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von Düring S, Nabecker S. Training human factors and equipment failures to increase intubation safety. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Williams E, Dassios T, Greenough A. Carbon dioxide monitoring in the newborn infant. Pediatr Pulmonol 2021; 56:3148-3156. [PMID: 34365738 DOI: 10.1002/ppul.25605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/06/2022]
Abstract
Carbon dioxide (CO2 ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO2 levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO2 (EtCO2 ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO2 measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO2 can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.
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Affiliation(s)
- Emma Williams
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291-326. [PMID: 33773829 DOI: 10.1016/j.resuscitation.2021.02.014] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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Sankaran D, Zeinali L, Iqbal S, Chandrasekharan P, Lakshminrusimha S. Non-invasive carbon dioxide monitoring in neonates: methods, benefits, and pitfalls. J Perinatol 2021; 41:2580-2589. [PMID: 34148068 PMCID: PMC8214374 DOI: 10.1038/s41372-021-01134-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/25/2021] [Accepted: 06/09/2021] [Indexed: 01/21/2023]
Abstract
Wide fluctuations in partial pressure of carbon dioxide (PaCO2) can potentially be associated with neurological and lung injury in neonates. Blood gas measurement is the gold standard for assessing gas exchange but is intermittent, invasive, and contributes to iatrogenic blood loss. Non-invasive carbon dioxide (CO2) monitoring has become ubiquitous in anesthesia and critical care and is being increasingly used in neonates. Two common methods of non-invasive CO2 monitoring are end-tidal and transcutaneous. A colorimetric CO2 detector (a modified end-tidal CO2 detector) is recommended by the International Liaison Committee on Resuscitation (ILCOR) and the American Academy of Pediatrics to confirm endotracheal tube placement. Continuous CO2 monitoring is helpful in trending PaCO2 in critically ill neonates on respiratory support and can potentially lead to early detection and minimization of fluctuations in PaCO2. This review includes a description of the various types of CO2 monitoring and their applications, benefits, and limitations in neonates.
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Affiliation(s)
- Deepika Sankaran
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA.
| | - Lida Zeinali
- grid.27860.3b0000 0004 1936 9684Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA USA
| | - Sameeia Iqbal
- grid.414164.20000 0004 0442 4003Division of Neonatology, Children’s Hospital of Orange County, Orange, CA USA
| | - Praveen Chandrasekharan
- grid.273335.30000 0004 1936 9887Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, NY USA
| | - Satyan Lakshminrusimha
- grid.27860.3b0000 0004 1936 9684Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA USA
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Blank DA, Badurdeen S, Omar F Kamlin C, Jacobs SE, Thio M, Dawson JA, Kane SC, Dennis AT, Polglase GR, Hooper SB, Davis PG. Baby-directed umbilical cord clamping: A feasibility study. Resuscitation 2018; 131:1-7. [PMID: 30036590 DOI: 10.1016/j.resuscitation.2018.07.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/25/2018] [Accepted: 07/20/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Over five percent of infants born worldwide will need help breathing after birth. Delayed cord clamping (DCC) has become the standard of care for vigorous infants. DCC in non-vigorous infants is uncommon because of logistical difficulties in providing effective resuscitation during DCC. In Baby-Directed Umbilical Cord Clamping (Baby-DUCC), the umbilical cord remains patent until the infant's lungs are exchanging gases. We conducted a feasibility study of the Baby-DUCC technique. METHODS We obtained antenatal consent from pregnant women to enroll infants born at ≥32 weeks. Vigorous infants received ≥2 min of DCC. If the infant received respiratory support, the umbilical cord was clamped ≥60 s after the colorimetric carbon dioxide detector turned yellow. Maternal uterotonic medication was administered after umbilical cord clamping. A paediatrician and researcher entered the sterile field to provide respiratory support during a cesarean birth. Maternal and infant outcomes in the delivery room and prior to hospital discharge were analysed. RESULTS Forty-four infants were enrolled, 23 delivered via cesarean section (8 unplanned) and 15 delivered vaginally (6 via instrumentation). Twelve infants were non-vigorous. ECG was the preferred method for recording HR. Two infants had a HR < 100 BPM. All HR values were >100 BPM by 80 s after birth. Median time to umbilical cord clamping was 150 and 138 s in vigorous and non-vigorous infants, respectively. Median maternal blood loss was 300 ml. CONCLUSIONS It is feasible to provide resuscitation to term and near-term infants during DCC, after both vaginal and cesarean births, clamping the umbilical cord only when the infant is physiologically ready.
