Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Fast and accurate newborn heart rate monitoring at birth: A systematic review

Aim

To examine speed and accuracy of newborn heart rate measurement by various assessment methods employed at birth.

Methods

A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283364) Study selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence.

Results

Pulse oximetry is slower and less precise than ECG for heart rate assessment. Both auscultation and palpation are imprecise for heart rate assessment. Other devices such as digital stethoscope, Doppler ultrasound, an ECG device using dry electrodes incorporated in a belt, photoplethysmography and electromyography are studied in small numbers of newborns and data are not available for extremely preterm or bradycardic newborns receiving resuscitation. Digital stethoscope is fast and accurate. Doppler ultrasound and dry electrode ECG in a belt are fast, accurate and precise when compared to conventional ECG with gel adhesive electrodes.

Limitations

Certainty of evidence was low or very low for most comparisons.

Conclusion

If resources permit, ECG should be used for fast and accurate heart rate assessment at birth. Pulse oximetry and auscultation may be reasonable alternatives but have limitations. Digital stethoscope, doppler ultrasound and dry electrode ECG show promise but need further study.

Ventilator strategies in congenital diaphragmatic hernia

This review focuses on contemporary mechanical ventilator practices used in the initial management of neonates born with congenital diaphragmatic hernia (CDH). Both conventional and non-conventional ventilation modes in CDH are reviewed. Special emphasis is placed on the rationale for gentle ventilation and the current evidence-based clinical practice guidelines that are recommended for supporting these fragile infants. The interplay between CDH lung hypoplasia and other key cardiopulmonary elements of the disease, namely a reduced pulmonary vascular bed, abnormal pulmonary vascular remodeling, and left ventricular hypoplasia, are discussed. Finally, we provide insights into future avenues for mechanical ventilator research in CDH.

Outcomes of Nonvigorous Neonates Born through Meconium-Stained Amniotic Fluid after a Practice Change to No Routine Endotracheal Suctioning from a Developing Country

OBJECTIVE

 The International Liaison Committee on Resuscitation (ILCOR) 2015 gave a weak recommendation based on low certainty of evidence against routine endotracheal (ET) suctioning in non-vigorous (NV) neonates born through meconium-stained amniotic fluid (MSAF) and suggested for immediate resuscitation without direct laryngoscopy. A need for ongoing surveillance post policy change has been stressed upon. This study compared the outcomes of NV MSAF neonates before and after implementation of the ILCOR 2015 recommendation.

STUDY DESIGN

 This was a prospective cohort study of term NV MSAF neonates who underwent immediate resuscitation without ET suctioning (no ET group, July 2018 to June 2019, n = 276) compared with historical control who underwent routine ET suction (ET group, July 2015 to June 2016, n = 271).

RESULTS

 Baseline characteristics revealed statistically significant higher proportion of male gender and small for gestational age neonates in the prospective cohort. There was no significant difference in the incidence of primary outcome of meconium aspiration syndrome (MAS) between the groups (no ET group: 27.2% vs ET group: 25.1%; p = 0.57). NV MSAF neonates with hypoxic ischemic encephalopathy (HIE) was significantly lesser in the prospective cohort (no ET group: 19.2% vs ET group: 27.3%; p = 0.03). Incidence of air leaks and need for any respiratory support significantly increased after policy change. In NV MSAF neonates with MAS, need for mechanical ventilation (MV) (no ET group: 24% vs ET group: 39.7%; p = 0.04) and mortality (no ET group: 18.7% vs ET group: 33.8%; p = 0.04) were significantly lesser.

CONCLUSION

 Current study from a developing country indicates that immediate resuscitation and no routine ET suctioning of NV MSAF may not be associated with increased risk of MAS and may be associated with decreased risk of HIE. Increased requirement of any respiratory support and air leak post policy change needs further deliberation. Decreased risk of MV and mortality among those with MAS was observed.

KEY POINTS

· Not performing ET suction in NV MSAF infants is not associated with increase in the incidence of MAS.. · Initiating immediate resuscitation without ET suctioning was associated with decreased risk of HIE but increased receipt of any respiratory support and air leak.. · Large multicentric trial is required to generate robust evidence..

ILCOR pediatric life support recommendations translation to constituent council guidelines: An emphasis on similarities and differences

The International Liaison Committee on Resuscitation (ILCOR) performs rigorous scientific evidence evaluation and publishes Consensus on Science with Treatment Recommendations. These evidence-based recommendations are incorporated by ILCOR constituent resuscitation councils to inform regional guidelines, and further translated into training approaches and materials and implemented by laypersons and healthcare providers in- and out-of-hospital. There is variation in council guidelines as a result of the weak strength of evidence and interpretation. In this manuscript, we highlight ten important similarities and differences in regional council pediatric resuscitation guidelines, and further emphasize three differences that identify key knowledge gaps and opportunity for "natural experiments."

Amplification of Heart Sounds Using Digital Stethoscope in Simulation-Based Neonatal Resuscitation

OBJECTIVE

 The accuracy, timeliness, and reliability of the current methods of heart rate (HR) determination in neonatal resuscitation are debatable, each having its own limitations. We aim to compare three methods of HR assessment: (1) traditional stethoscope, (2) electrocardiogram and traditional stethoscope, and (3) digital stethoscope with loudspeaker amplification of heart sounds.

STUDY DESIGN

 This was a simulated crossover experiment using a high-fidelity manikin. Each team with a physician, a nurse, and a respiratory therapist performed the resuscitations using the three methods (three different scenarios) in different order. The person controlling the HR via manikin controller was blinded, but the single recorder and the providers were not.

RESULTS

 Eighteen resuscitations were completed (six teams of three methods each). The time to first HR recording (p < 0.001), total number of HR recorded (p < 0.001), and time to recognize dips in HR was significantly improved in the digital stethoscope group (p = 0.009).

CONCLUSION

 Use of digital stethoscope with amplification improved documentation of HR and earlier recognition of HR changes.

KEY POINTS

· Amplified heartbeats during neonatal resuscitation improved documentation.. · Amplified infant heartbeats resulted in earlier recognition of HR changes (increase or decrease).. · Providers using this method had greater satisfaction..

A Customizable Digital Cognitive Aid for Neonatal Resuscitation: A Simulation-Based Randomized Controlled Trial

OBJECTIVE

Adherence to the International Liaison Committee on Resuscitation (ILCOR) algorithm optimizes the initial management of critically ill neonates. In this randomized controlled trial, we assessed the impact of a customizable sequential digital cognitive aid (DCA), adapted from the 2020 ILCOR recommendations, compared with a poster cognitive aid (standard of care [SOC]), on technical and nontechnical performance of junior trainees during a simulated critical neonatal event at birth.

METHODS

For this prospective, bicentric video-recorded study, students were recruited on a voluntary basis, and randomized into groups of 3 composed of a pediatric resident and two midwife students. They encountered a simulated cardiac arrest at birth either (1) with DCA use and ILCOR algorithm poster displayed on the wall (intervention group) or (2) with sole ILCOR algorithm poster (poster cognitive aid [SOC]). Technical and nontechnical skills (NTS) between the two groups were assessed using a standardized scoring of videotaped performances. A neonate specific NTS score was created from the adult Team score.

RESULTS

108 students (36 groups of three) attended the study, 20 groups of 3 in the intervention group and 16 groups of 3 in the poster cognitive aid (SOC) group. The intervention group showed a significant improvement in the technical score (P < 0.001) with an average of 24/27 points (24.0 [23.5-25.0]) versus 20.8/27 (20.8 [19.9-22.5]) in poster cognitive aid (SOC) group. No nontechnical score difference was observed. Feedback on the application was positive.

CONCLUSIONS

During a simulated critical neonatal event, use of a DCA was associated with higher technical scores in junior trainees, compared with the sole use of ILCOR poster algorithm.

Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives

Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.

