Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Oxygen targets in critically ill patients: from pathophysiology to population enrichment strategies

Oxygen supplementation is widely used to enhance oxygen delivery and to treat or prevent hypoxia; however, it requires careful management to avoid the harmful effects of excessive oxygen exposure. Both hyperoxia (inspiratory oxygen fraction exceeding 0.21) and hyperoxemia (arterial oxygen tension oxygen partial pressure [PaO2] > 100 mmHg) can contribute to lung injury, promote systemic vasoconstriction, and increase the production of reactive oxygen species, which can impair macromolecular and cellular functions. Conversely, in certain situations, hyperoxemia may provide benefits, such as hemodynamic stabilization in hyperdynamic shock, immunomodulation, and bactericidal effects. The literature presents conflicting evidence regarding the impact of different oxygen targets (i.e., PaO2 and/or peripheral saturation of oxygen [SpO2]) on both short- and long-term outcomes in patients with acute critical conditions, such as acute respiratory distress syndrome, sepsis, cardiac arrest, and acute central nervous system injuries. These discrepancies may stem from the small differences between the oxygenation targets used in randomized trials, the physiological limitations of PaO2 and SpO2 targets, which reflect blood oxygen content rather than oxygen delivery, the lack of measurements of microvascular function or oxygen delivery, and the heterogeneity in treatment response. Furthermore, advanced analytical methods (e.g., machine learning) are emerging as promising tools to implement population enrichment strategies. By refining patient sub-group identification, these approaches can significantly optimize precision medicine, enabling more personalized oxygen therapy tailored to individual patient characteristics.

Epidemiology of Neonatal Prehospital Care at the San Diego (US) - Tijuana (Mexico) International Border

OBJECTIVES

Neonates, infants 30 days of age or younger are understudied in prehospital emergencies. Our objective was to describe prehospital assessment and care for patients <30 days of age at the San Diego-Tijuana Point of Entry (POE). Additional objectives included describing assessments, care, frequency, and level of care for newborns brought to the border by Mexican ambulances.

METHODS

This was a retrospective analysis from January 1, 2014, to January 01, 2020, of all 9-1-1 calls involving patients <30 days of age at the San Diego POEs. The 9-1-1 responses to newly delivered patients were "newborns". Patients who were not immediately post-delivery were "neonates." Patient demographics, response intervals, clinician interventions, and dispositional data were collected from electronic patient records. Descriptive statistics were applied.

RESULTS

A total of 57 patients <30 days of age were included. With 27 newborn patients, 15 were delivered by emergency medical services (EMS) personnel (27, 55.6%). Initial appearance, pulse, grimace, activity, and respiration (APGAR) scores were 8-10 in 44.4% and 5-7 in 29.6%. Procedures included newborn care (88.9%), advanced life support (ALS) assessment (63.0%), and warming (59.3%). There were five patients that had stimulation, 7 received oxygen, and 3 received Bag-Valve-Mask (BVM) ventilation. No serial heart rates were documented. Regarding 30 neonates, the predominant method of transport to the POE was Mexican ambulance (n 16, 53.3%). Medications administered included oxygen (n 16, 53.3%) and albuterol/ipratropium (n 1, 3.3%). Procedures included ALS assessment (n 19, 63.3%), pulse oximetry (n 22, 73.3%), and 3-lead electrocardiogram (n 8, 26.7%). Three patients (10%) received BVM. Mexican Ambulances brought 16 neonates. A physician or nurse was present in 37.5% of transfers, 50% were incubated, 25% intubated, 37.5% on supplemental oxygen, and 71% had preexisting intravenous access. These were not interfacility transfers but were 9-1-1 activations by U.S. border agents; and 14 neonates did not arrive via Mexican ambulance. Their complaints were respiratory distress (n 7, 50%) and Brief Resolved Unexplained Episode (n 4, 28.6%).

CONCLUSIONS

We found that 9-1-1 transports at the San Diego-Tijuana POE for patients <30 days were few and involved resuscitation, neonates in Mexican ambulances with specialized equipment, physicians, and unfamiliar medications. Neonates arriving via private transport had respiratory distress and BRUE.

Impact of a Two-Person Mask Ventilation Technique During Neonatal Resuscitation: A Simulation-Based Randomized Controlled Trial

OBJECTIVE

To assess whether the two-person ventilation technique during simulated neonatal resuscitation enables higher ventilation quality compared with the one-person technique, as measured by expiratory tidal volume (eVT), mask leak, positive inspiratory pressure, respiratory rate, and minute ventilation.

STUDY DESIGN

We conducted a randomized, cross-over simulation trial including 74 neonatal care providers at the Neonatal Simulation Center, Children's Hospital of Philadelphia. Participants performed bag-mask ventilation using one-person and two-person techniques in a randomized order. Ventilation parameters were recorded using a respiratory function monitor. Visual attention was analyzed using eye-tracking technology. The primary outcome was the time to achieve effective ventilation defined by eVT between 4-8 ml/kg and mask leak ≤30% for 10 consecutive seconds.

RESULTS

No participant achieved the primary ventilation target in either technique. The two-person technique showed higher eVT (9.7 mL/kg vs 8.4 mL/kg, absolute difference -1.3 mL/kg, 95% CI [-2.4, -0.1], P = .032) and a significant reduction in mask leak (48.9% vs 62.9%, absolute difference of 14.0%, 95% CI [6.4, 22.0], P < .001). Eye-tracking indicated differing visual attention patterns between techniques, with the two-person technique focusing more on the mask and bag (dwell time: 25% one-person vs 34% two-person, P = .13).

CONCLUSIONS

The two-person ventilation technique was associated with increased eVT and decreased mask leak during simulated neonatal resuscitation. Further research is needed to evaluate the impact of different ventilation devices and techniques in clinical settings.

CLINICAL TRIAL REGISTRATION

Since this was a simulation-based study, registration in a clinical trial registry was not required.

A comparative study of the use of extended reality simulation in neonatal resuscitation training

BACKGROUND

360° video and virtual reality (VR) simulation may offer innovative opportunities as portable simulation-based technologies to enhance Neonatal Resuscitation Program (NRP) training, updates, and refreshers. The purpose of this study was to compare the use of 360° video with VR simulation in NRP training and the effect on NRP learning outcomes.

METHODS

Thirty (N = 30) NRP providers were randomly assigned to either VR simulation or 360° video study groups (n = 15 each) with pre and posttests of confidence, posttests of user satisfaction, usefulness, presence, and simulator sickness, and a performance demonstration of positive pressure ventilation (PPV) on a manikin-simulator. Participants were then exposed to the other condition and again post-tested.

RESULTS

Both systems were positively viewed. However, participants reported significantly higher perceptions of usefulness in enhancing learning and increased sense of presence with the VR simulation. VR simulation participants gained more confidence in certain NRP skills, such as proper mask placement (adjusted p-value 0.038) and newborn response evaluation (adjusted p-value 0.017). A blinded assessment of PPV skills showed participants exposed to VR performed significantly better in providing effective PPV (adjusted p-value 0.005).

CONCLUSIONS

NRP providers found both systems useful; however, VR simulation was more helpful in improving learning performance and enhancing learning. Participants reported an increased feeling of presence and confidence in certain areas with VR and performed better on a crucial NRP skill, providing effective PPV. VR technologies may offer an alternative modality for increasing access to standardized and portable refresher learning opportunities on NRP.

Comparative effectiveness of self-learning and instructor-assisted pediatric cardiopulmonary resuscitation training: A prospective randomized study

BACKGROUND

Unlike that for adults, training for cardiopulmonary resuscitation of infant and child is scarce, and warrants efforts for greater accessibility. Effective self-learning could expand training accessibility and facilitate the development of effective infant and child cardiopulmonary resuscitation training methods.

AIM

This study was conducted to develop a pediatric cardiopulmonary resuscitation self-learning training program, implement nurse training, and evaluate training effectiveness by comparing trainees' achievement of self-efficacy in pediatric cardiopulmonary resuscitation, with or without instructor assistance.

DESIGN

Prospective randomized controlled study.

SETTINGS

General hospital.

PARTICIPANTS

Nurses working in a general hospital.

METHODS

Participants were randomly and sequentially assigned to either an instructor-assisted or a self-learning group and completed a pre-training survey, pediatric cardiopulmonary resuscitation training, post-training survey and test, and a 1-year follow-up test. Pediatric cardiopulmonary resuscitation training was divided into infant and child cardiopulmonary resuscitation training.

RESULTS

Among the 97 participants, instructor-assisted and self-learning groups trained in pediatric cardiopulmonary resuscitation showed no significant difference in correct chest compressions, ventilation performance, and self-efficacy at the post-training assessment. However compared to the pre-training assessment, these parameters increased significantly in both groups at the post-training assessment (self-efficacy: infant cardiopulmonary resuscitation: pre-training 15.48, post-training: 17.25 vs pre-training 19.74, post-training 20.05; child cardiopulmonary resuscitation: pre-training 15.78, post-training 17.90 vs pre-training 19.48, post-training 20.55; both p < 0.001), respectively. In the self-learning group, at the 1-year follow-up, the rate of correct infant resuscitation compression decreased significantly from 89 (immediate post-training score) to 76 (p = 0.07), without significant intergroup difference. Regarding the time of measurement, although the main effect was significant (p < 0.001), the interaction effect of instructor-assisted training and time of measurement on pediatric cardiopulmonary resuscitation self-efficacy was not.

CONCLUSION

Pediatric cardiopulmonary resuscitation training did not differ significantly with training modality and improved self-efficacy, which changed significantly over time. These results aid the design of effective self-learning training programs for pediatric cardiopulmonary resuscitation training.

