Hydrogen peroxide production in leukocytes during cerebral hypoxia and reoxygenation with 100% or 21% oxygen in newborn piglets

The role of oxygen in the development and treatment of bronchopulmonary dysplasia

Oxygen (O2) is crucial for both the development and treatment of one of the most important consequences of prematurity: bronchopulmonary dysplasia (BPD). In fetal life, the hypoxic environment is important for alveolar development and maturation. After birth, O2 becomes a double-edged sword. While O2 is needed to prevent hypoxia, it also causes oxidative stress leading to a plethora of morbidities, including retinopathy and BPD. The advent of continuous O2 monitoring with pulse oximeters has allowed clinicians to recognize the narrow therapeutic margins of oxygenation for the preterm infant, but more knowledge is needed to understand what these ranges are at different stages of the preterm infant's life, including at birth, in the neonatal intensive care unit and after hospital discharge. Future research, especially in innovative technologies such as automated O2 control and remote oximetry, will improve the understanding and treatment of the O2 needs of infants with BPD.

Oxygen for the delivery room respiratory support of moderate-to-late preterm infants. An international survey of clinical practice from 21 countries

AIM

The aim of this study was to determine clinician opinion regarding oxygen management in moderate-late preterm resuscitation.

METHODS

An anonymous online questionnaire was distributed through email/social messaging platforms to neonatologists in 21 countries (October 2020-March 2021) via REDCap.

RESULTS

Of the 695 respondents, 69% had access to oxygen blenders and 90% had pulse oximeters. Respondents from high-income countries were more likely to have oxygen blenders than those from middle-income countries (72% vs. 66%). Most initiated respiratory support with FiO₂ 0.21 (43%) or 0.3 (36%) but only 45% titrated FiO₂ to target SpO₂ . Most (89%) considered heart rate as a more important indicator of response than SpO₂ . Almost all (96%) supported the need for well-designed trials to examine oxygenation in moderate-late preterm resuscitation.

CONCLUSION

Most clinicians resuscitated moderate-late preterm infants with lower initial FiO₂ but some cannot/will not target SpO₂ or titrate FiO₂ . Most consider heart rate as a more important indicator of infant response than SpO₂ .Large and robust clinical trials examining oxygen use for moderate-late preterm resuscitation, including long-term neurodevelopmental outcomes, are supported amongst clinicians.

Immune responses in perinatal brain injury

The perinatal period has often been described as immune deficient. However, it has become clear that immune responses in the neonate following exposure to microbes or as a result of tissue injury may be substantial and play a role in perinatal brain injury. In this article we will review the immune cell composition under normal physiological conditions in the perinatal period, both in the human and rodent. We will summarize evidence of the inflammatory responses to stimuli and discuss how neonatal immune activation, both in the central nervous system and in the periphery, may contribute to perinatal hypoxic-ischemic brain injury.

Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen

Objective:

It is well known that a brief exposure to 100% oxygen for only a few minutes could be toxic for a preterm infant. The effectiveness of neonatal resuscitation was compared with low concentration oxygen (30%) and high concentration oxygen (HOG) (100%).

Methods:

Thirty-two preterm neonates were born in Isfahan Shahid Beheshti hospital with gestational age of 29-34 weeks who required resuscitation were randomized into two groups. The resuscitation was begun with 30% O₂ in low concentration oxygen group (LOG). The infants were examined every 60-90 seconds and if their HR was less than 100, 10% was added to the previous FIO₂(fraction of inspired oxygen) until the HR increased to 100 and SO₂(saturation of oxygen) increased to 85%. In HOG resuscitation begun with 100% O₂ and every 60-90 seconds, FIO₂ was decreased 10 – 15% until the HR reached to 100 and SO₂ reached to 85%.

Findings:

The FIO₂ in LOG was increased stepwise to 45% and in HOG was reduced to 42.1% to reach stable oxygen saturation more than 85% at the fifth minute in both groups. At the first and third minutes after birth and there was no significant differences between groups in heart rate and after 1,2,4 and 5 minutes after the birth there was also no significant differences in SO₂ between groups, regardless of the initial FIO₂.

Conclusion:

We can safely initiate resuscitation of preterm infants with a low FIO₂(approximately 30%) oxygen and then oxygen should be adjusted with the neonates needs.

Resuscitation with 100% oxygen increases injury and counteracts the neuroprotective effect of therapeutic hypothermia in the neonatal rat

INTRODUCTION

Mild therapeutic hypothermia (HT) reduces brain injury in survivors after perinatal asphyxia. Recent guidelines suggest that resuscitation of term infants should be started with air, but supplemental oxygen is still in use. It is not known whether supplemental oxygen during resuscitation affects the protection offered by subsequent HT.

RESULTS

Wilcoxon median (95% confidence interval) hippocampal injury scores (range 0.0-4.0; 0 to ≥90% injury) were 21% O(2) normothermia (NT): 2.00 (1.25-2.50), 21% O(2) HT: 1.00 (0.50-1.50), 100% O(2) NT: 2.50 (1.50-3.25), and 100% O(2) HT: 2.00 (1.25-2.50). Although HT significantly reduced hippocampal injury (B = -0.721, SEM = 0.297, P = 0.018), reoxygenation with 100% O(2) increased injury (B = +0.647, SEM = 0.297, P = 0.033). Regression constant B = 1.896, SEM = 0.257 and normally distributed residuals.

