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Morin C, Lee TF, O'Reilly M, Ramsie M, Cheung PY, Schmölzer GM. Cardiopulmonary resuscitation with 3:1 Compression:Ventilation or continuous compression with asynchronized ventilation in infantile piglets. Pediatr Res 2024:10.1038/s41390-024-03373-3. [PMID: 39048668 DOI: 10.1038/s41390-024-03373-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/22/2024] [Accepted: 04/11/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND To compare neonatal and pediatric resuscitation approaches to ventilation and chest compression by using either continuous chest compression with asynchronized ventilation (CCaV) or 3:1 Compression:Ventilation ration (3:1 C:V) during infant cardiopulmonary resuscitation. We hypothesized that 3:1 C:V compared to CCaV will reduce time to return of spontaneous circulation (ROSC) in infantile piglets with asphyxia-induced bradycardic cardiac arrest. METHODS Twenty infantile piglets (5-10 days old) were anesthetized and asphyxiated by clamping the endotracheal tube. Piglets were randomized to 3:1 C:V or CCaV for resuscitation (n = 10/group). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. RESULTS The median time (IQR) to ROSC among survivors was 157 (113-219) vs 421 (118-660) for 3:1 C:V and CCaV, respectively (p = 0.253). The duration of resuscitation with 3:1 C:V compared to CCaV was 206 (119-660) vs 660 (212-660)sec, respectively (p = 0.171). The number of piglets achieving ROSC with 3:1 C:V and CCaV were 7/10 and 6/10, respectively (p = 1.00). There was no difference in hemodynamic and respiratory parameters between groups. CONCLUSIONS Time to ROSC and survival was not different between 3:1 C:V and CCaV in infantile piglets. Either approach appears reasonable during infantile cardiopulmonary resuscitation. IMPACT Similar time to return of spontaneous circulation and survival with 3:1 C:V and CCaV in infant piglets equivalent to 28-day-old children. Either approach appears reasonable during infantile cardiopulmonary resuscitation. Lack of scientific data to provide recommendations on when to switch between neonatal to pediatric resuscitation guidelines. No difference in time to return of spontaneous circulation or survival between 3:1 C:V and CCaV in infantile piglets with asphyxia-induced bradycardic cardiac arrest. Both methods are viable options during infant cardiopulmonary resuscitation.
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Affiliation(s)
- Chelsea Morin
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marwa Ramsie
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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Koo J, Cheung PY, Pichler G, Solevåg AL, Law BHY, Katheria AC, Schmölzer GM. Chest compressions superimposed with sustained inflation during neonatal cardiopulmonary resuscitation: are we ready for a clinical trial? Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326769. [PMID: 38453436 DOI: 10.1136/archdischild-2023-326769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/17/2024] [Indexed: 03/09/2024]
Abstract
Neonates requiring cardiopulmonary resuscitation (CPR) are at risk of mortality and neurodevelopmental injury. Poor outcomes following the need for chest compressions (CCs) in the delivery room prompt the critical need for improvements in resuscitation strategies. This article explores a technique of CPR which involves CCs with sustained inflation (CC+SI). Unique features of CC+SI include (1) improved tidal volume delivery, (2) passive ventilation during compressions, (3) uninterrupted compressions and (4) improved stability of cerebral blood flow during resuscitation. CC+SI has been shown in animal studies to have improved time to return of spontaneous circulation and reduced mortality without significant increase in markers of inflammation and injury in the lung and brain, compared with standard CPR. The mechanics of CCs, rate of compressions, ventilation strategies and compression-to-ventilation ratios are detailed here. A large randomised controlled trial comparing CC+SI versus the current 3:1 compression-to-ventilation ratio is needed, given the growing evidence of its potential benefits.
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Affiliation(s)
- Jenny Koo
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Anne Lee Solevåg
- The Department of Paediatric and Adolescent Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Brenda Hiu Yan Law
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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O'Reilly M, Lee TF, Cheung PY, Schmölzer GM. Vasopressin versus epinephrine during neonatal cardiopulmonary resuscitation of asphyxiated post-transitional piglets. Resusc Plus 2023; 15:100427. [PMID: 37519409 PMCID: PMC10372457 DOI: 10.1016/j.resplu.2023.100427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/17/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Background Epinephrine is currently the only recommended cardio-resuscitative medication for use in neonatal cardiopulmonary resuscitation (CPR), as per the consensus of science and treatment recommendations. An alternative medication, vasopressin, might be beneficial in neonatal CPR due to its combined pulmonary vasodilation and systemic vasoconstriction properties. Aim We aimed to compare the time to return of spontaneous circulation (ROSC) with administration of vasopressin or epinephrine during CPR of asphyxiated post-transitional piglets. Methods Newborn piglets (n = 8/group) were anesthetized, tracheotomized and intubated, instrumented, and exposed to 50 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to receive vasopressin (Vaso, 0.4 U/kg) or epinephrine (Epi, 0.02 mg/kg) during CPR. Piglets were resuscitated with chest compressions superimposed with sustained inflations, and were administered either Vaso or Epi intravenously every 3 min until ROSC (max. 3 doses). Hemodynamic and cardiac function parameters were collected. Main Results The median (IQR) time to ROSC was 106 (93-140) s with Vaso and 128 (100-198) s with Epi (p = 0.28). The number of piglets that achieved ROSC was 8 (100%) with Vaso and 7 (88%) with Epi (p = 1.00). Vaso-treated piglets had a significantly longer post-resuscitation survival time (240 (240-240) min) than Epi-treated piglets (65 (30-240) min, p = 0.02). Vaso-treated piglets had significantly improved carotid blood flow immediately after ROSC (p < 0.05), had longer duration of post-resuscitation hypertension (p = 0.05), and had significantly improved heart rate, arterial pressure, and cerebral blood oxygen saturation 4 h after ROSC (p < 0.05). Conclusions Vasopressin improved post-resuscitation survival and hemodynamics, and might be an alternative cardio-resuscitative medication during neonatal CPR, but further studies are warranted.
