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Tuttle Z, Roberts C, Davis P, Malhotra A, Tan K, Bhatia R, Zhou L, Baker E, Hodgson K, Blank D. Combining activity and grimace scores reflects perinatal stability in infants <32 weeks gestational age. Pediatr Res 2024:10.1038/s41390-024-03130-6. [PMID: 38519793 DOI: 10.1038/s41390-024-03130-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/12/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Over 95% of infants less than 32 weeks gestational age-very preterm infants (VPTI)-require cardiorespiratory support at birth. Clinical condition at birth is assessed by the Apgar score, but the precision and accuracy of activity and grimace has not been evaluated. We hypothesised activity and grimace could predict the level of cardiorespiratory support required for stabilisation. METHODS Two hundred twenty-nine videos of VPTI resuscitations at Monash Children's Hospital and The Royal Women's Hospital, Melbourne were evaluated, with 78 videos eligible for assessment. Activity and grimace were scored (0, 1, or 2) by seven consultant neonatologists, with inter-rater reliability assessed. Activity and grimace were correlated with the maximum level of cardiorespiratory support required for stabilisation. RESULTS Kendall's Coefficient of Concordance (W) showed strong interobserver agreement for activity (W = 0.644, p < 0.001) and grimace (W = 0.722, p < 0.001). Neither activity nor grimace independently predicted the level of cardiorespiratory support required. Combining activity and grimace showed non-vigorous infants (combined score <2) received more cardiorespiratory support than vigorous (combined score ≥ 2). CONCLUSION Scoring of activity and grimace was consistent between clinicians. Independently, activity and grimace did not correlate with perinatal stabilisation. Combined scoring showed non-vigorous infants had greater resuscitation requirements. IMPACT Our study evaluates the precision and accuracy of activity and grimace to predict perinatal stability, which has not been validated in infants <32 weeks gestational age. We found strong score agreement between assessors, indicating video review is a practical and precise method for grading of activity and grimace. Combined scoring to allow a dichotomous evaluation of infants as non-vigorous or vigorous showed the former group required greater cardiorespiratory support at birth.
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Affiliation(s)
- Zachary Tuttle
- The Ritchie Centre, Monash University, Clayton, VIC, Australia.
| | - Calum Roberts
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Peter Davis
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, VIC, Australia
| | - Atul Malhotra
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Kenneth Tan
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Risha Bhatia
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
| | - Lindsay Zhou
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
| | - Elizabeth Baker
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, VIC, Australia
| | - Kate Hodgson
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, VIC, Australia
| | - Douglas Blank
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
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2
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Technology in the delivery room supporting the neonatal healthcare provider's task. Semin Fetal Neonatal Med 2022; 27:101333. [PMID: 35400603 DOI: 10.1016/j.siny.2022.101333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Very preterm infants are a unique and highly vulnerable group of patients that have a narrow physiological margin within which interventions are safe and effective. The increased understanding of the foetal to neonatal transition marks the intricacy of the rapid and major physiological changes that take place, making delivery room stabilisation and resuscitation an increasingly complex and sophisticated activity for caregivers to perform. While modern, automated technologies are progressively implemented in the neonatal intensive care unit (NICU) to enhance the caregivers in providing the right care for these patients, the technology in the delivery room still lags far behind. Diligent translation of well-known and promising technological solutions from the NICU to the delivery room will allow for better support of the caregivers in performing their tasks. In this review we will discuss the current technology used for stabilisation of preterm infants in the delivery room and how this could be optimised in order to further improve care and outcomes of preterm infants in the near future.
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3
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Gaertner VD, Rüegger CM, Bassler D, O'Currain E, Kamlin COF, Hooper SB, Davis PG, Springer L. Effects of tactile stimulation on spontaneous breathing during face mask ventilation. Arch Dis Child Fetal Neonatal Ed 2022; 107:508-512. [PMID: 34862191 DOI: 10.1136/archdischild-2021-322989] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/16/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We sought to determine the effect of stimulation during positive pressure ventilation (PPV) on the number of spontaneous breaths, exhaled tidal volume (VTe), mask leak and obstruction. DESIGN Secondary analysis of a prospective, randomised trial comparing two face masks. SETTING Single-centre delivery room study. PATIENTS Newborn infants ≥34 weeks' gestation at birth. METHODS Resuscitations were video recorded. Tactile stimulations during PPV were noted and the timing, duration and surface area of applied stimulus were recorded. Respiratory flow waveforms were evaluated to determine the number of spontaneous breaths, VTe, leak and obstruction. Variables were recorded throughout each tactile stimulation episode and compared with those recorded in the same time period immediately before stimulation. RESULTS Twenty of 40 infants received tactile stimulation during PPV and we recorded 57 stimulations during PPV. During stimulation, the number of spontaneous breaths increased (median difference (IQR): 1 breath (0-3); padj<0.001) and VTe increased (0.5 mL/kg (-0.5 to 1.7), padj=0.028), whereas mask leak (0% (-20 to 1), padj=0.12) and percentage of obstructed inflations (0% (0-0), padj=0.14) did not change, compared with the period immediately prior to stimulation. Increased duration of stimulation (padj<0.001) and surface area of applied stimulus (padj=0.026) were associated with a larger increase in spontaneous breaths in response to tactile stimulation. CONCLUSIONS Tactile stimulation during PPV was associated with an increase in the number of spontaneous breaths compared with immediately before stimulation without a change in mask leak and obstruction. These data inform the discussion on continuing stimulation during PPV in term infants. TRIAL REGISTRATION NUMBER Australian and New Zealand Clinical Trial Registry (ACTRN12616000768493).