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Affiliation(s)
- Douglas A Blank
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
| | - Shiraz Badurdeen
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
| | - C Omar F Kamlin
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia.
| | - Susan E Jacobs
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia.
| | - Marta Thio
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia.
| | - Jennifer A Dawson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia.
| | - Stefan C Kane
- The University of Melbourne, Department of Obstetrics and Gynecology, Melbourne, Australia; Pregnancy Research Centre, The Royal Women's Hospital, Melbourne, Australia.
| | - Alicia T Dennis
- The University of Melbourne, Department of Obstetrics and Gynecology, Melbourne, Australia; Department of Anaesthesia, The Royal Women's Hospital, Melbourne, Australia.
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia.
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Blank DA, Gaertner VD, Kamlin COF, Nyland K, Eckard NO, Dawson JA, Kane SC, Polglase GR, Hooper SB, Davis PG. Respiratory changes in term infants immediately after birth. Resuscitation 2018; 130:105-110. [PMID: 30003934 DOI: 10.1016/j.resuscitation.2018.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/12/2018] [Accepted: 07/08/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Over 5% of infants worldwide receive breathing support immediately after birth. Our goal was to define references ranges for exhaled carbon dioxide (ECO2), exhaled tidal volume (VTe), and respiratory rate (RR) immediately after birth in spontaneously breathing, healthy infants born at 36 weeks' gestational age or older. METHODS This was a single-centre, observational study at the Royal Women's Hospital in Melbourne, Australia, a busy perinatal referral centre. Immediately after the infant's head was delivered, we used a face mask to measure ECO2, VTe, and RR through the first ten minutes after birth. Respiratory measurements were repeated at one hour. RESULTS We analysed 14,731 breaths in 101 spontaneously breathing infants, 51 born via planned caesarean section and 50 born vaginally with a median (IQR) gestational age of 391/7 weeks (383/7-395/7). It took a median of 7 (4-10) breaths until ECO2 was detected. ECO2 quickly increased to peak value of 48 mmHg (43-53) at 143 s (76-258) after birth, and decreased to post-transitional values, 31 mmHg (28-24), by 7 min. VTe increased after birth, reaching a plateau of 5.3 ml/kg (2.5-8.4) by 130 s for the remainder of the study period. Maximum VTe was 19 ml/kg (16-22) at 257 s (82-360). RR values increased slightly over time, being higher from minute five to ten as compared to the first two minutes after birth. CONCLUSIONS This study provides reference ranges of exhaled carbon dioxide, exhaled tidal volumes, and respiratory rate for the first ten minutes after birth in term infants who transition without resuscitation.
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Affiliation(s)
- Douglas A Blank
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
| | - Vincent D Gaertner
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; School of Medicine, University Medical Center, Regensburg, Germany.
| | - C Omar F Kamlin
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
| | - Kevyn Nyland
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia.
| | - Neal O Eckard
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia.
| | - Jennifer A Dawson
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
| | - Stefan C Kane
- The University of Melbourne, Department of Obstetrics and Gynaecology, Australia; Department of Maternal Fetal Medicine, The Royal Women's Hospital, Melbourne, Australia.
| | - Graham R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
| | - Peter G Davis
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
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Schmölzer GM, Roehr CCC. WITHDRAWN: Techniques to ascertain correct endotracheal tube placement in neonates. Cochrane Database Syst Rev 2018; 7:CD010221. [PMID: 29975802 PMCID: PMC6513417 DOI: 10.1002/14651858.cd010221.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. OBJECTIVES To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. SELECTION CRITERIA We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. MAIN RESULTS We did not identify any studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.
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Affiliation(s)
- Georg M Schmölzer
- University of AlbertaDepartment of Pediatrics, Division of NeonatologyRoyal Alexandra Hospital, Rm. 418 CSC, 10240 Kingsway AveEdmontonABCanadaT5H 3V9
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Katheria A, Poeltler D, Durham J, Steen J, Rich W, Arnell K, Maldonado M, Cousins L, Finer N. Neonatal Resuscitation with an Intact Cord: A Randomized Clinical Trial. J Pediatr 2016; 178:75-80.e3. [PMID: 27574999 PMCID: PMC5527831 DOI: 10.1016/j.jpeds.2016.07.053] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/30/2016] [Accepted: 07/29/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess whether providing ventilation during delayed cord clamping (V-DCC) increases placental transfusion compared with delayed cord clamping alone (DCC only). STUDY DESIGN Inborn premature infants (230/7-316/7 weeks' gestational age) were randomized to receive at least 60 seconds of V-DCC (initial continuous positive airway pressure) with addition of positive pressure ventilation if needed) or without assisted ventilation (DCC only). For the DCC-only group, infants were dried and stimulated by gently rubbing the back if apneic. The primary outcome was the peak hematocrit in the first 24 hours of life. Delivery room outcomes were analyzed from video recordings and a data acquisition system. Hemodynamic measurements were performed with the use of functional echocardiography, near-infrared spectroscopy, and electrical cardiometry. RESULTS There was no difference in the primary outcome of peak hematocrit in the first 24 hours of life. The onset of breathing was similar between both groups (25 ± 20 and 27 ± 28 seconds, P = .627); however, infants receiving DCC received a greater duration of stimulation than V-DCC (41 ± 19 and 20 ± 21 seconds P = .002). There were no differences in delivery room interventions, early hemodynamics (cerebral oxygenation by near-infrared spectroscopy, cardiac output and stroke volume by electrical cardiometry, or superior vena cava flow by of functional echocardiography), or neonatal outcomes. CONCLUSIONS V-DCC was feasible but did not lead to any measurable clinical improvements immediately after delivery or reduce subsequent neonatal morbidity. Caretakers should consider providing adequate stimulation before cord clamping. TRIAL REGISTRATION ClinicalTrials.gov: NCT02231411.
