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Foth A, Stewart D, Tingay DG. Neonatal resuscitation with vasopressin instead of epinephrine: are we ready to challenge the status quo? Pediatr Res 2024; 95:1174-1176. [PMID: 38071278 DOI: 10.1038/s41390-023-02961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 04/24/2024]
Affiliation(s)
- Anna Foth
- Department of Neonatology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - David Stewart
- Department of Neonatology, Royal Children's Hospital, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David G Tingay
- Department of Neonatology, Royal Children's Hospital, Melbourne, VIC, Australia.
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
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Ramsie M, Cheung PY, Lee TF, O'Reilly M, Schmölzer GM. Comparison of various vasopressin doses to epinephrine during cardiopulmonary resuscitation in asphyxiated neonatal piglets. Pediatr Res 2024; 95:1265-1272. [PMID: 37940664 PMCID: PMC11035119 DOI: 10.1038/s41390-023-02858-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Current neonatal resuscitation guidelines recommend epinephrine for cardiac arrest. Vasopressin might be an alternative during asphyxial cardiac arrest. We aimed to compare vasopressin and epinephrine on incidence and time to return of spontaneous circulation (ROSC) in asphyxiated newborn piglets. DESIGN/METHODS Newborn piglets (n = 8/group) were anesthetized, intubated, instrumented, and exposed to 30 min of normocapnic hypoxia, followed by asphyxia and asystolic cardiac arrest. Piglets were randomized to 0.2, 0.4, or 0.8IU/kg vasopressin, or 0.02 mg/kg epinephrine. Hemodynamic parameters were continuously measured. RESULTS Median (IQR) time to ROSC was 172(103-418)s, 157(100-413)s, 122(93-289)s, and 276(117-480)s for 0.2, 0.4, 0.8IU/kg vasopressin, and 0.02 mg/kg epinephrine groups, respectively (p = 0.59). The number of piglets that achieved ROSC was 6(75%), 6(75%), 7(88%), and 5(63%) for 0.2, 0.4, 0.8IU/kg vasopressin, and 0.02 mg/kg epinephrine, respectively (p = 0.94). The epinephrine group had a 60% (3/5) rate of post-ROSC survival compared to 83% (5/6), 83% (5/6), and 57% (4/7) in the 0.2, 0.4, and 0.8IU/kg vasopressin groups, respectively (p = 0.61). CONCLUSION Time to and incidence of ROSC were not different between all vasopressin dosages and epinephrine. However, non-significantly lower time to ROSC and higher post-ROSC survival in vasopressin groups warrant further investigation. IMPACT Time to and incidence of ROSC were not statistically different between all vasopressin dosages and epinephrine. Non-significantly lower time to ROSC and higher post-ROSC survival in vasopressin-treated piglets. Overall poorer hemodynamic recovery following ROSC in epinephrine piglets compared to vasopressin groups. Human neonatal clinical trials examining the efficacy of vasopressin during asphyxial cardiac arrest will begin recruitment soon.
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Affiliation(s)
- Marwa Ramsie
- 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
| | - 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
| | - 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, 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, 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, University of Alberta, Edmonton, AB, Canada.
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Ramsie M, Cheung PY, Law B, Schmölzer G. Vasopressin versus epinephrine during cardiopulmonary resuscitation of asphyxiated newborns: A study protocol for a prospective, cluster, open label, single-center, randomized controlled phase 2 trial - The VERSE-Trial. Resusc Plus 2023; 16:100459. [PMID: 37663146 PMCID: PMC10474318 DOI: 10.1016/j.resplu.2023.100459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Introduction Current neonatal resuscitation guidelines recommend the use of epinephrine during neonatal cardiopulmonary resuscitation (CPR). However, newborns receiving epinephrine continue to have high rates of mortality and neurodevelopmental disability. The infrequent need for neonatal CPR, coupled with an inability to consistently anticipate which newborn infants are at risk of requiring CPR, explains the lack of high-quality evidence (i.e., large randomized clinical trials) to better guide healthcare providers in their resuscitative effort. Therefore, we need neonatal data to determine the optimal vasopressor therapy during neonatal CPR. The current pilot trial will examine the efficacy of vasopressin versus epinephrine during CPR of asphyxiated newborn infants. Methods and analysis The trial will be a prospective, cluster, open label, single-center, randomized controlled trial on two alternative cardiovascular supportive medications. This study will assess the primary outcome of time to return of spontaneous circulation (ROSC) in newborns requiring CPR in the delivery room who were treated with either vasopressin (intervention) or epinephrine (control). Secondary outcomes such as infant mortality and other clinical outcome measures will also be collected. An estimated 20 newborns will be recruited, and comparisons will be made between asphyxiated infants treated with either drugs. Ethics and dissemination This study has been approved by the Research Ethics Board at the University of Alberta (June 16, 2023). Study findings will be published in peer-reviewed journals, presented at conferences, and communicated to relevant participants and stakeholders.Trial registration: ClinicalTrial.gov Identifier: NCT05738148. Registered February 21, 2023.