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Christoph Martin Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Eoin O'Currain
- School of Medicine, University College Dublin and National Maternity Hospital Dublin, Dublin, Ireland
| | - C Omar Farouk Kamlin
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Laila Springer
- Department of Neonatology, University Clinic Tubingen, Tubingen, Germany
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4
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Guinsburg R, de Almeida MFB, Finan E, Perlman JM, Wyllie J, Liley HG, Wyckoff MH, Isayama T. Tactile Stimulation in Newborn Infants With Inadequate Respiration at Birth: A Systematic Review. Pediatrics 2022; 149:185380. [PMID: 35257181 DOI: 10.1542/peds.2021-055067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT For many years the International Liaison Committee on Resuscitation has recommended the use of tactile stimulation for initial management of infants born with inadequate respiratory effort at birth without systematically examining its effectiveness. OBJECTIVE Systematic review to compare the effectiveness of tactile stimulation with routine handling in newly born term and preterm infants. DATA SOURCES Medline, Embase, Cochrane CENTRAL, along with clinical trial registries. STUDY SELECTION Randomized and non-randomized studies were included based on predetermined criteria. DATA EXTRACTION Data were extracted independently by authors. Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) was used to assess risk of bias in non-randomized studies. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess the certainty of evidence. RESULTS Among 2455 unique articles identified, 2 observational studies were eligible and qualitatively summarized. Because one of the studies was at critical risk of bias, only the other study including 243 preterm infants on continuous positive airway pressure with clinical indications for tactile stimulation was analyzed. It showed a reduction in tracheal intubation in infants receiving tactile stimulation compared with no tactile stimulation (12 of 164 vs 14 of 79, risk ratio of 0.41 [95% confidence interval 0.20 to 0.85]); however, the certainty of evidence was very low. LIMITATIONS The available data were limited and only from observational studies. CONCLUSIONS A potential benefit of tactile stimulation was identified but was limited by the very low certainty of evidence. More research is suggested to evaluate the effectiveness as well as the optimal type and duration of tactile stimulation.
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Affiliation(s)
- Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Emer Finan
- Department of Paediatrics, Sinai Health, Toronto, Ontario, Canada
| | - Jeffrey M Perlman
- Weill Cornell Medicine and New York-Presbyterian Komansky Children's Hospital, New York, New York
| | - Jonathan Wyllie
- Department of Paediatrics and Neonatology, James Cook University Hospital, South Tees National Health Services Foundation Trust, Middlesbrough, United Kingdom
| | - Helen G Liley
- Mater Research Institute and Mater Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Myra H Wyckoff
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Weiner GM, Zaichkin J. Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines. Neoreviews 2022; 23:e238-e249. [PMID: 35362042 DOI: 10.1542/neo.23-4-e238] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Although most newborns require no assistance to successfully transition to extrauterine life, the large number of births each year and limited ability to predict which newborns will need assistance means that skilled clinicians must be prepared to respond quickly and efficiently for every birth. A successful outcome is dependent on a rapid response from skilled staff who have mastered the cognitive, technical, and behavioral skills of neonatal resuscitation. Since its release in 1987, over 4.5 million clinicians have been trained by the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program®. The guidelines used to develop this program were updated in 2020 and the Textbook of Neonatal Resuscitation, 8th edition, was released in June 2021. The updated guidelines have not changed the basic approach to neonatal resuscitation, which emphasizes the importance of anticipation, preparation, teamwork, and effective ventilation. Several practices have changed, including the prebirth questions, initial steps, use of electronic cardiac monitors, the initial dose of epinephrine, the flush volume after intravascular epinephrine, and the duration of resuscitation with an absent heart rate. In addition, the program has enhanced components of the textbook to improve learning, added new course delivery options, and offers 2 course levels to allow learners to study the material that is most relevant to their role during neonatal resuscitation. This review summarizes the recent changes to the resuscitation guidelines, the textbook, and the Neonatal Resuscitation Program course.
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Affiliation(s)
- Gary M Weiner
- Department of Pediatrics, Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
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6
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Kaufmann M, Mense L, Springer L, Dekker J. Tactile stimulation in the delivery room: past, present, future. A systematic review. Pediatr Res 2022:10.1038/s41390-022-01945-9. [PMID: 35124690 DOI: 10.1038/s41390-022-01945-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/05/2021] [Accepted: 12/14/2021] [Indexed: 11/08/2022]
Abstract
In current resuscitation guidelines, tactile stimulation is recommended for infants with insufficient respiratory efforts after birth. No recommendations are made regarding duration, onset, and method of stimulation. Neither is mentioned how tactile stimulation should be applied in relation to the gestational age. The aim was to review the physiological mechanisms of respiratory drive after birth and to identify and structure the current evidence on tactile stimulation during neonatal resuscitation. A systematic review of available data was performed using PubMed, covering the literature up to April 2021. Two independent investigators screened the extracted references and assessed their methodological quality. Six studies were included. Tactile stimulation management, including the onset of stimulation, overall duration, and methods as well as the effect on vital parameters was analyzed and systematically presented. Tactile stimulation varies widely between, as well as within different centers and no consensus exists which stimulation method is most effective. Some evidence shows that repetitive stimulation within the first minutes of resuscitation improves oxygenation. Further studies are warranted to optimize strategies to support spontaneous breathing after birth, assessing the effect of stimulating various body parts respectively within different gestational age groups.