[A cross-sectional survey of delivery room transitional care management for very/extremely preterm infants in 24 hospitals in Shenzhen City]

OBJECTIVES

To investigate the current status of delivery room transitional care management for very/extremely preterm infants in Shenzhen City.

METHODS

A cross-sectional survey was conducted in November 2022, involving 24 tertiary hospitals participating in the Shenzhen Neonatal Data Network. The survey assessed the implementation of transitional care management in the delivery room, including prenatal preparation, delivery room resuscitation, and post-resuscitation management in the neonatal intensive care unit. Very/extremely preterm infants were divided into four groups based on gestational age: <26 weeks, 26-28+6 weeks, 29-30+6 weeks, and 31-31+6 weeks. Descriptive analysis was performed on the results.

RESULTS

A total of 140 very/extremely preterm infants were included, with 10 cases in the <26 weeks group, 45 cases in the 26-28+6 weeks group, 49 cases in the 29-30+6 weeks group, and 36 cases in the 31-31+6 weeks group. Among these infants, 99 (70.7%) received prenatal counseling, predominantly provided by obstetricians (79.8%). The main personnel involved in resuscitation during delivery were midwives (96.4%) and neonatal resident physicians (62.1%). Delayed cord clamping was performed in 52 cases (37.1%), with an average delay time of (45±17) seconds. Postnatal radiant warmer was used in 137 cases (97.9%) for thermoregulation. Positive pressure ventilation was required in 110 cases (78.6%), with 67 cases (60.9%) using T-piece resuscitators and 42 cases (38.2%) using a blended oxygen device. Blood oxygen saturation was monitored during resuscitation in 119 cases (85.0%). The median time from initiating transitional care measures to closing the incubator door was 87 minutes.

CONCLUSIONS

The implementation of delivery room transitional care management for very/extremely preterm infants in the hospitals participating in the Shenzhen Neonatal Data Network shows varying degrees of deviation from the corresponding expert consensus in China. It is necessary to bridge the gap through continuous quality improvement and multicenter collaboration to improve the quality of the transitional care management and outcomes in very/extremely preterm infants.

Delivery room resuscitation intensity and associated neonatal outcomes of 24+0-31+6 weeks' preterm infants in China: a retrospective cross-sectional study

BACKGROUND

The aim of this study was to review current delivery room (DR) resuscitation intensity in Chinese tertiary neonatal intensive care units and to investigate the association between DR resuscitation intensity and short-term outcomes in preterm infants born at 24+0-31+6 weeks' gestation age (GA).

METHODS

This was a retrospective cross-sectional study. The source population was infants born at 24+0-31+6 weeks' GA who were enrolled in the Chinese Neonatal Network 2019 cohort. Eligible infants were categorized into five groups: (1) regular care; (2) oxygen supplementation and/or continuous positive airway pressure (O2/CPAP); (3) mask ventilation; (4) endotracheal intubation; and (5) cardiopulmonary resuscitation (CPR). The association between DR resuscitation and short-term outcomes was evaluated by inverse propensity score-weighted logistic regression.

RESULTS

Of 7939 infants included in this cohort, 2419 (30.5%) received regular care, 1994 (25.1%) received O2/CPAP, 1436 (18.1%) received mask ventilation, 1769 (22.3%) received endotracheal intubation, and 321 (4.0%) received CPR in the DR. Advanced maternal age and maternal hypertension correlated with a higher need for resuscitation, and antenatal steroid use tended to be associated with a lower need for resuscitation (P < 0.001). Severe brain impairment increased significantly with increasing amounts of resuscitation in DR after adjusting for perinatal factors. Resuscitation strategies vary widely between centers, with over 50% of preterm infants in eight centers requiring higher intensity resuscitation.

CONCLUSIONS

Increased intensity of DR interventions was associated with increased mortality and morbidities in very preterm infants in China. There is wide variation in resuscitative approaches across delivery centers, and ongoing quality improvement to standardize resuscitation practices is needed.

Unveiling pseudo-pulseless electrical activity (pseudo-PEA) in ultrasound-integrated infant resuscitation

Point-of-care ultrasound (POCUS) holds immense potential to manage critically deteriorating infants within the neonatal intensive care unit (NICU) and is increasingly used in neonatal clinical practice worldwide. Recent ultrasound-based protocols such as the Sonographic Assessment of liFe-threatening Emergencies-Revised (SAFE-R) and Crashing Neonate Protocol (CNP) offer step-by-step guidance for diagnosing and addressing reversible causes of cardiorespiratory collapse. Traditionally, pulseless electrical activity (PEA) has been diagnosed solely based on absent pulses on clinical examination, disregarding myocardial activity. However, integrating POCUS into resuscitation unveils the concept of pseudo-PEA, where cardiac motion activity is observed visually on the ultrasound but fails to generate a detectable pulse due to inadequate cardiac output. Paradoxically, existing neonatal resuscitation protocols lack directives for identifying and effectively leveraging pseudo-PEA insights in infants, limiting their potential to enhance outcomes. Pseudo-PEA is extensively described in adult literature owing to routine POCUS use in resuscitation. This review article comprehensively evaluates the adult pseudo-PEA literature to glean insights adaptable to neonatal care. Additionally, we propose a simple strategy to integrate POCUS during neonatal resuscitation, especially in infants who do not respond to routine measures.

CONCLUSION

Pseudo-PDA is a newly recognized diagnosis in infants with the use of POCUS during resuscitation. This article highlights the importance of cross-disciplinary learning in tackling emerging challenges within neonatal medicine.

WHAT IS KNOWN

• Point-of-Care ultrasound (POCUS) benefits adult cardiac arrest management, particularly in distinguishing true Pulseless Electrical Activity (PEA) from pseudo-PEA. • Pseudo-PEA is when myocardial motion can be seen on ultrasound but fails to generate palpable pulses or sustain circulation despite evident cardiac electrical activity.

WHAT IS NEW

• Discuss recognition and management of pseudo-PEA in infants. • A proposed algorithm to integrate POCUS into active neonatal cardiopulmonary resuscitation (CPR) procedures.

T-Piece resuscitator versus self-inflating bag for delivery room resuscitation in preterm neonates: a randomized controlled trial

The establishment of adequate ventilation is the cornerstone of neonatal resuscitation in the delivery room (DR). This parallel-group, accessor-blinded randomized controlled trial compared the changes in peripheral oxygen saturation (SpO2), heart rate (HR), and cerebral regional oxygen saturation (crSO2) with the use of a T-piece resuscitator (TPR) versus self-inflating bag (SIB) as a mode of providing positive pressure ventilation (PPV) during DR resuscitation in preterm neonates. Seventy-two preterm neonates were randomly allocated to receive PPV with TPR (n = 36) or SIB (n = 36). The primary outcome was SpO2 (%) at 5 min. The secondary outcomes included the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, fractional-inspired oxygen (FiO2) requirement, minute-specific SpO2, HR and FiO2 trends for the first 5 min of life, need for DR-intubation, crSO2, need and duration of respiratory support, and other in-hospital morbidities. Mean SpO2 at 5 min was 74.5 ± 17.8% and 69.4 ± 22.4%, in TPR and SIB groups, respectively [Mean difference, 95% Confidence Interval 5.08 (-4.41, 14.58); p = 0.289]. No difference was observed in the time to achieve a SpO2 ≥ 80% and > 85%, HR > 100/min, the requirement of FiO2, DR-intubation, and the need and duration of respiratory support. There was no significant difference in the minute-specific SpO2, HR, and FiO2 requirements for the first 5 min. CrSO2 (%) at one hour was lower by 5% in the TPR group compared to SIB; p = 0.03. Other complications were comparable.

CONCLUSIONS

TPR and SIB resulted in comparable SpO2 at 5 min along with similar minute-specific SpO2, HR, and FiO2 trends.