DISCUSSION

We confirm an ~50% neuroprotective effect of therapeutic HT in the neonatal rat. Reoxygenation with 100% O(2) increased injury and worsened reflex performance. HT was neuroprotective whether applied after reoxygenation with air or 100% O(2). However, HT after 100% O(2) gave no net neuroprotection.

METHODS

In an established neonatal rat model, hypoxia-ischemia (HI) was followed by 30-min reoxygenation in either 21% O(2) or 100% O(2) before 5 h of NT (37 °C) or HT (32 °C). The effects of HT and 100% O(2) on histopathologic injury in the hippocampus, basal ganglia, and cortex, and on postural reflex performance 7 d after the insult, were estimated by linear regression.

Normoxic versus hyperoxic resuscitation in pediatric asphyxial cardiac arrest: effects on oxidative stress

OBJECTIVE

To determine the effects of normoxic vs. hyperoxic resuscitation on oxidative stress in a model of pediatric asphyxial cardiac arrest.

DESIGN

Prospective, interventional study.

SETTING

University research laboratory.

SUBJECTS

Postnatal day 16-18 rats (n = 5 per group).

INTERVENTIONS

Rats underwent asphyxial cardiac arrest for 9 min. Rats were randomized to receive 100% oxygen, room air, or 100% oxygen with polynitroxyl albumin (10 mL·kg⁻¹ intravenously, 0 and 30 min after resuscitation) for 1 hr from the start of cardiopulmonary resuscitation. Shams recovered in 100% oxygen or room air after surgery.

MEASUREMENTS AND MAIN RESULTS

Physiological variables were recorded at baseline to 1 hr after resuscitation. At 6 hrs after asphyxial cardiac arrest, levels of reduced glutathione and protein-thiols (fluorescent assay), activities of total superoxide dismutase and mitochondrial manganese superoxide dismutase (cytochrome c reduction method), manganese superoxide dismutase expression (Western blot), and lipid peroxidation (4-hydroxynonenal Michael adducts) were evaluated in brain tissue homogenates. Hippocampal 3-nitrotyrosine levels were determined by immunohistochemistry 72 hrs after asphyxial cardiac arrest. Survival did not differ among groups. At 1 hr after resuscitation, Pao2, pH, and mean arterial pressure were decreased in room air vs. 100% oxygen rats (59 ± 3 vs. 465 ± 46 mm Hg, 7.36 ± 0.05 vs. 7.42 ± 0.03, 35 ± 4 vs. 45 ± 5 mm Hg; p < .05). Rats resuscitated with 100% oxygen had decreased hippocampal reduced glutathione levels vs. sham (15.3 ± 0.4 vs. 20.9 ± 4.1 nmol·mg protein⁻¹; p < .01). Hippocampal manganese superoxide dismutase activity was significantly increased in 100% oxygen rats vs. sham (14 ± 2.4 vs. 9.5 ± 1.6 units·mg protein⁻¹, p < .01), with no difference in protein expression of manganese superoxide dismutase. Room air and 100% oxygen plus polynitroxyl albumin groups had hippocampal reduced glutathione and manganese superoxide dismutase activity levels comparable with sham. Protein thiol levels were unchanged across groups. Compared with all other groups, rats receiving 100% oxygen had increased immunopositivity for 3-nitrotyrosine in the hippocampus and increased lipid peroxidation in the cortex.

CONCLUSIONS

Resuscitation with 100% oxygen leads to increased oxidative stress in a model that mimics pediatric cardiac arrest. This may be prevented by using room air or giving an antioxidant with 100% oxygen resuscitation.

Why are we still using oxygen to resuscitate term infants?

This article summarizes the historical background for the use of oxygen during newborn resuscitation and describes some of the research and the process of changing the previous practice from a high- to a low-oxygen approach. Findings of a recent Cochrane review suggest that more than 100,000 newborn lives might be saved globally each year by changing from 100 to 21% oxygen for newborn resuscitation. This estimate represents one of the largest yields for a simple therapeutic approach to decrease neonatal mortality in the history of pediatric research. Available data also suggest that, for the very low birth weight infant, use of the low-oxygen approach should be considered with the understanding that some of the smallest and sickest preterm neonates will need some level of oxygen supplementation during the first minutes of postnatal life. As more data are needed for the very preterm population, creation of strict guidelines for these infants would be premature at present. However, it can be stated that term and late preterm infants in need of resuscitation should, in general, be started on 21% oxygen, and if resuscitation is not started with 21% oxygen, a blender should be available, enabling the administration of the lowest FiO(2) possible to keep heart rate and SaO(2) within the target range. For extremely low birth weight infants, initial FiO(2) could be between 0.21 and 0.30 and adjusted according to the response in SaO(2) and heart rate.