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Affiliation(s)
- Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA.
| | - Debra Poeltler
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Jayson Durham
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Jane Steen
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Kathy Arnell
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Mauricio Maldonado
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Larry Cousins
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Neil Finer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
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Stabilisierung und Reanimation des Neugeborenen direkt nach der Geburt. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0045-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Wyllie J, Bruinenberg J, Roehr C, Rüdiger M, Trevisanuto D, Urlesberger B. Die Versorgung und Reanimation des Neugeborenen. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0090-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 564] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:249-63. [DOI: 10.1016/j.resuscitation.2015.07.029] [Citation(s) in RCA: 271] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mian Q, Cheung PY, O'Reilly M, Pichler G, van Os S, Kushniruk K, Aziz K, Schmölzer GM. Spontaneously Breathing Preterm Infants Change in Tidal Volume to Improve Lung Aeration Immediately after Birth. J Pediatr 2015; 167:274-8.e1. [PMID: 25998060 DOI: 10.1016/j.jpeds.2015.04.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/26/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine the temporal course of lung aeration at birth in preterm infants <33 weeks gestation. STUDY DESIGN The research team attended deliveries of preterm infants <33 weeks gestation at the Royal Alexandra Hospital. Infants who received only continuous positive airway pressure were eligible for inclusion. A combined carbon dioxide (CO2) and flow-sensor was placed between the mask and the ventilation device. To analyze lung aeration patterns during spontaneous breathing, tidal volume (VT), and exhaled CO2 (ECO2) were recorded for the first 100 breaths. RESULTS Thirty preterm infants were included with a total of 1512 breaths with mask leak <30%. Mean (SD) gestational age and birth weight was 30 (1) weeks and 1478 (430) g. Initial VT and ECO2 for the first 30 breaths was 5-6 mL/kg and 15-22 mm Hg, respectively. VT and ECO2 increased over the next 20 breaths to 7-8 mL/kg and 25-32 mm Hg, respectively. For the remaining observation period VT decreased to 4-6 mL/kg and ECO2 continued to increase to 35-37 mm Hg. CONCLUSIONS Preterm infants begin taking deeper breaths approximately 30 breaths after initiating spontaneous breathing to inflate their lungs. Concurrent CO2 removal rises as alveoli are recruited. Lung aeration occurs in 2 phases: initially, large volume breaths with poor alveolar aeration followed by smaller breaths with elimination of CO2 as a consequence of adequate aeration.
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Affiliation(s)
- Qaasim Mian
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Po-Yin Cheung
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Megan O'Reilly
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Gerhard Pichler
- Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Sylvia van Os
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
| | - Karin Kushniruk
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
| | - Khalid Aziz
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
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Schmölzer GM, Hooper SB, Wong C, Kamlin COF, Davis PG. Exhaled carbon dioxide in healthy term infants immediately after birth. J Pediatr 2015; 166:844-9.e1-3. [PMID: 25596099 DOI: 10.1016/j.jpeds.2014.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/13/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To measure exhaled carbon dioxide (ECO2) in term infants immediately after birth. STUDY DESIGN Infants >37 weeks gestation born at The Royal Women's Hospital, Melbourne, Australia were eligible. A combined flow sensor and mainstream carbon dioxide (CO2) analyzer was placed in series proximal to a facemask to measure ECO2 and tidal volumes in the first 120 seconds after birth. RESULTS Term infants (n = 20) with a mean (SD) birth weight of 2976 (697) g and gestational age of 38 (2) weeks were included. Infants took a median (range) 3 (1-8) breaths before ECO2 was detected. The median (range) of maximum ECO2 was 51 (40-73) mm Hg at 70 (21-106) seconds after birth. Within the first 10 breaths, CO2 increased from 0-27 (22-34) mm Hg. The median (IQR) tidal volume during the breaths without CO2 was 1.2 (0.8-3.1) mL/kg compared with 7.3 (3.2-10.9) mL/kg during the first 10 breaths where CO2 was exhaled. CONCLUSIONS The first breaths for an infant after birth did not contain ECO2. With aeration of the distal gas exchange regions, tidal volume and ECO2 significantly increased. ECO2 can be used to monitor lung aeration immediately after birth.