CLINICAL TRIAL REGISTRATION

Clinical trial registry of India, Registration no: CTRI/2021/10/037384, Registered prospectively on: 20/10/2021, https://ctri.icmr.org.in/ .

WHAT IS KNOWN

• Compared to self-inflating bags (SIB), T-piece resuscitators (TPR) provide more consistent inflation pressure and tidal volume as shown in animal and bench studies. • There is no strong recommendation for one device over the other in view of low certainty evidence.

WHAT IS NEW

• TPR and SIB resulted in comparable peripheral oxygen saturation (SpO2) at 5 min along with similar minute-specific SpO2, heart rate, and fractional-inspired oxygen requirement trends. • Short-term complications and mortality rates were comparable with both devices.

Extrauterine Placental Perfusion and Oxygenation in Infants With Very Low Birth Weight: A Randomized Clinical Trial

Importance

An extrauterine placental perfusion (EPP) approach for physiological-based cord clamping (PBCC) may support infants with very low birth weight (VLBW) during transition without delaying measures of support.

Objective

To test whether EPP in resuscitation of infants with VLBW results in higher hematocrit levels, better oxygenation, or improved infant outcomes compared with delayed cord clamping (DCC).

Design, Setting, and Participants

This nonblinded, single-center randomized clinical trial was conducted at a tertiary care neonatal intensive care unit. Infants with a gestational age greater than 23 weeks and birth weight less than 1500 g born by cesarean delivery between May 2019 and June 2021 were included. Data were analyzed from October through December 2021.

Intervention

Prior to cesarean delivery, participants were allocated to receive EPP or DCC. In the EPP group, infant and placenta, connected by an intact umbilical cord, were detached from the uterus and transferred to the resuscitation unit. Respiratory support was initiated while holding the placenta over the infant. The umbilical cord was clamped when infants showed regular spontaneous breathing, stable heart rates greater than 100 beats/min, and adequate oxygen saturations. In the DCC group, cords were clamped 30 to 60 seconds after birth before infants were transferred to the resuscitation unit, where respiratory support was started.

Main Outcomes and Measure

The primary outcome was the mean hematocrit level in the first 24 hours after birth. Secondary prespecified outcome parameters comprised oxygenation during transition and short-term neonatal outcome.

Results

Among 60 infants randomized and included, 1 infant was excluded after randomization; there were 29 infants in the EPP group (mean [SD] gestational age, 27 weeks 6 days [15.0 days]; 14 females [48.3%]) and 30 infants in the DCC group (mean [SD] gestational age, 28 weeks 1 day [17.1 days]; 17 females [56.7%]). The mean (SD) birth weight was 982.8 (276.6) g and 970.2 (323.0) g in the EPP and DCC group, respectively. Intention-to-treat analysis revealed no significant difference in mean hematocrit level (mean difference [MD], 2.1 percentage points; [95% CI, -2.2 to 6.4 percentage points]). During transition, infants in the EPP group had significantly higher peripheral oxygen saturation as measured by pulse oximetry (adjusted MD at 5 minutes, 15.3 percentage points [95% CI, 2.0 to 28.6 percentage points]) and regional cerebral oxygen saturation (adjusted MD at 5 minutes, 11.3 percentage points [95% CI, 2.0 to 20.6 percentage points]). Neonatal outcome parameters were similar in the 2 groups.

Conclusions and Relevance

This study found that EPP resulted in similar hematocrit levels as DCC, with improved cerebral and peripheral oxygenation during transition. These findings suggest that EPP may be an alternative procedure for PBCC in infants with VLBW.

Trial Registration

ClinicalTrials.gov Identifier: NCT03916159.

Use of Pulse Oximetry during Resuscitation of 230 Newborns-A Video Analysis

BACKGROUND

European guidelines recommend the use of pulse oximetry (PO) during newborn resuscitation, especially when there is a need for positive pressure ventilation or supplemental oxygen. The objective was to evaluate (i) to what extent PO was used, (ii) the time and resources spent on the application of PO, and (iii) the proportion of time with a useful PO signal during newborn resuscitation.

METHODS

A prospective observational study was conducted at Stavanger University Hospital, Norway, between 6 June 2019 and 16 November 2021. Newborn resuscitations were video recorded, and the use of PO during the first ten minutes of resuscitation was recorded and analysed.

RESULTS

Of 7466 enrolled newborns, 289 (3.9%) received ventilation at birth. The resuscitation was captured on video in 230 cases, and these newborns were included in the analysis. PO was applied in 222 of 230 (97%) newborns, median (quartiles) 60 (24, 58) seconds after placement on the resuscitation table. The proportion of time used on application and adjustments of PO during ongoing ventilation and during the first ten minutes on the resuscitation table was 30% and 17%, respectively. Median two healthcare providers were involved in the PO application. Video of the PO monitor signal was available in 118 (53%) of the 222 newborns. The proportion of time with a useful PO signal during ventilation and during the first ten minutes on the resuscitation table was 5% and 35%, respectively.

CONCLUSION

In total, 97% of resuscitated newborns had PO applied, in line with resuscitation guidelines. However, the application of PO was time-consuming, and a PO signal was only obtained 5% of the time during positive pressure ventilation.

Thermoregulation and golden hour practices in extremely preterm infants: an international survey

BACKGROUND

Are thermoregulation and golden hour practices in extremely preterm (EP) infants comparable across the world? This study aims to describe these practices for EP infants based on the neonatal intensive care unit's (NICUs) geographic region, country's income status and the lowest gestational age (GA) of infants resuscitated.

METHODS

The Director of each NICU was requested to complete the e-questionnaire between February 2019 and August 2021.

RESULTS

We received 848 responses, from all geographic regions and resource settings. Variations in most thermoregulation and golden hour practices were observed. Using a polyethylene plastic wrap, commencing humidity within 60 min of admission, and having local protocols were the most consistent practices (>75%). The odds for the following practices differed in NICUs resuscitating infants from 22 to 23 weeks GA compared to those resuscitating from 24 to 25 weeks: respiratory support during resuscitation and transport, use of polyethylene plastic wrap and servo-control mode, commencing ambient humidity >80% and presence of local protocols.

CONCLUSION

Evidence-based practices on thermoregulation and golden hour stabilisation differed based on the unit's region, country's income status and the lowest GA of infants resuscitated. Future efforts should address reducing variation in practice and aligning practices with international guidelines.

IMPACT

A wide variation in thermoregulation and golden hour practices exists depending on the income status, geographic region and lowest gestation age of infants resuscitated. Using a polyethylene plastic wrap, commencing humidity within 60 min of admission and having local protocols were the most consistent practices. This study provides a comprehensive description of thermoregulation and golden hour practices to allow a global comparison in the delivery of best evidence-based practice. The findings of this survey highlight a need for reducing variation in practice and aligning practices with international guidelines for a comparable health care delivery.

Use of access port covers in transport incubators to improve thermoregulation during neonatal transport

Hypothermia in newborns increases the risk of health complications and mortality. This study aimed to evaluate the effectiveness of using covers over snap-open access ports of a transport incubator to maintain the temperature within. The change in temperature inside the transport incubator was evaluated over a 15-min period at three ambient room temperatures (20 °C, 24 °C, and 28 °C), as well as for three snap-open access port conditions: closed, where ports are closed; open, where the two ports on one side are open; and covered, where the two ports on one side are open but a cover is used. The automatic temperature control of the incubator was set to 37 °C for all conditions. We repeated the same experiments three times. The temperature decrease inside the incubator was greater for the open than for the closed or covered access port conditions at all three 4 °C-increasing room temperatures (p < 0.05). The incubator temperature decreased as a function of decreasing room temperature only for the open condition, with no significant difference between the closed and covered conditions. Therefore, snap-open access port covers provide an option to maintain a constant temperature within the transport incubator, which may lower the risk of neonatal hypothermia.

