C. P. F. O'donnell

Oxygen saturation and heart rate during delivery room resuscitation of infants <30 weeks gestation with air or 100% oxygen.

Background: Because of concerns about harmful effects of 100% oxygen on newborn infants, air has started to be used for resuscitation in the delivery room. Objective: To describe changes in preductal oxygen saturation (Spo2) and heart rate (HR) in the first 10 min after birth in very preterm infants initially resuscitated with 100% oxygen (OX100) or air (OX21). Patients and methods: In July 2006, policy changed from using 100% oxygen to air. Observations of Spo2 and HR before and after the change were recorded whenever a member of the research team was available to attend the birth. Results: There were 20 infants in the OX100 group and 106 in the OX21 group. In the OX100 group, Spo2 had risen to a median of 84% after 2 min and 94% by 5 min. In the OX21 group, median Spo2 was 31% at 2 min and 54% at 5 min. In the OX21 group, 92% received supplemental oxygen at a median of 5 min; the Spo2 rose to a median of 81% by 6 min. In the first 10 min after birth, 80% and 55% of infants in the OX100 and OX21 groups, respectively, had an Spo2 ⩾95%. Increases in HR over the first 10 min were very similar in the two groups. Conclusions: Most very preterm infants received supplemental oxygen if air was used for the initial resuscitation. In these infants, the use of backup 100% oxygen and titration against Spo2 resulted in a similar course to “normal” term and preterm infants. Of the infants resuscitated with 100% oxygen, 80% had Spo2 ⩾95% during the first 10 min. The HR changes in the two groups were very similar.

Positive pressure ventilation at neonatal resuscitation: review of equipment and international survey of practice

Background: The equipment used to provide positive pressure ventilation to newborns needing resuscitation at delivery varies between institutions. Devices were reviewed and their use surveyed in a sample of neonatal centres worldwide. Aim: To determine which equipment is used to resuscitate newborns at delivery in a sample of teaching hospitals around the world. Methods: A questionnaire was sent via e‐mail to a neonatologist at each of 46 NICUs in 23 countries on five continents, asking which resuscitation equipment they used. If it was not returned, follow‐up was by e‐mail. Results: Data were obtained from 40 (87%) centres representing 19 countries. Round face masks are used at 34 (85%) centres, anatomically shaped masks are used exclusively at six (15%) and a mixture of types are used at 11 (28%). Straight endotracheal tubes are used exclusively at 36 (90%) centres; shouldered tubes are used infrequently at three of the four centres that have them. The self‐inflating bag is the most commonly used manual ventilation device (used at 33 (83%) centres), the Laerdal Infant Resuscitator± the most popular model. Flow‐inflating bags are used at 10 (25%) centres. The Neopuff Infant Resuscitator± is used at 12 (30%) centres. Varying oxygen concentrations are provided during neonatal resuscitation at half of the centres, while 100% oxygen is routinely used at the other half.

Pulse oximetry for monitoring infants in the delivery room: a review

During the first few minutes of life, oxygen saturation (saturation by pulse oximetry, SpO2) increases from intrapartum levels of 30–40%.1 In algorithms for neonatal resuscitation published by the International Liaison Committee for Resuscitation,2 European Resuscitation Council3 and Australian Resuscitation Council,4 clinical assessment of an infant’s colour (a measure of oxygenation) and heart rate are used as major action points. However, studies have shown that clinical assessment of colour during neonatal transition is unreliable.5,6 O’Donnell et al 6 showed that the SpO2 at which observers perceived infants to be pink varied widely, ranging from 10% to 100%. Assessing colour is difficult and therefore is a poor proxy for tissue oxygenation during the first few minutes of life.nnKattwinkel7 suggested pulse oximetry may help achieve normoxia in the delivery room. The American Heart Association8 suggests that “administration of a variable concentration of oxygen guided by pulse oximetry may improve the ability to achieve normoxia more quickly”. Although “normoxia” and an acceptable time to achieve this during neonatal transition have not been defined, Leone and Finer9 advocate a target “SpO2 of 85 to 90% by three minutes after birth for all infants except in special circumstances”—for example, diaphragmatic hernia or cyanotic congenital heart disease. International surveys show that oximetry is increasingly used during neonatal resuscitation.10,11nnTo date, there are no evidence-based guidelines for using oximetry to measure an infant’s SpO2 and to guide interventions during neonatal transition after birth. We reviewed the literature to evaluate the evidence on the use of SpO2 measurements immediately after birth.nnPulse oximetry measures SpO2 continuously and non-invasively, without the need for calibration, and correlates closely with arterial oxygen saturation.12 Pulse oximetry is based on the red and infrared light-absorption …