Evaluating decision regret after extremely preterm birth

OBJECTIVES

Little is known about decision regret following extremely premature birth. We assessed decision regret in women who delivered an extremely premature infant, comparing decision regret scores based on resuscitation decision.

METHODS

Electronic survey assessment of decision regret using a validated tool included women who delivered at 22-25 completed weeks of gestation at two hospitals 2004-2019. Comparison of 'active care', 'comfort care' and 'other' groups was quantified and comments reviewed.

RESULTS

442 of 787 (56%) eligible women were contacted, 242 of 442 (55%) completed surveys, response rate 242 of 787 (31%). Women not contacted were younger (p=0.0001) and/or delivered in an earlier year (p=0.002). There was a higher percentage of white women who completed the survey (p=0.004). Decision regret was elevated in all groups, varied widely, but was lower in 'active care' compared with 'comfort care' (Decision Regret Score 14 vs 39, p<0.0001). Lower decision regret occurred in women who recalled a prenatal consult (p=0.014) or identified as the primary decision-maker compared with women who perceived the doctor had a major role (p=0.02) or made the decision (p<0.0001). Lower decision regret occurred in women whose infant was alive at survey completion compared with women whose infant died in the hospital (p<0.0001) or after discharge (p=0.01).

CONCLUSIONS

Decision regret was elevated in all groups. Women who recalled prenatal consultation, identified as the primary decision-maker, chose intensive care and/or whose infant survived had lower regret scores.

CLINICAL TRIAL REGISTRATION

NCT04074525.

Evaluating the efficacy of endotracheal and intranasal epinephrine administration in severely asphyxic bradycardic newborn lambs: a randomised preclinical study

OBJECTIVE

Intravenous epinephrine administration is preferred during neonatal resuscitation, but may not always be rapidly administered due to lack of equipment or trained staff. We aimed to compare the time to return of spontaneous circulation (ROSC) and post-ROSC haemodynamics between intravenous, endotracheal (ET) and intranasal (IN) epinephrine in severely asphyxic, bradycardic newborn lambs.

METHODS

After instrumentation, severe asphyxia (heart rate <60 bpm, blood pressure ~10 mm Hg) was induced by clamping the cord in near-term lambs. Resuscitation was initiated with ventilation followed by chest compressions. Lambs were randomly assigned to receive intravenous (0.02 mg/kg), ET (0.1 mg/kg) or IN (0.1 mg/kg) epinephrine. If ROSC was not achieved after three allocated treatment doses, rescue intravenous epinephrine was administered. After ROSC, lambs were ventilated for 60 min.

RESULTS

ROSC in response to allocated treatment occurred in 8/8 (100%) intravenous lambs, 4/7 (57%) ET lambs and 5/7 (71%) IN lambs. Mean (SD) time to ROSC was 173 (32) seconds in the intravenous group, 360 (211) seconds in the ET group and 401 (175) seconds in the IN group (p<0.05 intravenous vs IN). Blood pressure and cerebral oxygen delivery were highest in the intravenous group immediately post-ROSC (p<0.05), whereas the ET group sustained the highest blood pressure over the 60-min observation (p<0.05).

CONCLUSION

Our study supports neonatal resuscitation guidelines, highlighting intravenous administration as the most effective route for epinephrine. ET and IN epinephrine should only be considered when intravenous access is delayed or not feasible.

Chest Compression Superimposed with Sustained Inflation or 3:1 Compression/Ventilation Ratio During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: A Systematic Review and Meta-Analysis

Background: Current resuscitation guidelines recommend a 3:1 chest compression/ventilation (C:V) ratio, which is associated with high morbidity and mortality. An alternative might be continuous chest compression superimposed with high distending pressure or sustained inflation (CC + SI). Objective: To compare CC + SI with 3:1 C:V during neonatal cardiopulmonary resuscitation (CPR). Methods: MEDLINE (through PubMed), Google Scholar, EMBASE, and Clinical Trials.gov through June 2024. Randomized controlled trials comparing CC + SI with 3:1 C:V during neonatal CPR in the delivery room were included. Data Analysis included Risk of bias was assessed using the Covidence collaboration tool, and results were pooled into a meta-analysis using a fixed effects model. Main outcomes were In-hospital mortality (primary). Time to return of spontaneous circulation (ROSC) and air leak (secondary). Results: Two studies were included. The pooled data suggests no difference in infant mortality between CC + SI versus 3:1 C:V during neonatal CPR (RR 0.64, 95% CI 0.21,1.7, p = 0.33, I2 = 63%). The use of CC + SI during neonatal CPR could result in 182 fewer per 1000 (from 351 fewer to 311 more) infant deaths. The pooled data suggested a significant reduction in time to ROSC with CC + SI versus 3:1 C:V during neonatal CPR (mean difference 115 s (from 184.75 to 45.36 s), p = 0.001, I2 = 26%). Air leak was not different between groups. Conclusions: While in-hospital mortality and air leak were not different between groups, time to ROSC was significantly reduced. A large clinical trial is warranted to assess if CC + SI improves outcomes.

Addressing the gap in preterm resuscitation practices in high-income and low-middle income countries: a multicenter survey of the Asian neonatal network collaboration

Background

Optimum neonatal resuscitation practices are vital for improving neonatal survival and neurodevelopment outcomes, particularly in extremely preterm infants. However, such practices may vary between high-income countries (HICs) and low-middle-income countries (LMICs). This study aimed to evaluate the resuscitation practices of high-risk infants in a large multi-country sample of healthcare facilities among HICs and LMICs in Asia under the AsianNeo Network.

Methods

In 2021, a customized 6-item online survey on resuscitation practices of infants born at <29 weeks gestation (or birth weight <1,200 g) was sent by the representative of each country's neonatal network to all the Neonatal Intensive Care Units (NICUs) participating in AsianNeo network. At the time of the survey, there were 446 participating hospitals in eight countries: four high-income countries (Japan, Singapore, South Korea, and Taiwan) and four low-middle-income countries (Malaysia, Indonesia, Philippines, and Thailand).

Results

The study included 446 hospitals, with a response rate of 72.6% (ranging from 62.7% to 100%), with 179 (55.2%) in HICs and 145 (44.7%) in LMICs. Routine attendance of experienced NICU physicians during resuscitations is reported to be higher in HICs than LMICs, both during daytime (79% vs. 40%) and nighttime (62% vs. 23%). The NRP guidelines in each country were varied, with 4 out of 8 countries using indigenously developed guidelines. Equipment availability during resuscitation was also variable; saturation monitors, radiant warmers, and plastic wraps were available in almost all hospitals, whereas oxygen and air blenders, heated humidified gas, and end-tidal CO2 detectors were more available in HICs. The most common device for Positive Pressure Ventilation (PPV) was the T-piece resuscitator (52.3%).

Conclusion

The neonatal resuscitation practices for extremely preterm infants, encompassing staff, equipment, and guidelines, exhibited variance between HICs and LMICs in the AsianNeo region. Further enhancements are imperative to narrow this gap and optimize neonatal outcomes.

Supraglottic airway in neonatal porcine model

BACKGROUND

Positive pressure ventilation (PPV) in the delivery room is routinely performed using a face mask attached to a ventilation device. In 2023, the Consensus of Science and Treatment Recommendations for neonatal resuscitation stated that a supraglottic airway (SGA) can be used for PPV if resources and training permits. However, there is very limited data on tidal volume (VT) delivery using SGAs. We aimed to compare VT delivery using five ventilation devices (i.e., self-inflating bag (SIB)), T-Piece resuscitator, flow-inflating bag (FIB), NextStepTM, and Fabian ventilator with an SGA at two compliance levels using a neonatal piglet model.

DESIGN/METHODS

Randomized crossover experimental animal trial using 10 mixed-breed neonatal piglets (1-3 days; 1.8-2.4 kg). Piglets were anesthetized, SGA placed, instrumented, and randomized to PPV for one minute with SIB with or without a respiratory function monitor (RFM), T-Piece resuscitator ± RFM, FIB ± RFM, NextStepTM, and Fabian Ventilator at two compliance levels. Compliance changes were achieved by placing a wrap around the piglets' chest and tightening it. Our primary outcome was targeted VT delivery of 5 mL/kg at 0.5 and 1.5 mL/cmH2O lung compliance.

RESULTS

At 0.5 mL/cmH2O compliance, mean(SD) expired VT with the NextStepTM was 5.0(0.1)mL/kg compared to Fabian 5.1(0.2), SIB 6.3(1.8), SIB + RFM 5.3(0.8), T-Piece 5.9(1.5), T-Piece+RFM 5.5(0.6), FIB 7.7(1.8), FIB + RFM 8.5(2.9)mL/kg. At 1.5 mL/cmH2O compliance, mean(SD) expired VT with the NextStepTM was 5.1(0.2)mL/kg compared to Fabian 5.1(0.2),SIB 11.6(3.4), SIB + RFM 7.1(1.8), T-Piece 9.8(1.8), T-Piece+RFM 7.9(1.3), FIB 12.6(3.2), FIB + RFM 9.2(1.4)mL/kg.

CONCLUSION

The NextStepTM provides consistent VT during PPV with little variation despite compliance changes. Clinical studies are warranted.

IMPACT

Current guidelines recommend fixed peak inflation pressure in resuscitation, linked to lung and brain injury. The NextStepTM Neonatal Resuscitator, a cost-effective device, offers volume-targeted positive pressure ventilation with consistent tidal volumes delivery. With two different compliances, the NextStepTM Neonatal Resuscitator delivered a consistent tidal volume similar to a mechanical ventilator. The NextStepTM Neonatal Resuscitator outperformed self-inflating or flow-inflating bags and T-Piece resuscitators to deliver targeted tidal volumes. The NextStepTM Neonatal Resuscitator could be an alternative ventilation device for neonatal resuscitation.