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Affiliation(s)
| | | | | | - Georg M. Schmölzer
- Corresponding author at: Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada.
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Bruckner M, Neset M, O’Reilly M, Lee TF, Cheung PY, Schmölzer GM. Four Different Finger Positions and Their Effects on Hemodynamic Changes during Chest Compression in Asphyxiated Neonatal Piglets. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020283. [PMID: 36832412 PMCID: PMC9954809 DOI: 10.3390/children10020283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/10/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023]
Abstract
Background: The Neonatal Life Support Consensus on Science With Treatment Recommendations states that chest compressions (CC) be performed preferably with the 2-thumb encircling technique. The aim of this study was to compare the hemodynamic effects of four different finger positions during CC in a piglet model of neonatal asphyxia. Methods: Seven asphyxiated post-transitional piglets were randomized to CC with 2-thumb-, 2-finger-, knocking-fingers-, and over-the-head 2-thumb-techniques for one minute at each technique. CC superimposed with sustained inflations were performed manually. Results: Seven newborn piglets (age 0-4 days, weight 2.0-2.1 kg) were included in the study. The mean (SD) slope rise of carotid blood flow was significantly higher with the 2-thumb-technique and over-the-head 2-thumb-technique (118 (45) mL/min/s and 121 (46) mL/min/s, respectively) compared to the 2-finger-technique and knocking-finger-technique (75 (48) mL/min/s and 71 (67) mL/min/s, respectively) (p < 0.001). The mean (SD) dp/dtmin (as an expression of left ventricular function) was significantly lower with the 2-thumb-technique, with -1052 (369) mmHg/s, compared to -568 (229) mmHg/s and -578(180) mmHg/s (both p = 0.012) with the 2-finger-technique and knocking-finger-technique, respectively. Conclusion: The 2-thumb-technique and the over-the-head 2-thumb-technique resulted in improved slope rises of carotid blood flow and dp/dtmin during chest compression.
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Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2E3, Canada
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Mattias Neset
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2E3, Canada
| | - Megan O’Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2E3, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2E3, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2E3, Canada
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2E3, Canada
- Correspondence:
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Vali P, Lesneski A, Hardie M, Alhassen Z, Chen P, Joudi H, Sankaran D, Lakshminrusimha S. Continuous chest compressions with asynchronous ventilations increase carotid blood flow in the perinatal asphyxiated lamb model. Pediatr Res 2021; 90:752-758. [PMID: 33469187 PMCID: PMC8286977 DOI: 10.1038/s41390-020-01306-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND The neonatal resuscitation program (NRP) recommends interrupted chest compressions (CCs) with ventilation in the severely bradycardic neonate. The conventional 3:1 compression-to-ventilation (C:V) resuscitation provides 90 CCs/min, significantly lower than the intrinsic newborn heart rate (120-160 beats/min). Continuous CC with asynchronous ventilation (CCCaV) may improve the success of return of spontaneous circulation (ROSC). METHODS Twenty-two near-term fetal lambs were randomized to interrupted 3:1 C:V (90 CCs + 30 breaths/min) or CCCaV (120 CCs + 30 breaths/min). Asphyxiation was induced by cord occlusion. After 5 min of asystole, resuscitation began following NRP guidelines. The first dose of epinephrine was given at 6 min. Invasive arterial blood pressure and left carotid blood flow were continuously measured. Serial arterial blood gases were collected. RESULTS Baseline characteristics between groups were similar. Rate of and time to ROSC was similar between groups. CCCaV was associated with a higher PaO2 (partial oxygen tension) (22 ± 5.3 vs. 15 ± 3.5 mmHg, p < 0.01), greater left carotid blood flow (7.5 ± 3.1 vs. 4.3 ± 2.6 mL/kg/min, p < 0.01) and oxygen delivery (0.40 ± 0.15 vs. 0.13 ± 0.07 mL O2/kg/min, p < 0.01) compared to 3:1 C:V. CONCLUSIONS In a perinatal asphyxiated cardiac arrest lamb model, CCCaV showed greater carotid blood flow and cerebral oxygen delivery compared to 3:1 C:V resuscitation. IMPACT In a perinatal asphyxiated cardiac arrest lamb model, CCCaV improved carotid blood flow and oxygen delivery to the brain compared to the conventional 3:1 C:V resuscitation. Pre-clinical studies assessing neurodevelopmental outcomes and tissue injury comparing continuous uninterrupted chest compressions to the current recommended 3:1 C:V during newborn resuscitation are warranted prior to clinical trials.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, CA, USA.