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Affiliation(s)
- Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; The Ritchie Center, Monash University, Melbourne, Australia; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Critical Care Stream, Murdoch Children Research Institute, Melbourne, Australia
| | | | - Connie Wong
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - C Omar F Kamlin
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Critical Care Stream, Murdoch Children Research Institute, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Australia
| | - Peter G Davis
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Critical Care Stream, Murdoch Children Research Institute, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Australia
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Blank D, Rich W, Leone T, Garey D, Finer N. Pedi-cap color change precedes a significant increase in heart rate during neonatal resuscitation. Resuscitation 2014; 85:1568-72. [PMID: 25236763 DOI: 10.1016/j.resuscitation.2014.08.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 08/19/2014] [Accepted: 08/21/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Heart rate is the most important indicator of infant well-being during neonatal resuscitation. The Nellcor Pedi-Cap turns gold when exposed to exhaled gas with CO₂>15 mmHg. The aim of this study was to determine if Pedi-Cap gold color change during neonatal resuscitation precedes an increase in heart rate in babies with bradycardia receiving mask ventilation. METHODS This was a single-center retrospective review of video recordings and physiologic data of newborns with bradycardia receiving mask positive pressure ventilation during neonatal resuscitation. Subjects were included if the baby's HR<100 BPM within the first 90 s of resuscitation. The primary outcome was the change in HR prior to Pedi-Cap gold color change compared to the HR after Pedi-Cap gold color change. RESULTS Forty-one newborns during the study period had HR<100 BPM and received mask positive pressure ventilation with a Pedi-Cap. The median heart rate 10s prior to Pedi-Cap gold color change was 75 BPM (IQR 62-85) and increased to 136 BPM (IQR 113-158) 30 s after gold color change (p<0.001). SpO₂ increased from 45 ± 17% prior to Pedi-Cap gold color change to 52 ± 17% 30s after gold color change (p=0.001). CONCLUSIONS Colorimetric CO₂ detection during mask positive pressure ventilation in neonatal resuscitation precedes a significant increase in heart rate and SpO₂. The Pedi-Cap can be easily applied during resuscitation, requires no electricity, provides immediate feedback and may be a useful, simple tool early in resuscitation and may be especially useful in resource limited settings.
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Affiliation(s)
- Doug Blank
- Division of Neonatology, UCSD Medical Center, University of California, San Diego, CA, USA.
| | - Wade Rich
- Division of Neonatology, UCSD Medical Center, University of California, San Diego, CA, USA
| | - Tina Leone
- Division of Neonatology, Columbia University, New York, NY, USA
| | - Donna Garey
- Division of Neonatology, UCSD Medical Center, University of California, San Diego, CA, USA
| | - Neil Finer
- Division of Neonatology, UCSD Medical Center, University of California, San Diego, CA, USA
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Abstract
BACKGROUND The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO2). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement. OBJECTIVES To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions. SELECTION CRITERIA We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO2 detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria. MAIN RESULTS We did not identify any studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.
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Affiliation(s)
- Georg M Schmölzer
- Department of Pediatrics, Division of Neonatology, University of Alberta, Royal Alexandra Hospital, Rm. 418 CSC, 10240 Kingsway Ave, Edmonton, AB, Canada, T5H 3V9
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van Os S, Cheung PY, Pichler G, Aziz K, O'Reilly M, Schmölzer GM. Exhaled carbon dioxide can be used to guide respiratory support in the delivery room. Acta Paediatr 2014; 103:796-806. [PMID: 24698203 DOI: 10.1111/apa.12650] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/04/2014] [Accepted: 04/01/2014] [Indexed: 11/30/2022]
Abstract
UNLABELLED Respiratory support in the delivery room remains challenging. Assessing chest rise is imprecise, and mask leak and airway obstruction are common problems. We describe recordings of respiratory signals during delivery room resuscitations and discuss guidance on positive-pressure ventilation using respiratory parameters and exhaled carbon dioxide (ECO2 ) during neonatal resuscitations. CONCLUSION Observing tidal volume and ECO2 waveforms adds objectivity to clinical assessments. ECO2 could help assess lung aeration and improve lung recruitment immediately after birth.