Reduced expression of DNA glycosylases in post-hypoxic newborn pigs undergoing therapeutic hypothermia

Supplementary oxygen during resuscitation of the asphyxiated newborn is associated with increased generation of reactive oxygen species and oxidative stress. It is suspected that hyperoxic reoxygenation may cause increased damage to DNA, resulting in replication errors, and cell death or potential fixation of mutations if unrepaired. Therapeutic hypothermia may attenuate the development of brain damage after asphyxia, but it is not known how post-hypoxic hyperoxia and hypothermia affect accumulation of DNA-damage and DNA repair. Anaesthetised newborn pigs were randomised to control (n=6) or severe global hypoxia (n=46). After 20min of reoxygenation with either room air or 100% O(2), followed by 6.5h of normothermia (deep rectal temperature 39°C) or total body cooling (35°C), oxidative DNA damage (8-hydroxy-2'-deoxyguanosine) in brain, liver and urine, and transcription of DNA repair glycosylases (NEIL1, NEIL3, and OGG1) in brain and liver were measured. Hypoxic pigs displayed increased urinary 8-oxodG levels: mean (SD) 8-oxodG/creatinine was 3.55 (1.46) vs. control 2.02 (0.53), p<0.05, but levels were not affected by hyperoxia or hypothermia. Accumulation of 8-oxodG in the brain and liver did not differ across groups. Post-hypoxic transcription of DNA glycosylases was down-regulated by hypothermia: OGG1 in hippocampus and liver (p<0.01); NEIL1 in hippocampus (p<0.01), cortex and striatum (p<0.05) and liver (p<0.001); and NEIL3 in hippocampus (p<0.01) and cerebellum (p<0.001). Hyperoxia did not affect transcription of glycosylases in the brain. We confirm increased oxidative stress after hypoxia. DNA repair glycosylases were down-regulated by hypothermia but with no effect on accumulation of oxidative damage in genomic DNA.

Early protective effect of hypothermia in newborn pigs after hyperoxic, but not after normoxic, reoxygenation

Abstract Mild hypothermia can attenuate the development of brain damage after asphyxia. Supplemental oxygen during resuscitation increases generation of reactive oxygen species, compared to room air. It is unknown if supplemental oxygen affects hypothermic neuroprotection. We studied the early effects of hyperoxic reoxygenation and subsequent hypothermia on tissue oxygenation, microcirculation, inflammation and brain damage after global hypoxia. Anesthetized newborn pigs were randomized to control (n=6), or severe global hypoxia (n=46). Three pigs died during hypoxia or reoxygenation. After 20-min reoxygenation with room air (n=22) or 100% oxygen (n=21), pigs were randomized to normothermia (deep rectal temperature 39 degrees C, n=22) or total body cooling (35 degrees C, n=21) for 6.5 h before the experiment was terminated. We demonstrated a differential effect of post-hypoxic hypothermia between animals reoxygenated with 100% oxygen and with room air, with reduced damage only in hypothermic animals reoxygenated with 100% oxygen (P=0.001). Hyperoxic reoxygenation resulted in a significant overshoot in striatal oxygen tension, without affecting microcirculation. Inflammatory response after the insult did not differ between groups. The results indicate an early protective effect of hypothermia which may vary with oxygen level used during reoxygenation.

Hypoxia-induced cell damage is reduced by mild hypothermia and postconditioning with catalase in-vitro: application of an enzyme based oxygen deficiency system

Mild hypothermia and pharmacological postconditioning are widespread therapeutical treatment options that positively influence the clinical outcome after tissue hypoxia. In the study presented, a two-enzyme based in-vitro oxygen deficiency model in combination with cultured HT-1080 fibrosarcoma cells was employed to mimic the in-vivo situation of hypoxia and to evaluate the influence of mild hypothermia and postconditioning with catalase on hypoxia-mediated cell damage. Using the in-vitro oxygen deficiency model, partial pressure of oxygen was rapidly reduced to levels below 5mmHg in the culture media and cells responded with an increased expression of hypoxia inducible factor-1 on protein level. Hypoxia resulted in significant cell rounding and retraction of cytoplasmic cell extensions. Evaluation of cytotoxicity revealed a 3.5-fold increase in lactate dehydrogenase levels which was accompanied by 40-fold elevated levels of hydrogen peroxide. The hypoxia-induced increase of lactate dehydrogenase was 2.5-fold reduced in the hypothermia group, although morphological correlates of cytotoxicity were still visible. Hypothermia did not significantly influence hydrogen peroxide concentrations in the culture media. Pharmacological postconditioning with catalase however dose-dependently decreased hypoxia-induced lactate dehydrogenase release. This cytoprotective effect was accompanied by a dose-dependent, up to 50-fold reduction of hydrogen peroxide concentrations and retention of normal cell morphology. We suggest that the described in-vitro oxygen deficiency model is a convenient and simple culture system for the investigation of cellular and subcellular events associated with oxygen deficiency. Moreover, our in-vitro results imply that catalase postconditioning may be a promising approach to attenuate hypoxia-induced and hydrogen peroxide-mediated cell and tissue damage.