| | - Amy Lesneski
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Morgan Hardie
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Ziad Alhassen
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Peggy Chen
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Houssam Joudi
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Deepika Sankaran
- Department of Pediatrics, University of California Davis, Sacramento, CA
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Hidalgo CG, Solevag AL, Kim SY, Shim GH, Cheung PY, Lee TF, O'Reilly M, Schmölzer GM. Sustained inflation with 21% versus 100% oxygen during cardiopulmonary resuscitation of asphyxiated newborn piglets - A randomized controlled animal study. Resuscitation 2020; 155:39-47. [PMID: 32712173 DOI: 10.1016/j.resuscitation.2020.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 06/29/2020] [Accepted: 07/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current neonatal resuscitation guidelines recommend using 100% oxygen during chest compressions (CC), however the most effective oxygen concentration during cardiopulmonary resuscitation remains controversial. AIM In term newborn piglets with asphyxia-induced cardiac arrest does 21% oxygen compared to 100% oxygen during resuscitation using CC during sustained inflation (SI; CC + SI) will have a reduced time to return of spontaneous circulation (ROSC). INTERVENTION AND MEASUREMENTS Twenty-two mixed breed piglets (1-3 days old, 1.7-2.4 kg), were obtained on the day of the experiment and anesthetized, intubated, instrumented, and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were resuscitated using CC + SI and randomized to 21% oxygen (n = 8) or 100% oxygen (n = 8). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. MAIN RESULTS Baseline parameters were similar between 21% and 100% oxygen groups. There was no difference in asphyxiation (duration and degree) between groups. Time to ROSC was similar between 21% and 100% oxygen groups: median (interquartile range - IQR) 80 (70-190)sec vs. 90 (70-324)sec, (p = 0.56). There was no significant difference in the rate of ROSC between 21% and 100% oxygen groups: 7/8 (88%) vs. 5/8 (63%), (p = 0.569). All piglets that achieved ROSC survived to four hours post-resuscitation. Hemodynamics and regional perfusion were not significantly different between groups. CONCLUSIONS In term newborn piglets resuscitated by CC + SI, the use of 21% oxygen resulted in a similar time to ROSC, short-term survival, and hemodynamic recovery compared to 100% oxygen.
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Affiliation(s)
- Catalina Garcia Hidalgo
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Anne L Solevag
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Seung Yeun Kim
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Department of Pediatrics, Eulji University Hospital, Daejeon, South Korea
| | - Gyu Hong Shim
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, South Korea
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, T5H 3V9, Edmonton, Alberta, Canada; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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Kim SY, Shim GH, O'Reilly M, Cheung PY, Lee TF, Schmölzer GM. Asphyxiated Female and Male Newborn Piglets Have Similar Outcomes With Different Cardiopulmonary Resuscitation Interventions. Front Pediatr 2020; 8:602228. [PMID: 33425814 PMCID: PMC7793777 DOI: 10.3389/fped.2020.602228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/16/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Male newborns have a greater risk of poor cardiovascular and respiratory outcomes compared to females. The mechanisms associated with the "male disadvantage" remains unclear. We have previously shown no difference between male and female newborn piglets during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery. However, it is unknown if there are differences in resuscitation outcomes between males and females during different cardiopulmonary resuscitation techniques. Intervention and Measurements: Secondary analysis of 184 term newborn mixed breed duroc piglets (1-3 days of age, weighing 2.0 (0.2) kg) from seven different studies, which were exposed to 30-50 min of normocapnic hypoxia followed by asphyxia until asystole. This was followed by cardiopulmonary resuscitation. For the analysis, piglets were divided into male and female groups, as well as resuscitation technique groups (sustained inflation, 3:1 compression-to-ventilation ratio, or asynchronous ventilations during chest compressions). Cardiac function, carotid blood flow, and cerebral oxygenation were continuously recorded throughout the experiment. Main results: Regardless of resuscitation technique, there was no significant difference between males and females in the number achieving return of spontaneous circulation (ROSC) [95/123 (77%) vs. 48/61 (79%)], the time to achieve ROSC [112 (80-185) s vs. 110 (77-186) s], and the 4-h survival rate [81/95 (85%) vs. 40/48 (83%)]. Levels of the injury markers interleukin (IL)-1ß, IL-6, IL-8, and tumor necrosis factor-α in frontoparietal cortex tissue homogenates were similar between males and females. Conclusions: Regardless of resuscitation technique, there was no significant effect of sex on resuscitation outcome, survival, and hemodynamic recovery in asphyxiated newborn piglets.
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Affiliation(s)
- Seung Yeon Kim
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, Eulji University Hospital, Daejeon, South Korea
| | - Gyu-Hong Shim
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, South Korea
| | - Megan O'Reilly
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Tze-Fun Lee
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Vali P, Sankaran D, Rawat M, Berkelhamer S, Lakshminrusimha S. Epinephrine in Neonatal Resuscitation. CHILDREN (BASEL, SWITZERLAND) 2019; 6:E51. [PMID: 30987062 PMCID: PMC6518253 DOI: 10.3390/children6040051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
Abstract
Epinephrine is the only medication recommended by the International Liaison Committee on Resuscitation for use in newborn resuscitation. Strong evidence from large clinical trials is lacking owing to the infrequent use of epinephrine during neonatal resuscitation. Current recommendations are weak as they are extrapolated from animal models or pediatric and adult studies that do not adequately depict the transitioning circulation and fluid-filled lungs of the newborn in the delivery room. Many gaps in knowledge including the optimal dosing, best route and timing of epinephrine administration warrant further studies. Experiments on a well-established ovine model of perinatal asphyxial cardiac arrest closely mimicking the newborn infant provide important information that can guide future clinical trials.
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Affiliation(s)
- Payam Vali
- UC Davis School of Medicine, Sacramento, CA 95817, USA;
| | | | - Munmun Rawat
- SUNY Buffalo, Buffalo, NY 14222, USA; (D.S.); (M.R.); (S.B.)