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Affiliation(s)
- Sylvia van Os
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
| | - Po-Yin Cheung
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Gerhard Pichler
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; Medical University Graz; Graz Austria
| | - Khalid Aziz
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Megan O'Reilly
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Georg M. Schmölzer
- Neonatal Research Unit; Alberta Health Services; Royal Alexandra Hospital; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
- Division of Neonatology; Department of Pediatrics; Medical University Graz; Graz Austria
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Hawkes GA, Kelleher J, Ryan CA, Dempsey EM. A review of carbon dioxide monitoring in preterm newborns in the delivery room. Resuscitation 2014; 85:1315-9. [PMID: 25086296 DOI: 10.1016/j.resuscitation.2014.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/14/2014] [Accepted: 07/18/2014] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements. AIM To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room. METHODS Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials. RESULTS The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B. DISCUSSION CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.
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Affiliation(s)
- G A Hawkes
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland
| | - J Kelleher
- Department of Neonatology, University Maternity Hospital Limerick, Ireland
| | - C A Ryan
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland
| | - E M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland.
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Kumar P, Yamada NK, Fuerch JH, Halamek LP. The neonatal resuscitation program: current recommendations and a look at the future. Indian J Pediatr 2014; 81:473-80. [PMID: 24652267 DOI: 10.1007/s12098-013-1332-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022]
Abstract
The Neonatal Resuscitation Program (NRP) consists of an algorithm and curriculum to train healthcare professionals to facilitate newborn infants' transition to extrauterine life and to provide a standardized approach to the care of infants who require more invasive support and resuscitation. This review discusses the most recent update of the NRP algorithm and recommended guidelines for the care of newly born infants. Current challenges in training and assessment as well as the importance of ergonomics in the optimization of human performance are discussed. Finally, it is recommended that in order to ensure high-performing resuscitation teams, members should be selected and retained based on objective performance criteria and frequent participation in realistic simulated clinical scenarios.
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Affiliation(s)
- Praveen Kumar
- Division of Newborn Medicine, Department of Pediatrics, Batson Children's Hospital, The University of Mississippi Medical Center, Jackson, MS, 39216-4505, USA,
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Hawkes GA, O'Connell BJ, Livingstone V, Hawkes CP, Ryan CA, Dempsey EM. Efficacy and user preference of two CO2 detectors in an infant mannequin randomized crossover trial. Eur J Pediatr 2013; 172:1393-9. [PMID: 23756915 DOI: 10.1007/s00431-013-2057-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 05/28/2013] [Indexed: 10/26/2022]
Abstract
Assessment of effective ventilation in neonatal mask ventilation can be difficult. This study aims to determine whether manual ventilation with a T-piece resuscitator containing an inline CO2 detector (either a Pedi-Cap® CO2 detector or a Neo-StatCO2 <Kg® CO2 detector connected to a facemask) facilitates effective positive pressure ventilation compared to no device in a mannequin study. Paediatric and neonatal trainees were randomly assigned to determine which method they began with (no device, Pedi-Cap or a Neo-Stat). The participants used each method for a period of 3 min. They were video-recorded to determine the amount of effective ventilations delivered and the overall percentage efficiency of each method. Efficacy of ventilation was determined by comparing the number of manual ventilations delivered with the number of times chest rise was observed in the video recording. There were 19 paediatric trainees who provided a total of 7,790 ventilations, and 93% were deemed effective. The percentage of effective ventilations with the T-piece resuscitator alone, the PediCap and the NeoStat were 90, 94 and 96%, respectively. The difference was greatest in the first minute (T-piece resuscitator alone 87.5%, PediCap 94%, NeoStat 96%). Two thirds preferred the Neo-Stat. The use of a CO2 detector improves positive pressure ventilation in a mannequin model, especially in the first minute of positive pressure ventilation. The Neo-Stat CO2 detector was the preferred device by the majority of the participants.