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Affiliation(s)
- M. Ramsie
- 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
| | - P.-Y. 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
| | - B. Law
- 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
| | - G.M. Schmölzer
- 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
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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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Rawat M, Gugino S, Koenigsknecht C, Helman J, Nielsen L, Sankaran D, Nair J, Chandrasekharan P, Lakshminrusimha S. Masked Randomized Trial of Epinephrine versus Vasopressin in an Ovine Model of Perinatal Cardiac Arrest. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020349. [PMID: 36832479 PMCID: PMC9955402 DOI: 10.3390/children10020349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/24/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Current neonatal resuscitation guidelines recommend the use of epinephrine for bradycardia/arrest not responding to ventilation and chest compressions. Vasopressin is a systemic vasoconstrictor and is more effective than epinephrine in postnatal piglets with cardiac arrest. There are no studies comparing vasopressin with epinephrine in newly born animal models with cardiac arrest induced by umbilical cord occlusion. Objective: To compare the effect of epinephrine and vasopressin on the incidence and time to return of spontaneous circulation (ROSC), hemodynamics, plasma drug levels, and vasoreactivity in perinatal cardiac arrest. Design/Methods: Twenty-seven term fetal lambs in cardiac arrest induced by cord occlusion were instrumented and resuscitated following randomization to epinephrine or vasopressin through a low umbilical venous catheter. Results: Eight lambs achieved ROSC prior to medication. Epinephrine achieved ROSC in 7/10 lambs by 8 ± 2 min. Vasopressin achieved ROSC in 3/9 lambs by 13 ± 6 min. Plasma vasopressin levels in nonresponders were much lower than responders after the first dose. Vasopressin caused in vivo increased pulmonary blood flow and in vitro coronary vasoconstriction. Conclusions: Vasopressin resulted in lower incidence and longer time to ROSC compared to epinephrine in a perinatal model of cardiac arrest supporting the current recommendations for exclusive use of epinephrine in neonatal resuscitation.
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Affiliation(s)
- Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA
- Correspondence: ; Tel.: +1-716-323-0260; Fax: +1-716-323-0294
| | - Sylvia Gugino
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA
| | | | - Justin Helman
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA
| | - Lori Nielsen
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA
| | - Deepika Sankaran
- Department of Pediatrics, UC Davis Medical Center, Sacramento, CA 95817, USA
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA
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6
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Andersen HB, Andersen M, Andelius TCK, Pedersen MV, Løfgren B, Pedersen M, Ringgaard S, Kyng KJ, Henriksen TB. Epinephrine vs placebo in neonatal resuscitation: ROSC and brain MRS/MRI in term piglets. Pediatr Res 2023; 93:511-519. [PMID: 35681089 DOI: 10.1038/s41390-022-02126-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 05/01/2022] [Accepted: 05/17/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND We aimed to investigate the effect of epinephrine vs placebo on return of spontaneous circulation (ROSC) and brain magnetic resonance spectroscopy and imaging (MRS/MRI) in newborn piglets with hypoxic cardiac arrest (CA). METHODS Twenty-five piglets underwent hypoxia induced by endotracheal tube clamping until CA. The animals were randomized to CPR + intravenous epinephrine or CPR + placebo (normal saline). The primary outcome was ROSC, and secondary outcomes included time-to-ROSC, brain MRS/MRI, and composite endpoint of death or severe brain MRS/MRI abnormality. RESULTS ROSC was more frequent in animals treated with epinephrine than placebo; 10/13 vs 4/12, RR = 2.31 (95% CI: 1.09-5.77). We found no difference in time-to-ROSC (120 (113-211) vs 153 (116-503) seconds, p = 0.7) or 6-h survival (7/13 vs 3/12, p = 0.2). Among survivors, there was no difference between groups in brain MRS/MRI. We found no difference in the composite endpoint of death or severe brain MRS/MRI abnormality; RR = 0.7 (95% CI: 0.37-1.19). CONCLUSIONS Resuscitation with epinephrine compared to placebo improved ROSC frequency after hypoxic CA in newborn piglets. We found no difference in time-to-ROSC or the composite endpoint of death or severe brain MRS/MRI abnormality. IMPACT In a newborn piglet model of hypoxic cardiac arrest, resuscitation with epinephrine compared to placebo improved the rate of return of spontaneous circulation and more than doubled the 6-h survival. Brain MRS/MRI biomarkers were used to evaluate the effect of epinephrine vs placebo. We found no difference between groups in the composite endpoint of death or severe brain MRS/MRI abnormality. This study adds to the limited evidence regarding the effect and safety of epinephrine; the lack of high-quality evidence from randomized clinical trials was highlighted in the latest ILCOR 2020 guidelines, and newborn animal studies were specifically requested.