Evaluating enhanced pulse oximetry auditory displays for neonatal oxygen targeting: A randomized laboratory trial with clinicians and non-clinicians

Standard pulse oximeter auditory tones do not clearly indicate departures from the target range of oxygen saturation (SpO₂) of 90%-95% in preterm neonates. We tested whether acoustically enhanced tones would improve participants' ability to identify SpO₂ range. Twenty-one clinicians and 23 non-clinicians used (1) standard pulse oximetry variable-pitch tones plus alarms; (2) beacon-enhanced tones without alarms in which reference tones were inserted before standard pulse tones when SpO₂ was outside target range; and (3) tremolo-enhanced tones without alarms in which pulse tones were modified with tremolo when SpO₂ was outside target range. For clinicians, range identification accuracies (mean (SD)) in the standard, beacon, and tremolo conditions were 52% (16%), 73% (14%) and 76% (13%) respectively, and for non-clinicians 49% (16%), 76% (13%) and 72% (14%) respectively, with enhanced conditions always significantly more accurate than standard. Acoustic enhancements to pulse oximetry clearly indicate departures from preterm neonates' target SpO₂ range.

History of Neonatal Resuscitation: From Uncivilized to Evidence-based Practices

Neonatal resuscitation, an early and critical intervention in human life, has dramatically evolved. This procedure has gone through phases from uncivilized practices that were sometimes based on myths to the current evidence-based approaches. In this review, we will shed light on the evolution of neonatal resuscitation from early centuries to the current day. Our goal is to highlight the value of clinical research and its role in invalidating hazardous practices and establishing evidence-based guidelines.

Neonatal Resuscitation: A Critical Incident Technique Study Exploring Pediatric Registered Nurses' Experiences and Actions

BACKGROUND

Teamwork during neonatal resuscitation is essential. Situations arise quickly and unexpectedly and are highly stressful, requiring pediatric registered nurses (pRN) to respond effectively and in a structured manner. In Sweden, pRNs work in all pediatric settings including the neonatal intensive care unit. The experience and actions of pRNs are seldom explored, and studies within this area could develop and improve strategies for neonatal resuscitation situations.

PURPOSE

To describe pRNs' experiences and actions during neonatal resuscitation.

METHODS

A qualitative interview study based on the critical incident technique was performed. Sixteen pRNs from 4 neonatal intensive care units in Sweden were interviewed.

RESULTS

Critical situations were divided into 306 experiences and 271 actions. pRNs' experiences were divided into 2 categories: individual- and team-focused experiences. Critical situations were managed by individual- or team-focused actions.

Transitional circulation and hemodynamic monitoring in newborn infants

Transitional circulation is normally transient after birth but can vary markedly between infants. It is actually in a state of transition between fetal (in utero) and neonatal (postnatal) circulation. In the absence of definitive clinical trials, information from applied physiological studies can be used to facilitate clinical decision making in the presence of hemodynamic compromise. This review summarizes the peculiar physiological features of the circulation as it transitions from one phenotype into another in term and preterm infants. The common causes of hemodynamic compromise during transition, intact umbilical cord resuscitation, and advanced hemodynamic monitoring are discussed. IMPACT: Transitional circulation can vary markedly between infants. There are alterations in preload, contractility, and afterload during the transition of circulation after birth in term and preterm infants. Hemodynamic monitoring tools and technology during neonatal transition and utilization of bedside echocardiography during the neonatal transition are increasingly recognized. Understanding the cardiovascular physiology of transition can help clinicians in making better decisions while managing infants with hemodynamic compromise. The objective assessment of cardio-respiratory transition and understanding of physiology in normal and disease states have the potential of improving short- and long-term health outcomes.

Neonatal resuscitation after birth: Swedish midwives' experiences of and perceptions about separation of mothers and their newborn babies

INTRODUCTION

This study aimed to investigate midwives' experiences of and perceptions about mother-baby separation during resuscitation of the baby following birth.

METHODS

A qualitative study was conducted using an author-designed questionnaire. Fifty-four midwives from two Swedish birth units with different working methods regarding neonatal resuscitation - at the mother's bedside in the birth room or in a designated resuscitation room outside the birth room - completed the questionnaire. Data were analyzed using qualitative content analysis.

RESULTS

Most midwives had experience of removing a newborn baby in need of critical care from the birth room, thus separating the mother and baby. The midwives identified the difficulties and challenges involved in carrying out emergency care in the birth room after birth and had divergent opinions about what they considered possible in these birth situations. They agreed on the benefits, for both mother and baby, in performing emergency care in the birth room and avoiding a separation altogether, if possible.

CONCLUSIONS

There are good opportunities to reduce separation of mother and baby after birth; training, knowledge, education and the right environmental conditions are important factors in successfully implementing new ways of working. It is possible to work towards reducing separation and this work should continue and strive to eliminate separation as far as possible.

Endotracheal intubation performance at a large obstetric hospital delivery room, Hanoi, Vietnam

INTRODUCTION

Intrapartum-related events account for nearly 700,000 neonatal deaths globally yearly. Endotracheal intubation is a cornerstone in preventing many of these deaths, but it is a difficult skill to acquire. Previous studies have described intubation performances in high-income countries, but data from low- and middle-income countries are lacking. We aimed to assess the performance of delivery room intubation in a lower middle-income country.

METHODS

This prospective observational study was conducted at the Phu San Hanoi Hospital, Vietnam, from September 2020 to January 2021. Video cameras were positioned above the resuscitation tables and data were extracted using adopted software (NeoTapAS). All neonates requiring positive pressure ventilation were included. Our main variables of interest were time to first intubation attempt, first intubation attempt duration, and successful first intubation attempt.

RESULTS

18,107 neonates were born during the five months. Of these, 75 (0.4%) received positive pressure ventilation, and 36 (0.2%) required endotracheal intubation of whom 24 were captured on video. The median time to the first intubation attempt was 252 seconds (range 91-771 seconds), the median first attempt duration was 49 seconds (range 10-105 seconds), and the first attempt success rate was 75%.

CONCLUSION

Incidences of positive pressure ventilation and endotracheal intubation were low in comparison to global estimates. Three out of four intubations were successful at the first attempt and the procedural duration was often longer than recommended. Future studies should focus on how to achieve and maintain intubation skills and could include considering alternative devices for airway management at birth.

Initial Use of 100% but Not 60% or 30% Oxygen Achieved a Target Heart Rate of 100 bpm and Preductal Saturations of 80% Faster in a Bradycardic Preterm Model

Background: Currently, 21−30% supplemental oxygen is recommended during resuscitation of preterm neonates. Recent studies have shown that 58% of infants < 32 week gestation age are born with a heart rate (HR) < 100 bpm. Prolonged bradycardia with the inability to achieve a preductal saturation (SpO2) of 80% by 5 min is associated with mortality and morbidity in preterm infants. The optimal oxygen concentration that enables the achievement of a HR ≥ 100 bpm and SpO2 of ≥80% by 5 min in preterm lambs is not known. Methods: Preterm ovine model (125−127 d, gestation equivalent to human neonates < 28 weeks) was instrumented, and asphyxia was induced by umbilical cord occlusion until bradycardia. Ventilation was initiated with 30% (OX30), 60% (OX60), and 100% (OX100) for the first 2 min and titrated proportionately to the difference from the recommended preductal SpO2. Our primary outcome was the incidence of the composite of HR ≥ 100 bpm and SpO2 ≥ 80%, by 5 min. Secondary outcomes were to evaluate the time taken to achieve the primary outcome, gas exchange, pulmonary/systemic hemodynamics, and the oxidative injury. Results: Eighteen lambs (OX30-6, OX60-5. OX100-7) had an average HR < 91 bpm with a pH of <6.92 before resuscitation. Sixty seven percent achieved the primary outcome in OX100, 40% in OX60, and none in OX30. The time taken to achieve the primary outcome was significantly shorter with OX100 (6 ± 2 min) than with OX30 (10 ± 3 min) (* p = 0.04). The preductal SpO2 was highest with OX100, while the peak pulmonary blood flow was lowest with OX30, with no difference in O2 delivery to the brain or oxidative injury by 10 min. Conclusions: The use of 30%, 60%, and 100% supplemental O2 in a bradycardic preterm ovine model did not demonstrate a significant difference in the composite primary outcome. The current recommendation to use 30% oxygen did not achieve a preductal SpO2 of 80% by 5 min in any preterm lambs. Clinical studies to optimize supplemental O2 in depressed preterm neonates not requiring chest compressions are warranted.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis

AIM

Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation).