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Affiliation(s)
- G A Hawkes
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
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Nicoll J, O‘Reilly M, LaBossiere J, Lee T, Cowan S, Bigam D, Cheung P, Schmölzer G. Effect of cardiac output changes on exhaled carbon dioxide in newborn piglets. Resuscitation 2013; 84:1439-42. [DOI: 10.1016/j.resuscitation.2013.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 05/05/2013] [Accepted: 05/07/2013] [Indexed: 11/25/2022]
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Schmölzer GM, Bhatia R, Davis PG, Tingay DG. A comparison of different bedside techniques to determine endotracheal tube position in a neonatal piglet model. Pediatr Pulmonol 2013; 48:138-45. [PMID: 22615185 DOI: 10.1002/ppul.22580] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 03/06/2012] [Indexed: 12/22/2022]
Abstract
RATIONALE Endotracheal tube (ETT) malposition is common and an increasing number of non-invasive techniques to aid rapid identification of tube position are available. Electrical impedance tomography (EIT) is advocated as a tool to monitor ventilation. OBJECTIVE This study aimed to compare EIT with five other non-invasive techniques for identifying ETT position in a piglet model. METHODOLOGY Six saline lavage surfactant-depleted piglets were studied. Periods of ventilation with ETT placed in the oesophagus or a main bronchus (MB) were compared with an appropriately placed mid-tracheal ETT. Colorimetric end-tidal CO(2) (Pedi-Cap®), SpO(2) and heart rate, tidal volume (${\rm V}_{{\rm T}_{{\rm ao}} } $) using a hot-wire anemometer at the airway opening, tidal volume using respiratory inductive plethysmography (${\rm V}_{{\rm T}_{{\rm RIP}} } $) and regional tidal ventilation within each hemithorax (EIT) were measured. RESULTS Oesophageal ventilation: Pedi-Cap® demonstrated absence of color change. ${\rm V}_{{\rm T}_{{\rm ao}} } $, ${\rm V}_{{\rm T}_{{\rm RIP}} } $, and EIT correctly demonstrated no tidal ventilation. SpO(2) decreased from mean (SD) 96 (2)% to 74 (12)% (P < 0.05; Bonferroni post-test), without heart rate change. MB ventilation: SpO(2) , heart rate and Pedi-Cap® were unchanged compared with mid-tracheal position. ${\rm V}_{{\rm T}_{{\rm ao}} } $ and ${\rm V}_{{\rm T}_{{\rm RIP}} } $ decreased from a mean (SD) 10.8 (5.6) ml/kg and 14.6 (6.2) ml/kg to 5.5 (1.9) ml/kg and 6.4 (2.6) ml/kg (both P < 0.05; Bonferroni post-test). EIT identified the side of MB ventilation, with a mean (SD) 95 (3)% reduction in tidal volume in the unventilated lung. CONCLUSIONS EIT not only correctly identified oesophageal ventilation but also localized the side of MB ventilation. At present, no one technique is without limitations and clinicians should utilize a combination in addition to clinical judgement.
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Affiliation(s)
- Georg M Schmölzer
- Neonatal Research, Murdoch Childrens Research Institute, Melbourne, Australia.
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Schmölzer GM, O'Reilly M, Davis PG, Cheung PY, Roehr CC. Confirmation of correct tracheal tube placement in newborn infants. Resuscitation 2012; 84:731-7. [PMID: 23211476 DOI: 10.1016/j.resuscitation.2012.11.028] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 11/26/2012] [Accepted: 11/26/2012] [Indexed: 11/29/2022]
Abstract
Tracheal intubation remains a common procedure during neonatal intensive care. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes. The current gold standard test to confirm tube position is a chest radiograph, however this is often delayed until after ventilation has commenced. Hence, point of care methods to confirm correct tube placement have been developed. The aim of this article is to review the available literature on tube placement in newborn infants. We reviewed books, resuscitation manuals and articles from 1830 to the present with the search terms "Infant, Newborn", "Endotracheal intubation", "Resuscitation", "Clinical signs", "Radiography", "Respiratory Function Tests", "Laryngoscopy", "Ultrasonography", and "Bronchoscopy". Various techniques have been studied to help clinicians assess tube placement. However, despite 85 years of clinical practice, the search for higher success rates and quicker intubation continues. Currently, chest radiography remains the gold standard test to confirm tube position. However, rigorous evaluation of new techniques is required to ensure the safety of newborn infants.
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Hawkes CP, Ryan CA, Dempsey EM. Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: A qualitative review. Resuscitation 2012; 83:797-802. [DOI: 10.1016/j.resuscitation.2011.12.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 10/14/2022]
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Delivery room resuscitation of preterm infants in Canada: current practice and views of neonatologists at level III centers. J Perinatol 2012; 32:491-7. [PMID: 21941233 DOI: 10.1038/jp.2011.128] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To explore physicians' experiences and views related to resuscitation practice of preterm infants at birth, and determine whether the Canadian modifications of 2006 Neonatal Resuscitation Program (NRP) guidelines have been accepted by neonatologists. STUDY DESIGN Neonatologists (n=146) at 25 tertiary neonatal intensive care units (NICUs) across Canada were contacted via email to participate in a web-based survey about their practice regarding resuscitation of preterm infants in the delivery room (DR). RESULT In all, 78 respondents (53%) from 23 centres completed the survey. Participants reported significant variability in temperature control measures. Hypothermia, <36.5 °C on NICU admission, was reported by 49% of respondents. Room air is used by 59% of respondents to initiate resuscitation. The majority (91%) of participants use pulse oximetry to titrate oxygen administration. Although more than two thirds (69%) of respondents target an oxygen saturation range of 85 to 92%, 51% of respondents would allow 5 to 10 min for the oxygen saturation to reach the target level. Carbon dioxide detectors are commonly used to confirm endotracheal tube placement (90%). Although respondents (96%) agree on the use of positive end- expiratory pressure (PEEP), when providing positive pressure ventilation (PPV), only 60% would initiate PPV with a pre-set peak inspiratory pressure, mostly 20 cm H(2)O. CONCLUSION DR resuscitation practices are highly variable in Canadian NICU's and the currently recommended NRP guidelines are not uniformly followed. Factors leading to variability and discordance in practice should be investigated to facilitate better compliance.