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Affiliation(s)
- Hannah B Andersen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Mads Andersen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ted C K Andelius
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mette V Pedersen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bo Løfgren
- Research Center for Emergency, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kasper J Kyng
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Tine B Henriksen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Ramachandran S, Bruckner M, Kapadia V, Schmölzer GM. Chest compressions and medications during neonatal resuscitation. Semin Perinatol 2022; 46:151624. [PMID: 35752466 DOI: 10.1016/j.semperi.2022.151624] [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] [Indexed: 11/24/2022]
Abstract
Prolonged resuscitation in neonates, although quite rare, may occur in response to profound intractable bradycardia as a result of asphyxia. In these instances, chest compressions and medications may be necessary to facilitate return of spontaneous circulation. While performing chest compressions, the two thumb method is preferred over the two finger technique, although several newer approaches are under investigation. While the ideal compression to ventilation ratio is still uncertain, a 3:1 ratio remains the recommendation by the Neonatal Resuscitation Program. Use of feedback mechanisms to optimize neonatal cardiopulmonary resuscitation (CPR) show promise and are currently under investigation. While performing optimal cardiac compressions to pump blood, use of medications to restore spontaneous circulation will likely be necessary. Current recommendations are that epinephrine, an endogenous catecholamine be used preferably intravenously or by intraosseous route, with the dose repeated every 3-5 minutes until return of spontaneous circulation. Finally, while the need for volume replacement is rare, it may be considered in instances of acute blood loss or poor response to resuscitation.
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Affiliation(s)
| | - Marlies Bruckner
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Vishal Kapadia
- Division of Neonatology, UT Southwestern Medical Center at Dallas
| | - Georg M Schmölzer
- 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
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Delivery Room ST Segment Analysis to Predict Short Term Outcomes in Near-Term and Term Newborns. CHILDREN 2022; 9:children9010054. [PMID: 35053679 PMCID: PMC8774395 DOI: 10.3390/children9010054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/16/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022]
Abstract
Background: ST-segment changes to the fetal electrocardiogram (ECG) may indicate fetal acidosis. No large-scale characterization of ECG morphology immediately after birth has been performed, but ECG is used for heart rate (HR) assessment. We aimed to investigate ECG morphology immediately after birth in asphyxiated infants, using one-lead dry-electrode ECG developed for HR measurement. Methods: Observational study in Tanzania, between 2013–2018. Near-term and term infants that received bag-mask ventilation (BMV), and healthy controls, were monitored with one-lead dry-electrode ECG with a non-diagnostic bandwidth. ECGs were classified as normal, with ST-elevations or other ST-segment abnormalities including a biphasic ST-segment. We analyzed ECG morphology in relation to perinatal variables or short-term outcomes. Results: A total of 494 resuscitated and 25 healthy infants were included. ST-elevations were commonly seen both in healthy infants (7/25; 28%) and resuscitated (320/494; 65%) infants. The apparent ST-elevations were not associated with perinatal variables or short-term outcomes. Among the 32 (6.4%) resuscitated infants with “other ST-segment abnormalities”, duration of BMV was longer, 1-min Apgar score lower and normal outcomes less frequent than in the resuscitated infants with normal ECG or ST-elevations. Conclusions: ST-segment elevation was commonly seen and not associated with negative outcomes when using one-lead dry-electrode ECG. Other ST-segment abnormalities were associated with prolonged BMV and worse outcome. ECG with appropriate bandwidth and automated analysis may potentially in the future aid in the identification of severely asphyxiated infants.
