Tina A. Leone

Resuscitation of Preterm Neonates by Using Room Air or 100% Oxygen

OBJECTIVE. In this study of preterm neonates of <32 weeks, we prospectively compared the use of room air versus 100% oxygen as the initial resuscitation gas. METHODS. A 2-center, prospective, randomized, controlled trial of neonates with gestational ages of 23 to 32 weeks who required resuscitation was performed. The oxygen group was initially resuscitated with 100% oxygen, with decreases in the fraction of inspired oxygen after 5 minutes of life if pulse oxygen saturation was >95%. The room air group was initially resuscitated with 21% oxygen, which was increased to 100% oxygen if compressions were performed or if the heart rate was <100 beats per minute at 2 minutes of life. Oxygen was increased in 25% increments if pulse oxygen saturation was <70% at 3 minutes of life or <80% at 5 minutes of life. RESULTS. Twenty-three infants in the oxygen group (mean gestational age: 27.6 weeks; range: 24–31 weeks; mean birth weight: 1013 g; range: 495–2309 g) and 18 in the room air group (mean gestational age: 28 weeks; range: 25–31 weeks; mean birth weight: 1091 g; range: 555–1840 g) were evaluated. Every resuscitated patient in the room air group met rescue criteria and received an increase in the fraction of inspired oxygen by 3 minutes of life, 6 patients directly to 100% and 12 with incremental increases. Pulse oxygen saturation was significantly lower in the room air group from 2 to 10 minutes (pulse oxygen saturation at 3 minutes: 55% in the room air group vs 87% in the oxygen group). Heart rates did not differ between groups in the first 10 minutes of life, and there were no differences in secondary outcomes. CONCLUSIONS. Resuscitation with room air failed to achieve our target oxygen saturation by 3 minutes of life, and we recommend that it not be used for preterm neonates.

A Survey of Delivery Room Resuscitation Practices in the United States

Objective. To determine current resuscitation practices of neonatologists in the United States. METHODS. A 15-question survey was developed and mailed to neonatal directors in May 2004. ELRESULTS. Of the total of 797 surveys mailed, 84 were returned undeliverable or unanswered and 450 were returned completed (63% response rate). Respondents were mainly (70%) from level III NICUs. Most programs resuscitate newborns in the delivery room (83%), rather than in a separate room. The number and background of individuals attending deliveries vary greatly, with 31% of programs having <3 individuals attending deliveries. Flow-inflating bags are most commonly used (51%), followed by self-inflating bags (40%) and T-piece resuscitators (14%). Pulse oximeters are used during resuscitation by 52% of programs, and 23% of respondents indicated that there was a useful signal within 1 minute after application. Blenders are available for 42% of programs, of which 77% use pure oxygen for the initial resuscitation and 68% use oximeters to alter the fraction of inspired oxygen. Thirty-two percent of programs use carbon dioxide detectors to confirm intubation, 48% routinely and 43% when there is difficulty confirming intubation. Preterm infants are wrapped with plastic wrap to prevent heat loss in 29% of programs, of which 77% dry the infant before wrap application. A majority of programs (76%) attempt to provide continuous positive airway pressure or positive end expiratory pressure (PEEP) during resuscitation, most commonly with a flow-inflating bag (58%), followed by a self-inflating bag with PEEP valve (19%) and T-piece resuscitator (16%). A level of 5 cm H2O is used by 55% of programs. CONCLUSIONS. Substantial variations exist in neonatal resuscitation practices, some of which are not addressed in standard guidelines. Future guidelines should include recommendations regarding the use of blenders, oximeters, continuous positive airway pressure/PEEP, and plastic wrap during resuscitation.

Oxygen Saturation Monitoring for the Preterm Infant: The Evidence Basis for Current Practice

Many of the morbid conditions associated with extreme immaturity are potentiated by an excess of free radicals occurring in infants who developmentally have decreased levels of antioxidants. The optimal oxygen saturation values for the resuscitation, stabilization, and ongoing care of the very low birth weight infant remain largely undefined. We have reviewed the currently available evidence for clinical oxygen use in the newborn period. Until the results of further studies are available, a reasonable approach to resuscitation would include initial resuscitation with 30–40% oxygen for very preterm infants using targeted SpO2 values and blended oxygen during the first 10 min. For ongoing management of preterm infants, SpO2 targets of 85–93% seem to be most appropriate, with alarm limits set within 1 to 2% of these targets with intermittent audits to ensure compliance. There is no strong evidence to support the use of altered limits for the infant who develops early evidence of retinopathy of prematurity. Further prospective studies are required to evaluate the effects of varied oxygen targets on long-term outcome.