NeoScore: a new tool to assess technical and non-technical skills during neonatal resuscitation

BACKGROUND

Training with high-technology manikins improves cardio-pulmonary resuscitation (CPR) skill retention, but a checklist to assess both technical and non-technical skills is lacking. This study aimed to develop a standardized checklist to evaluate healthcare's performance during simulated Neonatal Resuscitation Program (NRP) scenarios.

MATERIALS AND METHODS

Twenty-two international neonatal resuscitation experts participated in a two-step modified Delphi process, rating each checklist item on a scale of 1-5 and providing feedback. Items with a mean rating below 4 or receiving comments were reviewed. Inter-rater reliability (IRR) of the final tool was assessed using video-recordings of simulated scenarios.

RESULTS

The final checklist, validated by 15 experts, includes 33 items. Mean expert rating of all items was 4.35. The checklist showed moderate inter-rater reliability (ICC = 0.67) overall, with excellent reliability (ICC = 0.8) for technical skills.

CONCLUSION

The tool effectively evaluates technical skills but requires further refinement for non-technical skills assessment.

Reference Ranges for Cerebral Oxygenation in Neonates During Immediate Transition After Birth: Differences Between Devices

AIM

The aim was to define reference ranges for cerebral oxygen saturation (crSO2-ROOT) during immediate transition after birth in stable neonates.

METHODS

In a prospective observational study, the crSO2-ROOT was continuously measured in neonates during the first 15 min after birth. The neonatal sensor was placed on the head and fixed with a bandage. Median values and 10th and 90th centiles were calculated for each minute. Additionally, cerebral fractional tissue oxygen extraction (cFTOE-ROOT) was calculated using crSO2-ROOT and arterial oxygen saturation (SpO2) measured with pulse oximetry. These crSO-ROOT values were compared with already published reference ranges of cerebral oxygen saturation measured using different devices: crSO2-INVOS and cTOI-NIRO.

RESULTS

The data of 122 neonates (14 preterm/108 term neonates) were analysed. The crSO2-ROOT values had a similar course when compared to cTOI-NIRO values, whereas crSO2-INVOS values were initially lower and exceeded during the first minutes after birth.

CONCLUSION

The present observational study added reference ranges of crSO2-ROOT in stable neonates immediately after birth. As there are differences regarding reference ranges of various near-infrared spectroscopy (NIRS) devices, it is important to be aware of this information for future clinical use.

Oxygenation associated with cord management strategies among preterm infants <32 weeks gestation during the transition period

OBJECTIVE

Compare changes in SpO2 and FiO2 post-birth among preterm infants after delayed cord clamping (DCC), umbilical cord milking (UCM) or early cord clamping (ECC).

STUDY DESIGN

Retrospective study of infants <32 weeks gestation born between 2014 and 2021. ECC was clamping 0-59 s, DCC was clamping ≥60 s after delivery, UCM defined as milking the intact umbilical cord several times before clamping.

RESULTS

Of 463 infants; 257 received DCC, 168 received UCM, 38 received ECC. UCM infants had higher median SpO2 values at 4-(79% UCM vs 69% DCC, p = 0.027) and 5-(85% UCM vs 80% DCC, p = 0.023) minutes after-birth compared to DCC. DCC and UCM infants required lower FiO2 levels in the first 5-minutes compared to ECC infants (DCC 0.38 ± 0.17, UCM 0.40 ± 0.20 vs ECC 0.51 ± 0.27, p's <0.001).

CONCLUSION

The proportion of infants achieving SpO2 ≥ 80% by 5 min was similar in all groups, FiO2 needed to achieve this goal was higher in ECC infants.

An Improvement Project to Lower Pneumothorax Rates in Neonates Born at 36 Weeks' Gestational Age or Beyond

OBJECTIVE

Our institutional data revealed high pneumothorax rates in term neonates resuscitated in the delivery room (DR). Other studies have reported that high rates of continuous positive airway pressure (CPAP) in the DR are associated with increased pneumothorax rates. We sought to test the hypothesis that quality improvement efforts to reduce the use of CPAP in the DR would be associated with a reduced incidence of pneumothorax.

METHODS

We performed a series of interventions to make minor revisions to our DR respiratory care algorithm focusing on optimizing CPAP use by providing education to the DR team to the revisions. For neonates born at 36 weeks of gestation or beyond, we evaluated the use of CPAP in the DR and the number of births between pneumothorax events before and after the algorithm was implemented. We used statistical process control charts to assess improvement.

RESULTS

CPAP utilization in the DR for infants 36 weeks or older decreased from 3.4% to 1.0%. Frequency of pneumothorax decreased, with births between pneumothorax events increasing from 293 to 530. We found no increase in the number of neonates requiring a higher level of care with respiratory distress.

CONCLUSION

We found that a reduction in the use of CPAP in DR was associated with a decrease in the rate of pneumothorax without an increase in neonates requiring additional care with respiratory distress.

Effect of vasopressin on brain and cardiac tissue during neonatal cardiopulmonary resuscitation of asphyxiated post-transitional piglets

Background

Epinephrine is currently the only recommended cardio-resuscitative medication for use in neonatal cardiopulmonary resuscitation (CPR), as per consensus of science and treatment recommendations. An alternative medication, vasopressin, may be beneficial, however there is limited data regarding its effect on cardiac and brain tissue following recovery from neonatal CPR.

Aim

To compare the effects of vasopressin and epinephrine during resuscitation of asphyxiated post-transitional piglets on cardiac and brain tissue injury.

Methods

Newborn piglets (n = 10/group) were anesthetized, tracheotomized and intubated, instrumented, and exposed to hypoxia-asphyxia and cardiac arrest. Piglets were randomly allocated to receive intravenous vasopressin (Vaso, 0.4 U/kg) or epinephrine (Epi, 0.02 mg/kg) during CPR until return of spontaneous circulation (ROSC). Left ventricle cardiac tissue, and frontoparietal cerebral cortex and thalamus samples from brain tissue were collected from piglets that survived four hours after ROSC. The concentrations of the pro-inflammatory cytokines interleukin (IL)-1β, IL-6, IL-8, and tumour necrosis factor (TNF)-α, cardiac troponin-1, lactate, and levels of oxidized and total glutathione were quantified in tissue homogenates.

Main Results

The median time (IQR) to ROSC was 127 (98-162)sec with Vaso and 197 (117-480)sec with Epi (p = 0.07). ROSC rate was 10/10 (100 %) with Vaso and 7/10 (70 %) with Epi (p = 0.21); survival to four hours after ROSC was 10/10 (100 %) with Vaso and 5/7 (71 %) with Epi (p = 0.15). Kaplan-Meier survival curves were significantly different between groups (p = 0.011). Cardiac tissue IL-8 concentration was significantly lower with Vaso than Epi (16.9 (2.94)pg/mg vs. 33.0 (6.75)pg/mg, p = 0.026). All other markers of cardiac and brain tissue injury were similar between Vaso and Epi groups.

Conclusions

Vasopressin is effective in the resuscitation of asphyxiated newborn piglets and is associated with reduced inflammation of the myocardium compared to epinephrine, and there was no evidence of increased tissue injury in the frontoparietal cortex and thalamus regions of the brain. Vasopressin might be a viable alternative to epinephrine during neonatal CPR, but further studies are warranted.

Respiratory metrics of neonatal positive pressure ventilation on different ventilatory rates: A simulation study

Background

Effective ventilation is the core of neonatal resuscitation (NR). T-piece resuscitators (TPR) and self-inflating bags (SIB) are the two most widely utilized resuscitation devices. Nevertheless, limited information is available regarding the respiratory metrics during NR with these devices.

Objectives

This study aimed to evaluate the respiratory metrics at different ventilatory rates (VR) using a TPR or SIB during NR training.

Methods

An observational, simulation study was conducted during a NR training course. The participants were instructed to perform positive pressure ventilation at predetermined pressures and varying rates using TPR and SIB. They were subsequently grouped into three categories based on their actual VR: 20-40 breaths per minute (bpm) (SlowVR), 40-60 bpm (StdVR), and 60-80 bpm (FastVR). Respiratory metrics were recorded and analyzed using a neonatal active lung model (NALM).

Results

Of the 71 participants in the training course, data from 66 were validated by analyzing 198 ventilations. In general, the participants manipulated the TPR slightly slower than the SIB. Notably, the positive end-expiratory pressure (PEEP) detected via TPR in the NALM was substantially higher, whereas the tidal volume (Tv) and minute volume (MV) with TPR were significantly smaller than those with SIB (p < 0.05). A significant decrease in the peak alveolar pressure (palva) was observed with faster TPR ventilation (p < 0.001), whereas no such reduction was observed with SIB (p = 0.103). Additionally, faster VR correlated positively with higher PEEP levels for both TPR (F = 7.543, p = 0.002) and SIB (F = 7.720, p = 0.002) and inversely with smaller Tv for both TPR (F = 19.239, p < 0.001) and SIB (F = 14.937, p < 0.001). However, no significant differences in MV were observed across the different VR for either TPR or SIB (both p > 0.05).

Conclusions

Faster VR were inversely associated with smaller Tv but increased PEEP in both devices. Despite the guidelines of NR, VR exceeding 60 bpm with TPR might sometimes be used, was associated with excessive PEEP in TPR, which may not be a safe in clinical practice. The effect of varying VR on MV was relatively minor for both TPR and SIB.

Physiological versus time based cord clamping in very preterm infants (ABC3): a parallel-group, multicentre, randomised, controlled superiority trial

Background

Physiological-based cord clamping (PBCC) in preterm infants is beneficial for cardiovascular transition at birth and may optimize placental transfusion. Whether PBCC can improve clinical outcomes is unknown. The aim of the Aeration, Breathing, Clamping (ABC3) trial was to test whether PBCC results in improved intact survival in very preterm infants.

