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Sotiropoulos JX, Oei JL, Schmölzer GM, Hunter KE, Williams JG, Webster AC, Vento M, Kapadia V, Rabi Y, Dekker J, Vermeulen MJ, Sundaram V, Kumar P, Saugstad OD, Seidler AL. NETwork Meta-analysis Of Trials of Initial Oxygen in preterm Newborns (NETMOTION): A Protocol for Systematic Review and Individual Participant Data Network Meta-Analysis of Preterm Infants <32 Weeks' Gestation Randomized to Initial Oxygen Concentration for Resuscitation. Neonatology 2022; 119:517-524. [PMID: 35785768 DOI: 10.1159/000525127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/25/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Internationally recognized guidelines recommend the judicious use of low oxygen (21-30%), titrated to peripheral oxygen saturation targets, for the initiation of resuscitation of very and extremely preterm infants (<32 weeks' gestation). However, despite more than 10 randomized controlled trials on this question, the ideal initial oxygen concentration for this group of vulnerable infants remains uncertain. AIMS This study aims to assess the effect of various initial oxygen concentrations on (1) all-cause mortality, chronic lung disease, intraventricular hemorrhage, and retinopathy of prematurity; and (2) reaching the prescribed oxygen saturation targets by 5 min after birth, in preterm infants requiring resuscitation. METHODS We will conduct a systematic review and network meta-analysis using individual participant data. Studies of preterm infants <32 weeks' gestation, randomized to initial oxygen concentration, will be included. We will systematically search medical databases and trial registries for eligible studies (published or unpublished). Records will be screened by two independent reviewers, with conflicts resolved by the inclusion of a third reviewer. Identified initial oxygen concentrations will be grouped into the following nodes: low (≤30%), intermediate (60%), and high (≥90%) oxygen. A two-step random-effects contrast-based network meta-regression will be calculated to compare and rank different oxygen concentrations. Analyses will be intention-to-treat, with the primary outcome of all-cause mortality. DISCUSSION This is the first individual participant data network meta-analysis of initial oxygen concentrations for the resuscitation of preterm infants. This novel approach may address long-standing uncertainty regarding optimal oxygen supplementation practice for the resuscitation of preterm infants <32 weeks' gestation.
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Affiliation(s)
- James X Sotiropoulos
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia, .,School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia, .,Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia,
| | - Ju Lee Oei
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia.,Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Georg M Schmölzer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Neonatology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Kylie E Hunter
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Jonathan G Williams
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Angela C Webster
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Maximo Vento
- University and Polytechnic Hospital La Fe, Valencia, Spain.,Health Research Institute La Fe, Valencia, Spain
| | - Vishal Kapadia
- Department of Pediatrics, U.T. Southwestern Medical Center, Dallas, Texas, USA
| | - Yacov Rabi
- Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ola D Saugstad
- Department of Pediatrics, U.T. Southwestern Medical Center, Dallas, Texas, USA.,Department of Pediatric Research, Rikshospitalet, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Anna Lene Seidler
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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Schwaberger B, Urlesberger B, Schmölzer GM. Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review. CHILDREN-BASEL 2021; 8:children8100882. [PMID: 34682147 PMCID: PMC8534639 DOI: 10.3390/children8100882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5H 3V9, Canada
- Correspondence: ; Tel.: +1-780-735-4660
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Abstract
The premature infant is to some extent protected from hypoxia, however defense against hyperoxia is poorly developed. The optimal assessment of oxygenation is to measure oxygen delivery and extraction. At the bedside PaO2 and SpO2 are approximations of oxygenation at the tissue level. After birth asphyxia it is crucial to know whether or not to give oxygen supplementation, when, how much, and for how long. Oxygen saturation targets in the delivery room have been studied, but the optimal targets might still be unknown because factors like gender and delayed cord clamping influence saturation levels. However, SpO2 > 80% at 5 min of age is associated with favorable long term outcome in preterm babies. Immature infants most often need oxygen supplementation beyond the delivery room. Predefined saturation levels, and narrow alarm limits together with the total oxygen exposure may impact on development of oxygen related diseases like ROP and BPD. Hyperoxia is a strong trigger for genetic and epigenetic changes, contributing to the development of these conditions and perhaps lifelong changes.
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Affiliation(s)
| | - Ola Didrik Saugstad
- Department of Pediatric Research, University of Oslo & Ann and Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, Norway.