Neonatal resuscitation 1: a model to measure inspired and expired tidal volumes and assess leakage at the face mask

Background: Neonatal resuscitation is a common and important intervention, and adequate ventilation is the key to success. In the delivery room, positive pressure ventilation is given with manual ventilation devices using face masks. Mannequins are widely used to teach and practise this technique. During both simulated and real neonatal resuscitation, chest excursion is used to assess tidal volume delivery, and leakage from the mask is not measured. Objective: To describe a system that allows measurement of mask leakage and estimation of tidal volume delivery. Methods: Respiratory function monitors, a modified resuscitation mannequin, and a computer were used to measure leakage from the mask and to assess tidal volume delivery in a model of neonatal resuscitation. Results: The volume of gas passing through a flow sensor was measured at the face mask. This was a good estimate of the tidal volume entering and leaving the lung in this model. Gas leakage between the mask and mannequin was also measured. This occurred principally during inflation, although gas leakage during deflation was seen when the total leakage was large. A volume of gas that distended the mask but did not enter the lung was also measured. Conclusion: This system can be used to assess the effectiveness of positive pressure ventilation given using a face mask during simulated neonatal resuscitation. It could be useful for teaching neonatal resuscitation and assessing ventilation through a face mask.

Neonatal resuscitation: review of ventilation equipment and survey of practice in Australia and New Zealand.

Objective:u2003 The equipment used to provide positive pressure ventilation at neonatal resuscitation varies between institutions. Available devices were reviewed and their use surveyed in a geographically defined region. The aim of this study was to establish which resuscitation equipment is used at neonatal intensive care units in Australia and New Zealand.

Ethical and legal aspects of video recording neonatal resuscitation

Neonatal resuscitation is a common and important intervention. It is also a stressful and sometimes chaotic experience. Recollections of events may be inaccurate and teaching and learning in such circumstances are difficult. Video can accurately document events during delivery room (DR) resuscitation; it can therefore be used to assess compliance with guidelines and the effect of interventions.nnIn many hospitals photographs or video recordings of infants can only be made with written parental permission. It is difficult and may be inappropriate to prospectively obtain parental permission to video all DR resuscitations. When a high-risk delivery is imminent, parents are invariably anxious and mothers may be in pain or unwell. They may thus be unable to give permission appropriately. If previous permission is needed, it is only possible to record resuscitations where there is considerable advance warning. This seriously limits the applicability of the findings because infants born after an unanticipated emergency, likely to be the most ill and thus of most interest, are excluded.nnWe wished to audit the care given to newborns in the DRs of our hospital. Here, we describe the ethical and legal issues we encountered before we commenced recording DR resuscitations at our hospital.nnAudit is the testing of current practice against previously established guidelines or benchmarks; this contrasts with research, which is aimed at the discovery of new knowledge that is intended ultimately to help establish guidelines. In general, previous informed consent of participants is a prerequisite for research, but not for audit. Quality assurance activities are an integral part of healthcare delivery.1 Healthcare providers recognise the need to ensure that their service is of a high quality and consistent with available resources; and that not to do so is unethical.2 First reported in the 1960s,3 videotaping emergency medical procedures has long …

Pinching, electrocution, ravens' beaks, and positive pressure ventilation: a brief history of neonatal resuscitation.

Since ancient times many different methods have been used to revive newborns. Although subject to the vagaries of fashion for 2000 years, artificial respiration has been accepted as the mainstay of neonatal resuscitation for about the last 40. Formal teaching programmes have evolved over the last 20 years. The last 10 years have seen international collaboration, which has resulted in careful evaluation of the available evidence and publication of recommendations for clinical practice. There is, however, little evidence to support current recommendations, which are largely based on expert opinion. The challenge for neonatologists today is to gather robust evidence to support or refute these recommendations, thereby refining this common and important intervention.

Free-flow oxygen delivery to newly born infants

Resuscitation guidelines recommend administration of free-flow oxygen to newly born infants who breathe but remain cyanosed. Self-inflating resuscitation bags are described as unreliable for this purpose. We measured oxygen concentrations ⩾80% delivered through a 240 mL Laerdal self-inflating resuscitation bag and from 5 mm tubing inside a cupped hand.