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Sankaran D, Chandrasekharan PK, Gugino SF, Koenigsknecht C, Helman J, Nair J, Mathew B, Rawat M, Vali P, Nielsen L, Tancredi DJ, Lakshminrusimha S. Randomised trial of epinephrine dose and flush volume in term newborn lambs. Arch Dis Child Fetal Neonatal Ed 2021; 106:578-583. [PMID: 33687959 PMCID: PMC8543198 DOI: 10.1136/archdischild-2020-321034] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Neonatal resuscitation guidelines recommend 0.5-1 mL saline flush following 0.01-0.03 mg/kg of epinephrine via low umbilical venous catheter for persistent bradycardia despite effective positive pressure ventilation (PPV) and chest compressions (CC). We evaluated the effects of 1 mL vs 3 mL/kg flush volumes and 0.01 vs 0.03 mg/kg doses on return of spontaneous circulation (ROSC) and epinephrine pharmacokinetics in lambs with cardiac arrest. DESIGN Forty term lambs in cardiac arrest were randomised to receive 0.01 or 0.03 mg/kg epinephrine followed by 1 mL or 3 mL/kg flush after effective PPV and CC. Epinephrine (with 1 mL flush) was repeated every 3 min until ROSC or until 20 min. Haemodynamics, blood gases and plasma epinephrine concentrations were monitored. RESULTS Ten lambs had ROSC before epinephrine administration and 2 died during instrumentation. Among 28 lambs that received epinephrine, 2/6 in 0.01 mg/kg-1 mL flush, 3/6 in 0.01 mg/kg-3 mL/kg flush, 5/7 in 0.03 mg/kg-1 mL flush and 9/9 in 0.03 mg/kg-3 mL/kg flush achieved ROSC (p=0.02). ROSC was five times faster with 0.03 mg/kg epinephrine compared with 0.01 mg/kg (adjusted HR (95% CI) 5.08 (1.7 to 15.25)) and three times faster with 3 mL/kg flush compared with 1 mL flush (3.5 (1.27 to 9.71)). Plasma epinephrine concentrations were higher with 0.01 mg/kg-3 mL/kg flush (adjusted geometric mean ratio 6.0 (1.4 to 25.7)), 0.03 mg/kg-1 mL flush (11.3 (2.1 to 60.3)) and 0.03 mg/kg-3 mL/kg flush (11.0 (2.2 to 55.3)) compared with 0.01 mg/kg-1 mL flush. CONCLUSIONS 0.03 mg/kg epinephrine dose with 3 mL/kg flush volume is associated with the highest ROSC rate, increases peak plasma epinephrine concentrations and hastens time to ROSC. Clinical trials evaluating optimal epinephrine dose and flush volume are warranted.
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Affiliation(s)
- Deepika Sankaran
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Praveen K Chandrasekharan
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Sylvia F Gugino
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Carmon Koenigsknecht
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Justin Helman
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Bobby Mathew
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Lori Nielsen
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
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10
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Sehgal A, Allison BJ, Miller SL, Polglase GR, McNamara PJ, Hooper SB. Impact of Acute and Chronic Hypoxia-Ischemia on the Transitional Circulation. Pediatrics 2021; 147:peds.2020-016972. [PMID: 33622795 DOI: 10.1542/peds.2020-016972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/24/2022] Open
Abstract
The transition from intrauterine life to extrauterine existence encompasses significant cardiorespiratory adaptations. These include rapid lung aeration and increase in pulmonary blood flow (PBF). Perinatal asphyxia and fetal growth restriction can severely hamper this transition. Hypoxia is the common denominator in these 2 disease states, with the former characterized by acute insult and the latter by utero-placental insufficiency and a chronic hypoxemic state. Both may manifest as hemodynamic instability. In this review, we emphasize the role of physiologic-based cord clamping in supplementing PBF during transition. The critical role of lung aeration in initiating pulmonary gas exchange and increasing PBF is discussed. Physiologic studies in animal models have enabled greater understanding of the mechanisms and effects of various therapies on transitional circulation. With data from sheep models, we elaborate instrumentation for monitoring of cardiovascular and pulmonary physiology and discuss the combined effect of chest compressions and adrenaline in improving transition at birth. Lastly, physiologic adaptation influencing management in human neonatal cohorts with respect to cardiac and vascular impairments in hypoxic-ischemic encephalopathy and growth restriction is discussed. Impairments in right ventricular function and vascular mechanics hold the key to prognostication and understanding of therapeutic rationale in these critically ill cohorts. The right ventricle and pulmonary circulation seem to be especially affected and may be explored as therapeutic targets. The role of comprehensive assessments using targeted neonatal echocardiography as a longitudinal, reliable, and easily accessible tool, enabling precision medicine facilitating physiologically appropriate treatment choices, is discussed.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia; .,Departments of Paediatrics and
| | - Beth J Allison
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Suzanne L Miller
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Graeme R Polglase
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa; and.,Internal Medicine, University of Iowa Health Care, Iowa City, Iowa
| | - Stuart B Hooper
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
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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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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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Hooper SB, Te Pas AB, Polglase GR, Wyckoff M. Animal models in neonatal resuscitation research: What can they teach us? Semin Fetal Neonatal Med 2018; 23:300-305. [PMID: 30001819 DOI: 10.1016/j.siny.2018.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Animal models have made and continue to make important contributions to neonatal medicine. For example, studies in fetal sheep have taught us much about the physiology of the fetal-to-neonatal transition. However, whereas animal models allow multiple factors to be investigated in a logical and systematic manner, no animal model is perfect for humans and so we need to understand the fundamental differences in physiology between the species in question and humans. Although most physiological systems are well conserved between species, some small differences exist and so wherever possible the knowledge generated from preclinical studies in animals should be tested in clinical trials. However, with the rise of evidence-based medicine the distinction between scientific knowledge generation and evidence gathering has been confused and the two have been lumped together. This misunderstands the contribution that scientific knowledge can provide. Science should be used to guide the gathering of evidence by informing the design of clinical trials, thereby increasing their likelihood of success. While scientific knowledge is not evidence, in the absence of evidence it is likely to be the best option for guiding clinical practice.
