Resuscitation beyond 10 minutes of term babies born without signs of life

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

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

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

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Duration of Resuscitation at Birth, Mortality, and Neurodevelopment: A Systematic Review

CONTEXT

The International Liaison Committee on Resuscitation Neonatal Life Support Task Force reviewed evidence for the duration of cardiopulmonary resuscitation (CPR) for newborns immediately after birth.

OBJECTIVE

To summarize evidence for ongoing CPR on the outcomes of survival, neurodevelopment, and the composite of survival without moderate or severe neurodevelopmental impairment (NDI).

DATA SOURCES

Medline, Embase, Evidence-Based Medicine Reviews, Cumulative Index to Nursing and Allied Health Literature, and Scientific Electronic Library Online were searched between inception and February 29, 2020.

STUDY SELECTION

Two independent reviewers selected studies of newborns with at least 10 minutes of asystole, bradycardia, or pulseless electrical activity for which CPR is indicated.

DATA EXTRACTION

Two independent reviewers extracted data and appraised the risk of bias.

RESULTS

In 16 eligible studies, researchers reported outcomes of 579 newborns born between 1982 and 2017. Within individual studies, 2% to 100% of infants survived to last follow-up (hospital discharge through 12 years). Summarized across studies, 237 of 579 (40.9%) newborns survived to last follow-up. In 13 studies, researchers reported neurodevelopmental outcomes of 277 newborns. Of these, 30 of 277 (10.8%) survived without moderate or severe impairment, and 240 of 277 (87%) met the composite outcome of death or NDI (191 died and 49 survived with moderate or severe impairment).

LIMITATIONS

There was very low certainty of evidence because of risk of bias and inconsistency.

CONCLUSIONS

Infants with ongoing CPR at 10 minutes after birth are at high risk for mortality and neurodisability, but survival without moderate or severe NDI is possible. One specified duration of CPR is unlikely to uniformly predict survival or survival without neuroimpairment.

Apgar score of 0 at 10 min and survival to 1 year of age: a retrospective cohort study in Washington state

OBJECTIVE

To determine 1-year survival in a cohort of newborns with an Apgar score of 0 at 5 and 10 min of age.

STUDY DESIGN

A retrospective cohort study of the Washington State Comprehensive Hospital Abstract Reporting System from 2005 to 2014.

RESULTS

Of 879,340 births, 199 (0.02%) had an Apgar score of 0 at 5 min, and 109 (0.01%) also had a score of 0 at 10 min. One-year survival was 46% for newborns with Apgar score of 0 at 5 and 10 min. One-year survival by gestational age was 4% for newborns <30 weeks, 38% for 30-35 weeks, and 67% for ≥36 weeks.

CONCLUSION

Survival at 1 year of age for newborns with an Apgar score of 0 at 5 and 10 min has improved, as compared with historic cohorts. Cautious optimism is warranted since morbidity-free survival could not be assessed.

Singapore Neonatal Resuscitation Guidelines 2016

We present the revised Neonatal Resuscitation Guidelines for Singapore. The 2015 International Liaison Committee on Resuscitation Neonatal Task Force's consensus on science and treatment recommendations (2015), and guidelines from the American Heart Association and European Resuscitation Council were debated and discussed. The final recommendations of the National Resuscitation Council, Singapore, were derived after the task force had carefully reviewed the current available evidence in the literature and addressed their relevance to local clinical practice.

Outcome of term infants using apgar scores at 10 minutes following hypoxic-ischemic encephalopathy

OBJECTIVE

The objective of this study was to determine whether Apgar scores at 10 minutes are associated with death or disability in early childhood after perinatal hypoxic-ischemic encephalopathy.

METHODS

This was a secondary analysis of infants who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network hypothermia trial. Infants who were born at >or=36 weeks' gestation and had clinical and/or biochemical abnormalities at birth and encephalopathy at <6 hours were studied. Logistic regression and classification and regression-tree analysis were used to determine associations between Apgar scores at 10 minutes and neurodevelopmental outcome, adjusting for covariates. Death or disability (moderate or severe) at 18 to 22 months of age was the measured outcome.

RESULTS

Twenty of 208 infants were excluded (missing data). More than 90% of the infants had Apgar scores of 0 to 2 at 1 minute, and Apgar scores at 5 and 10 minutes shifted to progressively higher values; at 10 minutes, 27% of infants had Apgar scores of 0 to 2. After adjustment, each point decrease in Apgar score at 10 minutes was associated with a 45% increase in the odds of death or disability. Death or disability occurred in 76%, 82%, and 80% of infants with 10-minute Apgar scores of 0, 1, and 2, respectively. Classification and regression-tree analysis indicated that Apgar scores at 10 minutes were discriminators of outcome.

CONCLUSIONS

Apgar scores at 10 minutes provide useful prognostic data before other evaluations are available for infants with hypoxic-ischemic encephalopathy. Death or moderate/severe disability is common but not uniform with Apgar scores of <3; caution is needed before adopting a specific time interval to guide duration of resuscitation.

The ethics of delivery-room resuscitation

Perinatal care continues to improve and the number of extremely preterm babies delivered increases. What is the outcome for those babies? Under what circumstances should we not initiate resuscitation or under what circumstances should we discontinue support? How accurate and predictive are the data we have and how can these be improved? Who should make the decisions and how should they be made? Should we follow different guidelines in different settings? The following narrative will examine some of these questions but cannot answer them all.