Premedication for Nonemergent Neonatal Intubations: A Randomized, Controlled Trial Comparing Atropine and Fentanyl to Atropine, Fentanyl, and Mivacurium

OBJECTIVE. The purpose of this work was to investigate whether using a muscle relaxant would improve intubation conditions in infants, thereby decreasing the incidence and duration of hypoxia and time and number of attempts needed to successfully complete the intubation procedure. PATIENTS/METHODS. This was a prospective, randomized, controlled, 2-center trial. Infants requiring nonemergent intubation were randomly assigned to receive atropine and fentanyl or atropine, fentanyl, and mivacurium before intubation. Incidence and duration of hypoxia were determined at oxygen saturation thresholds of ≤85%, ≤75%, ≤60%, and ≤40%. Videotape was reviewed to determine the time and number of intubation attempts and duration of action of mivacurium. RESULTS. Analysis of 41 infants showed that incidence of oxygen saturation ≤60% of any duration was significantly less in the mivacurium group (55% vs 24%). The incidence of saturation level of any duration ≤85%, 75%, and 40%; cumulative time ≥30 seconds; and time below the thresholds were not significantly different. Total procedure time (472 vs 144 seconds) and total laryngoscope time (148 vs 61 seconds) were shorter in the mivacurium group. Successful intubation was achieved in ≤2 attempts significantly more often in the mivacurium group (35% vs 71%). CONCLUSIONS. Premedication with atropine, fentanyl, and mivacurium compared with atropine and fentanyl without a muscle relaxant decreases the time and number of attempts needed to successfully intubate while significantly reducing the incidence of severe desaturation. Premedication including a short-acting muscle relaxant should be considered for all nonemergent intubations in the NICU.

Using Intensive Care Technology in the Delivery Room: A New Concept for the Resuscitation of Extremely Preterm Neonates

Despite dramatic improvements in survival rates of preterm infants over the last 50 years, there have been no significant further improvements in survival or morbidity rates over the most recent 10 years.1,2 Survival rates among infants with a birth weight of 500 to 1500 g in participating centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network of the United States were 84% in 1995–1996 and 85% in 1997–2002; the survival rate without major neonatal morbidity (which included bronchopulmonary dysplasia [BPD], intraventricular hemorrhage, and necrotizing enterocolitis) was unchanged (70%) between these 2 time periods.1 Similar findings were observed in epidemiologic data from Norway and Germany, which were published almost coincidentally.2,3 New paradigms for addressing care of extremely preterm infants may be necessary to achieve further improvements in outcome. Before the last decade, increased survival rates of preterm infants had been attributed to regionalization of high-risk pregnancies, use of prenatal corticosteroids, and an aggressive approach to perinatal therapy.4 Birth in a high-risk perinatal center with a higher level of neonatal care is associated with better survival rates than birth in a center that provides a lower level of care,5 and mortality and morbidity rates are increased for the most immature infants who require transport after birth.6 Some of the major morbidities associated with extreme prematurity such as BPD and intraventricular/periventricular hemorrhage could potentially be affected by management in the first minutes of life. However, the principles of care that occur in the NICU are not always used in the delivery room (DR). Care of the smallest preterm infants in the DR has received very little attention in newborn-resuscitation protocols. It is only with the most recent edition of the Neonatal Resuscitation Program textbook7 … Address correspondence to Maximo Vento, PhD, MD, Hospital Universitario Materno Infantil La Fe, Neonatal Research Unit, Division of Neonatology, Avenida de Campanar, 21, E46009 Valencia, Spain. E-mail: maximo.vento{at}uv.es or maximovento{at}telefonica.net

Disposable Colorimetric Carbon Dioxide Detector Use as an Indicator of a Patent Airway During Noninvasive Mask Ventilation

Colorimetric carbon dioxide detectors are useful indicators of proper endotracheal tube placement. We have found that they also are helpful during bag and mask ventilation as an indicator of a patent airway. In this report, we describe our experience with these devices for use during preintubation airway stabilization as observed during videotaped performances from a prospective, randomized trial of intubation premedication.

Point-of-care ultrasound in the neonatal intensive care unit: international perspectives

To explore international variation in implementation of point-of-care ultrasound in the neonatal intensive care unit (NICU), contributions were invited from neonatologists and paediatric cardiologists in six countries. The contributors show variation in national implementation that ranges from almost total coverage through to a minority of NICUs having point-of-care ultrasound capability. To a varying degree in all systems the main barriers have been concerns from the consultative specialties that traditionally use ultrasound, relating to the risk of misdiagnosis but also involving different clinical needs, liability concerns and lack of outcome-based evidence. All contributors agreed that safe point-of-care ultrasound depends on close collaboration with the consultative specialties and also that there is a need to develop training and accreditation structures for neonatologists using ultrasound.

