Part 11: neonatal resuscitation. European Resuscitation Council

Does Resuscitation Training Reduce Neonatal Deaths in Low-Resource Communities? A Systematic Review of the Literature

Every year, nearly 1 million babies succumb to birth asphyxia (BA) within the Asia-Pacific region. The present study sought to determine whether educational interventions containing some element of resuscitation training would decrease the relative risk (RR) of neonatal mortality attributable to BA in low-resource communities. We systematically reviewed 3 electronic databases and identified 14 relevant reports. For community deliveries, providing traditional birth attendants (TBAs) with neonatal resuscitation training modestly reduced the RR in 3 of 4 studies. For institutional deliveries, training a range of clinical staff clearly reduced the RR within 2 of 8 studies. When resuscitation-specific training was directed to community and institutional health care workers, a slight benefit was observed in 1 of 2 studies. Specific training in neonatal resuscitation appears most effective when provided to TBAs (specifically, those presented with ongoing opportunities to review and update their skills), but this particular intervention alone may not appreciably reduce mortality.

Reanimación del recién nacido

At birth approximately 10 % of term or near-term neonates require initial stabilization maneuvers to establish a cry or regular breathing, maintain a heart rate greater than 100 beats per minute (bpm), and good color and muscular tone. About 1 % requires ventilation and very few infants receive chest compressions or medication. However, birth asphyxia is a worldwide problem and can lead to death or serious sequelae. Recently, the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR) published new guidelines on resuscitation at birth. These guidelines review specific questions such as the use of air or 100 % oxygen in the delivery room, dose and routes of adrenaline delivery, the peripartum management of meconium-stained amniotic fluid, and temperature control. Assisted ventilation in preterm infants is briefly described. New devices to improve the care of newborn infants, such as the laryngeal mask airway or CO2 detectors to confirm tracheal tube placement, are also discussed. Significant changes have occurred in some practices and are included in this document.

Reventilation with room air or 100% oxygen after asphyxia differentially affects cerebral neuropathology in newborn pigs

AIM

To test if reventilation with room air (RA) or 100% oxygen (O2) after asphyxia would differentially affect neuronal damage in different brain areas of newborn pigs.

METHODS

Anaesthetized piglets were subjected to 10 min asphyxia (n=27) or served as time controls (n=7). Reventilation started with either RA or O2 for 1 h, and was continued with RA for an additional 1-3 h. Cortical or cerebellar blood flow was assessed with laser-Doppler flowmetry (LDF). Haematoxylin/eosin-stained sections from six brain regions were prepared for blinded neuropathological examination and scoring.

RESULTS

Asphyxia resulted in significant neuronal damage compared to time controls in all areas examined except the pons. O2 ventilation elicited greater neuronal lesions in the hippocampus and the cerebellum but smaller damage in the basal ganglia compared to RA. The assessed physiological parameters including the LDF signals were similar in both ventilation groups, except for PaO2 in the first hour of reventilation (RA 75+/-5 mmHg, O2 348+/-57 mmHg; p<0.05). Interestingly, however, reactive hyperaemia was much higher in the O2-sensitive cerebellum as compared with the cortex (1101+/-227 vs 571+/-73; p<0.05, area under the curve).

CONCLUSION

O2 toxicity after asphyxia was demonstrated in the piglet hippocampus and cerebellum but not in the cerebral cortex or basal ganglia. The observed regional differences may be associated with local haemodynamic factors.

Recent developments in airway management of the paediatric patient

PURPOSE OF THE REVIEW

During the last two years, several studies have enhanced our knowledge about the influence of pharmacological agents and routine airway management manoeuvres on the airway of paediatric patients. New supraglottic airway devices have been introduced into routine paediatric anaesthesia practice, and the design of paediatric endotracheal tubes has been modified. This review summarizes the most recent and relevant scientific developments in paediatric airway management.

RECENT FINDINGS

Strong evidence has been gained that the lateral position is the best to ensure a clear airway in anaesthetized or sedated spontaneously breathing children. Remifentanil has emerged as an appealing drug for airway management in anaesthetized or sedated children. The paediatric ProSeal-Laryngeal mask airway offers important advantages over the Classic-Laryngeal mask airway for supraglottic airway management. The newly designed Microcuff paediatric endotracheal tube offers an improved age-appropriate design.

SUMMARY

Remifentanil has found a place in airway management in paediatric patients. Recent improvements in the design of paediatric supraglottic airway devices and endotracheal tubes are promising. Further research is needed to consolidate their role in improving the perioperative outcome in paediatric patients.