Moving from experience to evidence: changes in US Neonatal Resuscitation Program based on International Liaison Committee on Resuscitation Review

The Neonatal Workgroup of the International Liaison Committee on Resuscitation recently made available their rigorous review of the scientific evidence base for selected neonatal resuscitation issues. The Neonatal Resuscitation Program guidelines have been recently revised based on that review and published as the Textbook of Neonatal Resuscitation, 5th edn. This review article highlights pertinent changes in recommendations, including revisions in: oxygen use; CO(2) detectors for confirmation of intubation; management of the infant born through meconium-stained amniotic fluid; initial ventilation devices and strategies; thermal protection of very small preterm infants; medications, including doses and routes of delivery; postresuscitation therapies for consideration and ethical issues in initiation and discontinuation of resuscitation. Journal of Perinatology (2008) 28, S35-S40; doi:10.1038/jp.2008.48.

The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort

OBJECTIVE

The purpose of this study was to investigate the outcomes of infants who had Apgar scores of zero at 10 minutes and were resuscitated successfully.

STUDY DESIGN

The literature was reviewed systematically to identify the outcomes of cases; in addition, the perinatal database at the John Radcliffe Hospital, Oxford, was used to identify similar cases. Eligible infants were identified through hospital records, and outcomes of all infants with an Apgar score of zero at 10 minutes, who were born between January 1991 and December 2004, were reviewed.

RESULTS

Eighty-five cases were identified from the literature. With the Oxford database, 9 of 83,065 infants (0.12/1000 births) met our study criteria. Six of the 9 infants died before leaving hospital. One infant with severe quadriparesis and microcephaly died at 11 months of age. One infant at follow-up examination at 5 years had severe spastic quadriparesis with severe global delay. One infant with grade 2 hypoxic-ischemic encephalopathy, who was born with severe anemia that was corrected promptly at birth, had mild disability at follow-up examination at 2 years. Thus, death or severe disability occurred in 8 of 9 infants. Combining the results of metaanalysis of published data with our results of 94 infants, 88 infants (94%) either died or were handicapped severely; 2 infants (2%) were handicapped moderately, and 1 infant (1%) was handicapped mildly. For 3 infants (3%), the long-term outcome could not be determined.

CONCLUSION

The outcome of infants with an Apgar score of zero at 10 minutes is almost universally poor.

Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room

OBJECTIVE

Given the paucity of information regarding endotracheal epinephrine for newborn resuscitation, the objectives of this study were: (1) to determine the frequency of endotracheal epinephrine use in newborns in the delivery room, and (2) to determine whether the previously recommended dose of 0.01 to 0.03 mg/kg of endotracheal epinephrine is effective in establishing a return of spontaneous circulation.

PATIENTS AND METHODS

A retrospective review was conducted for all neonates who received > or = 1 dose of epinephrine in the delivery room between January 1999 and December 2004. Infants who received > or = 1 dose of endotracheal epinephrine in the delivery room during resuscitation were included in the study population whether or not they survived to be admitted to the NICU. Exclusion criteria included lethal congenital anomalies, delivery outside the hospital, and missing medical charts.

RESULTS

Of 93,656 infants, 52 neonates (0.06%) received epinephrine in the delivery room, 5 of whom met exclusion criteria. Of the remaining 47 infants, 44 (94%) received the first dose via the endotracheal tube. Only 14 (32%) of 44 achieved return of spontaneous circulation after endotracheal tube administration of epinephrine. Of the 30 remaining infants, 23 (77%) had return of spontaneous circulation with intravenous epinephrine after initially failing endotracheal tube epinephrine. There were no differences in clinical characteristics between newborns who responded to endotracheal tube versus intravenous epinephrine except for a lower blood glucose on NICU admission (52 vs 113 mg%).

CONCLUSIONS

Endotracheal epinephrine is frequently used when intensive resuscitation is required in the delivery room. The previously recommended endotracheal epinephrine dose of 0.01 to 0.03 mg/kg is often ineffective. Higher endotracheal doses will likely be needed to improve efficacy. A prospective study is needed to determine the best endotracheal epinephrine dosing regimen. Until such information is available, intravenous administration should be the preferred route of delivery.

Non-initiation and discontinuation of resuscitation

Whereas certain aspects of neonatal resuscitation may benefit from evidence evaluation using standard evaluation techniques, the ethical aspects of non-initiation and discontinuation of resuscitative efforts are more subjective and might certainly be influenced by the biases of the reviewers. The outcome data are relatively straightforward, although survival and morbidity data differ significantly by region and even among hospitals classified at similar levels in the same region. However, the interpretation of that data is necessarily somewhat subjective. Whereas certain aspects of neonatal resuscitation may benefit from evidence evaluation using standard evaluation techniques, the ethical aspects of non-initiation and discontinuation of resuscitative efforts are more subjective and might certainly be influenced by the biases of the reviewers. The outcome data are relatively straightforward, although survival and morbidity data differ significantly by region and even among hospitals classified at similar levels in the same region. However, the interpretation of that data is necessarily somewhat subjective. Does a survival rate of 1% of patients at a certain weight or gestational age warrant full resuscitative efforts? What about 20% or 49%? Similar questions could be posed regarding significant morbidity. However, as the science of neonatal resuscitation advances, it is important to review objective evidence-based outcome data in certain situations in which non-initiation or discontinuation of resuscitative efforts may be appropriate to determine if certain common themes can be elicited.