Accumulation of 8-oxoguanine in liver DNA during hyperoxic resuscitation of newborn mice

Supplementary oxygen during resuscitation of the asphyxiated newborn is associated with long-term detrimental effects including increased risk of childhood cancer. It is suspected that the resuscitation procedure results in accumulated DNA damage and mutagenesis. Base excision repair (BER) is the major pathway for repair of premutagenic oxidative DNA lesions. This study addresses DNA base damage and BER in brain, lung, and liver in neonatal mice (P7) after hyperoxic resuscitation. Mice were randomized to 8% oxygen or room air for 60 min in a closed chamber and subsequent reoxygenation with 100% oxygen for 0 to 90 min. During this treatment, 8-oxoguanine accumulated in liver but not in lung or cerebellum. We observed a linear relation between 8-oxoguanine and reoxygenation time in liver DNA from hypoxic animals (n = 28; B = 0.011 [0.001, 0.020]; p = 0.037). BER activity was not significantly changed during resuscitation. Our data suggest that after hypoxia, the capacity for immediate repair in liver tissue is inadequate to meet increasing amounts of DNA damage. The duration of supplementary oxygen use during resuscitation should be kept as short as justifiable to minimize the risk of genetic instability.

Refining the role of oxygen administration during delivery room resuscitation: what are the future goals?

Oxygen was discovered more than 200 years ago and was thought to be both essential and beneficial for all animal life. Although it is now over 100 years since oxygen was first shown to damage biological tissues exposed to high concentrations, and more than 50 years since it was implicated in the aetiology of retinopathy of prematurity, the use of 100% oxygen was still recommended for the resuscitation of all babies at birth as recently as 2000. However, the 2005 International Liaison Committee on Resuscitation (ILCOR) recommendations allow for the initiation of resuscitation with concentrations of oxygen between 21 and 100%. There are strong arguments in favour of a radical curtailment of the use of oxygen in resuscitation at birth, and for devoting resources to defining the margins of safety for its use in the neonatal period in general.

Postresuscitation N-acetylcysteine treatment reduces cerebral hydrogen peroxide in the hypoxic piglet brain

OBJECTIVE

Reactive oxygen species have been implicated in the pathogenesis of hypoxia-reoxygenation injury. However, little information is known regarding the temporal profile of cerebral hydrogen peroxide (HPO) production and its response to N-acetylcysteine (an antioxidant) administration during neonatal hypoxia-reoxygenation. Using an acute swine model of neonatal hypoxia-reoxygenation, we examined the short-term neuroprotective effects of N-acetylcysteine on cerebral HPO production and oxidative stress in the brain.

DESIGN

Controlled, block-randomized animal study.

SETTING

University animal research laboratory.

SUBJECTS

Newborn piglets (1-3 days, 1.7-2.1 kg).

INTERVENTIONS

At 5 min after reoxygenation, piglets were given either saline or N-acetylcysteine (20 or 100 mg/kg/h) in a blinded, randomized fashion.

MEASUREMENTS AND RESULTS

Newborn piglets were block-randomized into a sham-operated group (without hypoxia-reoxygenation, n = 5) and three hypoxic-reoxygenated groups (2 h of normocapnic alveolar hypoxia followed by 2h of reoxygenation, n = 7/group). Heart rate, mean arterial pressure, cortical HPO concentration, amino acid levels in cerebral microdialysate, and cerebral tissue glutathione and lipid hydroperoxide levels were examined. Hypoxic piglets were hypotensive and acidotic, and they recovered similarly in all hypoxic-reoxygenated groups. In hypoxic-reoxygenated control piglets, the cortical HPO concentration gradually increased during reoxygenation. Both doses of N-acetylcysteine abolished the increased HPO concentration and oxidized glutathione levels and tended to reduce the glutathione ratio and lipid hydroperoxide levels in the cerebral cortex (p = 0.08 and p = 0.1 vs. controls, respectively). N-acetylcysteine at 100mg/kg/h also increased the cerebral extracellular taurine levels.

CONCLUSION

In newborn piglets with hypoxia-reoxygenation, postresuscitation administration of N-acetylcysteine reduces cerebral HPO production and oxidative stress, probably through a taurine-related mechanism.

Oxygen as a neonatal health hazard: call for détente in clinical practice

Education in oxygenation and in how oxygen is given to newborns needs to increase. Treatment with oxygen should no longer be considered proverbial and customary, regardless of our 'past experience' or consensus recommendations in clinical guidelines, since oxygen may lead to acute or chronic health effects.

CONCLUSION

Inappropriate oxygen use is a neonatal health hazard associated with aging, DNA damage and cancer, retinopathy of prematurity, injury to the developing brain, infection and others. Neonatal exposure to pure O2, even if brief, or to pulse oximetry >95% when breathing supplemental O2 must be avoided as much as possible.

Reventilation with room air or 100% oxygen after asphyxia differentially affects cerebral neuropathology in newborn pigs

AIM

To test if reventilation with room air (RA) or 100% oxygen (O2) after asphyxia would differentially affect neuronal damage in different brain areas of newborn pigs.