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Affiliation(s)
- Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Myra Wyckoff
- Department of Pediatrics, Neonatal and Perinatal Medicine, University of Texas, South Western Medical Center, Dallas, TX, USA
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Effects of epinephrine on hemodynamic changes during cardiopulmonary resuscitation in a neonatal piglet model. Pediatr Res 2018; 83:897-903. [PMID: 29244793 DOI: 10.1038/pr.2017.316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/27/2017] [Indexed: 01/25/2023]
Abstract
BackgroundAsphyxia is the most common reason for newborns to fail to make a successful fetal-to-neonatal transition. There is currently a lack of data evaluating hemodynamic effects of epinephrine during neonatal cardiopulmonary resuscitation.MethodsTwenty-four newborn piglets were exposed to asphyxia. Thereafter, positive pressure ventilation was commenced for 30 s, followed by chest compressions (CC). Piglets were randomized into three experimental groups: 3:1 compression:ventilation ratio; CC during sustained inflation (SI) at a rate of 90 CC per minute, or CC during SI at a rate of 120 CC per minute. Epinephrine (0.01 mg/kg per dose) was administered to a maximum of four doses. Hemodynamic parameters were measured throughout the experiment.ResultsAnimals were divided into survivors and nonsurvivors. End-diastolic and developed pressures declined after epinephrine administration in the survivor group. dp/dt min was significantly higher in the survivor group whereas dp/dt max showed no significant differences. Epinephrine had no effect on either heart rate or cardiac output in both groups. Ejection fraction increased after epinephrine with no significant difference between groups.ConclusionEpinephrine did not affect survival rates or return of spontaneous circulation in our postnatal porcine model of neonatal asphyxia.
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Aliyev A, Seyedghodraty M, Mohammadi M, Mirzaei F, Marahem M. Impact of high-fat diet and hypoxia on the serum levels of main vasoconstrictors in male rabbits. J Cardiovasc Thorac Res 2017; 9:90-94. [PMID: 28740628 PMCID: PMC5516057 DOI: 10.15171/jcvtr.2017.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 04/26/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction: During atherosclerosis process, vasoconstriction phenomenon occurs which in turn leads to tissue hypoxia. A few studies have been performed on the combination of atherosclerosis and hypoxia as stressors that may accelerate secretion of constrictors. The aim of present study was to evaluate the effects of atherosclerosis and hypoxia on serum levels of main vasoconstrictors (epinephrine, norepinephrine and renin).
Methods: In this interventional study, 32 New Zealand white rabbits were randomly divided into four groups (n = 8): normal diet (control group), normal diet exposed to hypoxia (11%, 10 days), high-fat diet (cholesterol-2%, 8 weeks), and high-fat diet with hypoxia. Later, serum levels of renin, epinephrine and norepinephrine were measured on second, 56th and 66th days.
Results: High-fat diet and hypoxia caused significant increase in epinephrine and norepinephrine concentrations on days 56 and 66 compared to the control group (P < 0.05). Also, renin showed significance increase in high-fat diet and high-fat diet+ hypoxia groups compared to the control group (P < 0.05).
Conclusion: Both high-fat diet and hypoxia increase renin levels in male rabbits. Furthermore, the combination of high-fat diet and hypoxia immensely increases renin levels. Both hypoxia and combined of high-fat diet and hypoxia increase norepinephrine levels. However epinephrine is only increased in the combination of high-fat diet and hypoxia. So the presence of hypoxia in combination with high-fat diet, cause accelerated and aggravated atherosclerosis.