Methods

The ABC3 trial was a parallel-group, multicentre, randomised, controlled superiority clinical trial conducted in all Dutch tertiary referral centers for perinatal care involving infants born before 30 weeks of gestation. Infants were randomised to either PBCC or time-based delayed cord clamping (TBCC), stratified by gestational age and treatment center. Infants receiving PBCC were stabilised with umbilical cord intact, which was clamped after reaching cardiorespiratory stability (heart rate >100 bpm and SpO2 >85% while supplemental oxygen <40%). In TBCC the cord was clamped after 30-60 s. The primary outcome was survival without major cerebral injury and/or necrotizing enterocolitis. The primary and key secondary analyses were done in both the intention-to-treat and per-protocol populations. The trial was registered with ClinicalTrials.gov (NCT03808051).

Findings

From January 25, 2019, through October 2, 2022, 669 infants were randomised (median gestational age 27+5 weeks (IQR 26+2-28+6)) and included in the intention-to-treat population. Intact survival occurred in 241 of 339 infants (71.1%) after PBCC, compared with 223 of 330 (67.6%) after TBCC (odds ratio 1.18, 95% CI 0.84-1.66; absolute risk difference 3.1 %points, 95% CI -11.0 to 15.8, p = 0.33). Pre-specified subgroup analysis showed 69.9% intact survival in male infants after PBCC, compared with 61.8% after TBCC (odds ratio 2.32, 95% CI 1.42-3.78, p for interaction 0.026). Secondary outcomes showed fewer red blood cell transfusions after PBCC (rate ratio 0.83, 95% CI 0.75-0.92, p = 0.0003), lower incidence of late-onset sepsis (27.4% versus 33.3%, odds ratio 0.77, 95% CI 0.62-0.95, p = 0.013) and lower admission temperature (36.3 °C versus 36.7 °C, mean difference -0.5, 95% CI -0.8 to -0.3, p < 0.0001). Parents were less anxious (Likert scale 1.52 (SD 0.97) versus 2.23 (SD 1.35); p < 0.001) and more content (Likert scale 4.74 (SD 0.75) versus 4.49 (SD 0.97); p < 0.001) after PBCC.

Interpretation

PBCC in very preterm infants did not increase survival without major cerebral injury or necrotizing enterocolitis compared to TBCC in the entire cohort. A possible beneficial effect in male infants requires confirmation from other trials. PBCC was safe to perform and parents reported more contentment and less anxiety.

Funding

The Netherlands Organization for Health Research and Development.

Chest compressions superimposed with sustained inflation during neonatal cardiopulmonary resuscitation: are we ready for a clinical trial?

Neonates requiring cardiopulmonary resuscitation (CPR) are at risk of mortality and neurodevelopmental injury. Poor outcomes following the need for chest compressions (CCs) in the delivery room prompt the critical need for improvements in resuscitation strategies. This article explores a technique of CPR which involves CCs with sustained inflation (CC+SI). Unique features of CC+SI include (1) improved tidal volume delivery, (2) passive ventilation during compressions, (3) uninterrupted compressions and (4) improved stability of cerebral blood flow during resuscitation. CC+SI has been shown in animal studies to have improved time to return of spontaneous circulation and reduced mortality without significant increase in markers of inflammation and injury in the lung and brain, compared with standard CPR. The mechanics of CCs, rate of compressions, ventilation strategies and compression-to-ventilation ratios are detailed here. A large randomised controlled trial comparing CC+SI versus the current 3:1 compression-to-ventilation ratio is needed, given the growing evidence of its potential benefits.

Resuscitation With Placental Circulation Intact Compared With Cord Milking: A Randomized Clinical Trial

Importance

Among preterm newborns undergoing resuscitation, delayed cord clamping for 60 seconds is associated with reduced mortality compared with early clamping. However, the effects of longer durations of cord clamping with respiratory support are unknown.

Objective

To determine whether resuscitating preterm newborns while keeping the placental circulation intact and clamping the cord after a long delay would improve outcomes compared with umbilical cord milking.

Design, Setting, and Participants

This randomized clinical trial (PCI Trial) was conducted at 8 Italian neonatal intensive care units from April 2016 through February 2023 and enrolled preterm newborns born between 23 weeks 0 days and 29 weeks 6 days of gestation from singleton pregnancies.

Interventions

Enrolled newborns were randomly allocated to receive at-birth resuscitation with intact placental circulation for 180 seconds or umbilical cord milking followed by an early cord clamping (within 20 seconds of life).

Main Outcomes and Measures

The primary outcome was the composite end point of death, grade 3 to 4 intraventricular hemorrhage, and bronchopulmonary dysplasia at 36 weeks of postconception age. Prespecified secondary end points were the single components of the composite primary outcome. An intention-to-treat analysis was conducted.

Results

Of 212 mother-newborn dyads who were randomized, 209 (median [IQR] gestational age, 27 [26-28] weeks; median [IQR] birth weight, 900 [700-1070] g) were enrolled in the intention-to-treat population; 105 were randomized to the placental circulation intact group, and 104 were randomized to the cord milking group. The composite outcome of death, grade 3 to 4 intraventricular hemorrhage, or bronchopulmonary dysplasia occurred in 35 of 105 newborns (33%) in the placental circulation intact group vs 39 of 104 newborns (38%) in the cord milking group (odds ratio, 0.83; 95% CI, 0.47-1.47; P = .53).

Conclusions and Relevance

In a randomized clinical trial of preterm newborns at 23 to 29 weeks' gestational age, intact placental resuscitation for 3 minutes did not lower the composite outcome of death, grade 3 to 4 intraventricular hemorrhage, or bronchopulmonary dysplasia compared with umbilical cord milking.

Trial Registration

Clinicaltrials.gov Identifier: NCT02671305.

Beyond the delivery room: Resuscitation in the neonatal intensive care unit

Cardiopulmonary resuscitation is a critical component of neonatal care. While the basic principles of resuscitation are consistent across different settings, the specific challenges and resources available in the delivery room and the Neonatal Intensive Care Unit (NICU) vary significantly. Understanding the differences between these settings is essential for optimizing resuscitation outcomes. This article explores four key areas of difference-environment and equipment, team composition and roles, care protocols and practices, and patient population and condition-and how they impact neonatal resuscitation efforts. By examining these differences, healthcare neonatal care teams can better prepare for the specific resuscitation needs in each setting, ultimately improving neonatal survival and long-term health outcomes.

Pathological fetal heart rate tracing patterns and neonatal outcomes among parturients beyond 32 weeks of gestation: a prospective observational study

PURPOSE

Distinct clinical phenotypes of pathological fetal heart rate (FHR) tracings may affect neonatal outcomes differently. This study aimed to determine and differentiate neonatal outcomes amongst the clinical phenotypes of pathological FHR tracing.

METHODS

This prospective observational study included women in labour with pathological fetal heart rate tracing during delivery. Pathological fetal heart rate tracings were characterized into 11 clinical phenotypes and corresponding neonatal and maternal outcomes were recorded. Neonates and mothers were followed till discharge from the hospital. The primary outcome was a 5-min Apgar score. The secondary outcomes were NICU admission, mode of delivery, mode of anesthesia, neonatal morbidity and mortality.

RESULT

271 women with pathological fetal heart rate tracing at the time of delivery were included in the study. Most of the women (64%) underwent cesarean delivery. The most common pathological fetal heart rate tracing was repetitive late decelerations (24.7%), followed by reduced variability with repetitive variable decelerations (24.4%). The 5-min Apgar score was comparable across all clinical phenotypes of pathological fetal heart rate tracing. Tachycardia with reduced variability was associated with a significantly higher likelihood of NICU admission (aOR 5.03, 95% CI 1.32-19.27, p = 0.018). Reduced variability, repetitive late decelerations and the combination of repetitive late decelerations with prolonged decelerations and reduced variability showed moderately increased odds of NICU admission.

CONCLUSIONS

The 5-min Apgar score remained comparable in all clinical phenotypes of pathological fetal heart rate tracing. Nonetheless, the odds of NICU admission were significantly higher in women with tachycardia and reduced variability.

Post-resuscitation care in the NICU

Post-cardiac arrest syndrome is a unique pathophysiologic condition that is well-described in adult and pediatric populations. Early, goal-directed care after cardiac arrest can mitigate ongoing injury, improve clinical outcomes, and prevent re-arrest. There is a paucity of evidence about post-cardiac arrest care in the NICU, however, pediatric principles and guidelines can be applied in the NICU in the appropriate clinical context.

Advantages of a Data-Capture System with Video to Record Neonatal Resuscitation Interventions

OBJECTIVE

To assess the completeness and accuracy of neonatal resuscitation documentation the electronic medical record (EMR) compared with a data-capture system including video.

STUDY DESIGN

Retrospective observational study of 226 infants assessed for resuscitation at birth between April 2019 and October 2021 at Sharp Mary Birch Hospital, San Diego. Completeness was defined as the presence of documented resuscitative interventions in the EMR. We assessed the timing and frequency of interventions to determine the accuracy of the EMR documentation using video recordings as an objective record for comparison. Inaccuracy of EMR documentation was scored as missing (not documented), under-reported, or over-reported.

RESULTS

Overall, the completeness of resuscitation interventions documented in the EMR was high (85%-100%), but the accuracy of documentation varied between 39% and 100% Modes of respiratory support were accurately captured in 96%-100% of the EMRs. Time to successful intubation (39%) and maximum fraction of inspired oxygen (47%) were the least accurately documented interventions in the EMR. Under-reporting of interventions with several events (eg, number of positive pressure ventilation events and intubation attempts) were also common errors in the EMR.