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The SURV1VE trial-sustained inflation and chest compression versus 3:1 chest compression-to-ventilation ratio during cardiopulmonary resuscitation of asphyxiated newborns: study protocol for a cluster randomized controlled trial. Trials 2019; 20:139. [PMID: 30782199 PMCID: PMC6381608 DOI: 10.1186/s13063-019-3240-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 02/01/2019] [Indexed: 11/19/2022] Open
Abstract
Background The need for cardiopulmonary resuscitation (CPR) is often unexpected, and the infrequent use of CPR in the delivery room (DR) limits the opportunity to perform rigorous clinical studies to determine the best method for delivering chest compression (CC) to newborn infants. The current neonatal resuscitation guidelines recommend using a coordinated 3:1 compression-to-ventilation (C:V) ratio (CC at a rate of 90/min and ventilations at a rate of 30/min). In comparison, providing CC during a sustained inflation (SI) (CC + SI) significantly improved hemodynamics, minute ventilation, and time to return of spontaneous circulation (ROSC) compared to 3:1 C:V ratio in asphyxiated piglets. Similarly, a small pilot trial in newborn infants showed similar results. Until now no study has examined different CC techniques during neonatal resuscitation in asphyxiated newborn infants in the DR. To date, no trial has been performed to directly compare CC + SI and 3:1 C:V ratio in the DR during CPR of asphyxiated newborn infants. Methods This is a large, international, multi-center, prospective, unblinded, cluster randomized controlled trial in asphyxiated newborn infants at birth. All term and preterm infants > 28+ 0 by best obstetrical estimate who require CPR at birth due to bradycardia (< 60/min) or asystole are eligible. The primary outcome of this study is to compare the time to ROSC in infants born > 28+ 0 weeks’ gestational age with bradycardia (< 60/min) or asystole immediately after birth who receive either CC + SI or 3:1 C:V ratio as the CPR strategy. Discussion Morbidity and mortality rates are extremely high for newborns requiring CC. We believe the combination of simultaneous CC and SI during CPR has the potential to significantly improve ROSC and survival. In addition, we believe that CC + SI might improve respiratory and hemodynamic parameters and potentially minimize morbidity and mortality in newborn infants. In addition, this will be the first randomized controlled trial to examine CC in the newborn period. Trial registration ClinicalTrials.gov, NCT02858583. Registered on 8 August 2016 Electronic supplementary material The online version of this article (10.1186/s13063-019-3240-8) contains supplementary material, which is available to authorized users.
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Chest Compressions in the Delivery Room. CHILDREN-BASEL 2019; 6:children6010004. [PMID: 30609872 PMCID: PMC6352088 DOI: 10.3390/children6010004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/18/2018] [Accepted: 12/26/2018] [Indexed: 12/23/2022]
Abstract
Annually, an estimated 13–26 million newborns need respiratory support and 2–3 million newborns need extensive resuscitation, defined as chest compression and 100% oxygen with or without epinephrine in the delivery room. Despite such care, there is a high incidence of mortality and neurologic morbidity. The poor prognosis associated with receiving chest compression alone or with medications in the delivery room raises questions as to whether improved cardiopulmonary resuscitation methods specifically tailored to the newborn could improve outcomes. This review discusses the current recommendations, mode of action, different compression to ventilation ratios, continuous chest compression with asynchronous ventilations, chest compression and sustained inflation optimal depth, and oxygen concentration during cardiopulmonary resuscitation.
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Solevåg AL, Schmölzer GM, Cheung PY. Is Supplemental Oxygen Needed in Cardiac Compression?-The Influence of Oxygen on Cerebral Perfusion in Severely Asphyxiated Neonates With Bradycardia or Cardiac Asystole. Front Pediatr 2019; 7:486. [PMID: 31824899 PMCID: PMC6879425 DOI: 10.3389/fped.2019.00486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 11/06/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies have investigated hemodynamic recovery using 21% vs. 100% oxygen during cardiopulmonary resuscitation (CPR) with chest compression (CC) in term infants. Animal studies indicate that systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR. One of the main goals of resuscitation is to maintain cerebral oxygen delivery and prevent cerebral hypo- and hyperoxygenation. Oxygen delivery to the brain depends on cerebral hemodynamics, concentration of inhaled oxygen and blood oxygen content. The aim of this paper was to synthesize available research about cerebral oxygen delivery during CPR using different oxygen concentrations. Our research questions included how do different oxygen concentrations during CPR with CC influence cerebral perfusion and oxygen delivery, and how do cerebral hemodynamics during CC influence outcomes. Methods: A search in Medline Ovid using the search terms hypoxia AND oxygen AND cerebrovascular circulation AND infant, newborn. Inclusion criteria included studies of hypoxia and resuscitation of term infants. Studies were excluded if no measures of cerebral blood flow (CBF), oxygenation, or perfusion were reported. Results: The search retrieved 21 papers. None of the studies directly fulfilled our inclusion criteria. The reference lists of some of the retrieved papers provided relevant animal studies with slightly conflicting results regarding blood flow and oxygen delivery to the brain using 21 or 100% oxygen. No study in term infants was identified, but we included one study in preterm infants. Studies in asphyxiated animals indicate that 100% oxygen increases CBF and oxygenation during and after CC with a potential increase in oxidative stress. Conclusion: In asphyxia, cerebral autoregulation may be impaired. Pure oxygen administration during CC may result in cerebral hyperperfusion and increased cerebral oxygen delivery, which may be associated with oxidative stress-related damage to the brain tissue. As systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR, it is important to investigate whether brain damage could be aggravated when 100% oxygen is used.
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Affiliation(s)
- Anne Lee Solevåg
- Department of Paediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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12
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La Garde RP, Cheung PY, Yaskina M, Lee TF, O'Reilly M, Schmölzer GM. Sex Differences Between Female and Male Newborn Piglets During Asphyxia, Resuscitation, and Recovery. Front Pediatr 2019; 7:290. [PMID: 31380324 PMCID: PMC6646717 DOI: 10.3389/fped.2019.00290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/27/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Male and female newborns have differences in their fetal development, fetal-to-neonatal transition, and postnatal morbidity. However, the cardiovascular fetal-to-neonatal adaption is similar between sexes. No study has examined sex differences in newborns during hypoxia, asphyxia, cardio-pulmonary resuscitation, or post-resuscitation recovery. Methods: Secondary analysis (two previous publications and two studies currently under peer-review) of 110 term newborn mixed breed piglets (1-3 days of age, weighing 2.0 ± 0.2 kg), which were exposed to 30 min normocapnic hypoxia followed by asphyxia until asystole, which was achieved by disconnecting the ventilator and clamping the endotracheal tube. This was followed by cardio-pulmonary resuscitation. For the analysis piglets were divided into female and male groups. Cardiac function, carotid blood flow, and cerebral and renal oxygenation were continuously recorded throughout the experiment. Results: A total of 35/41 (85%) female and 54/69 (78%) male piglets resuscitated achieved ROSC (p = 0.881). The median (IQR) time to achieve return of spontaneous circulation in females and males was 111 (80-228) s and 106 (80-206) s (p = 0.875), respectively. The 4-h survival rate was similar between females and males with 28/35 (80%) and 49/54 (91%) piglets surviving (p = 0.241), respectively. Conclusions: No difference between female and male newborn piglets was observed during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery.
