1
|
Polglase GR, Hwang C, Blank DA, Badurdeen S, Crossley KJ, Kluckow M, Gill AW, Camm E, Galinsky R, Brian Y, Hooper SB, Roberts CT. Assessing the influence of abdominal compression on time to return of circulation during resuscitation of asphyxiated newborn lambs: a randomised preclinical study. Arch Dis Child Fetal Neonatal Ed 2024; 109:405-411. [PMID: 38123977 PMCID: PMC11228194 DOI: 10.1136/archdischild-2023-326047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE During neonatal resuscitation, the return of spontaneous circulation (ROSC) can be achieved using epinephrine which optimises coronary perfusion by increasing diastolic pressure. Abdominal compression (AC) applied during resuscitation could potentially increase diastolic pressure and therefore help achieve ROSC. We assessed the use of AC during resuscitation of asystolic newborn lambs, with and without epinephrine. METHODS Near-term fetal lambs were instrumented for physiological monitoring and after delivery, asphyxiated until asystole. Resuscitation was commenced with ventilation followed by chest compressions. Lambs were randomly allocated to: intravenous epinephrine (20 µg/kg, n=9), intravenous epinephrine+continuous AC (n=8), intravenous saline placebo (5 mL/kg, n=6) and intravenous saline+AC (n=9). After three allocated treatment doses, rescue intravenous epinephrine was administered if ROSC had not occurred. Time to achieve ROSC was the primary outcome. Lambs achieving ROSC were ventilated and monitored for 60 min before euthanasia. Brain histology was assessed for micro-haemorrhage. RESULTS Use of AC did not influence mean time to achieve ROSC (epinephrine lambs 177 s vs epinephrine+AC lambs 179 s, saline lambs 602 s vs saline+AC lambs 585 s) or rate of ROSC (nine of nine lambs, eight of eight lambs, one of six lambs and two of eight lambs, respectively). Application of AC was associated with higher diastolic blood pressure (mean value >10 mm Hg), mean and systolic blood pressure and carotid blood flow during resuscitation. Cortex and deep grey matter micro-haemorrhage was more frequent in AC lambs. CONCLUSION Use of AC during resuscitation increased diastolic blood pressure, but did not impact time to ROSC.
Collapse
Affiliation(s)
- Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Colin Hwang
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Douglas A Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Shiraz Badurdeen
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Andrew W Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia
| | - Emily Camm
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Yoveena Brian
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
| |
Collapse
|
2
|
Polglase GR, Brian Y, Tantanis D, Blank DA, Badurdeen S, Crossley KJ, Kluckow M, Gill AW, Camm E, Galinsky R, Thomas Songstad N, Klingenberg C, Hooper SB, Roberts CT. Endotracheal epinephrine at standard versus high dose for resuscitation of asystolic newborn lambs. Resuscitation 2024; 198:110191. [PMID: 38522732 DOI: 10.1016/j.resuscitation.2024.110191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/21/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Endotracheal (ET) epinephrine administration is an option during neonatal resuscitation, if the preferred intravenous (IV) route is unavailable. OBJECTIVES We assessed whether endotracheal epinephrine achieved return of spontaneous circulation (ROSC), and maintained physiological stability after ROSC, at standard and higher dose, in severely asphyxiated newborn lambs. METHODS Near-term fetal lambs were asphyxiated until asystole. Resuscitation was commenced with ventilation and chest compressions. Lambs were randomly allocated to: IV Saline placebo (5 ml/kg), IV Epinephrine (20 micrograms/kg), Standard-dose ET Epinephrine (100 micrograms/kg), and High-dose ET Epinephrine (1 mg/kg). After three allocated treatment doses, rescue IV Epinephrine was administered if ROSC had not occurred. Lambs achieving ROSC were monitored for 60 minutes. Brain histology was assessed for microbleeds. RESULTS ROSC in response to allocated treatment (without rescue IV Epinephrine) occurred in 1/6 Saline, 9/9 IV Epinephrine, 0/9 Standard-dose ET Epinephrine, and 7/9 High-dose ET Epinephrine lambs respectively. Blood pressure during CPR increased after treatment with IV Epinephrine and High-dose ET Epinephrine, but not Saline or Standard-dose ET Epinephrine. After ROSC, both ET Epinephrine groups had lower pH, higher lactate, and higher blood pressure than the IV Epinephrine group. Cortex microbleeds were more frequent in High-dose ET Epinephrine lambs (8/8 lambs examined, versus 3/8 in IV Epinephrine lambs). CONCLUSIONS The currently recommended dose of ET Epinephrine was ineffective in achieving ROSC. Without convincing clinical or preclinical evidence of efficacy, use of ET Epinephrine at this dose may not be appropriate. High-dose ET Epinephrine requires further evaluation before clinical translation.