CONCLUSIONS

The self-reported modes of respiratory support were accurately documented in the EMR, whereas the timing of interventions was inaccurate when compared with video recordings. The use of a video-capture system in the delivery room provided a more objective record of the timing of specific interventions during neonatal resuscitations.

Oxygen saturation targets in neonatal care: A narrative review

Optimal oxygenation requires the delivery of oxygen to meet tissue metabolic demands while minimizing hypoxic pulmonary vasoconstriction and oxygen toxicity. Oxygen saturation by pulse oximetry (SpO2) is a continuous, non-invasive method for monitoring oxygenation. The optimal SpO2 target varies during pregnancy and neonatal period. Maternal SpO2 should ideally be ≥95 % to ensure adequate fetal oxygenation. Term neonates can be resuscitated with an initial oxygen concentration of 21 %, while moderately preterm infants require 21-30 %. Extremely preterm infants may need higher FiO2, followed by titration to desired SpO2 targets. During the NICU course, extremely preterm infants managed with an 85-89 % SpO2 target compared to 90-94 % are associated with a reduced incidence of severe retinopathy of prematurity (ROP) requiring treatment, but with higher mortality. During the later stages of ROP progression, studies suggest that higher SpO2 targets may help limit progression. A target SpO2 of 90-95 % is generally reasonable for term infants with respiratory disease or pulmonary hypertension, with few exceptions such as severe acidosis, therapeutic hypothermia, and possibly dark skin pigmentation, where 93-98 % may be preferred. Infants with cyanotic heart disease and single-ventricle physiology have lower SpO2 targets to avoid pulmonary over-circulation. In low- and middle-income countries (LMICs), the scarcity of oxygen blenders and continuous monitoring may pose a challenge, increasing the risks of both hypoxia and hyperoxia, which can lead to mortality and ROP, respectively. Strategies to mitigate hyperoxia among preterm infants in LMICs are urgently needed to reduce the incidence of ROP.

Effectiveness of Neonatal Resuscitation Training Programs, Implementation, and Scale-Up in Low- and Middle-Income Countries

INTRODUCTION

To describe recent evidence regarding the most effective neonatal resuscitation training program and scale-up of these programs in low- and middle-income countries (LMICs), which has contributed to the upcoming Lancet Global Newborn Care Series 2025, and forms part of a supplement describing an extensive synthesis on effective newborn interventions in LMICs.

METHODS

We included relevant studies from Medline, Embase, CINAHL, Cochrane CENTRAL and Global Index Medicus databases on the effectiveness and scale-up of Neonatal Resuscitation Training Programs (NRTP), with searches run August 2022. Data extraction and quality assessments were completed independently and in duplicate.

RESULTS

A total of 93 unique records met the eligibility criteria and were included in our analyses across the reviews. NRTPs improved most knowledge and skill-based outcomes but impact on mortality varied. Included studies identified knowledge and skill retention, standardized training protocols, and limited training opportunities for health care providers as challenges to current NRTPs.

CONCLUSION

Reported knowledge, skills, and mortality outcomes were similar across NRTPs. The Helping Babies Breathe (HBB) program was found to be cost-effective in Tanzania, suggesting that the HBB program or elements thereof are low-cost and scalable in LMICs. Future research across diverse settings should evaluate the cost-effectiveness of other NRTPs. To scale-up current NRTPs, programs should focus on improving long-term retention outcomes and improving training material accessibility.

INTRODUCTION

To describe recent evidence regarding the most effective neonatal resuscitation training program and scale-up of these programs in low- and middle-income countries (LMICs), which has contributed to the upcoming Lancet Global Newborn Care Series 2025, and forms part of a supplement describing an extensive synthesis on effective newborn interventions in LMICs.

METHODS

We included relevant studies from Medline, Embase, CINAHL, Cochrane CENTRAL and Global Index Medicus databases on the effectiveness and scale-up of Neonatal Resuscitation Training Programs (NRTP), with searches run August 2022. Data extraction and quality assessments were completed independently and in duplicate.

RESULTS

A total of 93 unique records met the eligibility criteria and were included in our analyses across the reviews. NRTPs improved most knowledge and skill-based outcomes but impact on mortality varied. Included studies identified knowledge and skill retention, standardized training protocols, and limited training opportunities for health care providers as challenges to current NRTPs.

CONCLUSION

Reported knowledge, skills, and mortality outcomes were similar across NRTPs. The Helping Babies Breathe (HBB) program was found to be cost-effective in Tanzania, suggesting that the HBB program or elements thereof are low-cost and scalable in LMICs. Future research across diverse settings should evaluate the cost-effectiveness of other NRTPs. To scale-up current NRTPs, programs should focus on improving long-term retention outcomes and improving training material accessibility.

2024 Systematic Review of Evidence-Based Guidelines for Prehospital Care

OBJECTIVES

Evidence-based guidelines (EBGs) are widely recognized as valuable tools to aggregate and translate scientific knowledge into clinical care. High-quality EBGs can also serve as important components of dissemination and implementation efforts focused on educating emergency medical services (EMS) clinicians about current evidence-based prehospital clinical care practices and operations. We aimed to perform the third biennial systematic review of prehospital EBGs to identify and assess the quality of prehospital EBGs published since 2021.

METHODS

We systematically searched Ovid Medline and EMBASE from January 1, 2021, to June 6, 2023, for publications relevant to prehospital care, based on an organized review of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised using the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool.

RESULTS

We identified 33 new guidelines addressing clinical and operational topics of EMS medicine. The most addressed EMS core content areas were time-life critical conditions (n = 17, 51.5%), special clinical considerations (n = 15, 45%), and injury (n = 12, 36%). Seven (21%) guidelines included all elements of the National Academy of Medicine (NAM) criteria for high-quality guidelines, including the full reporting of a systematic review of the evidence. Guideline appraisals by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool demonstrated modest compliance to reporting recommendations and similar overall quality compared to previously identified guidelines (mean overall domain score 67%, SD 12%), with Domain 5 ("Applicability") scoring the lowest of the six AGREE II domains (mean score of 53%, SD 13%).

CONCLUSIONS

This updated systematic review identified and appraised recent guidelines addressing prehospital care and identifies important targets for education of EMS personnel. Continued opportunities exist for prehospital guideline developers to include comprehensive evidence-based reporting into guideline development to facilitate widespread implementation of high-quality EBGs in EMS systems and incorporate the best available scientific evidence into initial education and continued competency activities.

Pathophysiology and Prevention of Manual-Ventilation-Induced Lung Injury (MVILI)

Manual ventilation, most commonly with a bag-valve mask, is a form of short-term ventilation used during resuscitative efforts in emergent and out-of-hospital scenarios. However, compared to mechanical ventilation, manual ventilation is an operator-dependent skill that is less well controlled and is highly subject to providing inappropriate ventilation to the patient. This article first reviews recent manual ventilation guidelines set forth by the American Heart Association and European Resuscitation Council for providing appropriate manual ventilation parameters (e.g., tidal volume and respiratory rate) in different patient populations in the setting of cardiopulmonary resuscitation. There is then a brief review of clinical and manikin-based studies that demonstrate healthcare providers routinely hyperventilate patients during manual ventilation, particularly in emergent scenarios. A discussion of the possible mechanisms of injury that can occur during inappropriate manual hyperventilation follows, including adverse hemodynamic alterations and lung injury such as acute barotrauma, gastric regurgitation and aspiration, and the possibility of a subacute, inflammatory-driven lung injury. Together, these injurious processes are described as manual-ventilation-induced lung injury (MVILI). This review concludes with a discussion that highlights recent progress in techniques and technologies for minimizing manual hyperventilation and MVILI, with a particular emphasis on tidal-volume feedback devices.

Cardiopulmonary resuscitation with 3:1 Compression:Ventilation or continuous compression with asynchronized ventilation in infantile piglets

BACKGROUND

To compare neonatal and pediatric resuscitation approaches to ventilation and chest compression by using either continuous chest compression with asynchronized ventilation (CCaV) or 3:1 Compression:Ventilation ration (3:1 C:V) during infant cardiopulmonary resuscitation. We hypothesized that 3:1 C:V compared to CCaV will reduce time to return of spontaneous circulation (ROSC) in infantile piglets with asphyxia-induced bradycardic cardiac arrest.

METHODS

Twenty infantile piglets (5-10 days old) were anesthetized and asphyxiated by clamping the endotracheal tube. Piglets were randomized to 3:1 C:V or CCaV for resuscitation (n = 10/group). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.

RESULTS

The median time (IQR) to ROSC among survivors was 157 (113-219) vs 421 (118-660) for 3:1 C:V and CCaV, respectively (p = 0.253). The duration of resuscitation with 3:1 C:V compared to CCaV was 206 (119-660) vs 660 (212-660)sec, respectively (p = 0.171). The number of piglets achieving ROSC with 3:1 C:V and CCaV were 7/10 and 6/10, respectively (p = 1.00). There was no difference in hemodynamic and respiratory parameters between groups.

CONCLUSIONS

Time to ROSC and survival was not different between 3:1 C:V and CCaV in infantile piglets. Either approach appears reasonable during infantile cardiopulmonary resuscitation.

IMPACT

Similar time to return of spontaneous circulation and survival with 3:1 C:V and CCaV in infant piglets equivalent to 28-day-old children. Either approach appears reasonable during infantile cardiopulmonary resuscitation. Lack of scientific data to provide recommendations on when to switch between neonatal to pediatric resuscitation guidelines. No difference in time to return of spontaneous circulation or survival between 3:1 C:V and CCaV in infantile piglets with asphyxia-induced bradycardic cardiac arrest. Both methods are viable options during infant cardiopulmonary resuscitation.