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Affiliation(s)
- Ramin P La Garde
- Medical University of Vienna, Vienna, Austria.,Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Maryna Yaskina
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Tze-Fun Lee
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Megan O'Reilly
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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13
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O'reilly M, Schmölzer GM. Evidence for vasopressors during cardiopulmonary resuscitation in newborn infants. Minerva Pediatr 2018; 71:159-173. [PMID: 30511562 DOI: 10.23736/s0026-4946.18.05452-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An estimated 0.1% of term infants and up to 15% of preterm infants (2-3 million worldwide) need extensive resuscitation, defined as chest compression and 100% oxygen with or without epinephrine in the delivery room. Despite these interventions, infants receiving extensive resuscitation in the DR have a high incidence of mortality and neurologic morbidity. Successful resuscitation from neonatal cardiac arrest requires the delivery of high-quality chest compression using the most effective vasopressor with the optimal dose, timing, and route of administration during CPR. Current neonatal resuscitation guidelines recommend administration of epinephrine once CPR has started at a dose of 0.01-0.03 mg/kg preferably given intravenously, with repeated doses every 3-5 min until return of spontaneous circulation. This review examines the current evidence for epinephrine and alternative vasopressors during neonatal cardiopulmonary resuscitation.
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Affiliation(s)
- Megan O'reilly
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, 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, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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14
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Schmölzer GM, O Reilly M, Fray C, van Os S, Cheung PY. Chest compression during sustained inflation versus 3:1 chest compression:ventilation ratio during neonatal cardiopulmonary resuscitation: a randomised feasibility trial. Arch Dis Child Fetal Neonatal Ed 2018; 103:F455-F460. [PMID: 28988159 DOI: 10.1136/archdischild-2017-313037] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 09/15/2017] [Accepted: 09/19/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Current neonatal resuscitation guidelines recommend 3:1 compression:ventilation (C:V) ratio. Recently, animal studies reported that continuous chest compressions (CC) during a sustained inflation (SI) significantly improved return of spontaneous circulation (ROSC). The approach of CC during SI (CC+SI) has not been examined in the delivery room during neonatal resuscitation. HYPOTHESIS It is a feasibility study to compare CC+SI versus 3:1 C:V ratio during neonatal resuscitation in the delivery room. We hypothesised that during neonatal resuscitation, CC+SI will reduce the time to ROSC. Our aim was to examine if CC+SI reduces ROSC compared with 3:1 C:V CPR in preterm infants <33 weeks of gestation. STUDY DESIGN Randomised feasibility trial. METHOD Once CC was indicated all eligible infants were immediately and randomly allocated to either CC+SI group or 3:1 C:V group. A sequentially numbered, brown, sealed envelope contained a folded card box with the treatment allocation was opened by the clinical team at the start of CC. STUDY INTERVENTIONS Infants in the CC+SI group received CC at a rate of 90/min during an SI with a duration of 20 s (CC+SI). After 20 s, the SI was interrupted for 1 s and the next SI was started for another 20 s until ROSC. Infants in the '3:1 group' received CC using 3:1 C:V ratio until ROSC. PRIMARY OUTCOME Overall the mean (SD) time to ROSC was significantly shorter in the CC+SI group with 31 (9) s compared with 138 (72) s in the 3:1 C:V group (p=0.011). CONCLUSION CC+SI is feasible in the delivery room. TRIAL REGISTRATION NUMBER Clinicaltrials.gov NCT02083705, pre-results.