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Affiliation(s)
- M Kaufmann
- Division of Neonatology and Paediatric Intensive Care Medicine, Department of Paediatrics, Medical Faculty, TU Dresden, Dresden, Germany.
| | - L Mense
- Division of Neonatology and Paediatric Intensive Care Medicine, Department of Paediatrics, Medical Faculty, TU Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Medical Faculty, TU Dresden, Dresden, Germany
| | - L Springer
- Division of Neonatology, Department of Paediatrics, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - J Dekker
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
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7
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Kaufmann M, Seipolt B, Rüdiger M, Mense L. Tactile stimulation in very preterm infants and their needs of non-invasive respiratory support. Front Pediatr 2022; 10:1041898. [PMID: 36467488 PMCID: PMC9715591 DOI: 10.3389/fped.2022.1041898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022] Open
Abstract
AIM Despite the lack of evidence, current resuscitation guidelines recommend tactile stimulation in apneic infants within the first minutes of life. The aim was to investigate whether timing, duration or intensity of tactile stimulation influences the extent of non-invasive respiratory support in extremely preterm infants during neonatal resuscitation. METHODS In an observational study, we analyzed 47 video recordings and physiological parameters during postnatal transition in preterm infants below 320/7 weeks of gestational age. Infants were divided into three groups according to the intensity of respiratory support. RESULTS All infants were stimulated at least once during neonatal resuscitation regardless of their respiratory support. Only 51% got stimulated within the first minute. Rubbing the feet was the preferred stimulation method and was followed by rubbing or touching the chest. Almost all very preterm infants were exposed to stimulation and manipulation most of the time within their first 15 min of life. Tactile stimulation lasted significantly longer but stimulation at multiple body areas started later in infants receiving prolonged non-invasive respiratory support. CONCLUSION This observational study demonstrated that stimulation of very preterm infants is a commonly used and easy applicable method to stimulate spontaneous breathing during neonatal resuscitation. The concomitant physical stimulation of different body parts and therefore larger surface areas might be beneficial.
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Affiliation(s)
- Maxi Kaufmann
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care Medicine, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany.,Saxony Center for Feto-Neonatal Health, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Barbara Seipolt
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care Medicine, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany.,Saxony Center for Feto-Neonatal Health, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Mario Rüdiger
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care Medicine, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany.,Saxony Center for Feto-Neonatal Health, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Lars Mense
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care Medicine, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany.,Saxony Center for Feto-Neonatal Health, TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany
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8
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Niemuth M, Küster H, Simma B, Rozycki H, Rüdiger M, Solevåg AL. A critical appraisal of tools for delivery room assessment of the newborn infant. Pediatr Res 2021:10.1038/s41390-021-01896-7. [PMID: 34969993 DOI: 10.1038/s41390-021-01896-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/19/2021] [Indexed: 11/09/2022]
Abstract
Assessment of an infant's condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed. IMPACT: This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn's postnatal condition. A revised neonatal scoring system should account for infant maturity and the interventions administered. Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.
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Affiliation(s)
- Mara Niemuth
- Department for Neonatology and Pediatric Intensive Care, Clinic for Pediatric and Adolescence Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Helmut Küster
- Clinic for Pediatric Cardiology, Intensive Care and Neonatology, University Medical Center Göttingen, Göttingen, Germany
| | - Burkhard Simma
- Department of Paediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Henry Rozycki
- Division of Neonatal Medicine, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, USA
| | - Mario Rüdiger
- Department for Neonatology and Pediatric Intensive Care, Clinic for Pediatric and Adolescence Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Anne Lee Solevåg
- The Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
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9
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Bruckner M, Schmölzer GM. Physiologic Changes during Neonatal Transition and the Influence of Respiratory Support. Clin Perinatol 2021; 48:697-709. [PMID: 34774204 DOI: 10.1016/j.clp.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria.
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10
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Simma B, den Boer M, Nakstad B, Küster H, Herrick HM, Rüdiger M, Aichner H, Kaufmann M. Video recording in the delivery room: current status, implications and implementation. Pediatr Res 2021:10.1038/s41390-021-01865-0. [PMID: 34819653 DOI: 10.1038/s41390-021-01865-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/09/2022]
Abstract
Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.
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Affiliation(s)
- B Simma
- Department of Paediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria.
| | - M den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - B Nakstad
- Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
- Division of Paediatrics and Adolescent Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - H Küster
- Clinic for Paediatric Cardiology, Intensive Care and Neonatology, University Medical Centre Göttingen, Göttingen, Germany
| | - H M Herrick
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Rüdiger
- Division of Neonatology and Paediatric Intensive Care Medicine, Department of Paediatrics, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - H Aichner
- Department of Paediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - M Kaufmann
- Division of Neonatology and Paediatric Intensive Care Medicine, Department of Paediatrics, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
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11
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Stimulating and maintaining spontaneous breathing during transition of preterm infants. Pediatr Res 2021; 90:722-730. [PMID: 31216570 DOI: 10.1038/s41390-019-0468-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/25/2019] [Accepted: 06/03/2019] [Indexed: 01/30/2023]
Abstract
Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.
