When should resuscitation at birth cease?

Duration of Resuscitation at Birth, Mortality, and Neurodevelopment: A Systematic Review

CONTEXT

The International Liaison Committee on Resuscitation Neonatal Life Support Task Force reviewed evidence for the duration of cardiopulmonary resuscitation (CPR) for newborns immediately after birth.

OBJECTIVE

To summarize evidence for ongoing CPR on the outcomes of survival, neurodevelopment, and the composite of survival without moderate or severe neurodevelopmental impairment (NDI).

DATA SOURCES

Medline, Embase, Evidence-Based Medicine Reviews, Cumulative Index to Nursing and Allied Health Literature, and Scientific Electronic Library Online were searched between inception and February 29, 2020.

STUDY SELECTION

Two independent reviewers selected studies of newborns with at least 10 minutes of asystole, bradycardia, or pulseless electrical activity for which CPR is indicated.

DATA EXTRACTION

Two independent reviewers extracted data and appraised the risk of bias.

RESULTS

In 16 eligible studies, researchers reported outcomes of 579 newborns born between 1982 and 2017. Within individual studies, 2% to 100% of infants survived to last follow-up (hospital discharge through 12 years). Summarized across studies, 237 of 579 (40.9%) newborns survived to last follow-up. In 13 studies, researchers reported neurodevelopmental outcomes of 277 newborns. Of these, 30 of 277 (10.8%) survived without moderate or severe impairment, and 240 of 277 (87%) met the composite outcome of death or NDI (191 died and 49 survived with moderate or severe impairment).

LIMITATIONS

There was very low certainty of evidence because of risk of bias and inconsistency.

CONCLUSIONS

Infants with ongoing CPR at 10 minutes after birth are at high risk for mortality and neurodisability, but survival without moderate or severe NDI is possible. One specified duration of CPR is unlikely to uniformly predict survival or survival without neuroimpairment.

Limitation of life-sustaining treatment in NICU: Physicians' beliefs and attitudes in the Buenos Aires region

OBJECTIVE

To explore the ethical beliefs and attitudes of Argentinean neonatologists regarding limitation of life-sustaining treatment (LST) for very sick infants.

METHODS

We used an anonymous questionnaire including direct questions and hypothetical clinical cases (inevitable demise and anticipated survival with severe long-term disability). Multivariable analysis was carried out to assess the relation between type of clinical case and physicians' LST attitudes.

RESULTS

Overall, 315 neonatologists in 34 units in the Buenos Aires region participated (response rate 54%). Most responders would agree with decisions to start or continue LST. In both clinical cases, continuing current treatment with no therapeutic escalation was the only form of LST limitation acceptable to a substantial proportion (about 60%) of neonatologists. Agreement with LST limitation was slightly but significantly more likely when death was inevitable.

CONCLUSION

Argentinean neonatologists showed a conservative attitude regarding LST limitation. Patient prognosis and options of non-treatment decision significantly influenced their choices.

Survival after delivery room cardiopulmonary resuscitation: A national registry study

AIMS

Survival after delivery room cardiopulmonary resuscitation (DR-CPR) is not well characterized in full-term infants, and survival outcomes after DR-CPR have not been defined across the spectrum of gestation. The study objectives were to define gestational age (GA) specific survival following DR-CPR and to assess the association between GA and DR-CPR characteristics and survival outcomes.

METHODS

Retrospective cohort study of prospectively collected data in the American Heart Association Get With the Guidelines-Resuscitation registry. Newborn infants without congenital abnormalities who received greater than 1 min of chest compressions for DR-CPR were included. GA was stratified by categorical subgroups: ≥36 weeks; 33-35^6/7 weeks; 29-32^6/7 weeks; 25-28^6/7 weeks; 22-24^6/7 weeks. The primary outcome was survival to hospital discharge; the secondary outcome was return of circulation (ROC).