METHODS

Anaesthetized piglets were subjected to 10 min asphyxia (n=27) or served as time controls (n=7). Reventilation started with either RA or O2 for 1 h, and was continued with RA for an additional 1-3 h. Cortical or cerebellar blood flow was assessed with laser-Doppler flowmetry (LDF). Haematoxylin/eosin-stained sections from six brain regions were prepared for blinded neuropathological examination and scoring.

RESULTS

Asphyxia resulted in significant neuronal damage compared to time controls in all areas examined except the pons. O2 ventilation elicited greater neuronal lesions in the hippocampus and the cerebellum but smaller damage in the basal ganglia compared to RA. The assessed physiological parameters including the LDF signals were similar in both ventilation groups, except for PaO2 in the first hour of reventilation (RA 75+/-5 mmHg, O2 348+/-57 mmHg; p<0.05). Interestingly, however, reactive hyperaemia was much higher in the O2-sensitive cerebellum as compared with the cortex (1101+/-227 vs 571+/-73; p<0.05, area under the curve).

CONCLUSION

O2 toxicity after asphyxia was demonstrated in the piglet hippocampus and cerebellum but not in the cerebral cortex or basal ganglia. The observed regional differences may be associated with local haemodynamic factors.

Air or 100% oxygen in neonatal resuscitation?

For more than 100 years, three principles have guided the treatment of neonatal asphyxia: maintain body heat, free air passages of obstructions, and stimulate respiration by supplying air to the lungs for oxygenation of the blood. This article addresses the question of which gas, air or 100% oxygen, is best supplied to the lungs to stimulate respiration. Evidence-based studies are presented and discussed.

Room air resuscitation versus oxygen resuscitation in the delivery room

The use of 100% oxygen for delivery room resuscitation is currently the recommended standard of the American Academy of Pediatrics and the Neonatal Resuscitation Program. However, there is mounting evidence from animal and human studies suggesting that resuscitation with room air (RA, 21% oxygen), including positive pressure ventilation with bag and face mask, may be as effective as that with 100% oxygen, and that the use of 100% oxygen may pose a risk of adverse physiologic sequelae. Resuscitation with RA has been demonstrated to result in faster recovery and improved neonatal mortality in comparison to 100% oxygen resuscitation. In addition, studies of normal oxygen saturation immediately after birth suggest delivery room personnel may be rushing to high saturation unnecessarily. The question for perinatal medical and nursing personnel involved in newborn resuscitation in the delivery room is whether the use of RA reduces the possible adverse effects of 100% oxygen, including delay in short-term stabilization, death, neurological disability, and possible secondary oxygen free radical injury. A systematic synopsis of both animal studies and human studies involving the advantages, disadvantages, possible risks, and short- and long-term effects of these 2 methods of resuscitation is presented.

Hyperoxia with 100% Oxygen following Hypoxia-Ischemia Increases Brain Damage in Newborn Rats

OBJECTIVE

To describe the effect of reoxygenation with 100% O2 as compared to the effect of room air in newborn rat brains after asphyxia.

METHODS

Experimental asphyxia (carotid artery ligation followed by hypoxic exposure with 8% O2 for 2 h) was performed on 7-day-old rats. After hypoxia-ischemia the rats were reoxygenated with either 100% O2 (hyperoxia group) or 21% O2 (room air group) for 24 h and then returned to the dam. The rats were killed 1 week after the experiment to study the cerebral cortex and hippocampus.

RESULTS

Rats reoxygenated with 100% O2 post-asphyxia showed more frequency of cortical damage (10 of 24 rats) than those reoxy genated with room air (3 of 24 rats) (chi2 test, p = 0.02).

CONCLUSION

We consider that hyperoxia with 100% oxygen after hypoxia-ischemia can cause more damage in the cerebral cortex than room air in newborn rats.

Cardiac function, myocardial glutathione, and matrix metalloproteinase-2 levels in hypoxic newborn pigs reoxygenated by 21%, 50%, or 100% oxygen

After asphyxia, it is standard to resuscitate the newborn with 100% oxygen, which may create a hypoxia-reoxygenation process that may contribute to subsequent myocardial dysfunction. We examined the effects of graded reoxygenation on cardiac function, myocardial glutathione levels, and matrix metalloproteinase (MMP)-2 activity during recovery. Thirty-two piglets (1-3 days old, weighing 1.5-2.1 kg) were anesthetized and instrumented for continuous monitoring of cardiac index, and systemic and pulmonary arterial pressures. After 2 h of hypoxia, piglets were randomized to receive reoxygenation for 1 h with 21%, 50%, or 100% oxygen (n = 8 each), followed by 3 h at 21% oxygen. At 2 h of hypoxemia (PaO2 32-34 mmHg), the animals had hypotension, decreased cardiac index, and elevated pulmonary arterial pressure (P < 0.001 vs. controls). Upon reoxygenation, cardiac function recovered in all groups with higher cardiac index and lower systemic vascular resistance in the 21% group at 30 min of reoxygenation (P < 0.05 vs. controls). Pulmonary artery pressure normalized in an oxygen-dependent fashion (100% = 50% > 21%), despite an immediate recovery of pulmonary vascular resistance in all groups. The hypoxia-reoxygenated (21%-100%) hearts had similarly increased MMP-2 activity and decreased glutathione levels (P < 0.05, 100% vs. controls), which correlated significantly with cardiac index and stroke volume during reoxygenation, and similar features of early myocardial necrosis. In neonatal resuscitation, if used with caution because of a slower resolution of pulmonary hypertension, 21% reoxygenation results in similar cardiac function and early myocardial injury as 50% or 100%. The significance of higher oxidative stress with high oxygen concentration is unknown, at least in the acute recovery period.