Umbilical cord management in newborn resuscitation: a systematic review and meta-analysis

BACKGROUND

Evidence supporting the benefits of delayed cord clamping is increasing; however, there is no clear recommendation on cord management during newborn resuscitation. This study aimed to investigate the effects of resuscitation initiated with an intact umbilical cord, hypothesizing it is a safe stabilization procedure that improves neonatal outcomes.

METHODS

Systematic search was conducted in MEDLINE, Embase, CENTRAL, and Web of Science from inception to March 1, 2024. Eligible articles compared neonatal outcomes in newborns receiving initial stabilization steps before and after cord clamping.

RESULTS

Twelve studies met our inclusion criteria, with six RCTs included in the quantitative analysis. No statistically significant differences were found in delivery room parameters, in-hospital mortality, or neonatal outcomes between the examined groups. However, intact cord resuscitation group showed higher SpO2 at 5 min after birth compared to cord clamping prior to resuscitation group (MD 6.67%, 95% CI [-1.16%, 14.50%]). There were no significant differences in early complications of prematurity (NEC ≥ stage 2: RR 2.05, 95% CI [0.34, 12.30], IVH: RR 1.25, 95% CI [0.77, 2.00]).

CONCLUSION

Intact cord management during resuscitation appears to be a safe intervention; its effect on early complications of prematurity remains unclear. Further high-quality RCTs with larger patient numbers are urgently needed.

IMPACT

Initiating resuscitation with an intact umbilical cord appears to be a safe intervention for newborns. No statistically significant differences were found in delivery room parameters, in-hospital mortality, and neonatal outcomes between the examined groups. The utilization of specialized resuscitation trolleys appears to be promising to reduce the risk of intraventricular hemorrhage in preterm infants. Further high-quality RCTs with larger sample sizes are urgently needed to refine recommendations.

Clinical Issues - September 2024

Selecting nonsterile sharps disposal containers Key words: sharps safety, Occupational Safety and Health Administration (OSHA), bloodborne pathogens, occupational exposure, disposal container. Life support certification requirements for perioperative RNs Key words: basic life support, advanced cardiac life support (ACLS), cardiopulmonary resuscitation, certification, training. Using crisis checklists in the perioperative environment Key words: emergency manuals, cognitive aids, clinical emergencies, crew resource management, crisis checklist. Walking patients to the OR Key words: fall prevention, fall risk, mobility assessment, safe patient handling and mobility (SPHM), ambulate.

Cerebral fractional tissue oxygen extraction (cFTOE) during immediate fetal-to-neonatal transition: a systematic qualitative review of the literature

Cerebral monitoring during immediate fetal-to-neonatal transition is of increasing interest. The cerebral fractional tissue oxygen extraction (cFTOE) is a useful parameter to gain insight in the balance between tissue oxygen delivery and consumption during this complex process. The aim of this study was to review the literature on cFTOE during the first 15 min immediately after birth. A systematic qualitative literature research was last performed on 23 November 2023 of PubMed and EMBASE with the following search terms: neonate, infant, newborn, transition, after birth, delivery room, NIRS, near-infrared spectroscopy, spectroscopy, cFTOE, cerebral fractional tissue oxygenation extraction, cerebral oxygenation, and fractional oxygen extraction. Additional published reports were identified through a manual search of references in retrieved articles and in review articles. The methodological quality of the included studies was assessed by predefined quality criteria. Only human studies with data of cFTOE in the first 15 min after birth were included. Accordingly, exclusion criteria were defined as no measurement of cFTOE or no measurement within the first 15 min after birth. Across all studies, a total of 3566 infants (2423 term, 1143 preterm infants) were analysed. Twenty-five studies were identified describing cFTOE within the first 15 min after birth. Four studies established reference ranges for cFTOE and another four studies focused on the effect of pre-/perinatal circumstances on cFTOE in the first 15 min after birth. Six studies investigated the course of cFTOE after transition in infants without complications. Eleven studies analysed different potentially influencing parameters on cFTOE during transition.

CONCLUSION

This systematic review provides a comprehensive insight on cFTOE during uncomplicated transition as well as the influence of perinatal circumstances, respiratory, haemodynamic, neurological, and laboratory parameters in preterm and term infants.

WHAT IS KNOWN

• The NIRS-measured cerebral fractional tissue oxygen extraction (cFTOE) is a useful parameter to estimate the balance between oxygen delivery and consumption. • During normal transition, the cFTOE decreases in the first minutes after birth and then remains at a stable plateau.

WHAT IS NEW

• The cFTOE is a promising parameter that gives additional information on cerebral oxygenation and perfusion in preterm and term infants. • Several hemodynamic, metabolic, respiratory, and perinatal factors are identified, influencing the oxygen extraction of the newborn's brain after birth.

Using Virtual Reality-Based Simulation in Neonatal Resuscitation Program Training

In this article, we investigate the incorporation of virtual reality (VR) into Neonatal Resuscitation Program (NRP) training. We describe the potential advantages and challenges of the use of VR with NRP. We compare conventional training approaches to VR-based simulation, reviewing diverse VR platforms and their specific roles in neonatal resuscitation education. In addition, technological and ethical aspects in medical training, current research, and prospective developments in this innovative educational tool are discussed.

Outcomes after delivery room positive pressure ventilation in late preterm and term infants

Objectives

Characterize short-term outcomes of late preterm and term infants who received positive pressure ventilation in the delivery room and compare these with infants who did not receive resuscitation at birth.

Study Design

Single center retrospective cohort study of infants born between 35 0/7 and 41 6/7 weeks' gestation in 2019. Baseline characteristics and outcomes of infants who received positive pressure ventilation were compared with controls who did not receive delivery room ventilation. The primary outcome was neonatal intensive care unit admission; secondary outcomes included multiple hospital morbidities and interventions.

Results

Among 202 infants who received delivery room positive pressure ventilation, 77 (38.1%) received ≤1 min, and 125 (61.9%) received >1 min of positive pressure ventilation. Neonatal intensive care unit admission directly following resuscitation was more common in the ventilation cohort (33%) compared with controls (1.5%), p ≤ 0.0001. After initial admission to the newborn nursery, intensive care unit transfer rates were similar in the positive pressure ventilation cohort (4%) and controls (5%). Antibiotic exposure, hypoxic ischemic encephalopathy, respiratory support in the neonatal intensive care unit, and pneumothorax were more common in the ventilation cohort. The composite outcome of any post-delivery complication occurred in 45% of positive pressure ventilation-exposed infants, compared to 15.8% of control infants (<0.0001); this was more common following >1 min (52.8%) than ≤1 min positive pressure ventilation (32.5%), p = 0.002.

Conclusion

Post-delivery complications are common following delivery room positive pressure ventilation, emphasizing the need for post-resuscitation monitoring in either the neonatal intensive care unitor newborn nursery setting.

Does ECG monitoring affect resuscitation for neonates with pulseless electrical activity in the delivery room? A simulated, pilot, crossover randomised trial

OBJECTIVE

To evaluate whether ECG monitoring impacts resuscitative steps during simulated neonatal resuscitation in the setting of pulseless electrical activity (PEA) in the delivery room.

DESIGN

This pilot, crossover randomised controlled trial recruited providers in teams of three who participated in two simulation scenarios (PEA with and without ECG monitoring). Teams were randomised to one scenario and then crossed over. All sessions were video-recorded. The primary outcome was time to pulse check once the manikin was programmed to become pulseless. The secondary outcomes were total pulse checks, time to positive pressure ventilation, intubation, chest compressions and administration of epinephrine, and teams' quotes and behaviours during resuscitation. The primary outcome was analysed using Kaplan-Meier survival curve. The secondary outcomes were compared with Wilcoxon signed-rank test. The quotes were analysed using content analysis with pattern coding.

RESULTS

Eighty-two healthcare providers were approached and 30 consented (10 teams). The mean time to check the pulse once the manikin was pulseless was 38.5 s (SD 30.1) without ECG vs 88.1 s (SD 46.1) with ECG (p<0.01). There was a significantly decreased number of pulse checks with the ECG compared with without (p<0.01). Time to intubation, chest compressions, start of positive pressure ventilation and epinephrine administration was not different between the groups. Quotes/behaviours revealed false reassurance and over-reliance on ECG monitoring, repeated pulse check errors and troubleshooting behaviours.

CONCLUSIONS

ECG monitoring in simulated neonatal resuscitation results in delayed recognition of a pulseless state, decreased number of pulse checks and a possible false sense of security. Simulated resuscitation clinical endpoints are unaffected.

The awareness of enhanced recovery after surgery (ERAS) cesarean delivery guidelines among anesthesiology and reanimation assistants in Turkey; a questionnaire study

BACKGROUND

To reduce maternal-fetal morbidity and mortality, it is becoming increasingly important for anesthetists to understand and implement enhanced recovery after surgery (ERAS) cesarean delivery guidelines. Our aim was to reveal the knowledge of anesthesia assistants in Turkey about ERAS during cesarean delivery and to increase their awareness of ERAS.

METHODS

This descriptive study was conducted in the city of Isparta, Turkey in 2023. The survey, which was approved by the ethics committee, was distributed to participants across Turkey via e-mail and online messages. The survey comprises of a total of 42 questions evaluating perioperative ERAS recommendations.

RESULTS

Of the 404 participants in our survey, 59.9% were associated with university hospitals and 65.8% had completed three or more years of education. A total of 87.9% of the participants were familiar with ERAS; however, only 42.8% had received ERAS training. Although 93.8% of the participants' institutions performed a cesarean delivery, ERAS recommendations were only implemented at a rate of 48%. This may be due to the absence of an ERAS team, which was identified in our survey at a high rate of 66.6%.