RESULTS

Among 1022 infants who received DR-CPR, 83% experienced ROC and 64% survived to hospital discharge. GA-stratified hospital survival rates were 83% (≥36 weeks), 66% (33-35 weeks), 60% (29-32 weeks), 52% (25-28 weeks), and 25% (22-24 weeks). Compared with GA ≥ 36 weeks, lower GA was independently associated with decreasing odds of survival (33-35 weeks: adjusted Odds Ratio [aOR] 0.46, 95% Confidence Interval [CI] 0.26-0.81; 29-32 weeks: aOR 0.40, 95% CI 0.23-0.69; 25-28 weeks: aOR 0.21, 95% CI 0.11-0.41; 22-24 weeks: aOR 0.06, 95% CI 0.03-0.10).

CONCLUSIONS

In this national registry of infants who received delivery room cardiopulmonary resuscitation (DR-CPR), 83% survived the event and two-thirds survived to hospital discharge. These results contribute to defining survival outcomes following DR-CPR across the continuum of gestation.

Outcomes related to 10-min Apgar scores of zero in Japan

OBJECTIVE

Apgar scores of zero at 10 min strongly predict mortality and morbidity in infants. However, recent data reported improved outcomes among infants with Apgar scores of zero at 10 min. We aimed to review the mortality rate and neurodevelopmental outcomes of infants with Apgar scores of zero at 10 min in Japan.

DESIGN

Observational study.

PATIENTS

Twenty-eight of 768 infants registered in the Baby Cooling Registry of Japan between 2012 and 2016, at >34 weeks' gestation, with Apgar scores of zero at 10 min who were treated with therapeutic hypothermia.

INTERVENTIONS

We investigated the time of first heartbeat detection in infants with favourable outcomes and who had neurodevelopmental impairments or died.

MAIN OUTCOME MEASURES

Clinical characteristics, mortality rate and neurodevelopmental outcomes at 18-22 months of age were evaluated.

RESULTS

Nine (32%) of the 28 infants died before 18 months of age; 16 (57%) survived, but with severe disabilities and 3 (11%) survived without moderate-to-severe disabilities. At 20 min after birth, 14 of 27 infants (52%) did not have a first heartbeat, 13 of them died or had severe disabilities and one infant, who had the first heartbeat at 20 min, survived without disability.

CONCLUSION

Our study adds to the recent evidence that neurodevelopmental outcomes among infants with Apgar scores of zero at 10 min may not be uniformly poor. However, in our study, all infants with their first heartbeat after 20 min of age died or had severe disabilities.

When Helping Babies Breathe Is Not Enough: Designing a Novel, Mid-Level Neonatal Resuscitation Algorithm for Médecins Sans Frontières Field Teams Working in Low-Resource Hospital Settings

BACKGROUND

Neonatal resuscitation (NR) combines a set of life-saving interventions in order to stabilize compromised newborns at birth or when critically ill. Médecins Sans Frontières/Doctors Without Borders (MSF), as an international medical-humanitarian organization working particularly in low-resource settings (LRS), assisted over 250,000 births in obstetric and newborn care aid projects in 2016 and provides thousands of newborn resuscitations annually. The Helping Babies Breathe (HBB) program has been used as formal guidance for basic resuscitation since 2012. However, in some MSF projects with the capacity to provide more advanced NR interventions but a lack of adapted guidance, staff have felt prompted to create their own advanced algorithms, which runs counter to the organization's aim for standardized protocols in all aspects of its care.

OBJECTIVES

The aim is to close a significant gap in neonatal care provision in LRS by establishing consensus on a protocol that would guide MSF field teams in their practice of more advanced NR.

METHODS

An independent committee of international experts was formed and met regularly from June 2016 to agree on the content and design of a new NR algorithm.

RESULTS

Consensus was reached on a novel, mid-level NR algorithm in April 2017. The algorithm was accepted for use by MSF Operational Center Paris.

CONCLUSION

This paper contributes to the literature on decision-making in the development of cognitive aids. The authors also highlight how critical gaps in healthcare delivery in LRS can be addressed, even when there is limited evidence to guide the process.