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12
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Cavallin F, Lochoro P, Ictho J, Nsubuga JB, Ameo J, Putoto G, Trevisanuto D. Back rubs or foot flicks for neonatal stimulation at birth in a low-resource setting: A randomized controlled trial. Resuscitation 2021; 167:137-143. [PMID: 34438002 DOI: 10.1016/j.resuscitation.2021.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/06/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Approximately 15% of infants require stimulation in low-resource settings, but data on effectiveness of different stimulation approaches are limited. We aimed to compare two recommended approaches of stimulation (back rubs vs. foot flicks) in reducing the need for face-mask ventilation in newly born infants who were not crying immediately after birth in a low-resource setting. METHODS A single center, open-label, randomized, superiority trial was conducted at St. Kizito Hospital in Matany (Uganda) between November 2019 and May 2020. Newly born infants with expected birthweight > 1500 grams who were not crying immediately after birth were randomly assigned to stimulation using back rubs or foot flicks. The primary outcome measure was the success rate of the stimulation, defined as the achievement of an effective crying preventing the need for face-mask ventilation. RESULTS Success of stimulation was achieved in 76/93 neonates (82%) using back rubs and 68/93 neonates (73%) using foot flicks (risk ratio 1.12, 95% confidence interval 0.96-1.31). No procedure-associated complications arose during the study. Time to first cry was not statistically different between the two arms (mean difference -11 seconds, 95% confidence interval -39 to 18). CONCLUSIONS In newly born infants who were not crying immediately after birth, this trial did not provide a conclusive message in favor of back rubs or foot flicks. Nonetheless, we could not exclude a possible benefit of back rubs in avoiding the need for positive pressure ventilation and, possibly, further advanced resuscitative maneuvers. CLINICAL TRIALS REGISTRATION clinicalTrial.gov: NCT04056091.
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Affiliation(s)
| | | | | | | | | | | | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padova, Padova, Italy.
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13
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European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291-326. [PMID: 33773829 DOI: 10.1016/j.resuscitation.2021.02.014] [Citation(s) in RCA: 235] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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14
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Cramer SJE, Zanten HA, Boezaard M, Hoek PM, Dekker J, Hooper SB, Pas AB. High variability in nurses' tactile stimulation methods in response to apnoea of prematurity-A neonatal manikin study. Acta Paediatr 2021; 110:799-804. [PMID: 32892397 PMCID: PMC7984214 DOI: 10.1111/apa.15564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/05/2020] [Accepted: 08/31/2020] [Indexed: 01/24/2023]
Abstract
Aim Neonatal intensive care unit (NICU) nurses provide tactile stimulation to terminate apnoea in preterm infants, but guidelines recommending specific methods are lacking. In this study, we evaluated current methods of tactile stimulation performed by NICU nurses. Methods Nurses were asked to demonstrate and explain their methods of tactile stimulation on a manikin, using an apnoea scenario. All nurses demonstrated their methods three times in succession, with the manikin positioned either prone, supine or lateral. Finally, the nurses were asked how they decided on the methods of tactile stimulation used. The stimulation methods were logged in chronological order by describing both the technique and the location. The nurses' explanations were transcribed and categorised. Results In total, 47 nurses demonstrated their methods of stimulation on the manikin. Overall, 57 different combinations of technique and location were identified. While most nurses (40/47, 85%) indicated they learned how to stimulate during their training, 15/40 (38%) of them had adjusted their methods over time. The remaining 7/47 (15%) stated that their stimulation methods were self‐developed. Conclusion Tactile stimulation performed by NICU nurses to terminate apnoea was highly variable in both technique and location, and these methods were based on either prior training or intuition.
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Affiliation(s)
- Sophie J. E. Cramer
- Division of Neonatology Department of Paediatrics Leiden University Medical Center Leiden the Netherlands
| | - Henriëtte Anje Zanten
- Division of Neonatology Department of Paediatrics Leiden University Medical Center Leiden the Netherlands
| | - Manon Boezaard
- Division of Neonatology Department of Paediatrics Leiden University Medical Center Leiden the Netherlands
| | - Petronella M. Hoek
- Division of Neonatology Department of Paediatrics Leiden University Medical Center Leiden the Netherlands
| | - Janneke Dekker
- Division of Neonatology Department of Paediatrics Leiden University Medical Center Leiden the Netherlands
- The Ritchie Center Hudson Institute of Medical Research Melbourne Victoria Australia
| | - Stuart B. Hooper
- The Ritchie Center Hudson Institute of Medical Research Melbourne Victoria Australia
| | - Arjan B. Pas
- Division of Neonatology Department of Paediatrics Leiden University Medical Center Leiden the Netherlands
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Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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16
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Kuypers K, Martherus T, Lamberska T, Dekker J, Hooper SB, Te Pas AB. Reflexes that impact spontaneous breathing of preterm infants at birth: a narrative review. Arch Dis Child Fetal Neonatal Ed 2020; 105:675-679. [PMID: 32350064 DOI: 10.1136/archdischild-2020-318915] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023]
Abstract
Some neural circuits within infants are not fully developed at birth, especially in preterm infants. Therefore, it is unclear whether reflexes that affect breathing may or may not be activated during the neonatal stabilisation at birth. Both sensory reflexes (eg, tactile stimulation) and non-invasive ventilation (NIV) can promote spontaneous breathing at birth, but the application of NIV can also compromise breathing by inducing facial reflexes that inhibit spontaneous breathing. Applying an interface could provoke the trigeminocardiac reflex (TCR) by stimulating the trigeminal nerve resulting in apnoea and a reduction in heart rate. Similarly, airflow within the nasopharynx can elicit the TCR and/or laryngeal chemoreflex (LCR), resulting in glottal closure and ineffective ventilation, whereas providing pressure via inflations could stimulate multiple receptors that affect breathing. Stimulating the fast adapting pulmonary receptors may activate Head's paradoxical reflex to stimulate spontaneous breathing. In contrast, stimulating the slow adapting pulmonary receptors or laryngeal receptors could induce the Hering-Breuer inflation reflex or LCR, respectively, and thereby inhibit spontaneous breathing. As clinicians are most often unaware that starting primary care might affect the breathing they intend to support, this narrative review summarises the currently available evidence on (vagally mediated) reflexes that might promote or inhibit spontaneous breathing at birth.