CONCLUSION

Awareness about ERAS was high among the participants, but the implementation rates of some recommendations were low. The reason for this may be the inability to form a multidisciplinary team and inadequate training of participants. For this purpose, we recommend the formation of a multidisciplinary team for ERAS protocol implementation and increased participant training opportunities.

Oxygen saturation and heart rate in healthy term and late preterm infants with delayed cord clamping

Blood oxygen in the fetus is substantially lower than in the newborn infant. In the minutes after birth, arterial oxygen saturation rises from around 50-60% to 90-95%. Initial respiratory efforts generate negative trans-thoracic pressures that drive liquid from the airways into the lung interstitium facilitating lung aeration, blood oxygenation, and pulmonary artery vasodilatation. Consequently, intra- (foramen ovale) and extra-cardiac (ductus arteriosus) shunting changes and the sequential circulation switches to a parallel pulmonary and systemic circulation. Delaying cord clamping preserves blood flow through the ascending vena cava, thus increasing right and left ventricular preload. Recently published reference ranges have suggested that delayed cord clamping positively influenced the fetal-to-neonatal transition. Oxygen saturation in babies with delayed cord clamping plateaus significantly earlier to values of 85-90% than in babies with immediate cord clamping. Delayed cord clamping may also contribute to fewer episodes of brady-or-tachycardia in the first minutes after birth, but data from randomized trials are awaited. IMPACT: Delaying cord clamping during fetal to neonatal transition contributes to a significantly earlier plateauing of oxygen saturation and fewer episodes of brady-and/or-tachycardia in the first minutes after birth. We provide updated information regarding the changes in SpO2 and HR during postnatal adaptation of term and late preterm infants receiving delayed compared with immediate cord clamping. Nomograms in newborn infants with delayed cord clamping will provide valuable reference ranges to establish target SpO2 and HR in the first minutes after birth.

Cardiac output calculation using the Liljestrand and Zander formula: is this method applicable during immediate transition after birth? - A post hoc analysis

The transition from intrauterine to extrauterine life is a critical period for neonates. Assessing the cardiovascular transition during this period immediately after birth is crucial but challenging. The present study compares adjusted estimated cardiac output values calculated by the Liljestrand and Zander formula (COest/adj LaZ) with non-invasively measured cardiac output values (CO-bioimpedance) during immediate transition after birth. We performed a secondary outcome analysis of a prospective observational study in preterm and term neonates. Ten and 15 min after birth, arterial blood pressure and heart rate were assessed, and CO-bioimpedance was measured using electrical bioimpedance method (Aesculon monitor, Osypka, Germany). We calculated COest/adj LaZ and compared it to CO-bioimpedance. Further, we performed a correlation analysis. Thirty-two neonates with a median (IQR) gestational age of 37.0 (32.0-39.4) weeks were included. Mean ± SD CO-bioimpedance was 0.62 ± 0.15 l/min, and COest/adj LaZ was calculated to be 0.64 ± 0.10 l/min, whereby both correlated significantly (p = 0.025, r = 0.359) with each other.  Conclusion: The present study demonstrates high comparability of COest/adj LaZ and CO-bioimpedance in neonates during immediate transition after birth, suggesting that cardiac output can be derived in a cost-effective and feasible manner if other methods are not available. What is Known: • Echocardiography is considered the gold standard for non-invasive CO evaluation, but its feasibility during the immediate transition period is limited. What is New: • Non-invasive methods such as CO-bioimpedance for cardiac output (CO) measurement and the Liljestrand and Zander (LaZ) formula for estimating CO offer promising alternatives during the immediate transition period.

Lung ultrasound for prediction of surfactant requirement in Indian preterm neonates: a diagnostic accuracy study

Surfactant replacement for respiratory distress syndrome (RDS) is currently guided by oxygen (FiO2) requirement in preterm neonates. Lung ultrasound (LUS) has emerged as an important predictive tool; however, there is a paucity of evidence from developing countries. The objective of this study was to determine the diagnostic accuracy of the LUS score in comparison to standard criteria based on FiO2 requirement for prediction of surfactant requirement. In this prospective study, preterm neonates of < 34 weeks' gestation with RDS were included within 2 h of life. Surfactant was administered if the FiO2 requirement exceeded 30%. Baseline characteristics, respiratory parameters, and LUS clips were recorded soon after birth and compared between the surfactant and non-surfactant groups. LUS scoring was later performed by masked assessors which was not used in the management of neonates. Among 82 neonates (mean gestation 30.6 weeks and weight 1375 g) included in the study, 33 (40.2%) received surfactant. The surfactant group had a higher Silverman score, required higher FiO2 and mean airway pressure, and needed invasive ventilation more frequently. The mean (± SD) LUS score was significantly higher in the surfactant (9.4 ± 3.2) compared to the non-surfactant group (5.1 ± 2.1). The diagnostic accuracy of LUS scoring was determined by ROC curve analysis (AUC (95% CI): 0.83 (0.74-0.92), p < 0.01). A cutoff score of ≥ 8 for LUS was considered optimal for the prediction of surfactant requirement (sensitivity and specificity (95% CI) of 70% (51-84) and 80% (66-90), respectively).    Conclusion: Lung ultrasound is a valid diagnostic tool for the prediction of surfactant requirements in resource-limited settings. What is Known: • Lung ultrasound has a good diagnostic accuracy in predicting the need for surfactant administration in preterm neonates in developed countries, but its role in developing countries is unclear. What is New: • Lung ultrasound proved to be a valid diagnostic tool in predicting surfactant replacement therapy in resource-limited settings. • The diagnostic performance of lung ultrasound was better in neonates on non-invasive ventilation, compared to invasive ventilation.

Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database

OBJECTIVE

To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine.

STUDY DESIGN

We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR.

RESULTS

In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine.

CONCLUSIONS

This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC.

Initial Oxygen Concentration for the Resuscitation of Infants Born at Less Than 32 Weeks' Gestation: A Systematic Review and Individual Participant Data Network Meta-Analysis

Importance

Resuscitation with lower fractional inspired oxygen (FiO2) reduces mortality in term and near-term infants but the impact of this practice on very preterm infants is unclear.

Objective

To evaluate the relative effectiveness of initial FiO2 on reducing mortality, severe morbidities, and oxygen saturations (SpO2) in preterm infants born at less than 32 weeks' gestation using network meta-analysis (NMA) of individual participant data (IPD).

Data Sources

MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, and WHO ICTRP from 1980 to October 10, 2023.

Study Selection

Eligible studies were randomized clinical trials enrolling infants born at less than 32 weeks' gestation comparing at least 2 initial oxygen concentrations for delivery room resuscitation, defined as either low (≤0.3), intermediate (0.5-0.65), or high (≥0.90) FiO2.

Data Extraction and Synthesis

Investigators from eligible studies were invited to provide IPD. Data were processed and checked for quality and integrity. One-stage contrast-based bayesian IPD-NMA was performed with noninformative priors and random effects and adjusted for key covariates.

Main Outcomes and Measures

The primary outcome was all-cause mortality at hospital discharge. Secondary outcomes were morbidities of prematurity and SpO2 at 5 minutes.

Results

IPD were provided for 1055 infants from 12 of the 13 eligible studies (2005-2019). Resuscitation with high (≥0.90) initial FiO2 was associated with significantly reduced mortality compared to low (≤0.3) (odds ratio [OR], 0.45; 95% credible interval [CrI], 0.23-0.86; low certainty) and intermediate (0.5-0.65) FiO2 (OR, 0.34; 95% CrI, 0.11-0.99; very low certainty). High initial FiO2 had a 97% probability of ranking first to reduce mortality. The effects on other morbidities were inconclusive.

Conclusions and Relevance

High initial FiO2 (≥0.90) may be associated with reduced mortality in preterm infants born at less than 32 weeks' gestation compared to low initial FiO2 (low certainty). High initial FiO2 is possibly associated with reduced mortality compared to intermediate initial FiO2 (very low certainty) but more evidence is required.

Video recording in the delivery room: current status, implications and implementation

Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.

Early or delayed cord clamping during transition of term newborns: does it make any difference in cerebral tissue oxygenation?

BACKGROUND

According to the World Health Organization's recommendation, delayed cord clamping in term newborns can have various benefits. Cochrane metaanalyses reported no differences for mortality and early neonatal morbidity although a limited number of studies investigated long-term neurodevelopmental outcomes. The aim of our study is to compare the postnatal cerebral tissue oxygenation values in babies with early versus delayed cord clamping born after elective cesarean section.

METHODS

In this study, a total of 80 term newborns delivered by elective cesarean section were included. Infants were randomly grouped as early (clamped within 15 s, n:40) and delayed cord clamping (at the 60th second, n:40) groups. Peripheral arterial oxygen saturation (SpO2) and heart rate were measured by pulse oximetry while regional oxygen saturation of the brain (rSO2) was measured with near-infrared spectrometer. Fractional tissue oxygen extraction (FTOE) was calculated for every minute between the 3rd and 15th minute after birth. (FTOE = pulse oximetry value-rSO2/pulse oximetry value). The measurements were compared for both groups.

RESULTS

The demographical characteristics, SpO2 levels (except postnatal 6th, 8th, and 14th minutes favoring DCC p < 0.05), heart rates and umbilical cord blood gas values were not significantly different between the groups (p > 0.05). rSO2 values were significantly higher while FTOE values were significantly lower for every minute between the 3rd and 15th minutes after birth in the delayed cord clamping group (p < 0.05).