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Affiliation(s)
- Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Alberta Health Services, Edmonoton, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Megan O Reilly
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Alberta Health Services, Edmonoton, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Caroline Fray
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Alberta Health Services, Edmonoton, Canada
| | - Sylvia van Os
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Alberta Health Services, Edmonoton, Canada
| | - Po-Yin Cheung
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Alberta Health Services, Edmonoton, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
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15
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Vali P, Gugino S, Koenigsknecht C, Helman J, Chandrasekharan P, Rawat M, Lakshminrusimha S, Nair J. The Perinatal Asphyxiated Lamb Model: A Model for Newborn Resuscitation. J Vis Exp 2018. [PMID: 30175999 DOI: 10.3791/57553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Birth asphyxia accounts for nearly one million deaths worldwide each year, and is one of the primary causes of early neonatal morbidity and mortality. Many aspects of the current neonatal resuscitation guidelines remain controversial given the difficulties in conducting randomized clinical trials owing to the infrequent and often unpredictable need for extensive resuscitation. Most studies on neonatal resuscitation stem from manikin models that fail to truly reflect physiologic changes or piglet models that have cleared their lung fluid and that have completed the transition from fetal to neonatal circulation. The present protocol provides a detailed step-by-step description on how to create a perinatal asphyxiated fetal lamb model. The proposed model has a transitioning circulation and fluid-filled lungs, which mimics human newborns following delivery, and is, therefore, an excellent animal model to study newborn physiology. An important limitation to lamb experiments is the higher associated cost.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California Davis
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16
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Pasquin MP, Cheung PY, Patel S, Lu M, Lee TF, Wagner M, O'Reilly M, Schmölzer GM. Comparison of Different Compression to Ventilation Ratios (2: 1, 3: 1, and 4: 1) during Cardiopulmonary Resuscitation in a Porcine Model of Neonatal Asphyxia. Neonatology 2018; 114:37-45. [PMID: 29649792 DOI: 10.1159/000487988] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/27/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND High-quality chest compression is essential during neonatal cardiopulmonary resuscitation (CPR). However, the optimal compression to ventilation ratio (C:V) that should be used during neonatal CPR to optimize coronary and cerebral perfusion while providing adequate ventilation remains unknown. OBJECTIVE We hypothesized that different C:V ratios (e.g., 2: 1 or 4: 1) will reduce the time to return of spontaneous circulation (ROSC) in severely asphyxiated piglets. METHODS Thirty-one newborn piglets (1-4 days old) were anesthetized, intubated, instrumented, and exposed to 50-min normocapnic hypoxia followed by asphyxia. Piglets were randomized into 4 groups: 2: 1 (n = 8), 3: 1 (n = 8), 4: 1 (n = 8) C:V ratio, or a sham group (n = 7). Cardiac function, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. RESULTS Thirty-one piglets were included in the study, and there was no difference in the duration of asphyxia or the degree of asphyxiation (as indicated by pH, PaCO2, and lactate) among the different groups. The median (IQR) time to ROSC was similar between the groups with 127 (82-210), 96 (88-126), and 119 (83-256) s in the 2: 1, 3: 1, and 4: 1 C:V ratio groups, respectively (p = 0.67 between groups). Similarly, there was no difference in 100% oxygen requirement or epinephrine administration between the experimental groups. CONCLUSIONS Different C:V ratios resulted in similar ROSC, mortality, oxygen, and epinephrine administration during resuscitation in a porcine model of neonatal asphyxia.
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Affiliation(s)
- Matteo P Pasquin
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Sparsh Patel
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Min Lu
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Michael Wagner
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University Vienna, Vienna, Austria
| | - Megan O'Reilly
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University Vienna, Vienna, Austria
| | - Georg M Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University Vienna, Vienna, Austria
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17
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Garcia-Hidalgo C, Cheung PY, Solevåg AL, Vento M, O'Reilly M, Saugstad O, Schmölzer GM. A Review of Oxygen Use During Chest Compressions in Newborns-A Meta-Analysis of Animal Data. Front Pediatr 2018; 6:400. [PMID: 30619794 PMCID: PMC6305367 DOI: 10.3389/fped.2018.00400] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/03/2018] [Indexed: 11/21/2022] Open
Abstract
Background: International consensus statements for resuscitation of newborn infants recommend provision of 100% oxygen once chest compressions are required. However, 100% oxygen exacerbates reperfusion injury and reduces cerebral perfusion in newborn babies. Objective: We aimed to establish whether resuscitation with air during chest compression is feasible and safe in newborn infants compared with 100% oxygen. Methods: Systematic search of PubMed, Google Scholar and CINAHL for articles examining variable oxygen concentrations during chest compressions in term newborns. Results: Overall, no human studies but eight animal studies (n = 323 animals) comparing various oxygen concentrations during chest compression were identified. The pooled analysis showed no difference in mortality rates for animals resuscitated with air vs. 100% oxygen (risk ratio 1.04 [0.35, 3.08], I2 = 0%, p = 0.94). ROSC was also similar between groups with a mean difference of -3.8 [-29.7-22] s, I2 = 0%, p = 0.77. No difference in oxygen damage or adverse events were identified between groups. Conclusions: Air had similar time to ROSC and mortality as 100% oxygen during neonatal chest compression. A large randomized controlled clinical trial comparing air vs. 100% oxygen during neonatal chest compression is warranted.
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Affiliation(s)
- Catalina Garcia-Hidalgo
- Faculty of Science, University of Alberta, Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Anne Lee Solevåg
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Maximo Vento
- Health Research Centre, University and Polytechnic Hospital La Fe, Valencia, Spain.,Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain.,Spanish Maternal and Infant Health and Development Network, National Network, Spain
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ola Saugstad
- Department of Pediatric Research, University of Oslo, Oslo, Norway
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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18
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Luong DH, Cheung PY, O'Reilly M, Lee TF, Schmolzer GM. Electrocardiography vs. Auscultation to Assess Heart Rate During Cardiac Arrest With Pulseless Electrical Activity in Newborn Infants. Front Pediatr 2018; 6:366. [PMID: 30538976 PMCID: PMC6277703 DOI: 10.3389/fped.2018.00366] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background: In 2015, the neonatal resuscitation guidelines incorporated the use of electrocardiography (ECG) to monitor heart rate of newborns. However, previous studies have indicated that cardiac arrest with pulseless electrical activity rhythm (PEA) may occur in the delivery room, rendering this method problematic. Objective: To evaluate the accuracy of ECG and auscultation to assess heart rate during PEA. Methods: A total of 45 piglets (age 1-3 days, weight 1.7-2.3 kg) were exposed to 30 min normocapnic alveolar hypoxia followed by asphyxia until asystole, achieved by disconnecting the ventilator and clamping the endotracheal tube. During asphyxia, heart rate (HR) was assess using auscultation, ECG, and carotid blood flow (CBF). At the time of asystole (defined as zero CBF) HR auscultated using a neonatal/infant stethoscope was compared to ECG traces. Results: The median (IQR) duration of asphyxia was 325 (200-491) s. In 8 (18%) piglets, CBF, ECG, and auscultation identified asystole. In 22 (49%) piglets no CBF and no audible heart sounds, were observed, while ECG displayed a HR ranging from 17 to 75/min. Fifteen (33%) piglets remained bradycardic (defined as HR of < 100/min) after 10 min of asphyxia, which was identified by CBF, ECG, and auscultation. The overall accuracy of ECG and auscultation in the detection of HR were 51 and 80%, respectively (p = 0.004). Conclusion: In cases with PEA ECG is not superior in correctly identifying HR in newborn piglets.
