Khalid Aziz

Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.

### Newborn TransitionnnThe transition from intrauterine to extrauterine life that occurs at the time of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transition is brought about by initiation of air breathing and cessation of the placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-well-oxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the low-resistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting across the ductus arteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption.nnApproximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after positive-pressure ventilation (PPV), 2% will be intubated to support respiratory function, and 0.1% will require chest compressions and/or epinephrine to achieve this transition.1–3 Although the vast majority of newborn infants do not require intervention to make these transitional changes, the large number of births worldwide means that many infants require some assistance to achieve cardiorespiratory stability each year.nnNewly born infants who are breathing or crying and have good tone immediately after birth must be dried and kept warm so as to avoid hypothermia. These actions can be provided with the baby lying on the mother’s chest and should not require separation of mother and baby. This does not preclude the need for clinical assessment of the baby. …

Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

The following guidelines are a summary of the evidence presented in the 2015 International Consensus on Cardiopulmo nary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR).1,2 Throughout the online version of this publication, live links are provided so the reader can connect directly to systematic reviews on the International Liaison Committee on Resuscitation (ILCOR) Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, NRP 787). We encourage readers to use the links and review the evidence and appendices.nnThese guidelines apply primarily to newly born infants transitioning from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed newborn transition and require resuscitation during the first weeks after birth.3 Practitioners who resuscitate infants at birth or at any time during the initial hospitalization should consider following these guidelines. For purposes of these guidelines, the terms newborn and neonate apply to any infant during the initial hospitalization. The term newly born applies specifically to an infant at the time of birth.3nnImmediately after birth, infants who are breathing and crying may undergo delayed cord clamping (see Umbilical Cord Management section). However, until more evidence is available, infants who are not breathing or crying should have the cord clamped (unless part of a delayed cord clamping research protocol), so that resuscitation measures can commence promptly.nnApproximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitation measures,4 such as cardiac compressions and medications. Although most newly born infants successfully transition from intrauterine to extrauterine life without special help, because of the large total number of births, a significant number will require some degree of resuscitation.3nnNewly born infants who do not …

Improved outcome of preterm infants when delivered in tertiary care centers.

OBJECTIVE Previous studies that compared outcomes of infants born outside tertiary care centers (outborn) with those born in tertiary care centers (inborn) did not account for admission illness severity and perinatal risks. The objective of this study was to examine whether outborn status is associated with higher mortality and morbidity, after adjustment for perinatal risks and admission illness severity (using the Score for Neonatal Acute Physiology, Version II [SNAP‐II]) among preterm infants who were admitted to Neonatal Intensive Care Units (NICUs). METHODS Logistic regression analysis was used to compare the risk‐adjusted outcomes of 3769 singleton infants born at or before 32 weeks gestation, who were admitted to 17 Canadian NICUs during 1996–1997. RESULTS Outborn and inborn infants had significantly different gestational ages, perinatal risk factors (maternal hypertension, prenatal care, antenatal corticosteroid therapy, 5‐minute Apgar score, delivery type, small for gestational age) and admission SNAP‐II. Outborn infants were at higher risk of death (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2, 2.5), grade III or IV intraventricular hemorrhage (adjusted OR 2.2, 95% CI 1.5, 3.2), patent ductus arteriosus (adjusted OR 1.6, 95% CI 1.2, 2.1), respiratory distress syndrome (adjusted OR 4.8, 95% CI 3.6, 6.3), and nosocomial infection (adjusted OR 2.5, 95% CI 1.9, 3.3), even after adjusting for perinatal risks and admission illness severity. CONCLUSIONS Outborn infants were less mature and more ill than inborn infants at NICU admission. However, even after adjustment for perinatal risks and admission illness severity, inborn infants had better outcomes than outborn infants. Our results support in‐utero transfer of high‐risk pregnancies to a tertiary level facility.