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Affiliation(s)
- Kristel Kuypers
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tessa Martherus
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tereza Lamberska
- Neonatology, General University Hospital in Prague, Prague, Czech Republic
| | - Janneke Dekker
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Arjan B Te Pas
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Delivery Room Management of Infants with Very Low Birth Weight in 3 European Countries-The Video Apgar Study. J Pediatr 2020; 222:106-111.e2. [PMID: 32418815 DOI: 10.1016/j.jpeds.2020.03.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess delivery room management of infants born preterm at 4 Level III perinatal centers in 3 European countries. STUDY DESIGN This was a prospective, multicenter observational study. Management at birth was video-recorded and evaluated (Interact version 9.6.1; Mangold-International, Arnstorf, Germany). Data were analyzed and compared within and between centers. RESULTS The infants (n = 138) differed significantly with respect to the median (25%, 75%) birth weight (grams) (Center A: 1200 [700, 1550]; Center B: 990 [719, 1240]; Center C: 1174 [835, 1435]; Center D: 1323 [971, 1515] [B vs A, C, D: P < .05]), gestational week (Center A: 28.4 [26.3, 30.0]; Center B: 27.9 [26.7, 29.6]; Center C: 29.3 [26.4, 31.0]; Center D: 30.3 [28.0, 31.9]), Apgar scores, rates of cesarean delivery, and time spent in the delivery room. Management differed significantly for frequency and drying time, rates of electrocardiographic monitoring, suctioning or stimulation, and for fundamental interventions such as time for achieving a reliable peripheral oxygen saturation signal (seconds) (Center A: 97.6 ± 79.3; Center B: 65.1 ± 116.2; Center C: 97.1 ± 67.0; Center D: 114.4 ± 140.5; B vs A, C, D: P < .001) and time for intubation (seconds) (Center A: 48.7 ± 4.2; Center B: 49.0 ± 30.7; Center C: 69.1 ±37.9; Center D: 65.1 ± 23.8; B vs D, P < .025). Mean procedural times did not meet guideline recommendations. The sequence of interventions was similar at all centers. CONCLUSIONS The Video Apgar Study showed great variability in and between 4 neonatal centers in Europe. The study also showed it is difficult to adhere to published guidelines for recommended times for important, basic measures such as peripheral oxygen saturation measurements and intubation.
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18
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Bjorland PA, Ersdal HL, Øymar K, Rettedal SI. Compliance with Guidelines and Efficacy of Heart Rate Monitoring during Newborn Resuscitation: A Prospective Video Study. Neonatology 2020; 117:175-181. [PMID: 32248187 PMCID: PMC9533428 DOI: 10.1159/000506772] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/24/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Newborn resuscitation guidelines recommend initial assessment of heart rate (HR) and initiation of positive pressure ventilation (PPV) within 60 s after birth in non-breathing newborns. Pulse oximeter (PO) and electrocardiogram (ECG) are suggested methods for continuous HR monitoring during resuscitation. Our aim was to evaluate compliance with guidelines and the efficacy of PO versus ECG monitoring in real-life newborn resuscitations. METHODS In this prospective observational study, we video recorded resuscitations of newborns ≥34 weeks of gestation receiving PPV at birth. RESULTS 104 resuscitations were analysed. Median (IQR) time from birth to arrival at the resuscitation bay was 48 (22-68) s (n = 62), to initial HR assessment 70 (47-118) s (n = 61), and to initiation of PPV 78 (42-118) s (n = 62). Initial HR assessment (stethoscope or palpation) and initiation of PPV were achieved within 60 s for 35% of the resuscitated newborns. Time to initial HR assessment and initiating PPV was significantly longer following vaginal deliveries than caesarean sections: 84 (70-139) versus 44 (30-66) s (p < 0.001) and 93 (73-139) versus 38 (30-66) s (p < 0.001). Time from birth and sensor application to provision of a reliable HR signal from PO versus ECG was 348 (217-524) (n = 42) versus 174 (105-277) s (n = 30) (p < 0.001) and 199 (77-352) (n = 65) versus 16 (11-22) s (n = 52) (p < 0.001). CONCLUSION Initial HR assessment and initiation of PPV were achieved within 60 s after birth in only 1/3 of newborn resuscitations. When applied for continuous HR monitoring, ECG was superior to PO in time to achieve reliable HR signals in real-life resuscitations.