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Schmölzer G, Resch B, Schwindt JC. Standards zur Versorgung von reifen Neugeborenen in Österreich. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2472-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Schmölzer GM, Poulton DA, Dawson JA, Kamlin COF, Morley CJ, Davis PG. Assessment of flow waves and colorimetric CO2 detector for endotracheal tube placement during neonatal resuscitation. Resuscitation 2010; 82:307-12. [PMID: 21167628 DOI: 10.1016/j.resuscitation.2010.11.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 10/26/2010] [Accepted: 11/09/2010] [Indexed: 11/28/2022]
Abstract
AIM Clinical assessment and end-tidal CO(2) (ETCO(2)) detectors are routinely used to verify endotracheal tube (ETT) placement. However, ETCO(2) detectors may mislead clinicians by failing to identify correct placement under a variety of conditions. A flow sensor measures gas flow in and out of an ETT. We reviewed video recordings of neonatal resuscitations to compare a colorimetric CO(2) detector (Pedi-Cap®) with flow sensor recordings for assessing ETT placement. METHODS We reviewed recordings of infants <32 weeks gestation born between February 2007 and January 2010. Airway pressures and gas flow were recorded with a respiratory function monitor. Video recording were used (i) to identify infants who were intubated in the delivery room and (ii) to observe colour change of the ETCO(2) detector. Flow sensor recordings were used to confirm whether the tube was in the trachea or not. RESULTS Of the 210 infants recorded, 44 infants were intubated in the delivery room. Data from 77 intubation attempts were analysed. In 35 intubations of 20 infants both a PediCap® and flow sensor were available for analysis. In 21 (60%) intubations, both methods correctly identified successful ETT placement and in 3 (9%) both indicated the ETT was not in the trachea. In the remaining 11 (31%) intubations the PediCap® failed to change colour despite the flow wave indicating correct ETT placement. CONCLUSION Colorimetric CO(2) detectors may mislead clinicians intubating very preterm infants in the delivery room. They may fail to change colour in spite of correct tube placement in up to one third of the cases.
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Affiliation(s)
- Georg M Schmölzer
- Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.
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Roehr CC, Gröbe S, Rüdiger M, Hummler H, Nelle M, Proquitté H, Hammer H, Schmalisch G. Delivery room management of very low birth weight infants in Germany, Austria and Switzerland--a comparison of protocols. Eur J Med Res 2010; 15:493-503. [PMID: 21159574 PMCID: PMC3352658 DOI: 10.1186/2047-783x-15-11-493] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 10/26/2010] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Surveys from the USA, Australia and Spain have shown significant inter-institutional variation in delivery room (DR) management of very low birth weight infants (VLBWI, <1500g) at birth, despite regularly updated international guidelines. OBJECTIVE To investigate protocols for DR management of VLBWI in Germany, Austria and Switzerland and to compare these with the 2005 ILCOR guidelines. METHODS DR management protocols were surveyed in a prospective, questionnaire-based survey in 2008. Results were compared between countries and between academic and non-academic units. Protocols were compared to the 2005 ILCOR guidelines. RESULTS In total, 190/249 units (76%) replied. Protocols for DR management existed in 94% of units. Statistically significant differences between countries were found regarding provision of 24 hr in house neonatal service; presence of a designated resuscitation area; devices for respiratory support; use of pressure-controlled manual ventilation devices; volume control by respirator; and dosage of Surfactant. There were no statistically significant differences regarding application and monitoring of supplementary oxygen, or targeted saturation levels, or for the use of sustained inflations. Comparison of academic and non-academic hospitals showed no significant differences, apart from the targeted saturation levels (SpO2) at 10 min. of life. Comparison with ILCOR guidelines showed good adherence to the 2005 recommendations. SUMMARY Delivery room management in German, Austrian and Swiss neonatal units was commonly based on written protocols. Only minor differences were found regarding the DR setup, devices used and the targeted ranges for SpO2 and FiO2. DR management was in good accordance with 2005 ILCOR guidelines, some units already incorporated evidence beyond the ILCOR statement into their routine practice.
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Affiliation(s)
- C C Roehr
- Department of Neonatology, Charité Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany.