METHODS

Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed.

RESULTS

25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes.

CONCLUSIONS

Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Technology in the delivery room supporting the neonatal healthcare provider's task

Very preterm infants are a unique and highly vulnerable group of patients that have a narrow physiological margin within which interventions are safe and effective. The increased understanding of the foetal to neonatal transition marks the intricacy of the rapid and major physiological changes that take place, making delivery room stabilisation and resuscitation an increasingly complex and sophisticated activity for caregivers to perform. While modern, automated technologies are progressively implemented in the neonatal intensive care unit (NICU) to enhance the caregivers in providing the right care for these patients, the technology in the delivery room still lags far behind. Diligent translation of well-known and promising technological solutions from the NICU to the delivery room will allow for better support of the caregivers in performing their tasks. In this review we will discuss the current technology used for stabilisation of preterm infants in the delivery room and how this could be optimised in order to further improve care and outcomes of preterm infants in the near future.

Preliminary study of automated oxygen titration at birth for preterm infants

OBJECTIVE

To study the feasibility of automated titration of oxygen therapy in the delivery room for preterm infants.

DESIGN

Prospective non-randomised study of oxygenation in sequential preterm cohorts in which FiO₂ was adjusted manually or by an automated control algorithm during the first 10 min of life.

SETTING

Delivery rooms of a tertiary level hospital.

PARTICIPANTS

Preterm infants <32 weeks gestation (n=20 per group).

INTERVENTION

Automated oxygen control using a purpose-built device, with SpO₂ readings input to a proportional-integral-derivative algorithm, and FiO₂ alterations actuated by a motorised blender. The algorithm was developed via in silico simulation using abstracted oxygenation data from the manual control group. For both groups, the SpO₂ target was the 25th-75th centile of the Dawson nomogram.

MAIN OUTCOME MEASURES

Proportion of time in the SpO₂ target range (25th-75th centile, or above if in room air) and other SpO₂ ranges; FiO₂ adjustment frequency; oxygen exposure.

RESULTS

Time in the SpO₂ target range was similar between groups (manual control: median 60% (IQR 48%-72%); automated control: 70 (60-84)%; p=0.31), whereas time with SpO₂ >75th centile when receiving oxygen differed (manual: 17 (7.6-26)%; automated: 10 (4.4-13)%; p=0.048). Algorithm-directed FiO₂ adjustments were frequent during automated control, but no manual adjustments were required in any infant once valid SpO₂ values were available. Oxygen exposure was greater during automated control, but final FiO₂ was equivalent.

CONCLUSION

Automated oxygen titration using a purpose-built algorithm is feasible for delivery room management of preterm infants, and warrants further evaluation.

Single versus continuous sustained inflations during chest compressions and physiological-based cord clamping in asystolic lambs

BACKGROUND

The feasibility and benefits of continuous sustained inflations (SIs) during chest compressions (CCs) during delayed cord clamping (physiological-based cord clamping; PBCC) are not known. We aimed to determine whether continuous SIs during CCs would reduce the time to return of spontaneous circulation (ROSC) and improve post-asphyxial blood pressures and flows in asystolic newborn lambs.

METHODS

Fetal sheep were surgically instrumented immediately prior to delivery at ~139 days' gestation and asphyxia induced until lambs reached asystole. Lambs were randomised to either immediate cord clamping (ICC) or PBCC. Lambs then received a single SI (SIsing; 30 s at 30 cmH2O) followed by intermittent positive pressure ventilation, or continuous SIs (SIcont: 30 s duration with 1 s break). We thus examined 4 groups: ICC +SIsing, ICC +SIcont, PBCC +SIsing, and PBCC +SIcont. Chest compressions and epinephrine administration followed international guidelines. PBCC lambs underwent cord clamping 10 min after ROSC. Physiological and oxygenation variables were measured throughout.

RESULTS

The time taken to achieve ROSC was not different between groups (mean (SD) 4.3±2.9 min). Mean and diastolic blood pressure was higher during chest compressions in PBCC lambs compared with ICC lambs, but no effect of SIs was observed. SIcont significantly reduced pulmonary blood flow, diastolic blood pressure and oxygenation after ROSC compared with SIsing.

CONCLUSION

We found no significant benefit of SIcont over SIsing during CPR on the time to ROSC or on post-ROSC haemodynamics, but did demonstrate the feasibility of continuous SIs during advanced CPR on an intact umbilical cord. Longer-term studies are recommended before this technique is used routinely in clinical practice.

Direct Derivatization in Dried Blood Spots for Oxidized and Reduced Glutathione Quantification in Newborns

The glutathione (GSH)-to-glutathione disulfide (GSSG) ratio is an essential node contributing to intracellular redox status. GSH/GSSG determination in whole blood can be accomplished by liquid chromatography–mass spectrometry (LC-MS) after the derivatization of GSH with N-ethylmaleimide (NEM). While this is feasible in a laboratory environment, its application in the clinical scenario is cumbersome and therefore ranges reported in similar populations differ noticeably. In this work, an LC-MS procedure for the determination of GSH and GSSG in dried blood spot (DBS) samples based on direct in situ GSH derivatization with NEM of only 10 µL of blood was developed. This novel method was applied to 73 cord blood samples and 88 residual blood volumes from routine newborn screening performed at discharge from healthy term infants. Two clinical scenarios simulating conditions of sampling and storage relevant for routine clinical analysis and clinical trials were assessed. Levels of GSH-NEM and GSSG measured in DBS samples were comparable to those obtained by liquid blood samples. GSH-NEM and GSSG median values for cord blood samples were significantly lower than those for samples at discharge. However, the GSH-NEM-to-GSSG ratios were not statistically different between both groups. With DBS testing, the immediate manipulation of samples by clinical staff is reduced. We therefore expect that this method will pave the way in providing an accurate and more robust determination of the GSH/GSSG values and trends reported in clinical trials.

Neonatal resuscitation practices in Italy: a survey of the Italian Society of Neonatology (SIN) and the Union of European Neonatal and Perinatal Societies (UENPS)

BACKGROUND

Providing appropriate care at birth remains a crucial strategy for reducing neonatal mortality and morbidity. We aimed to evaluate the consistency of practice and the adherence to the international guidelines on neonatal resuscitation in level-I and level-II Italian birth hospitals.

METHODS

This was a cross-sectional electronic survey. A 91-item questionnaire focusing on current delivery room practices in neonatal resuscitation was sent to the directors of 418 Italian neonatal facilities.

RESULTS

The response rate was 61.7% (258/418), comprising 95.6% (110/115) from level-II and 49.0% (148/303) from level-I centres. In 2018, approximately 300,000 births occurred at the participating hospitals, with a median of 1664 births/centre in level-II and 737 births/centre in level-I hospitals. Participating level-II hospitals provided nasal-CPAP and/or high-flow nasal cannulae (100%), mechanical ventilation (99.1%), HFOV (71.0%), inhaled nitric oxide (80.0%), therapeutic hypothermia (76.4%), and extracorporeal membrane oxygenation ECMO (8.2%). Nasal-CPAP and/or high-flow nasal cannulae and mechanical ventilation were available in 77.7 and 21.6% of the level-I centres, respectively. Multidisciplinary antenatal counselling was routinely offered to parents at 90.0% (90) of level-II hospitals, and 57.4% (85) of level-I hospitals (p < 0.001). Laryngeal masks were available in more than 90% of participating hospitals while an end-tidal CO₂ detector was available in only 20%. Significant differences between level-II and level-I centres were found in the composition of resuscitation teams for high-risk deliveries, team briefings before resuscitation, providers qualified with full resuscitation skills, self-confidence, and use of sodium bicarbonate.