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Affiliation(s)
- Peder Aleksander Bjorland
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway, .,Department of Clinical Science, University of Bergen, Bergen, Norway,
| | - Hege Langli Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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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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20
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Kuypers KL, Lamberska T, Martherus T, Dekker J, Böhringer S, Hooper SB, Plavka R, te Pas AB. The effect of a face mask for respiratory support on breathing in preterm infants at birth. Resuscitation 2019; 144:178-184. [DOI: 10.1016/j.resuscitation.2019.08.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 11/24/2022]
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van Henten TMA, Dekker J, Te Pas AB, Zivanovic S, Hooper SB, Roehr CC. Tactile stimulation in the delivery room: do we practice what we preach? Arch Dis Child Fetal Neonatal Ed 2019; 104:F661-F662. [PMID: 30824474 DOI: 10.1136/archdischild-2018-316344] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Tessa M A van Henten
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Paediatrics, University of Oxford, Oxford, UK
| | - Janneke Dekker
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Stuart B Hooper
- The Ritchie Centre, The Hudson Institute for Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Victoria, Australia
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Bjorland PA, Øymar K, Ersdal HL, Rettedal SI. Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study. BMJ Paediatr Open 2019; 3:e000592. [PMID: 31909225 PMCID: PMC6936999 DOI: 10.1136/bmjpo-2019-000592] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation. DESIGN SETTING AND PATIENTS A prospective observational study in an unselected population at Stavanger University Hospital, Norway, from October 2016 until September 2017. INTERVENTIONS Using a data collection form and video recordings, we registered and analysed resuscitative interventions. MAIN OUTCOME MEASURES Incidence of continuous positive airway pressure (CPAP), positive pressure ventilation (PPV), intubation, chest compressions and intravenous fluid or epinephrine boluses. Short-term outcomes of resuscitated newborns. RESULTS All 4693 newborns in the study period were included in the study. Two hundred and ninety-one (6.2%) newborns received interventions in the first minutes of life beyond drying and stimulation. PPV was provided in 170 (3.6%) while CPAP (without PPV) was provided in 121 (2.6%) newborns. Duration of PPV was median (IQR) 106 s (54-221). Intubations were performed in 19 (0.4%) newborns, with a mean (SD) intubation time of 47 (21) s. Ten (0.2%) newborns received chest compressions and epinephrine was administrated in three (0.1%) newborns. Sixty-three per cent of the treated newborns from 34 weeks' gestational age were returned to parental care without further follow-up. CONCLUSIONS The need for resuscitative interventions after birth was frequent in this unselected population in a high-resource setting, but full cardiopulmonary resuscitation was rare. Short-term outcomes were good, suggesting that most newborns treated with resuscitative interventions were not severely affected.
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Affiliation(s)
- Peder Aleksander Bjorland
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Hordaland, Norway
| | - Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Hordaland, Norway
| | - Hege Langli Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Maya-Enero S, Botet-Mussons F, Figueras-Aloy J, Izquierdo-Renau M, Thió M, Iriondo-Sanz M. Adherence to the neonatal resuscitation algorithm for preterm infants in a tertiary hospital in Spain. BMC Pediatr 2018; 18:319. [PMID: 30301452 PMCID: PMC6178255 DOI: 10.1186/s12887-018-1288-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/18/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND There is evidence that delivery room resuscitation of very preterm infants often deviates from internationally recommended guidelines. There were no published data in Spain regarding the quality of neonatal resuscitation. Therefore, we decided to evaluate resuscitation team adherence to neonatal resuscitation guidelines after birth in very preterm infants. METHODS We conducted an observational study. We video recorded resuscitations of preterm infants < 32 weeks' gestational age and evaluated every step during resuscitation according to a score-sheet specifically designed for this purpose, following Carbine's method, where higher scores indicated that more intense resuscitation maneuvers were required. We divided the score achieved by the total possible points per patient to obtain the percentage of adherence to the algorithm. We also compared resuscitations performed by staff neonatologists to those performed by pediatricians on-call. We compared percentages of adherence to the algorithm with the Chi-square test for large groups and Fisher's exact test for smaller groups. We compared assigned Apgar scores with those given after analyzing the recordings and described them by their median and interquartile range. We measured the interrater agreement between Apgar scores with Cohen's kappa coefficient. Linear and logarithmic regressions were drawn to characterize the pattern of algorithm adherence. Statistical analysis was performed using SPSS V.20. A p-value < 0.05 was considered significant. Our Hospital Ethics Committee approved this project, and we obtained parental written consent beforehand. RESULTS Sixteen percent of our resuscitations followed the algorithm. The number of mistakes per resuscitation was low. Global adherence to the algorithm was 80.9%. Ventilation and surfactant administration were performed best, whereas preparation and initial steps were done with worse adherence to the algorithm. Intubation required, on average, 2.2 attempts; success on the first attempt happened in 33.3% of cases. Only 12.5% of intubations were achieved within the allotted 30 s. Many errors were attributable to timing. Resuscitations led by pediatricians on-call were performed as correctly as those by staff neonatologists. CONCLUSIONS Resuscitation often deviates from the internationally recognized algorithm. Perfectly performed resuscitations are infrequent, although global adherence to the algorithm is high. Neonatologists and pediatricians need intubation training.