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4
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Marshall S, Lang AM, Perez M, Saugstad OD. Delivery room handling of the newborn. J Perinat Med 2019; 48:1-10. [PMID: 31834864 PMCID: PMC7771218 DOI: 10.1515/jpm-2019-0304] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/07/2019] [Indexed: 01/24/2023]
Abstract
For newly born babies, especially those in need of intervention at birth, actions taken during the first minute after birth, the so-called "Golden Minute", can have important implications for long-term outcomes. Both delivery room handling, including identification of maternal and infant risk factors and provision of effective resuscitation interventions, and antenatal care decisions regarding antenatal steroid administration and mode of delivery, are important and can affect outcomes. Anticipating risk factors for neonates at high risk of requiring resuscitation can decrease time to resuscitation and improve the prognosis. Following a review of maternal and fetal risk factors affecting newborn resuscitation, we summarize the current recommendations for delivery room handling of the newborn. This includes recommendations and rationale for the use of delayed cord clamping and cord milking, heart rate assessment [including the use of electrocardiogram (ECG) electrodes in the delivery room], role of suctioning in newborn resuscitation, and the impact of various ventilatory modes. Oxygenation should be monitored by pulse oximetry. Effects of oxygen and surfactant on subsequent pulmonary outcomes, and recommendations for provisions of appropriate thermoregulatory support are discussed. Regular teaching of delivery room handling should be mandatory.
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Affiliation(s)
- Stephanie Marshall
- Ann and Robert H. Lurie, Children’s Hospital of Chicago, Chicago, IL, USA
| | - Astri Maria Lang
- Department of Neonatology, Division of Child Health, and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Marta Perez
- Ann and Robert H. Lurie, Children’s Hospital of Chicago, Chicago, IL, USA
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Owen LS, Manley BJ, Davis PG. Delivery room emergencies: Respiratory emergencies in the DR. Semin Fetal Neonatal Med 2019; 24:101039. [PMID: 31645310 DOI: 10.1016/j.siny.2019.101039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of newborns transition to extra uterine life without support. However, respiratory emergencies in the delivery room are a common occurrence. Whilst some situations are predictable e.g. the anticipated birth of an extremely preterm infant, others are less so. In this chapter we address the most frequent scenarios that result in delivery room respiratory emergencies and discuss the latest recommendations for their management. We outline the need for a trained resuscitation team and appropriate equipment to provide respiratory support at every birth. We address the basic care that all infants should receive, the detailed application of non-invasive ventilation and the use of advanced airway techniques. We discuss the unique challenges presented by extreme prematurity including umbilical cord management, use of supplemental oxygen, initial modes of respiratory support and surfactant delivery. We will explore optimal techniques in the management of infants with lung hypoplasia, pneumothorax and meconium aspiration.
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Affiliation(s)
- Louise S Owen
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Brett J Manley
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
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Oxygen therapy of the newborn from molecular understanding to clinical practice. Pediatr Res 2019; 85:20-29. [PMID: 30297877 DOI: 10.1038/s41390-018-0176-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 01/30/2023]
Abstract
Oxygen is one of the most critical components of life. Nature has taken billions of years to develop optimal atmospheric oxygen concentrations for human life, evolving from very low, peaking at 30% before reaching 20.95%. There is now increased understanding of the potential toxicity of both too much and too little oxygen, especially for preterm and asphyxiated infants and of the potential and lifelong impact of oxygen exposure, even for a few minutes after birth. In this review, we discuss the contribution of knowledge gleaned from basic science studies and their implication in the care and outcomes of the human infant within the first few minutes of life and afterwards. We emphasize current knowledge gaps and research that is needed to answer a problem that has taken Nature a considerably longer time to resolve.