CONCLUSIONS

This survey provides insight into neonatal resuscitation practices in a large sample of Italian hospitals. Overall, adherence to international guidelines on neonatal resuscitation was high, but differences in practice between the participating centres and the guidelines exist. Clinicians and stakeholders should consider this information when allocating resources and planning perinatal programs in Italy.

Prise en charge périnatale du nouveau-né lors d’une naissance en milieu extrahospitalier

Les accouchements inopinés extrahospitaliers représentent environ 0,3 % des accouchements en France. La prise en charge du nouveau-né en préhospitalier par une équipe Smur fait partie de l’activité courante. L’évaluation initiale du nouveau-né comprend systématiquement la mesure de sa fréquence cardiaque (FC) et respiratoire (FR), l’appréciation de son tonus ainsi que la mesure de sa température axillaire. En cas de doute ou de transition incomplète un monitoring cardiorespiratoire sera immédiatement mis en place (FC, FR, SpO2). Nous faisons ici une mise au point sur les données connues et avons adapté les pratiques, si besoin, au contexte extrahospitalier, car la majeure partie des données rapportées dans la littérature concernent les prises en charge en maternité ou en milieu hospitalier. Nous abordons les points essentiels de la prise en charge des nouveau-nés, à savoir la réanimation cardiopulmonaire, le clampage tardif du cordon ombilical, la lutte contre l’hypothermie et l’hypoglycémie; ainsi que des situations particulières comme la prématurité, la conduite à tenir en cas de liquide méconial ou de certaines malformations congénitales. Nous proposons aussi quels peuvent être : le matériel nécessaire à la prise en charge des nouveau-nés en extrahospitalier, les critères d’engagement d’un renfort pédiatrique à la régulation ainsi que les méthodes de ventilation et d’abord vasculaire que l’urgentiste doit maîtriser. L’objectif de cette mise au point est de proposer des prises en charge les plus adaptées au contexte préhospitalier.

Assessment of optimal chest compression depth during neonatal cardiopulmonary resuscitation: a randomised controlled animal trial

AIM

The study aimed to examine the optimal anterior-posterior depth which will reduce the time to return of spontaneous circulation and improve survival during chest compressions. Asphyxiated neonatal piglets receiving chest compression resuscitated with a 40% anterior-posterior chest depth compared with 33%, 25% or 12.5% will have reduced time to return of spontaneous circulation and improved survival.

METHODS

Newborn piglets (n=8 per group) were anaesthetised, intubated, instrumented and exposed to 45 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to four intervention groups ('anterior-posterior 12.5% depth', 'anterior-posterior 25% depth', 'anterior-posterior 33% depth' or 'anterior-posterior 40% depth'). Chest compressions were performed using an automated chest compression machine with a rate of 90 per minute. Haemodynamic and respiratory parameters, applied compression force, and chest compression depth were continuously measured.

RESULTS

The median (IQR) time to return of spontaneous circulation was 600 (600-600) s, 135 (90-589) s, 85 (71-158)* s and 116 (63-173)* s for the 12.5%, 25%, 33% and 40% depth groups, respectively (*p<0.001 vs 12.5%). The number of piglets that achieved return of spontaneous circulation was 0 (0%), 6 (75%), 7 (88%) and 7 (88%) in the 12.5%, 25%, 33% and 40% anterior-posterior depth groups, respectively. Arterial blood pressure, central venous pressure, carotid blood flow, applied compression force, tidal volume and minute ventilation increased with greater anterior-posterior chest depth during chest compression.

CONCLUSIONS

Time to return of spontaneous circulation and survival were similar between 25%, 33% and 40% anterior-posterior depths, while 12.5% anterior-posterior depth did not result in return of spontaneous circulation or survival. Haemodynamic and respiratory parameters improved with increasing anterior-posterior depth, suggesting improved organ perfusion and oxygen delivery with 33%-40% anterior-posterior depth.

TRIAL REGISTRATION NUMBER

PTCE0000193.

Safe emergency neonatal airway management: current challenges and potential approaches

This review examines the airway adjuncts currently used to acutely manage the neonatal airway. It describes the challenges encountered with facemask ventilation and intubation. Evidence is presented on how to optimise intubation safety and success rates with the use of videolaryngoscopy and attention to the intubation environment. The supraglottic airway (laryngeal mask airway) is emerging as a promising neonatal airway adjunct. It can be used effectively with little training to provide a viable alternative to facemask ventilation and intubation in neonatal resuscitation and be used as an alternative conduit for the administration of surfactant.

Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines

Although most newborns require no assistance to successfully transition to extrauterine life, the large number of births each year and limited ability to predict which newborns will need assistance means that skilled clinicians must be prepared to respond quickly and efficiently for every birth. A successful outcome is dependent on a rapid response from skilled staff who have mastered the cognitive, technical, and behavioral skills of neonatal resuscitation. Since its release in 1987, over 4.5 million clinicians have been trained by the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program®. The guidelines used to develop this program were updated in 2020 and the Textbook of Neonatal Resuscitation, 8th edition, was released in June 2021. The updated guidelines have not changed the basic approach to neonatal resuscitation, which emphasizes the importance of anticipation, preparation, teamwork, and effective ventilation. Several practices have changed, including the prebirth questions, initial steps, use of electronic cardiac monitors, the initial dose of epinephrine, the flush volume after intravascular epinephrine, and the duration of resuscitation with an absent heart rate. In addition, the program has enhanced components of the textbook to improve learning, added new course delivery options, and offers 2 course levels to allow learners to study the material that is most relevant to their role during neonatal resuscitation. This review summarizes the recent changes to the resuscitation guidelines, the textbook, and the Neonatal Resuscitation Program course.

Maintaining Normothermia in Preterm Babies during Stabilisation with an Intact Umbilical Cord

Background: We had experienced an increase in admission hypothermia rates during implementation of deferred cord clamping (DCC) in our unit. Our objective was to reduce the number of babies with a gestation below 32 weeks who are hypothermic on admission, whilst practising DCC and providing delivery room cuddles (DRC). Method: A 12 month quality improvement project set, in a large Neonatal Intensive Care Unit, from January 2020 to December 2020. Monthly rates of admission hypothermia (<36.5 °C) for all eligible babies, were tracked prospectively. Each hypothermic baby was reviewed as part of a series of Plan, Do, Study Act (PDSA) cycles, to understand potential reasons and to develop solutions. Implementation of these solutions included the dissemination of the learning through a variety of methods. The main outcome measure was the proportion of babies who were hypothermic (<36.5 °C) on admission compared to the previous 12 months. Results: 130 babies with a gestation below 32 weeks were admitted during the study period. 90 babies (69.2%) had DCC and 79 babies (60%) received DRC. Compared to the preceding 12 months, the rate of hypothermia decreased from 25/109 (22.3%) to 13/130 (10%) (p = 0.017). Only 1 baby (0.8%) was admitted with a temperature below 36 °C and 12 babies (9.2%) were admitted with a temperature between 36 °C and 36.4 °C. Continued monitoring during the 3 months after the end of the project showed that the improvements were sustained with 0 cases of hypothermia in 33 consecutive admissions. Conclusions: It is possible to achieve low rates of admission hypothermia in preterm babies whilst providing DCC and DRC. Using a quality improvement approach with PDSA cycles is an effective method of changing clinical practice to improve outcomes.