Tidal Volume Threshold for Colorimetric Carbon Dioxide Detectors Available for Use in Neonates

OBJECTIVE. Colorimetric carbon dioxide detectors are used for confirmation of endotracheal intubation. The colorimetric carbon dioxide detectors that are used for neonates are labeled for use with infants and small children >1 and <15 kg. The objective of this study was to determine the minimal tidal volume that causes a breath-to-breath color change on 2 colorimetric carbon dioxide detectors. METHODS. Using an artificial-lung model, we determined the tidal volume threshold of 2 colorimetric carbon dioxide detectors (Pedi-Cap [Nellcor, Pleasanton, CA] or Mini StatCO2 [Mercury Medical, Clearwater, FL]) during ventilation with a T-piece resuscitator or neonatal ventilator. Digital video recordings of the colorimetric carbon dioxide detectors were made during 20 seconds of ventilation at each tidal volume. Seven clinicians who were blinded to the tidal volume reviewed the videos in random order and graded the color change to determine adequacy for clinical application. RESULTS. The Mini StatCO2 tidal volume threshold was 0.83 mL, and the Pedi-Cap tidal volume threshold was 1.08 mL. CONCLUSIONS. The lung model revealed that the tidal volume threshold for the tested colorimetric carbon dioxide detectors is less than the expected tidal volume of a 400-g infant and suggests that these devices are appropriate for use with any neonate to confirm intubation.

Use of Oxygen for Resuscitation of the Extremely Low Birth Weight Infant

The practice of mouth-to-mouth resuscitation was the first natural experiment using hypoxic gas mixtures for resuscitation. Although supplemental oxygen is now the standard during neonatal resuscitation, this practice has never been validated in prospective controlled trials. Neonatal resuscitation is primarily directed toward establishing early lung aeration and maintaining lung volume during expiration to overcome the initial vagal and hypoxic bradycardia. It remains unclear whether supplemental oxygen facilitates this process or contributes to potential hypoxia/reoxygenation injury, inhibition of breathing, and possible aggravation of atelectasis by the attenuation of nitrogen splinting. Accumulating evidence over the last decade has challenged clinicians to reconsider the optimal oxygen concentration for resuscitation of the newborn term infant. A critical review of 6 randomized trials that compared the use of room air (RA) and 100% oxygen reported that RA was associated with a significant lowering of mortality rate from 13% to 8% ( P = .0021), with a typical odds ratio (OR) of 0.57 (95% confidence interval [CI]: 0.42–0.78); however, no difference was observed for infants with a 1-minute Apgar score of <4 (typical OR: 0.81 [95% CI: 0.54–1.21]).1 In most of these trials, up to 30% of the infants in the RA group met prespecified failure criteria and received additional oxygen. However, a similar proportion of the oxygen-resuscitated infants also met the failure criteria. In term infants, the neonatal mortality rate was 5.9% in the RA group and 9.8% in the 100% O2 group (typical OR: 0.59 [95% CI: 0.40–0.870]). These results are similar to those reported in the Cochrane review by Tan et al.2 Subgroup analysis confined to preterm infants (all > 1000gm) revealed a greater reduction in mortality rate in the RA group, from 35% in the 100% O2 group to 21% in the RA group (typical OR: 0.51 [95% CI: … Address correspondence to Neil Finer, MD, UCSD Medical Center, 402 W Dickinson St, MPF Building, Suite 1-140, San Diego, CA 92103-8774. E-mail: nfiner{at}ucsd.edu

Delivery Room Intervention: Improving the Outcome

The authors have conducted video review of neonatal resuscitations since 1999. Over this 10-year period 3 phases of our experience have been recognized. Our early reviews helped us recognize what we were doing in the delivery room, an area that had been ignored in improved intervention. It was noted that on many occasions multiple people were trying to accomplish the same task, that bag and mask ventilation was almost exclusively the purview of the respiratory therapists and was not performed well by others, and that infants with low birth weight were often hypothermic on admission. After determining what was being done and how well it was being done, we moved on to how to do it better. This period included making environmental changes by warming the room, the use of occlusive wrap, determining the effectiveness of bag and mask ventilation with colorimetric CO(2) detectors, and the introduction of crew resource management to develop consistent and effective communication. The third and current phase of our experience is to determine how these interventions affect delivery room and potentially later outcomes. Well-designed clinical trials are still needed to further establish the most optimal resuscitation interventions.