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Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, Guinsburg R, Hazinski MF, Morley C, Richmond S, Simon WM, Singhal N, Szyld E, Tamura M, Velaphi S. Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S516-38. [PMID: 20956259 DOI: 10.1161/circulationaha.110.971127] [Citation(s) in RCA: 458] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon WM, Weiner GM, Wyckoff M, Zaichkin J. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S909-19. [PMID: 20956231 DOI: 10.1161/circulationaha.110.971119] [Citation(s) in RCA: 324] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, Guinsburg R, Hazinski MF, Morley C, Richmond S, Simon WM, Singhal N, Szyld E, Tamura M, Velaphi S. Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1319-44. [PMID: 20956431 DOI: 10.1542/peds.2010-2972b] [Citation(s) in RCA: 210] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon WM, Weiner GM, Wyckoff M, Zaichkin J. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010; 126:e1400-13. [PMID: 20956432 DOI: 10.1542/peds.2010-2972e] [Citation(s) in RCA: 268] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Wyllie J, Perlman JM, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, Guinsburg R, Hazinski MF, Morley C, Richmond S, Simon WM, Singhal N, Szyld E, Tamura M, Velaphi S. Part 11: Neonatal resuscitation. Resuscitation 2010; 81 Suppl 1:e260-87. [DOI: 10.1016/j.resuscitation.2010.08.029] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Resuscitation is one of the most frequently performed procedures in the neonatal period. Since the most recent guidelines from the International Liaison Committee on Resuscitation (ILCOR) appeared in 2005, experimental and clinical research has introduced changes regarding the different components of the procedure, with the common denominator being the least aggressive to the baby. Babies should be kept warm, avoiding suctioning as a general rule, adjusting pressure, volume and oxygen to the minimum to achieve stabilisation without causing harm to the airways or oxidative stress, and applying all the available technology in the delivery room before transportation to the neonatal intensive care unit. The response to ventilation should primarily be assessed by the heart rate. Babies of gestational age >or=32 weeks should be ventilated initially with 21% oxygen and if <32 weeks with 21-30% oxygen. Intubation, chest compressions, use of drugs or volume therapy are rarely needed in term or near term babies in need of resuscitation. The first minutes of life are decisive, and what we do during these minutes will have unequivocal influence later on.
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Affiliation(s)
- M Vento
- Neonatal Research Unit, Division of Neonatology, University Hospital La Fe, E 46009 Valencia, Spain.
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Schmölzer G, Hooper S, Crossley K, Allison B, Morley C, Davis P. Assessment of gas flow waves for endotracheal tube placement in an ovine model of neonatal resuscitation. Resuscitation 2010; 81:737-41. [DOI: 10.1016/j.resuscitation.2010.02.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 02/09/2010] [Accepted: 02/17/2010] [Indexed: 11/28/2022]
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Finer NN, Rich W, Wang C, Leone T. Airway obstruction during mask ventilation of very low birth weight infants during neonatal resuscitation. Pediatrics 2009; 123:865-9. [PMID: 19255015 DOI: 10.1542/peds.2008-0560] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The delivery of adequate but not excessive ventilation remains one of the most common problems encountered during neonatal resuscitation, especially in the very low birth weight infant. Our observations suggest that airway obstruction is a common occurrence after delivery of such infants, and we use colorimetric carbon dioxide detectors during bag-and-mask resuscitation to assist in determining whether the airway was patent. We reviewed our experience to determine the frequency of the occurrence of recognizable airway obstruction during resuscitation of very low birth weight infants. METHODS AND PATIENTS The previous prospective trial randomly assigned preterm infants <32 weeks' gestation to resuscitation with either room air or 100% oxygen using pulse oximetry. Colorimetric carbon dioxide detectors were used to assist with bag-and-mask ventilation and to confirm intubation. From the video recordings, the number of positive pressure breaths without a color change in the detector until the breaths were associated with an unequivocal color change was counted as obstructed breaths. From the analog tracings, the number of breaths that had a peak pressure plateau of >/=0.2 second and were not associated with a color change was recorded as the number of obstructed breaths. RESULTS None of the studied infants required cardiopulmonary resuscitation or received epinephrine, and all were judged to have an effective circulation during resuscitation. Six of the 24 infants enrolled in the trial received only continuous positive airway pressure. The remaining 18 infants received a median of 14 obstructed breaths (range: 4-37 breaths) delivered over a mean and median interval of 56.7 and 45.0 seconds, respectively (range: 10.0-220.0 seconds). A subgroup of 11 infants was analyzed using airway-pressure data. The target peak inspiratory pressure was 30 cm H(2)O. Ten of these 11 infants had obstructed breaths as defined by no change in the PediCap despite reaching the target pressure for >/=0.2 second. CONCLUSION Airway obstruction occurs in the majority of the very low birth weight infants who receive ventilation with a face mask during resuscitation and the use of a colorimetric detector can facilitate its recognition and management.
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Affiliation(s)
- Neil N Finer
- UCSD Medical Center, 402 W Dickenson St 8774, San Diego, CA 92103-8774, USA.
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