Oxygen for newborns: how much is too much?

International guidelines for newborn resuscitation recommend the use of 100% oxygen. However, high concentrations of oxygen after asphyxiation activate reactive oxygen species that may contribute to a number of morbidities. Animal models have been useful in describing their mechanisms, but only large-scale clinical trials can provide evidence that may be used to alter clinical practice. It has been demonstrated that neonates recover faster when resuscitated with room air as opposed to pure oxygen and neonatal mortality rates are improved. Increases in saturation are equal with oxygen and room air resuscitation. Studies of normal oxygen saturation immediately after birth suggest that clinicians may unnecessarily be rushing to high saturations. In the first weeks of life, lower saturation targets in preterm infants reduce retinopathy of prematurity and pulmonary complications and may improve growth. The neonatologist would be well served to think of oxygen as a medication, and use it sparingly.

[Air or oxygen for neonatal resuscitation in the delivery room?]

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full term or near term newborns. Results of recent meta-analysis of trials that compared ventilation with air versus pure oxygen at birth suggests current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations. Particularly severely asphyxiated infants might require supplemental oxygen with titration of oxygen delivery and continuous monitoring of oxygen saturation.

Room air resuscitation-two decades of neonatal research

Experimental as well as clinical studies have demonstrated that room air is as efficient as pure oxygen for newborn resuscitation. Recent data even indicate that outcome is improved if pure oxygen is avoided. Thus, in a meta-analysis, neonatal mortality was significantly lower in those newly born infants resuscitated with 21% than with 100% oxygen. Short-term recovery is also improved in the room air group since time to first breath is shorter, heart rate at 90 s and 5 min Apgar score are higher. Animal data indicate that injury in a number of organs, including the brain, is aggravated by giving pure oxygen to newly born depressed infants even for a brief period. Although the optimal oxygen concentration probably is not known for newborn infants in need of resuscitation, pure oxygen should be avoided. These data should be reflected in new guidelines that are under way.

Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis

BACKGROUND

International consensus statements for resuscitation of newborn infants recommend provision of 100% oxygen with positive pressure if assisted ventilation is required. However, 100% oxygen exacerbates reperfusion injury in animals and reduces cerebral perfusion in newborn babies. We aimed to establish whether resuscitation with air decreased mortality or neurological disability in newborn infants compared with 100% oxygen.

METHODS

We did a systematic review and meta-analysis of trials that compared resuscitation with air versus 100% oxygen, using the methods of the Cochrane Collaboration. We combined data for similar outcomes in the analysis where appropriate, using a fixed-effects model.

FINDINGS

Five trials (two masked and three unmasked), consisting of 1302 newborn infants, fulfilled the inclusion criteria. Most babies were born at or near term in developing countries. In the three unmasked studies, infants resuscitated with room air who remained cyanotic and bradycardic were switched to 100% oxygen at 90 s. The masked studies allowed crossover to the other gas during the first minutes of life. Although no individual trial showed a difference in mortality, the pooled analysis showed a significant benefit for infants resuscitated with air (relative risk 0.71 [95% CI 0.54 to 0.94], risk difference -0.05 [-0.08 to -0.01]). The effect on long-term development could not be reliably determined because of methodological limitations in the one study that followed up infants beyond 12 months of age.

INTERPRETATION

For term and near-term infants, we can reasonably conclude that air should be used initially, with oxygen as backup if initial resuscitation fails. The effect of intermediate concentrations of oxygen at resuscitation needs to be investigated. Future trials should include and stratify for premature infants.

Extracellular superoxide concentration increases following cerebral hypoxia but does not affect cerebral blood flow

Abnormalities of cerebral blood flow during and following hypoxia and ischemia contribute to the progression of tissue injury. Oxidative stress during and following hypoxia is known to markedly increase superoxide anion concentration. There is conflicting evidence that the concentration of superoxide anion regulates cerebral blood flow through its effect on vascular tone, although difficulties in measurement of superoxide anion complicate these studies. In order to test the hypothesis that changes in cerebral blood flow during and following hypoxia are due to changes in extracellular superoxide anion levels, we examined tissue oxygen levels by fiberoptic oximetry and superoxide anion levels using a previously validated cytochrome c coated electrode on the cortical surface and correlated these measurements to cerebral blood flow measured by laser Doppler in rats subjected to 20 min of hypoxia followed by hyperoxic reoxygenation recovery. The results showed a burst of superoxide anion with the onset of reoxygenation that temporally correlated with a transient peak in tissue oxygen tension lasting 10 min. and was eliminated by pretreatment with Cu-Zn superoxide dismutase conjugated to polyethylene glycol. Cerebral blood flow did not differ during hypoxia or recovery in the polyethylene glycol conjugated superoxide dismutase and control treatment groups. This study demonstrated no effect of increased superoxide anion concentration on cerebral blood flow during hyperoxic recovery following hypoxia.