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Chandrasekharan P, Rawat M, Gugino SF, Koenigsknecht C, Helman J, Nair J, Vali P, Lakshminrusimha S. Effect of various inspired oxygen concentrations on pulmonary and systemic hemodynamics and oxygenation during resuscitation in a transitioning preterm model. Pediatr Res 2018; 84:743-750. [PMID: 29967523 PMCID: PMC6275138 DOI: 10.1038/s41390-018-0085-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/25/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The Neonatal Resuscitation Program recommends initial resuscitation of preterm infants with low oxygen (O2) followed by titration to target preductal saturations (SpO2). We studied the effect of resuscitation with titrated O2 on gas exchange, pulmonary, and systemic hemodynamics. METHODOLOGY Twenty-nine preterm lambs (127 d gestation) were randomized to resuscitation with 21% O2 (n = 7), 100% O2 (n = 6), or initiation at 21% and titrated to target SpO2 (n = 16). Seven healthy term control lambs were ventilated with 21% O2. RESULTS Preductal SpO2 achieved by titrating O2 was within the desired range similar to term lambs in 21% O2. Resuscitation of preterm lambs with 21% and 100% O2 resulted in SpO2 below and above the target, respectively. Ventilation of preterm lambs with 100% O2 and term lambs with 21% O2 effectively decreased pulmonary vascular resistance (PVR). In contrast, preterm lambs with 21% O2 and titrated O2 demonstrated significantly higher PVR than term lambs on 21% O2. CONCLUSION(S) Initial resuscitation with 21% O2 followed by titration of O2 led to suboptimal pulmonary vascular transition at birth in preterm lambs. Ventilation with 100% O2 in preterm lambs caused hyperoxia but reduced PVR similar to term lambs on 21% O2. Studies evaluating the initiation of resuscitation at a higher O2 concentration followed by titration based on SpO2 in preterm neonates are needed.
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Affiliation(s)
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | | | | | - Justin Helman
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Payam Vali
- Department of Pediatrics, UC Davis, Sacramento, CA
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Vali P, Underwood M, Lakshminrusimha S. Hemoglobin oxygen saturation targets in the neonatal intensive care unit: Is there a light at the end of the tunnel? 1. Can J Physiol Pharmacol 2018; 97:174-182. [PMID: 30365906 DOI: 10.1139/cjpp-2018-0376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The optimal oxygenation target needed to prevent the extremes of hypoxia and oxygen toxicity in premature and sick newborns has been the subject of much research and debate. The advent of the pulse oximeter has allowed the continuous monitoring of oxyhemoglobin saturation and the delivery of oxygen with greater precision. Well-run, large clinical trials to determine the safest oxygen concentration have led to several revisions in guidelines for neonatal care. However, monitoring of oxyhemoglobin saturation has its limitations and does not provide a comprehensive assessment of tissue oxygenation. To identify optimal oxygen therapy, various other factors (partial pressure of arterial carbon dioxide, hemoglobin concentration, blood pH, and tissue metabolic demand) that influence perfusion and tissue oxygenation need to be considered.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
| | - Mark Underwood
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
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Garcia-Hidalgo C, Cheung PY, Solevåg AL, Vento M, O'Reilly M, Saugstad O, Schmölzer GM. A Review of Oxygen Use During Chest Compressions in Newborns-A Meta-Analysis of Animal Data. Front Pediatr 2018; 6:400. [PMID: 30619794 PMCID: PMC6305367 DOI: 10.3389/fped.2018.00400] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/03/2018] [Indexed: 11/21/2022] Open
Abstract
Background: International consensus statements for resuscitation of newborn infants recommend provision of 100% oxygen once chest compressions are required. However, 100% oxygen exacerbates reperfusion injury and reduces cerebral perfusion in newborn babies. Objective: We aimed to establish whether resuscitation with air during chest compression is feasible and safe in newborn infants compared with 100% oxygen. Methods: Systematic search of PubMed, Google Scholar and CINAHL for articles examining variable oxygen concentrations during chest compressions in term newborns. Results: Overall, no human studies but eight animal studies (n = 323 animals) comparing various oxygen concentrations during chest compression were identified. The pooled analysis showed no difference in mortality rates for animals resuscitated with air vs. 100% oxygen (risk ratio 1.04 [0.35, 3.08], I2 = 0%, p = 0.94). ROSC was also similar between groups with a mean difference of -3.8 [-29.7-22] s, I2 = 0%, p = 0.77. No difference in oxygen damage or adverse events were identified between groups. Conclusions: Air had similar time to ROSC and mortality as 100% oxygen during neonatal chest compression. A large randomized controlled clinical trial comparing air vs. 100% oxygen during neonatal chest compression is warranted.
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Affiliation(s)
- Catalina Garcia-Hidalgo
- Faculty of Science, University of Alberta, Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Anne Lee Solevåg
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Maximo Vento
- Health Research Centre, University and Polytechnic Hospital La Fe, Valencia, Spain.,Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain.,Spanish Maternal and Infant Health and Development Network, National Network, Spain
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ola Saugstad
- Department of Pediatric Research, University of Oslo, Oslo, Norway
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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