A double-masked, randomized control trial of iron supplementation in early infancy in healthy term breast-fed infants

OBJECTIVESnTo test whether iron supplementation affects hematologic, biochemical, and developmental status in term breast-fed infants.nnnSTUDY DESIGNnTerm breast-fed infants (n=77) were randomly selected to receive either 7.5 mg per day of elemental iron as ferrous sulfate or placebo from 1 to 6 months of age. Investigators and families were unaware of group assignment. Complete blood count and ferritin, red cell superoxide dismutase, catalase, plasma ferric reducing antioxidant power, and zinc and copper levels were analyzed at 1, 3.5, 6, and 12 months of age. Bayley mental and psychomotor developmental indexes (MDI and PDI) and visual acuity (with the use of Teller acuity cards) were assessed from 12 to 18 months of age. Analysis performed by analysis of variance and t tests was by intention to treat.nnnRESULTSnIron supplementation resulted in higher hemoglobin and mean corpuscular volume at 6 months of age and significantly higher visual acuity and PDI at 13 months of age (100+/-12 vs 93+/-9 [+/-SD]). Treatment and placebo groups did not differ in anthropometric indexes, compliance, biochemical status, or demographic characteristics.nnnCONCLUSIONSnIron supplementation of breast-fed infants appears safe and might have beneficial hematologic and developmental effects for some infants.

Part 7: Neonatal resuscitation

### Newborn TransitionnnThe transition from intrauterine to extrauterine life that occurs at the time of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transition is brought about by initiation of air breathing and cessation of the placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-well-oxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the low-resistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting across the ductus arteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption.nnApproximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after positive-pressure ventilation (PPV), 2% will be intubated to support respiratory function, and 0.1% will require chest compressions and/or epinephrine to achieve this transition.1–3 Although the vast majority of newborn infants do not require intervention to make these transitional changes, the large number of births worldwide means that many infants require some assistance to achieve cardiorespiratory stability each year.nnNewly born infants who are breathing or crying and have good tone immediately after birth must be dried and kept warm so as to avoid hypothermia. These actions can be provided with the baby lying on the mother’s chest and should not require separation of mother and baby. This does not preclude the need for clinical assessment of the baby. …

Evaluation of the effect of a computerized training simulator (ANAKIN) on the retention of neonatal resuscitation skills.

Background: Neonatal resuscitation knowledge and skills deteriorate after initial training. Purpose: To evaluate the effectiveness of a computerized simulator system (ANAKIN) as a means for boosting neonatal resuscitation knowledge, skills, and self-reported confidence beliefs. Method: A randomized pretest-posttest control group study design involving 60 3rd-year medical students. At a 4-month, post-training interval, experimental group was exposed to ANAKIN and control group to a training video. Both groups assessed at an 8-month, post-neonatal resuscitation training interval. Results: Knowledge level for both groups decreased significantly at 4- and 8-month, post-training intervals despite booster exposure. Confidence level for both study groups increased significantly following booster exposure. However, no significant difference between study group skill levels at 8 months and no significant relation between neonatal resuscitation knowledge, confidence, or skills. Conclusion: Computerized simulator system was as effective as video for maintaining resuscitation skills of medical students, and students were very satisfied with experience of remote computer simulation training.

Variations in rates of nosocomial infection among Canadian neonatal intensive care units may be practice-related

BackgroundNosocomial infection (NI), particularly with positive blood or cerebrospinal fluid bacterial cultures, is a major cause of morbidity in neonatal intensive care units (NICUs). Rates of NI appear to vary substantially between NICUs. The aim of this study was to determine risk factors for NI, as well as the risk-adjusted variations in NI rates among Canadian NICUs.MethodsFrom January 1996 to October 1997, data on demographics, intervention, illness severity and NI rates were submitted from 17 Canadian NICUs. Infants admitted at <4 days of age were included. NI was defined as a positive blood or cerebrospinal fluid culture after > 48 hrs in hospital.Results765 (23.5%) of 3253 infants <1500 g and 328 (2.5%) of 13228 infants ≥1500 g developed at least one episode of NI. Over 95% of episodes were due to nosocomial bacteremia. Major morbidity was more common amongst those with NI versus those without. Mortality was more strongly associated with NI versus those without for infants ≥1500 g, but not for infants <1500 g. Multiple logistic regression analysis showed that for infants <1500 g, risk factors for NI included gestation <29 weeks, outborn status, increased acuity on day 1, mechanical ventilation and parenteral nutrition. When NICUs were compared for babies <1500 g, the odds ratios for NI ranged from 0.2 (95% confidence interval [CI] 0.1 to 0.4) to 8.6 (95% CI 4.1 to 18.2) when compared to a reference site. This trend persisted after adjustment for risk factors, and was also found in larger babies.ConclusionRates of nosocomial infection in Canadian NICUs vary considerably, even after adjustment for known risk factors. The implication is that this variation is due to differences in clinical practices and therefore may be amenable to interventions that alter practice.