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Affiliation(s)
- Silvia Maya-Enero
- Neonatology Service, Hospital Clínic, seu Maternitat, ICGON (Institut Clínic de Ginecologia, Obstetrícia i Neonatologia), Barcelona University, Sabino de Arana, 1, 08028, Barcelona, Spain.
| | - Francesc Botet-Mussons
- Neonatology Service, Hospital Clínic, seu Maternitat, ICGON (Institut Clínic de Ginecologia, Obstetrícia i Neonatologia), Barcelona University, Sabino de Arana, 1, 08028, Barcelona, Spain
| | - Josep Figueras-Aloy
- Neonatology Service, Hospital Clínic, seu Maternitat, ICGON (Institut Clínic de Ginecologia, Obstetrícia i Neonatologia), Barcelona University, Sabino de Arana, 1, 08028, Barcelona, Spain
| | - Montserrat Izquierdo-Renau
- Neonatology Service, Hospital Sant Joan de Déu, BCNatal (Centre de Medicina Maternofetal i Neonatal de Barcelona, Hospital Sant Joan de Déu, Hospital Clínic), Barcelona University, Passeig de Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Marta Thió
- Neonatology Service, Hospital Sant Joan de Déu, BCNatal (Centre de Medicina Maternofetal i Neonatal de Barcelona, Hospital Sant Joan de Déu, Hospital Clínic), Barcelona University, Passeig de Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Martin Iriondo-Sanz
- Neonatology Service, Hospital Sant Joan de Déu, BCNatal (Centre de Medicina Maternofetal i Neonatal de Barcelona, Hospital Sant Joan de Déu, Hospital Clínic), Barcelona University, Passeig de Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain
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Pietravalle A, Cavallin F, Opocher A, Madella S, Cavicchiolo ME, Pizzol D, Putoto G, Trevisanuto D. Neonatal tactile stimulation at birth in a low-resource setting. BMC Pediatr 2018; 18:306. [PMID: 30236090 PMCID: PMC6146550 DOI: 10.1186/s12887-018-1279-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stimulation is the most common intervention during neonatal resuscitation at birth, but scarce information is available on the actual methods, timing and efficacy of this basic step. To evaluate the occurrence, patterns and response to tactile stimulation at birth in a low-resource setting. METHODS We reviewed 150 video recordings of neonatal resuscitation at Beira Central Hospital (Beira, Mozambique). Timing, method, duration and response to tactile stimulation were evaluated. RESULTS One hundred two out of 150 neonates (68.0%) received stimulation, while the remaining 48 (32.0%) received positive pressure ventilation and/or chest compressions directly. Overall, 546 stimulation episodes (median 4 episodes per subject, IQR 2-7) were performed. Median time to the first stimulation episode was 134 s (IQR 53-251); 29 neonates (28.4%) received stimulation within the first minute after birth. Multiple techniques of stimulation were administered in 66 neonates (64.7%), while recommended techniques (rubbing the back or flicking the soles of the feet) only in 9 (8.8%). Median duration of stimulation was 17 s (IQR 9-33). Only 9 neonates (8.8%) responded to stimulation. CONCLUSIONS In a low-resource setting, stimulation of newly born infants at birth is underperformed. Adherence to international guidelines is low, resulting in delayed initiation, inadequate technique, prolonged duration and low response to stimulation. Back rubs may provide some benefits, but large prospective studies comparing different methods of stimulation are required.
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Affiliation(s)
- Andrea Pietravalle
- Department of Woman’s and Child’s Health, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani 3, 35128 Padua, Italy
| | | | - Anna Opocher
- Department of Woman’s and Child’s Health, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani 3, 35128 Padua, Italy
| | - Stefania Madella
- Department of Woman’s and Child’s Health, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani 3, 35128 Padua, Italy
| | - Maria Elena Cavicchiolo
- Department of Woman’s and Child’s Health, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani 3, 35128 Padua, Italy
| | | | | | - Daniele Trevisanuto
- Department of Woman’s and Child’s Health, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani 3, 35128 Padua, Italy
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25
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Baik-Schneditz N, Urlesberger B, Schwaberger B, Mileder L, Schmölzer G, Avian A, Pichler G. Tactile stimulation during neonatal transition and its effect on vital parameters in neonates during neonatal transition. Acta Paediatr 2018; 107:952-957. [PMID: 29364540 DOI: 10.1111/apa.14239] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/16/2017] [Accepted: 01/19/2018] [Indexed: 11/29/2022]
Abstract
AIM This study analysed tactile stimulation during neonatal transition and resuscitation in preterm and term neonates born by Caesarean delivery. It examined the frequency, location and body region, duration and possible effects of stimulation on heart rate and arterial oxygen saturation (SpO2 ). METHODS Two independent investigators analysed video recordings of tactile stimulation on term and preterm neonates during neonatal transition from January 2012 to December 2014. They were recorded during a prospective observational study and randomised controlled trial at a tertiary centre, the Medical University of Graz, Austria. SpO2 and heart rate were continuously recorded. Data on the frequency, body region and duration of stimulation were collected. To investigate the possible effects of stimulation, SpO2 and heart rate were compared before and after stimulation. RESULTS Term infants received tactile stimulation more than once, and it tended to start later, last longer and be applied in more locations than in preterm infants. Only preterm infants showed a significant increase in SpO2 after stimulation and heart rates did not show any significant changes in either group. CONCLUSION Tactile stimulation was applied in different ways to preterm and term infants during neonatal transition and SpO2 showed a significant increase in preterm infants.