CONCLUSION

Our study revealed a significant increase in cerebral rsO2 values and a decrease in FTOE values in the delayed cord clamping (DCC) group, indicating a positive impact on cerebral oxygenation and hemodynamics. Furthermore, the DCC group exhibited a higher proportion of infants with cerebral rSO2 levels above the 90th percentile. This higher proportion, along with a lower of those with such parameter below the 10th percentile, suggest that DCC may lead to the targeted/optimal cerebral oxygenetaion of these babies. As a result, we recommend measuring cerebral oxygenation, in addition to peripheral SpO2, for infants experiencing perinatal hypoxia and receiving supplemental oxygen.

Comparing Intubation Rates in the Delivery Room by Interface

OBJECTIVE

Positive pressure ventilation (PPV) is crucial to the resuscitation of newborns. Although neonates often require PPV at birth, the optimal interface has not been determined. Both binasal prongs and face masks were deemed acceptable by the International Liaison Committee on Resuscitation in 2010 and have been utilized at our center since 2016; however, the choice is by provider preference. Previous studies have suggested that binasal prongs may be more effective than face masks at avoiding intubation in the delivery room. The objective of this study is to compare intubation rates of binasal prongs versus face masks for delivery room resuscitation of neonates born < 30 weeks' gestation.

STUDY DESIGN

This retrospective study compares delivery room intubation rates by interface for neonates < 30 weeks' gestation born between August 2016 and April 2021 at our level IV neonatal intensive care unit. Exclusion criteria included diagnosis of congenital diaphragmatic hernia, no PPV required, or no resuscitation attempted. Data collected included interface device, demographics, maternal data, delivery room data, admission data, and discharge outcomes. The three interface groups (binasal prongs, face mask, face mask, and binasal prongs) were compared utilizing chi-square, analysis of variance with post hoc analysis, and logistic regression.

RESULTS

Mean gestational ages and birth weights for the groups were 27.6 weeks and 1,126 g, 25.7 weeks and 839 g, and 27.1 weeks and 1,028 g, respectively. Neonates resuscitated with face masks were 9.9 times more likely to be intubated in the delivery room and 10.8 times more likely to be intubated at 6 hours of life compared with those resuscitated with binasal prongs after logistic regression analysis.

CONCLUSION

The findings in our study support delivery room resuscitation with binasal prongs as a useful method in reducing the need for intubation both in the delivery room and at 6 hours of life. Further prospective studies are warranted.

KEY POINTS

· The International Liaison Committee on Resuscitation recommends multiple interface options for neonatal resuscitation.. · Vermont Oxford Network endorses nasal interface for premature infants.. · Binasal prongs are associated with lower intubation rates..

A Randomized Controlled Simulation Trial of a Neonatal Resuscitation Digital Game Simulator for Labour and Delivery Room Staff

BACKGROUND

Healthcare providers (HCPs) working in labour and delivery rooms need to undergo regular refresher courses to maintain their neonatal resuscitation skills, which are shown to decline over time. However, due to their irregular schedules and limited time, HCPs encounter difficulties in readily accessing refresher programs. RETAIN is a digital game that simulates a delivery room to facilitate neonatal resuscitation training for HCPs.

OBJECTIVE

This study aims to ascertain whether participants enjoyed the RETAIN digital game simulator and whether it was at least as good as a video lecture at refreshing and maintaining participants' neonatal resuscitation knowledge.

METHODS

In this randomized controlled simulation trial, n = 42 labour and delivery room HCPs were administered a pre-test of neonatal resuscitation knowledge using a manikin. Then, they were randomly assigned to a control or a treatment group. For 20-30 min, participants in the control group watched a neonatal resuscitation lecture video, while those in the treatment group played the RETAIN digital game simulator of neonatal resuscitation scenarios. Then, all participants were administered a post-test identical to the pre-test. Additionally, participants in the treatment group completed a survey of attitudes toward the RETAIN simulator that provided a measure of enjoyment of the RETAIN game simulator. After two months, participants were administered another post-test identical to the pre-test.

RESULTS

For the primary outcome (neonatal resuscitation performance), an analysis of variance revealed that participants significantly improved their neonatal resuscitation performance over the first two time points, with a significant decline to the third time point, the same pattern of results across conditions, and no differences between conditions. For the secondary outcome (attitudes toward RETAIN), participants in the treatment condition also reported favourable attitudes toward RETAIN.

CONCLUSIONS

Labour and delivery room healthcare providers in both groups (RETAIN simulator or video lecture) significantly improved their neonatal resuscitation performance immediately following the intervention, with no group differences. The findings suggest that participants enjoyed interacting with the RETAIN digital game simulator, which provided a similar boost in performance right after use to the more traditional intervention.

Prevalence of bradycardia in 4876 newborns in the first minute after birth and association with positive pressure ventilation: a population-based cross-sectional study

OBJECTIVE

To determine the prevalence of bradycardia in the first minute after birth and association with positive pressure ventilation (PPV).

METHOD

A population-based cross-sectional study was conducted from June 2019 to December 2021 at Stavanger University Hospital, Norway. Parents consented to participation during pregnancy, and newborns ≥28 weeks' gestation were included at birth. Heart rate (HR) was captured immediately after birth and continuously for the first minute(s). Time of birth was registered on a tablet. Provision of PPV was captured using video.

RESULTS

Of 4876 included newborns, 164 (3.4%) did not breathe (two-thirds) or breathed ineffectively (one-third) and received PPV at birth. HR in the first minute had a wide distribution. The prevalence of first measured HR <100 and <60 beats/minute at median 16 s was 16.3% and 0.6%, respectively. HR increased in most cases. At 60 s, 3.7% had HR <100 beats/minute, of which 82% did not require PPV. In total, 25% of newborns had some registered HR <100 beats/minute during the first minute, of which 95% did not require PPV. Among newborns who received PPV, 76% and 62% had HR ≥100 beats/minute at 60 s and at start PPV, respectively.

CONCLUSION

Bradycardia with HR <100 bpm in the first minute of life was frequent, but mostly self-resolved. Among the 4% of newborns that remained bradycardic at 60 s, only 20% received PPV. Two-thirds of resuscitated newborns had HR ≥100 beats/minute at start PPV. None of the ventilated newborns were breathing adequately at start PPV.

TRIAL REGISTRATION NUMBER

NCT03849781.

Sustained inflation and chest compression versus 3:1 chest compression to ventilation ratio during cardiopulmonary resuscitation of asphyxiated newborns (SURV1VE): A cluster randomised controlled trial

OBJECTIVE

In newborn infants requiring chest compression (CC) in the delivery room (DR) does continuous CC superimposed by a sustained inflation (CC+SI) compared with a 3:1 compression:ventilation (3:1 C:V) ratio decreases time to return of spontaneous circulation (ROSC).

DESIGN

International, multicenter, prospective, cluster cross-over randomised trial.

SETTING

DR in four hospitals in Canada and Austria, PARTICIPANTS: Newborn infants >28 weeks' gestation who required CC.

INTERVENTIONS

Hospitals were randomised to CC+SI or 3:1 C:V then crossed over to the other intervention.

MAIN OUTCOME MEASURE

The primary outcome was time to ROSC, defined as the duration of CC until an increase in heart rate >60/min determined by auscultation of the heart, which was maintained for 60 s. Sample size of 218 infants (109/group) was sufficient to detect a clinically important 33% reduction (282 vs 420 s of CC) in time to ROSC. Analysis was intention-to-treat.

RESULTS

Patient recruitment occurred between 19 October 2017 and 22 September 2022 and randomised 27 infants (CC+SI (n=12), 3:1 C:V (n=15), two (one per group) declined consent). All 11 infants in the CC+SI group and 12/14 infants in the 3:1 C:V group achieved ROSC in the DR. The median (IQR) time to ROSC was 90 (60-270) s and 615 (174-780) s (p=0.0502 (log rank), p=0.16 (cox proportional hazards regression)) with CC+SI and 3:1 C:V, respectively. Mortality was 2/11 (18.2%) with CC+SI versus 8/14 (57.1%) with 3:1 C:V (p=0.10 (Fisher's exact test), OR (95% CI) 0.17; (0.03 to 1.07)). The trial was stopped due to issues with ethics approval and securing trial insurance as well as funding reasons.

CONCLUSION

The time to ROSC and mortality was not statistical different between CC+SI and 3:1 C:V.

TRIAL REGISTRATION

NCT02858583.

Laryngeal Mask Airway in Neonatal Resuscitation: A Survey of the Union of European Neonatal and Perinatal Societies

INTRODUCTION

Laryngeal mask airway (LMA) use in neonatal resuscitation is limited despite existing evidence and recommendations. This survey investigated the knowledge and experience of healthcare providers on the use of the LMA and explored barriers and solutions for implementation.

METHODS

This online, cross-sectional survey on LMA in neonatal resuscitation involved healthcare professionals of the Union of European Neonatal and Perinatal Societies (UENPS).

RESULTS

A total of 858 healthcare professionals from 42 countries participated in the survey. Only 6% took part in an LMA-specific course. Some delivery rooms were not equipped with LMA (26.1%). LMA was mainly considered after the failure of a face mask (FM) or endotracheal tube (ET), while the first choice was limited to neonates with upper airway malformations. LMA and FM were considered easier to position but less effective than ET, while LMA was considered less invasive than ET but more invasive than FM. Participants felt less competent and experienced with LMA than FM and ET. The lack of confidence in LMA was perceived as the main barrier to its implementation in neonatal resuscitation. More training, supervision, and device availability in delivery wards were suggested as possible actions to overcome those barriers.

CONCLUSION

Our survey confirms previous findings on limited knowledge, experience, and confidence with LMA, which is usually considered an option after the failure of FM/ET. Our findings highlight the need for increasing the availability of LMA in delivery wards. Moreover, increasing LMA training and having an LMA expert supervisor during clinical practice may improve the implementation of LMA use in neonatal clinical practice.