The role of oxygen in neonatal resuscitation

New knowledge has accumulated in recent years making it prudent to ask questions regarding current oxygenation policies and guidelines. Because new-born resuscitation affects so many individuals, and because resuscitation procedures may have dramatic consequences on infant and child health, intensified discussion and research in this field are not only necessary but are a requirement. In particular, there is a lack of data on infants born before term. It is difficult to give absolute recommendations on which oxygen concentration should be applied for newborn resuscitation; however, it seems that ambient air is safe. It is easy to handle, is always at hand, and is inexpensive. Conversely, regarding 100% O2, I believe we have sufficient data to conclude that this should not be given routinely at birth to depressed infants; however, whether it is beneficial or harmful to start out resuscitation with 30%, 40%, or 60% O2 is not known. No data exist to answer this question. A call for more research in this area is timely. The effect of pure oxygen on cell growth and cell death, gene activation, and possibly DNA damage should be carefully investigated. Even before such data are collected, it is known that pure oxygen at birth triggers long-term and poorly understood effects. Oxygen obviously is more toxic than previously thought, and oxygen given to small infants has a 50-year history of uncertain benefits. Table 1 summarizes the pros and cons of using 21%versus 100% 02 for newborn resuscitation. Brain circulation as assessed by microspheres is restored as quickly with 21% O2 as it is with 100% O2; however, microcirculation is somewhat slower. Metabolism, pulmonary flow, and myocardial performance are normalized just as quickly by 21% and 100% O2. Brain injury as assessed by glycerol augmentation, matrix injury, and neonatal mortality is less in infants given 21% versus 100% O2.

Adenine nucleotide metabolism and cell fate after oxidant exposure of rat cortical neurons: effects of inhibition of poly(ADP-ribose) polymerase

We exposed cultured neurons prelabeled with 14C-adenine to H2O2 with or without the poly(ADP-ribose) polymerase (PARP) inhibitor 3,4-Dihydro-5-[4-(1-piperidinyl)butoxy]-1(2H)-isoquinolinone (DPQ) to quantify its effects on acute ATP depletion, later ATP synthesis, cellular and nuclear morphology, extent of DNA fragmentation, and PARP cleavage. According to the extent of the acute ATP depletion, the exposures were classified as 'mild' (50 microM H2O2), 'moderate' (100-250 microM H2O2), or 'severe' (500 microM-1 mM H2O2) insults. Mild exposure had no significant effects on the parameters studied. In the 'moderately' exposed neurons, ATP depletion to 59+/-6% of control was associated with a decrease in the cell counts, apoptotic morphology, and cleavage of PARP. In this group, DPQ prevented the acute ATP (to 95+/-15% of control), preserved cell morphology, and improved cell survival. In the 'severe' group, ATP depletion to 18+/-4% was associated with necrosis and intact PARP. DPQ elevated ATP levels (to 44+/-12% of control) and post-insult ATP synthesis, improved cell counts, and altered cell morphology towards apoptosis rather than necrosis. Post-insult application of DPQ was less effective. Our results show that the extent of oxidant-induced ATP depletion and cell fate can be modified by PARP inhibition, to some extent also after the insult.

A consideration of neonatal resuscitation

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

Resuscitation with 100% O(2) does not protect the myocardium in hypoxic newborn piglets

BACKGROUND

Perinatal asphyxia is associated with cardiac dysfunction secondary to myocardial ischaemia. Cardiac troponin I (cTnI) is a marker of myocardial necrosis. Raised concentrations in the blood are related to perinatal asphyxia and increased morbidity.

OBJECTIVE

To assess porcine myocardial damage from enzyme release during hypoxaemia induced global ischaemia, and subsequent resuscitation with ambient air or 100% O(2). To investigate whether CO(2) level during resuscitation influences myocardial damage.

DESIGN

Newborn piglets (12-36 hours) were exposed to hypoxaemia by ventilation with 8% O(2) in nitrogen. When mean arterial blood pressure had fallen to 15 mm Hg, or base excess to < -20 mmol/l, the animals were randomly resuscitated by ventilation with either 21% O(2) (group A, n = 29) or 100% O(2) (group B, n = 29) for 30 minutes. Afterwards they were observed in ambient air for another 150 minutes. During resuscitation, the two groups were further divided into three subgroups with different CO(2) levels.

ANALYSIS

Blood samples were analysed for cTnI, myoglobin, and creatine kinase-myocardial band (CK-MB) at baseline and at the end of the study.

RESULTS

cTnI increased more than 10-fold (p < 0.001) in all the groups. Myoglobin and CK-MB doubled in concentration.

