔H2CO3 ↔ H20 + CO2
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In-Utero Passage of Meconium
• Associated with fetal hypoxia– Intestinal ischemia followed by
hyperperistalsis (Van Liere, 1942)– Meconium and reduced umbilical
venous oxygen ( Walker, 1954) – Autopsy studies of fetal asphyxia
showing no meconium in intestine ( White, 1955)
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In-Utero Passage of Meconium
Normal Physiology
Usher, 1988
05
101520253035404550
39-40Weeks
41+ Weeks 42+ Weeks
% withMeconium
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Meconium Aspiration Epidemiology
1000Die
7800Mechanical Ventilation
26,000Develop MAS
520,000Meconium Stained
4,000,000Births per Year
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Suction on Perineum?
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Results
Lancet 2004, 364: 597-602
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Copyright ©2000 American Academy of Pediatrics
Wiswell, T. E. et al. Pediatrics 2000;105:1-7
Risks for MAS
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Copyright ©2000 American Academy of Pediatrics
Wiswell, T. E. et al. Pediatrics 2000;105:1-7
Risks for all respiratory distress, not MAS
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Wiswell, T. E. et al. Pediatrics2000;105:1-7
ET Suction of Meconium
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Discontinuation of Resuscitation
• After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life (noheart beat and no respiratory effort).
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Summary
• Newborn resuscitation has little direct evidence based practices
• NRP has been helpful in establishing guidelines “Everyone singing from the same sheet of music…”
• Because it is published in NRP does notmean that we should stop questioning and trying to improve