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Affiliation(s)
- Deandra H Luong
- Faculty of Science, University of Alberta Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital Edmonton, AB, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital Edmonton, AB, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital Edmonton, AB, Canada
| | - Georg M Schmolzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital Edmonton, AB, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta Edmonton, AB, Canada
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19
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Solevåg AL, Schmölzer GM. Is 100% oxygen a sticking plaster for sore neonatal ventilation skills? Acta Paediatr 2017; 106:1548-1549. [PMID: 28876484 DOI: 10.1111/apa.14011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Anne Lee Solevåg
- Department of Paediatric and Adolescent Medicine; Akershus University Hospital; Lørenskog Norway
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation; Neonatal Research Unit; Royal Alexandra Hospital; Edmonton AB Canada
- Department of Pediatrics; University of Alberta; Edmonton AB Canada
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20
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A Chamber With a View. Crit Care Med 2017. [DOI: 10.1097/ccm.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Solevåg AL, Schmölzer GM. Optimal Chest Compression Rate and Compression to Ventilation Ratio in Delivery Room Resuscitation: Evidence from Newborn Piglets and Neonatal Manikins. Front Pediatr 2017; 5:3. [PMID: 28168185 PMCID: PMC5253459 DOI: 10.3389/fped.2017.00003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/09/2017] [Indexed: 11/25/2022] Open
Abstract
Cardiopulmonary resuscitation (CPR) duration until return of spontaneous circulation (ROSC) influences survival and neurologic outcomes after delivery room (DR) CPR. High quality chest compressions (CC) improve cerebral and myocardial perfusion. Improved myocardial perfusion increases the likelihood of a faster ROSC. Thus, optimizing CC quality may improve outcomes both by preserving cerebral blood flow during CPR and by reducing the recovery time. CC quality is determined by rate, CC to ventilation (C:V) ratio, and applied force, which are influenced by the CC provider. Thus, provider performance should be taken into account. Neonatal resuscitation guidelines recommend a 3:1 C:V ratio. CCs should be delivered at a rate of 90/min synchronized with ventilations at a rate of 30/min to achieve a total of 120 events/min. Despite a lack of scientific evidence supporting this, the investigation of alternative CC interventions in human neonates is ethically challenging. Also, the infrequent occurrence of extensive CPR measures in the DR make randomized controlled trials difficult to perform. Thus, many biomechanical aspects of CC have been investigated in animal and manikin models. Despite mathematical and physiological rationales that higher rates and uninterrupted CC improve CPR hemodynamics, studies indicate that provider fatigue is more pronounced when CC are performed continuously compared to when a pause is inserted after every third CC as currently recommended. A higher rate (e.g., 120/min) is also more fatiguing, which affects CC quality. In post-transitional piglets with asphyxia-induced cardiac arrest, there was no benefit of performing continuous CC at a rate of 90/min. Not only rate but duty cycle, i.e., the duration of CC/total cycle time, is a known determinant of CC effectiveness. However, duty cycle cannot be controlled with manual CC. Mechanical/automated CC in neonatal CPR has not been explored, and feedback systems are under-investigated in this population. Evidence indicates that providers perform CC at rates both higher and lower than recommended. Video recording of DR CRP has been increasingly applied and observational studies of what is actually done in relation to outcomes could be useful. Different CC rates and ratios should also be investigated under controlled experimental conditions in animals during perinatal transition.
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Affiliation(s)
- Anne Lee Solevåg
- The Department of Pediatric and Adolescent Medicine, Akershus University Hospital , Lørenskog , Norway
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton, AB , Canada
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22
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Li ES, Görens I, Cheung PY, Lee TF, Lu M, O'Reilly M, Schmölzer GM. Chest Compressions during Sustained Inflations Improve Recovery When Compared to a 3:1 Compression:Ventilation Ratio during Cardiopulmonary Resuscitation in a Neonatal Porcine Model of Asphyxia. Neonatology 2017; 112:337-346. [PMID: 28768280 DOI: 10.1159/000477998] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 06/06/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recently, sustained inflations (SI) during chest compression (CC) (CC+SI) have been suggested as an alternative to the current approach during neonatal resuscitation. No previous study compared CC+SI using CC rates of 90/min to the current 3:1 compression:ventilation ratio (C:V). OBJECTIVE To determine whether CC+SI versus a 3:1 C:V reduces the time to the return of spontaneous circulation (ROSC) and improves hemodynamic recovery in newborn piglets with asphyxia-induced bradycardia. INTERVENTION AND MEASUREMENTS Term newborn piglets were anesthetized, intubated, instrumented, and exposed to 45-min normocapnic hypoxia followed by asphyxia. Cardiopulmonary resuscitation (CPR) was initiated when the heart rate decreased to 25% of baseline. Piglets were randomized into 3 groups: CC during SI at a rate of 90 CC/min (SI+CC 90, n = 8), a 3:1 C:V using 90 CC and 30 inflations (3:1, n = 8), or a sham group (n = 6). Cardiac function, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. RESULTS CC+SI significantly reduced the median (IQR) time of ROSC, i.e., 34 s (28-156 s) versus 210 s (72-300 s) in the 3:1 group (p = 0.048). CC+SI also significantly reduced the requirement for 100% oxygen, improved respiratory parameters, and resulted in a similar hemodynamic recovery. CONCLUSIONS CC+SI during CPR significantly improved ROSC in a porcine model of neonatal resuscitation. This is of considerable clinical relevance because improved respiratory and hemodynamic parameters potentially minimize morbidity and mortality in newborn infants.