Survey on currently applied interventions in neonatal resuscitation (SCIN): A study protocol

INTRODUCTION

Around 140 million children are born every year and post-natal transition is uncomplicated in the vast majority. However, around 5%-15% of neonates receive supportive interventions during transition. Recent data on the interventions used is scarce. More data on the frequencies with which these interventions are used is needed to evaluate neonatal resuscitation, guide recommendations and to generate hypotheses for further research. The following protocol describes an international, multicentre survey on the interventions currently applied during neonatal resuscitation.

OBJECTIVES

To determine the frequencies at which different supportive interventions recommended by European Resuscitation Council (ERC) guidelines for neonatal resuscitation are used. To compare the frequencies between hospitals and patient groups and to investigate possible factors influencing any differences found.

METHODS

Participating hospitals will collect data on all interventions performed during neonatal resuscitation over a period of 6 months. All hospitals providing perinatal care are eligible regardless of size and designated level of neonatal care. Every neonate requiring more interventions than basic drying and tactile stimulation during the first 30 min of life will be included. The targeted sample size is at least 4,000 neonates who receive interventions. After anonymization, the data is pooled in a common database and descriptive and statistical analysis is performed globally and in subgroups. Possible correlations will be investigated with phi coefficient and chi square testing.

ETHICS AND DISSEMINATION

Consent of the institutional review board of the Technical University Dresden was obtained for the local data collection under the number BO-EK-198042022. Additionally, approval of local ethical or institutional review boards will be obtained by the participating hospitals if required. Results will be published in peer-reviewed journals and presented at suitable scientific conferences.

Resuscitation 2020: Proceedings From the NeoHeart 2020 International Conference

Resuscitation guidelines are developed and revised by medical societies throughout the world. These guidelines are increasingly based on evidence from preclinical and clinical research. The International Liaison Committee on Resuscitation reviews evidence for each resuscitation practice and provides summary consensus statements that inform resuscitation guideline committees. A similar process is used for different populations including neonatal, pediatric, and adult resuscitation. The NeoHeart 2020 Conference brought together experts in resuscitation to discuss recent evidence and guidelines for resuscitation practices. This review summarizes the main focus of discussion from this symposium.

Improving Newborn Resuscitation by Making Every Birth a Learning Event

One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.

Tidal volumes and pressures delivered by the NeoPuff T-piece resuscitator during resuscitation of term newborns

AIM

T-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when resuscitating term newborns immediately after birth, using the NeoPuff T-piece resuscitator.

METHOD

Observational study from June 2019 through March 2021 at Stavanger University Hospital, Norway, including term newborns ventilated with a T-piece resuscitator after birth, with consent to participate. Ventilation parameters of the first 100 inflations from each newborn were recorded by respiration monitors and divided into an early (inflation 1-20) and a late (inflation 21-100) phase.

RESULTS

Of the 7730 newborns born, 232 term newborns received positive pressure ventilation. Of these, 129 newborns were included. In the early and the late phase, the median (interquartile range) peak inflating pressure was 30 (28-31) and 30 (27-31) mbar, and tidal volume was 4.5 (1.6-7.8) and 5.7 (2.2-9.8) ml/kg, respectively. Increased inflation times were associated with an increase in volume before plateauing at an inflation time of 0.41 s in the early phase and 0.50 s in the late phase. Inflation rates exceeding 32 per minute in the early phase and 41 per minute in the late phase were associated with lower tidal volumes.

CONCLUSION

There was a substantial variation in tidal volumes despite a relatively stable peak inflating pressure. Delivered tidal volumes were at the lower end of the recommended range. Our results indicate that an inflation time of approximately 0.5 s and rates around 30-40 per minute are associated with the highest delivered tidal volumes.

The Use of a Disposable Umbilical Clamp to Secure an Umbilical Venous Catheter in Neonatal Emergencies—An Experimental Feasibility Study

Recent guidelines recommend the umbilical venous catheter (UVC) as the optimal vascular access method during neonatal resuscitation. In emergencies the UVC securement may be challenging and time-consuming. This experimental study was designed to test the feasibility of new concepts for the UVC securement. Umbilical cord remnants were catheterized with peripheral catheters and secured with disposable umbilical clamps. Three different securement techniques were investigated. Secure 1: the disposable umbilical clamp was closed at the level of the inserted catheter. Secure 2: the clamp was closed at the junction of the catheter and plastic wings. Secure 3: the setting of Secure 2 was combined with an umbilical tape. The main outcomes were the feasibility of fluid administration and the maximum force to release the securement. This study shows that inserting peripheral catheters into the umbilical vein and securing them with disposable umbilical clamps is feasible. Rates of lumen obstruction and the effectiveness of the securement were superior with Secure 2 and 3 compared to Secure 1. This new approach may be a rewarding option for umbilical venous catheterization and securement particularly in low-resource settings and for staff with limited experience in neonatal emergencies. However, although promising, these results need to be confirmed in clinical trials before being introduced into clinical practice.

Lung Deposition of Surfactant Delivered via a Dedicated Laryngeal Mask Airway in Piglets

It is unknown if the lung deposition of surfactant administered via a catheter placed through a laryngeal mask airway (LMA) is equivalent to that obtained by bolus instillation through an endotracheal tube. We compare the lung deposition of surfactant delivered via two types of LMA with the standard technique of endotracheal instillation. 25 newborn piglets on continuous positive airway pressure support (CPAP) were randomized into three groups: 1—LMA-camera (integrated camera and catheter channel; catheter tip below vocal cords), 2—LMA-standard (no camera, no channel; catheter tip above the glottis), 3—InSurE (Intubation, Surfactant administration, Extubation; catheter tip below end of endotracheal tube). All animals received 100 mg·kg⁻¹ of poractant alfa mixed with ^99mTechnetium-nanocolloid. Surfactant deposition was measured by gamma scintigraphy as a percentage of the administered dose. The median (range) total lung surfactant deposition was 68% (10–85), 41% (5–88), and 88% (67–92) in LMA-camera, LMA-standard, and InSurE, respectively, which was higher (p < 0.05) in the latter. The deposition in the stomach and nasopharynx was higher with the LMA-standard. The surfactant deposition via an LMA was lower than that obtained with InSurE. Although not statistically significant, introducing the catheter below the vocal cords under visual control with an integrated camera improved surfactant LMA delivery by 65%.

Delivery room CPAP in improving outcomes of preterm neonates in low-and middle-income countries: A systematic review and network meta-analysis

AIM

To study the impact of delivery room continuous positive airway pressure (DRCPAP) on outcomes of preterm neonates in low- and middle- income countries (LMICs) by comparing with interventions: oxygen supplementation, late DRCPAP, DRCPAP with sustained inflation, DRCPAP with surfactant and invasive mechanical ventilation (IMV).

METHODS

Medline, Embase, CENTRAL, WOS and CINAHL searched. Observational studies and randomized controlled trials (RCTs) were included. Pair-wise meta-analysis and Bayesian network meta-analysis (NMA) were utilized. Primary outcome was receipt of IMV.

RESULTS

Data from 11 of the 18 included studies (4 observational studies, 7 RCTs) enrolling 4210 preterm infants was synthesized. Moderate certainty of evidence (CoE) from NMA of RCTs comparing DRCPAP with surfactant administration versus DRCPAP alone suggested no decrease in subsequent receipt of IMV [Risk ratio (RR); 95% Credible Interval (CrI): 0.73; (0.34, 1.40)]. Very low CoE from observational studies comparing use of DRCPAP versus oxygen supplementation indicated a trend towards decreased IMV [RR; 95% Confidence Interval (CI): 0.75; (0.56-1.00)]. Although moderate CoE from NMA evaluating DRCPAP versus oxygen supplementation showed a trend towards decreased receipt of surfactant, it did not reach statistical significance [RR; 95% CrI: 0.69; (0.44, 1.06)]. Moderate CoE from NMA indicated that none of the interventions, when compared with use of supplemental oxygen alone or with each other decreased mortality or bronchopulmonary dysplasia.