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Affiliation(s)
- Nariae Baik-Schneditz
- Division of Neonatology; Department of Paediatrics; Medical University of Graz; Graz Austria
- Research Unit for Neonatal Micro- and Macrocirculation; Department of Paediatrics; Medical University of Graz; Graz Austria
| | - Berndt Urlesberger
- Division of Neonatology; Department of Paediatrics; Medical University of Graz; Graz Austria
- Research Unit for Neonatal Micro- and Macrocirculation; Department of Paediatrics; Medical University of Graz; Graz Austria
| | - Bernhard Schwaberger
- Division of Neonatology; Department of Paediatrics; Medical University of Graz; Graz Austria
- Research Unit for Neonatal Micro- and Macrocirculation; Department of Paediatrics; Medical University of Graz; Graz Austria
| | - Lukas Mileder
- Division of Neonatology; Department of Paediatrics; Medical University of Graz; Graz Austria
- Research Unit for Neonatal Micro- and Macrocirculation; Department of Paediatrics; Medical University of Graz; Graz Austria
| | - Georg Schmölzer
- Division of Neonatology; Department of Paediatrics; Medical University of Graz; Graz Austria
- Centre for the Studies of Asphyxia and Resuscitation; Royal Alexandra Hospital; Edmonton AB Canada
- Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation; Medical University of Graz; Graz Austria
| | - Gerhard Pichler
- Division of Neonatology; Department of Paediatrics; Medical University of Graz; Graz Austria
- Research Unit for Neonatal Micro- and Macrocirculation; Department of Paediatrics; Medical University of Graz; Graz Austria
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Dekker J, Hooper SB, Martherus T, Cramer SJE, van Geloven N, Te Pas AB. Repetitive versus standard tactile stimulation of preterm infants at birth - A randomized controlled trial. Resuscitation 2018; 127:37-43. [PMID: 29580959 DOI: 10.1016/j.resuscitation.2018.03.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/19/2018] [Accepted: 03/22/2018] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the direct effect of repetitive tactile stimulation on breathing effort of preterm infants at birth. METHODS This randomized controlled trial compared the effect of repetitive stimulation on respiratory effort during the first 4 min after birth with standard stimulation based on clinical indication in preterm infants with a gestational age of 27-32 weeks. All details of the stimulation performed were noted. The main study parameter measured was respiratory minute volume, other study parameters assessed measures of respiratory effort; tidal volumes, rate of rise to maximum tidal volumes, percentage of recruitment breaths, and oxygenation of the infant. RESULTS There was no significant difference in respiratory minute volume in the repetitive stimulation group when compared to the standard group. Oxygen saturation was significantly higher (87.6 ± 3.3% vs 81.7 ± 8.7%, p = .01) while the amount of FiO2 given during transport to the NICU was lower (28.2 (22.8-35.0)% vs 33.6 (29.4-44.1)%, p = .04). There was no significant difference in administration of positive pressure ventilation (52% vs 78%, p = .13), or the duration of ventilation (median (IQR) time 8 (0-118)s vs 35 (13-131)s, p = .23). Caregivers decided less often to administer caffeine in the delivery room to stimulate breathing in the repetitive stimulation group (10% vs 39%, p = .036). CONCLUSION Although the increase in respiratory effort during repetitive stimulation did not reach significance, oxygenation significantly improved with a lower level of FiO2 at transport to the NICU. Repetitive tactile stimulation could be of added value to improve breathing effort at birth.
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Affiliation(s)
- Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Stuart B Hooper
- The Ritchie Center, MIMR-PHI Institute of Medical Research, Melbourne, Australia
| | - Tessa Martherus
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie J E Cramer
- Department of Instrumental Affairs, Leiden University Medical Center, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Medical Statistics and Bio-informatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Cramer SJE, Dekker J, Dankelman J, Pauws SC, Hooper SB, Te Pas AB. Effect of Tactile Stimulation on Termination and Prevention of Apnea of Prematurity: A Systematic Review. Front Pediatr 2018; 6:45. [PMID: 29552548 PMCID: PMC5840648 DOI: 10.3389/fped.2018.00045] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 02/15/2018] [Indexed: 11/16/2022] Open
Abstract
Apnea of prematurity (AOP) is one of the most common diagnoses in preterm infants. Severe and recurrent apneas are associated with cerebral injury and adverse neurodevelopmental outcome. Despite pharmacotherapy and respiratory support to prevent apneas, a proportion of infants continue to have apneas and often need tactile stimulation, mask, and bag ventilation and/or extra oxygen. The duration of the apnea and the concomitant hypoxia and bradycardia depends on the response time of the nurse. We systematically reviewed the literature with the aim of providing an overview of what is known about the effect of manual and mechanical tactile stimulation on AOP. Tactile stimulation, manual or mechanical, has been shown to shorten the duration of apnea, hypoxia, and or bradycardia or even prevent an apnea. Automated stimulation, using closed-loop pulsating or vibrating systems, has been shown to be effective in terminating apneas, but data are scarce. Several studies used continuous mechanical stimulation, with pulsating, vibrating, or oscillating stimuli, to prevent apneas, but the reported effect varied. More studies are needed to confirm whether automated stimulation using a closed loop is more effective than manual stimulation, how and where the automated stimulation should be performed and the potential side effects.
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Affiliation(s)
- Sophie J E Cramer
- Department of Instrumental Affairs, Leiden University Medical Center, Leiden, Netherlands.,Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Jenny Dankelman
- Department of Biomedical Engineering, Delft University of Technology, Delft, Netherlands
| | - Steffen C Pauws
- Tilburg center for Cognition and Communication (TiCC), Tilburg University, Tilburg, Netherlands
| | - Stuart B Hooper
- The Ritchie Center, MIMR-PHI Institute of Medical Research, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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