CONCLUSION

The considerable increase in cTnI indicates seriously affected myocardium. Reoxygenation with 100% oxygen offered no biochemical benefit over ambient air. CK-MB and myoglobin were not reliable markers of myocardial damage. Normoventilation tended to produce better myocardial outcome than hyperventilation or hypoventilation.

Oxidative stress in asphyxiated term infants resuscitated with 100% oxygen

OBJECTIVE

To test the hypothesis that resuscitation of asphyxiated infants with pure oxygen causes hyperoxemia and oxidative stress.Study design Asphyxiated term newborn infants (n = 106) were randomly resuscitated with room air (RAR = 51) or 100% oxygen (OxR = 55). The Apgar score, time of the first cry, and establishment of a sustained pattern of respiration were recorded. Assays performed included: blood gases; reduced glutathione (GSH) and oxidized glutathione (GSSG) in whole blood; glutathione-related enzyme activities; and superoxide dismutase activity (SOD) in erythrocytes.

RESULTS

The RAR group needed less time of ventilation for resuscitation (5.3 +/- 1.5 vs 6.8 +/- 1.2 min; P <.05). Pure oxygen caused hyperoxemia (PO(2), 126.3 +/- 21.8 mm Hg) that did not occur with the use of room air (PO(2), 72.2 +/- 6.8 mm Hg). GSH was decreased and GSSG, the glutathione cycle enzymes, and SOD activities were increased in both asphyxiated groups. However, the 100% oxygen-resuscitated group showed significantly greater alterations that correlated positively with hyperoxemia.

CONCLUSIONS

Asphyxia causes oxidative stress in the perinatal period, and resuscitation with 100% oxygen causes hyperoxemia and increased oxidative stress. Because there are no advantages to resuscitation with 100% oxygen, room air may be preferred under certain circumstances for the resuscitation of asphyxiated neonates.

Hyperoxemia caused by resuscitation with pure oxygen may alter intracellular redox status by increasing oxidized glutathione in asphyxiated newly born infants

In a prospective, randomized, blinded trial we have studied the effects of resuscitation upon oxygenation in a group of asphyxiated newly born infants receiving room air or 100% oxygen as the gas source. During the acute phase of asphyxia and until the resuscitation procedure concluded, we determined serial blood gases as well as reduced and oxidized glutathione, enzymes involved in the glutathione redox cycle, and antioxidant enzyme activities. The use of 100% oxygen caused a remarkable increase of partial pressures of oxygen in arterial blood, with values that were frequently above physiological levels (> 100 mm Hg). In addition, we have found a significant correlation between hyperoxemia and the intra-erythrocyte GSSG (oxidized glutathione) concentration. We hypothesize that hyperoxemia may be 1 of the triggering factors responsible for an increased oxidation of GSH (reduced glutathione). Moreover, an increased antioxidant enzyme activity, which reflects an oxidative stress, indicates that the antioxidant capacity of the newly born infant may have been surpassed.

Acute neuronal injury after hypoxia is influenced by the reoxygenation mode in juvenile hippocampal slice cultures

In neonates asphyxia is usually followed by hyperoxia due to resuscitation procedures. In order to study whether hyperoxic reoxygenation might cause additional cell injury we subjected organotypic hippocampal slice cultures of juvenile rats to normoxic or hyperoxic reoxygenation (19 or 85% oxygen, respectively) following hypoxia (3% oxygen) for 30, 60, and 120 min. Cell injury was quantified by lactate dehydrogenase (LDH) release and propidium iodide (PI) fluorescence 1 h after end of the reoxygenation period. In both experimental groups, LDH activity was significantly enhanced by hypoxia as compared to normoxic controls. However, hyperoxic reoxygenation caused a larger increase in LDH activity than normoxic reoxygenation (e.g., by a factor of 1.60 vs. 1.29 following 120 min hypoxia). PI fluorescence increased after hypoxia in all principal cell layers of the hippocampus but again showed a larger enhancement after hyperoxic reoxygenation as compared to normoxic reoxygenation (e.g., by a factor of 3.9 vs. 1.7 for CA1 and 120 min of hypoxia). After normoxic reoxygenation, PI fluorescence intensity was lower in the dentate gyrus as compared to CA1 and CA3, while it reached similar values like CA1 after high oxygen supply. In conclusion, juvenile hippocampal slice cultures subjected to hyperoxic reoxygenation display a greater amount of acute neuronal injury than slice cultures undergoing normoxic reoxygenation.

Resuscitation of newborn infants with room air or oxygen

Oxygen is a toxic agent and a critical approach regarding its use during resuscitation at birth is developing. Animal data indicate that room air is efficient for newborn resuscitation. Three clinical studies have established that normal ventilation is delayed after oxygen resuscitation. Oxidative stress is augmented for several weeks in infants exposed to oxygen at birth -- the long-term implications of these observations remain unclear. There are limited data regarding the use of room air during complicated resuscitations, i.e. in meconium aspiration, the severely asphyxiated infant and in the preterm infant. Thus, it is necessary to continue ongoing rigorous examination of the long-accepted practice of oxygen administration during neonatal resuscitation.