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Affiliation(s)
- Ali Aliyev
- Department of Physiology, Baku State University, Baku, Azerbaijan
| | | | - Mustafa Mohammadi
- Department of Physiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariba Mirzaei
- Department of Physiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Marzieh Marahem
- Department of Physiology, Tabriz University of Medical Sciences, Tabriz, Iran
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Abstract
Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. Evidence for optimal dose, timing, and route of administration of epinephrine during neonatal resuscitation comes largely from extrapolated adult or animal literature. In this review, we provide the current recommendations for use of epinephrine during neonatal resuscitation and also the evidence behind these recommendations. In addition, we review the current proposed mechanism of action of epinephrine during neonatal resuscitation, review its adverse effects, and identify gaps in knowledge requiring urgent research.
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Affiliation(s)
- Vishal S. Kapadia
- Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Myra H. Wyckoff
- Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Vali P, Chandrasekharan P, Rawat M, Gugino S, Koenigsknecht C, Helman J, Jusko WJ, Mathew B, Berkelhamer S, Nair J, Wyckoff MH, Lakshminrusimha S. Evaluation of Timing and Route of Epinephrine in a Neonatal Model of Asphyxial Arrest. J Am Heart Assoc 2017; 6:JAHA.116.004402. [PMID: 28214793 PMCID: PMC5523751 DOI: 10.1161/jaha.116.004402] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Epinephrine administered by low umbilical venous catheter (UVC) or endotracheal tube (ETT) is indicated in neonates who fail to respond to positive pressure ventilation and chest compressions at birth. Pharmacokinetics of ETT epinephrine via fluid‐filled lungs or UVC epinephrine in the presence of fetal shunts is unknown. We hypothesized that epinephrine administered by ETT or low UVC results in plasma epinephrine concentrations and rates of return of spontaneous circulation (ROSC) similar to right atrial (RA) epinephrine. Methods and Results Forty‐four lambs were randomized into the following groups: RA epinephrine (0.03 mg/kg), low UVC epinephrine (0.03 mg/kg), postcompression ETT epinephrine (0.1 mg/kg), and precompression ETT epinephrine (0.1 mg/kg). Asystole was induced by umbilical cord occlusion. Resuscitation was initiated following 5 minutes of asystole. Thirty‐eight of 44 lambs achieved ROSC (10/11, 9/11, and 12/22 in the RA, UVC, and ETT groups, respectively; subsequent RA epinephrine resulted in a total ROSC of 19/22 in the ETT groups). Median time (interquartile range) to achieve ROSC was significantly longer in the ETT group (including those that received RA epinephrine) compared to the intravenous group (4.5 [2.9–7.4] versus 2 [1.9–3] minutes; P=0.02). RA and low UVC epinephrine administration achieved comparable peak plasma epinephrine concentrations (470±250 versus 450±190 ng/mL) by 1 minute compared to ETT values of 130±60 ng/mL at 5 minutes; P=0.03. Following ROSC with ETT epinephrine alone, there was a delayed peak epinephrine concentration (652±240 ng/mL). Conclusions The absorption of ETT epinephrine is low and delayed at birth. RA and low UVC epinephrine rapidly achieve high plasma concentrations resulting in ROSC.
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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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Pinto M, Solevåg AL, OʼReilly M, Aziz K, Cheung PY, Schmölzer GM. Evidence on Adrenaline Use in Resuscitation and Its Relevance to Newborn Infants: A Non-Systematic Review. Neonatology 2017; 111:37-44. [PMID: 27522216 DOI: 10.1159/000447960] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/24/2016] [Indexed: 11/19/2022]
Abstract
AIM Guidelines for newborn resuscitation state that if the heart rate does not increase despite adequate ventilation and chest compressions, adrenaline administration should be considered. However, controversy exists around the safety and effectiveness of adrenaline in newborn resuscitation. The aim of this review was to summarise a selection of the current knowledge about adrenaline during resuscitation and evaluate its relevance to newborn infants. METHODS A search in PubMed, Embase, and Google Scholar until September 1, 2015, using search terms including adrenaline/epinephrine, cardiopulmonary resuscitation, death, severe brain injury, necrotizing enterocolitis, bronchopulmonary dysplasia, and adrenaline versus vasopressin/placebo. RESULTS Adult data indicate that adrenaline improves the return of spontaneous circulation (ROSC) but not survival to hospital discharge. Newborn animal studies reported that adrenaline might be needed to achieve ROSC. Intravenous administration (10-30 μg/kg) is recommended; however, if there is no intravenous access, a higher endotracheal dose (50-100 μg/kg) is needed. The safety and effectiveness of intraosseous adrenaline remain undetermined. Early and frequent dosing does not seem to be beneficial. In fact, negative hemodynamic effects have been observed, especially with doses ≥30 μg/kg intravenously. Little is known about adrenaline in birth asphyxia and in preterm infants, but observations indicate that hemodynamics and neurological outcomes may be impaired by adrenaline administration in these conditions. However, a causal relationship between adrenaline administration and outcomes cannot be established from the few available retrospective studies. Alternative vasoconstrictors have been investigated, but the evidence is scarce. CONCLUSION More research is needed on the benefits and risks of adrenaline in asphyxia-induced bradycardia or cardiac arrest during perinatal transition.