LIMITATIONS

CoE was very low for primary outcome.

CONCLUSIONS

Present evidence is not sufficient for use of DRCPAP, but also did not show harm. Since it seems unlikely that there are marked variations in patient physiology to explain the difference in efficacy between high income countries and LMICs, we suggest future research evaluating other barriers in improving the effectiveness of DRCPAP in LMICs.

Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review

Premature infants born after less than 25 weeks' gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks' gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks' gestation at the threshold of viability.

A comparative evaluation and appraisal of 2020 American Heart Association and 2021 European Resuscitation Council neonatal resuscitation guidelines

AIM

The International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support forms the basis for guidelines developed by regional councils such as the American Heart Association (AHA) and the European Resuscitation Council (ERC). We aimed to determine if the updated guidelines are congruent, identify the source of variation, and score their quality.

METHODS

We compared the approach to developing recommendations, final recommendations, and cited evidence in the AHA 2020 and ERC 2021 neonatal resuscitation guidelines. Two investigators scored guideline quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

Differences in the recommendations were found between AHA 2020 and ERC 2021 neonatal resuscitation guidelines. The councils gave differing recommendations for practices that had sparse evidence and made recommendations based on expert consensus or observational studies. AGREE II assessment revealed that AHA scored better for the domain 'rigour of development', but ERC had a higher score for 'stakeholder involvement'. Both AHA and ERC scored relatively less for 'applicability'.

CONCLUSION

AHA and ERC guidelines are predominantly based on the ILCOR CoSTR. Differences in recommendations between the two were largely related to the evidence gathering process for questions not reviewed by ILCOR, paucity of evidence for some recommendations based on existing regional practices and supported by expert opinion, and different interpretation or application of same evidence. Overall, both guidelines scored well on the AGREE II assessment, but each had domains that could be improved in future editions.

Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis

Importance

Prevention of hypothermia in the delivery room is a cost-effective, high-impact intervention to reduce neonatal mortality, especially in preterm neonates. Several interventions for preventing hypothermia in the delivery room exist, of which the most beneficial is currently unknown.

Objective

To identify the delivery room thermal care intervention that can best reduce neonatal hypothermia and improve clinical outcomes for preterm neonates born at 36 weeks' gestation or less.

Data Sources

MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL databases were searched from inception to November 5, 2020.

Study Selection

Randomized and quasi-randomized clinical trials of thermal care interventions in the delivery room for preterm neonates were included. Peer-reviewed abstracts and studies published in non-English language were also included.

Data Extraction and Synthesis

Data from the included trials were extracted in duplicate using a structured proforma. A network meta-analysis with bayesian random-effects model was used for data synthesis.

Main Outcomes and Measures

Primary outcomes were core body temperature and incidence of moderate to severe hypothermia on admission or within the first 2 hours of life. Secondary outcomes were incidence of hyperthermia, major brain injury, and mortality before discharge. The 9 thermal interventions evaluated were (1) plastic bag or plastic wrap covering the torso and limbs with the head uncovered or covered with a cloth cap; (2) plastic cap covering the head; (3) skin-to-skin contact; (4) thermal mattress; (5) plastic bag or plastic wrap with a plastic cap; (6) plastic bag or plastic wrap along with use of a thermal mattress; (7) plastic bag or plastic wrap along with heated humidified gas for resuscitation or for initiating respiratory support in the delivery room; (8) plastic bag or plastic wrap along with an incubator for transporting from the delivery room; and (9) routine care, including drying and covering the body with warm blankets, with or without a cloth cap.

Results

Of the 6154 titles and abstracts screened, 34 studies that enrolled 3688 neonates were analyzed. Compared with routine care alone, plastic bag or wrap with a thermal mattress (mean difference [MD], 0.98 °C; 95% credible interval [CrI], 0.60-1.36 °C), plastic cap (MD, 0.83 °C; 95% CrI, 0.28-1.38 °C), plastic bag or wrap with heated humidified respiratory gas (MD, 0.76 °C; 95% CrI, 0.38-1.15 °C), plastic bag or wrap with a plastic cap (MD, 0.62 °C; 95% CrI, 0.37-0.88 °C), thermal mattress (MD, 0.62 °C; 95% CrI, 0.33-0.93 °C), and plastic bag or wrap (MD, 0.56 °C; 95% CrI, 0.44-0.69 °C) were associated with greater core body temperature. Certainty of evidence was moderate for 5 interventions and low for plastic bag or wrap with a thermal mattress. When compared with routine care alone, a plastic bag or wrap with heated humidified respiratory gas was associated with less risk of major brain injury (risk ratio, 0.23; 95% CrI, 0.03-0.67; moderate certainty of evidence) and a plastic bag or wrap with a plastic cap was associated with decreased risk of mortality (risk ratio, 0.19; 95% CrI, 0.02-0.66; low certainty of evidence).

Conclusions and Relevance

Results of this study indicate that most thermal care interventions in the delivery room for preterm neonates were associated with improved core body temperature (with moderate certainty of evidence). Specifically, use of a plastic bag or wrap with a plastic cap or with heated humidified gas was associated with lower risk of major brain injury and mortality (with low to moderate certainty of evidence).

Apgar score at 10 minutes and adverse outcomes among low-risk pregnancies

OBJECTIVE

Among low-risk pregnancies, we ascertained the association between 10-minute Apgar score and adverse outcomes of newborn infants.

METHOD

We conducted a retrospective cohort study using the U.S. vital statistics datasets (2011-2018), which included live births from low-risk women with non-anomalous singleton gestations who delivered at 37-41 weeks. When a newborn infant had an abnormal 5-minute Apgar score (0-5), a 10-minute Apgar score was documented in the birth certificate. Apgar score at 10 min was categorized as low (0-3), moderate (4-6), and normal (7-10). The primary outcome was composite neonatal adverse outcome. The secondary outcomes were individual neonatal adverse outcomes and infant mortality. Multivariable Poisson regression analyses were used to estimate the association between 10-minute Apgar score and adverse outcomes (using adjusted relative risk [aRR] and 95% confidence intervals [CI]).

RESULTS

Of 31.5 million live births delivered (2011-2018), 111,163 (0.4%) met inclusion criteria; of them, 74.2%, 20.7%, and 5.1% had normal, moderate, and low 10-minute Apgar scores, respectively. The overall composite neonatal adverse outcome was 100.6 per 1,000 live births and the risk was significantly higher among those with a moderate (aRR 3.19; 95% CI 3.06-3.31) or low 10-minute Apgar score (aRR 6.62; 95% CI 6.34-6.91) than with a normal 10-minute Apgar score. Infant mortality also showed a similar pattern. Newborn infants with improved Apgar scores from 5 to 10 min were associated with lower risks of the composite neonatal adverse outcome, as well as infant mortality, than those with scores that remained stable.

CONCLUSION

Among low-risk pregnancies, newborn infants with a lower 10-minute Apgar score were associated with a higher risk of adverse outcomes.

[Executive summary]

Die Leitlinien des European Resuscitation Council 2021 basieren auf einer Reihe systematischer Übersichtsarbeiten, Scoping-Reviews und Aktualisierungen der Evidenz des International Liaison Committee on Resuscitation und stellen die aktuellsten evidenzbasierten Leitlinien für die Praxis der Wiederbelebung in ganz Europa dar. Die Leitlinien umfassen die Epidemiologie des Kreislaufstillstands, die Rolle, die Systeme bei der Rettung von Menschenleben spielen, die Basismaßnahmen der Wiederbelebung Erwachsener, die erweiterten Reanimationsmaßnahmen bei Erwachsenen, die Wiederbelebung unter besonderen Umständen, die Postreanimationsbehandlung, die Erste Hilfe, die Versorgung und Reanimation von Neugeborenen, die lebensrettenden Maßnahmen bei Kindern, die Ethik und die Ausbildung.