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Affiliation(s)
- Elliott S Li
- Faculty of Science, McGill University, Montreal, QC, Canada
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23
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Te Pas AB, Sobotka K, Hooper SB. Novel Approaches to Neonatal Resuscitation and the Impact on Birth Asphyxia. Clin Perinatol 2016; 43:455-67. [PMID: 27524447 DOI: 10.1016/j.clp.2016.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Historically, recommendations for neonatal resuscitation were largely based on dogma, but there is renewed interest in performing resuscitation studies at birth. The emphasis for resuscitation following birth asphyxia is administering effective ventilation, as adequate lung aeration leads not only to an increase in oxygenation but also increased pulmonary blood flow and heart rate. To aerate the lung, an initial sustained inflation can increase heart rate, oxygenation, and blood pressure recovery much faster when compared with standard ventilation. Hyperoxia should be avoided, and extra oxygen given to restore cardiac function and spontaneous breathing should be titrated based on oxygen saturations.
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Affiliation(s)
- Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, J6-S, PO Box 9600, Leiden 2300 RC, The Netherlands.
| | - Kristina Sobotka
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Box 432, Göteborg 405 30, Sweden
| | - Stuart B Hooper
- The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash Institute of Medical Research, Monash University, 27-31 Wright Street, Clayton, Melbourne, Victoria 3168, Australia
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24
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Solevåg AL, Schmölzer GM, O'Reilly M, Lu M, Lee TF, Hornberger LK, Nakstad B, Cheung PY. Myocardial perfusion and oxidative stress after 21% vs. 100% oxygen ventilation and uninterrupted chest compressions in severely asphyxiated piglets. Resuscitation 2016; 106:7-13. [PMID: 27344929 DOI: 10.1016/j.resuscitation.2016.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 04/17/2016] [Accepted: 06/14/2016] [Indexed: 11/19/2022]
Abstract
AIM Despite the minimal evidence, neonatal resuscitation guidelines recommend using 100% oxygen when chest compressions (CC) are needed. Uninterrupted CC in adult cardiopulmonary resuscitation (CPR) may improve CPR hemodynamics. We aimed to examine 21% oxygen (air) vs. 100% oxygen in 3:1 CC:ventilation (C:V) CPR or continuous CC with asynchronous ventilation (CCaV) in asphyxiated newborn piglets following cardiac arrest. METHODS Piglets (1-3 days old) were progressively asphyxiated until cardiac arrest and randomized to 4 experimental groups (n=8 each): air and 3:1 C:V CPR, 100% oxygen and 3:1 C:V CPR, air and CCaV, or 100% oxygen and CCaV. Time to return of spontaneous circulation (ROSC), mortality, and clinical and biochemical parameters were compared between groups. We used echocardiography to measure left ventricular (LV) stroke volume at baseline, at 30min and 4h after ROSC. Left common carotid artery blood pressure was measured continuously. RESULTS Time to ROSC (heart rate ≥100min(-1)) ranged from 75 to 592s and mortality 50-75%, with no differences between groups. Resuscitation with air was associated with higher LV stroke volume after ROSC and less myocardial oxidative stress compared to 100% oxygen groups. CCaV was associated with lower mean arterial blood pressure after ROSC and higher myocardial lactate than those of 3:1 C:V CPR. CONCLUSION In neonatal asphyxia-induced cardiac arrest, using air during CC may reduce myocardial oxidative stress and improve cardiac function compared to 100% oxygen. Although overall recovery may be similar, CCaV may impair tissue perfusion compared to 3:1 C:V CPR.
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Affiliation(s)
- Anne Lee Solevåg
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada; Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway.
| | - Georg M Schmölzer
- Centre 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
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Min Lu
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | | | - Britt Nakstad
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Po-Yin Cheung
- Centre 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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25
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Li ES, Cheung PY, Lee TF, Lu M, O'Reilly M, Schmölzer GM. Return of spontaneous Circulation Is Not Affected by Different Chest Compression Rates Superimposed with Sustained Inflations during Cardiopulmonary Resuscitation in Newborn Piglets. PLoS One 2016; 11:e0157249. [PMID: 27304210 PMCID: PMC4909206 DOI: 10.1371/journal.pone.0157249] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/26/2016] [Indexed: 11/30/2022] Open
Abstract
Objective Recently, sustained inflations (SI) during chest compression (CC) have been suggested as an alternative to the current approach during neonatal resuscitation. However, the optimal rate of CC during SI has not yet been established. Our aim was to determine whether different CC rates during SI reduce time to return of spontaneous circulation (ROSC) and improve hemodynamic recovery in newborn piglets with asphyxia-induced bradycardia. Intervention and measurements Term newborn piglets were anesthetized, intubated, instrumented and exposed to 45-min normocapnic hypoxia followed by asphyxia. Resuscitation was initiated when heart rate decreased to 25% of baseline. Piglets were randomized into three groups: CC superimposed by SI at a rate of 90 CC per minute (SI+CC 90, n = 8), CC superimposed by SI at a rate of 120 CC per minute (SI+CC 120, n = 8), or a sham group (n = 6). Cardiac function, carotid blood flow, cerebral oxygenation and respiratory parameters were continuously recorded throughout the experiment. Main results Both treatment groups had similar time of ROSC, survival rates, hemodynamic and respiratory parameters during cardiopulmonary resuscitation. The hemodynamic recovery in the subsequent 4h was similar in both groups and was only slightly lower than sham-operated piglets at the end of experiment. Conclusion Newborn piglets resuscitated by SI+CC 120 did not show a significant advantage in ROSC, survival, and hemodynamic recovery as compared to those piglets resuscitated by SI+CC 90.
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Affiliation(s)
- Elliott S. Li
- Faculty of Science, McGill University, Montreal, Quebec, Canada
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Min Lu
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
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