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Affiliation(s)
- Merlin Pinto
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alta., Canada
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Solevåg AL, Cheung PY, O'Reilly M, Schmölzer GM. A review of approaches to optimise chest compressions in the resuscitation of asphyxiated newborns. Arch Dis Child Fetal Neonatal Ed 2016; 101:F272-6. [PMID: 26627554 DOI: 10.1136/archdischild-2015-309761] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 11/04/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Provision of chest compressions (CCs) and/or medications in the delivery room is associated with poor outcomes. Based on the physiology of perinatal asphyxia, we aimed to provide an overview of current recommendations and explore potential determinants of effective neonatal cardiopulmonary resuscitation (CPR): balancing ventilations and CC, CC rate, depth, full chest recoil, CC technique and adrenaline. DESIGN A search in the databases MEDLINE (Ovid) and EMBASE until 10 April 2015. SETTING Delivery room. PATIENTS Asphyxiated newborn infants. INTERVENTIONS CCs. MAIN OUTCOME MEASURES Haemodynamics, recovery and survival. RESULTS Current evidence is derived from mathematical models, manikin and animal studies, and small case series. No randomised clinical trials examining neonatal CC have been performed. There is no evidence to refute a CC to ventilation (C:V) ratio of 3:1. Raising the intrathoracic pressure, for example, by superimposing a sustained inflation on uninterrupted CC, and a CC rate >120/min may be beneficial. The optimal neonatal CC depth is unknown, but factors influencing depth and consistency include the C:V ratio. Incomplete chest wall recoil can cause less negative intrathoracic pressure between CC and reduced CPR effectiveness. CC should be performed with the two-thumb method over the lower third of the sternum. The optimal dose, route and timing of adrenaline administration remain to be determined. CONCLUSIONS Successful CPR requires the delivery of high-quality CC, encompassing optimal (A) C:V ratio (B) rate, (C) depth, (D) chest recoil between CC, (E) technique and (F) adrenaline dosage. More animal studies with high translational value and randomised clinical trials are needed.
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Affiliation(s)
- Anne Lee Solevåg
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada Department of Pediatrics, University of Alberta, Edmonton, Canada Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Po-Yin Cheung
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada 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, Edmonton, Canada Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada Department of Pediatrics, University of Alberta, Edmonton, Canada
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Solevåg AL, Cheung PY, Lie H, O’Reilly M, Aziz K, Nakstad B, Schmölzer GM. Chest compressions in newborn animal models: A review. Resuscitation 2015; 96:151-5. [DOI: 10.1016/j.resuscitation.2015.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/22/2015] [Accepted: 08/02/2015] [Indexed: 11/25/2022]
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Kalaniti K, Schmölzer GM, McNamara PJ. Neonatal resuscitation beyond the delivery room - does one protocol fit all? Acta Paediatr 2015; 104:971-3. [PMID: 26174225 DOI: 10.1111/apa.13116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/07/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Kaarthigeyan Kalaniti
- Division of Neonatology; Department of Pediatrics; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation; Neonatal Research Unit; Royal Alexandria Hospital; Edmonton AB Canada
- Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Patrick J McNamara
- Division of Neonatology; Department of Pediatrics; Hospital for Sick Children; University of Toronto; Toronto ON Canada
- Department of Physiology & Experimental Medicine Program; Hospital for Sick Children; Toronto ON Canada
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Pan J, Zhu JY, Kee HS, Zhang Q, Lu YQ. A review of compression, ventilation, defibrillation, drug treatment, and targeted temperature management in cardiopulmonary resuscitation. Chin Med J (Engl) 2015; 128:550-4. [PMID: 25673462 PMCID: PMC4836263 DOI: 10.4103/0366-6999.151115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: Important studies of cardiopulmonary resuscitation (CPR) techniques influence the development of new guidelines. We systematically reviewed the efficacy of some important studies of CPR. Data Sources: The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1964 to 2014. Study Selection: Original articles and critical reviews about CPR techniques were selected for review. Results: The survival rate after out-of-hospital cardiac arrest (OHCA) is improving. This improvement is associated with the performance of uninterrupted chest compressions and simple airway management procedures during bystander CPR. Real-time feedback devices can be used to improve the quality of CPR. The recommended dose, timing, and indications for adrenaline (epinephrine) use may change. The appropriate target temperature for targeted temperature management is still unclear. Conclusions: New studies over the past 5 years have evaluated various aspects of CPR in OHCA. Some of these studies were high-quality randomized controlled trials, which may help to improve the scientific understanding of resuscitation techniques and result in changes to CPR guidelines.