The Development and Testing of a Performance Checklist to Assess Neonatal Resuscitation Megacode Skill

PURPOSE. The purpose of this work was to develop and assess the feasibility, reliability, and validity of a brief performance checklist to evaluate skills during a simulated neonatal resuscitation (“megacode”) for the Neonatal Resuscitation Program of the American Academy of Pediatrics. METHODS. A performance checklist of items was created, validated, and modified in sequential phases involving: an expert committee, review, and feedback by Neonatal Resuscitation Program instructors for feasibility and criticality and use of the performance checklist by Neonatal Resuscitation Program instructors reviewing videotaped megacodes. The final 20-item performance checklist used a 3-point scale and was assessed by student and instructor volunteers. Megacode scores, the NRP multiple-choice examination scores, student assessments of their ability and performance, and sociodemographic descriptors for both students and instructors were collected. Data were analyzed descriptively. In addition, we assessed the megacode score internal consistency reliability, the correlations between megacode and multiple-choice examination scores, and the variance in scores based on instructor and student characteristics. RESULTS. A total of 468 students and 148 instructors volunteered for the study. The instrument was reliable and internally consistent. Students scores were high on most items. There was a significant but low correlation between the megacode score and the written knowledge examination. Instructor and student characteristics had little effect on the variance in scores. CONCLUSIONS. This performance checklist provides a feasible assessment tool. There is evidence for its reliability and validity.

Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint)

Reprint: The American Heart Association requests that this document be cited as follows: Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, Liley HG, Mildenhall L, Simon WM, Szyld E, Tamura M, Velaphi S; on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 7: neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation . 2015;132(suppl 1):S204–S241.nnReprinted with permission of the American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation. This article has been published in Circulation and Resuscitation .nn(Circulation. 2015;132[suppl 1]:S204–S241. DOI: 10.1161/CIR.0000000000000276.) nn### Newborn TransitionnnThe transition from intrauterine to extrauterine life that occurs at the time of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transition is brought about by initiation of air breathing and cessation of the placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-well-oxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the low-resistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting across the ductus arteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption.nnApproximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after positive-pressure ventilation (PPV), 2% will be intubated to support respiratory function, and 0.1% will require chest compressions and/or epinephrine to achieve this transition.1–3 …

Part 13: Neonatal resuscitation 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care (Reprint)

Reprint: The American Heart Association requests that this document be cited as follows: Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, Simon WM, Weiner GM, Zaichkin, JG. Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S543–S560.nnReprinted with permission of the American Heart Association, Inc. This article has been co-published in Circulation .nnThe following guidelines are a summary of the evidence presented in the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR).1,2 Throughout the online version of this publication, live links are provided so the reader can connect directly to systematic reviews on the International Liaison Committee on Resuscitation (ILCOR) Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, NRP 787). We encourage readers to use the links and review the evidence and appendices.nnThese guidelines apply primarily to newly born infants transitioning from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed newborn transition and require resuscitation during the first weeks after birth.3 Practitioners who resuscitate infants at birth or at any time during the initial hospitalization should consider following these guidelines. For purposes of these guidelines, the terms newborn and neonate apply to any infant during the initial hospitalization. The term newly born applies specifically to an infant at the time of birth.3nnImmediately after birth, infants who are breathing and crying may undergo delayed cord clamping (see Umbilical Cord Management section). However, until more evidence is available, infants who are not breathing or crying should have the cord clamped (unless part of a delayed cord clamping research protocol), so that resuscitation measures can …