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Affiliation(s)
| | | | | | | | - Yuan-Qiang Lu
- Department of Emergency Medicine, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, China
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Abstract
Birth asphyxia accounts for about 23% of the approximately 4 million neonatal deaths each year worldwide (Black et al., Lancet, 2010, 375(9730):1969-87). The majority of newborn infants require little assistance to undergo physiologic transition at birth and adapt to extrauterine life. Approximately 10% of infants require some assistance to establish regular respirations at birth. Less than 1% need extensive resuscitative measures such as chest compressions and approximately 0.06% require epinephrine (Wyllie et al. Resuscitation, 2010, 81 Suppl 1:e260–e287). Transition at birth is mediated by significant changes in circulatory and respiratory physiology. Ongoing research in the field of neonatal resuscitation has expanded our understanding of neonatal physiology enabling the implementation of improved recommendations and guidelines on how to best approach newborns in need for intervention at birth. Many of these recommendations are extrapolated from animal models and clinical trials in adults. There are many outstanding controversial issues in neonatal resuscitation that need to be addressed. This article provides a comprehensive and critical literature review on the most relevant and current research pertaining to evolving new strategies in neonatal resuscitation. The key elements to a successful neonatal resuscitation include ventilation of the lungs while minimizing injury, the judicious use of oxygen to improve pulmonary blood flow, circulatory support with chest compressions, and vasopressors and volume that would hasten return of spontaneous circulation. Several exciting new avenues in neonatal resuscitation such as delayed cord clamping, sustained inflation breaths, and alternate vasopressor agents are briefly discussed. Finally, efforts to improve resuscitative efforts in developing countries through education of basic steps of neonatal resuscitation are likely to decrease birth asphyxia and neonatal mortality.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
| | - Bobby Mathew
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
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Mion G, Rousseau JM, Selcer D, Samama CM. Cardiac arrest: should we consider norepinephrine instead of epinephrine? Am J Emerg Med 2014; 32:1560.e1-2. [PMID: 24997106 DOI: 10.1016/j.ajem.2014.05.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/19/2014] [Indexed: 10/25/2022] Open
Abstract
A patient scheduled for a laparoscopic cholecystectomy had an anaphylactic shock during induction of anesthesia. After the injection of vecuronium, an unusual fall of arterial pressure occurred, with bradycardia, enlargement of the QRS complex, then a circulatory arrest. Chest compressions were initiated, while intravenous epinephrine 1 mg was administered. The cardiac rhythm turned into a ventricular fibrillation (VF). Despite continuous chest compressions with repeated boluses of epinephrine and several external electric shocks, the patient remained in VF. Because of obviously β-adrenergic adverse effects, epinephrine was replaced with norepinephrine. Return of spontaneous circulation was observed, with the recovering of sinusal activity. After staying for several weeks in intensive care unit because of multiorgan failure, the patient recovered without sequelae. Blood samples and cutaneous testing confirmed an allergy to vecuronium. This case report of a cardiac anaphylaxis with prolonged cardiac arrest illustrates the dual activity and adverse effects of epinephrine. Although vasoconstriction is mandated during cardiopulmonary resuscitation to provide an acceptable perfusion pressure to organs, β-adrenergic stimulation seems deleterious to the heart. Experimental studies have shown that blocking the β-adrenergic effects of epinephrine attenuates postresuscitation myocardial dysfunction or helps the return of spontaneous circulation after VF. Norepinephrine, a potent α-adrenergic drug nearly devoid of β-adrenergic properties, could be an interesting alternative to epinephrine. It can improve organ perfusion during cardiopulmonary resuscitation and could be more efficient than epinephrine in case of VF.
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Affiliation(s)
- Georges Mion
- Département d'anesthésie-réanimation, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75679 Paris, France.
| | - Jean Marie Rousseau
- Service d'anesthésie, Clinique Esquirol St Hilaire, 1 rue Delmas, 47002 Agen, France.
| | - Dominique Selcer
- Département d'anesthésie-réanimation, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75679 Paris, France.
| | - Charles-Marc Samama
- Département d'anesthésie-réanimation, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75679 Paris, France.
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