Collapse
Affiliation(s)
- Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Yoveena Brian
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Darcy Tantanis
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Douglas A Blank
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia; Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Shiraz Badurdeen
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital & University of Sydney, Sydney, NSW, Australia
| | - Andrew W Gill
- Centre for Neonatal Research and Education, The University of Western Australia, Subiaco, WA, Australia
| | - Emily Camm
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | | | | | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia; Department of Paediatrics, Monash University, Melbourne, VIC, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.
| |
Collapse
|
3
|
Roberts CT, Klink S, Schmölzer GM, Blank DA, Badurdeen S, Crossley KJ, Rodgers K, Zahra V, Moxham A, Roehr CC, Kluckow M, Gill AW, Hooper SB, Polglase GR. Comparison of intraosseous and intravenous epinephrine administration during resuscitation of asphyxiated newborn lambs. Arch Dis Child Fetal Neonatal Ed 2022; 107:311-316. [PMID: 34462318 DOI: 10.1136/archdischild-2021-322638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/12/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Intraosseous access is recommended as a reasonable alternative for vascular access during newborn resuscitation if umbilical access is unavailable, but there are minimal reported data in newborns. We compared intraosseous with intravenous epinephrine administration during resuscitation of severely asphyxiated lambs at birth. METHODS Near-term lambs (139 days' gestation) were instrumented antenatally for measurement of carotid and pulmonary blood flow and systemic blood pressure. Intrapartum asphyxia was induced by umbilical cord clamping until asystole. Resuscitation commenced with positive pressure ventilation followed by chest compressions and the lambs received either intraosseous or central intravenous epinephrine (10 μg/kg); epinephrine administration was repeated every 3 min until return of spontaneous circulation (ROSC). The lambs were maintained for 30 min after ROSC. Plasma epinephrine levels were measured before cord clamping, at end asphyxia, and at 3 and 15 min post-ROSC. RESULTS ROSC was successful in 7 of 9 intraosseous epinephrine lambs and in 10 of 12 intravenous epinephrine lambs. The time and number of epinephrine doses required to achieve ROSC were similar between the groups, as were the achieved plasma epinephrine levels. Lambs in both groups displayed a similar marked overshoot in systemic blood pressure and carotid blood flow after ROSC. Blood gas parameters improved more quickly in the intraosseous lambs in the first 3 min, but were otherwise similar over the 30 min after ROSC. CONCLUSIONS Intraosseous epinephrine administration results in similar outcomes to intravenous epinephrine during resuscitation of asphyxiated newborn lambs. These findings support the inclusion of intraosseous access as a route for epinephrine administration in current guidelines.
Collapse
Affiliation(s)
- Calum T Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia .,Department of Paediatrics, Monash University, Clayton, Victoria, Australia.,Monash Newborn, Monash Health, Clayton, Victoria, Australia
| | - Sarah Klink
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, University of Alberta, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Douglas A Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia.,Monash Newborn, Monash Health, Clayton, Victoria, Australia
| | - Shiraz Badurdeen
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Newborn Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Karyn Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Valerie Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Alison Moxham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK.,Newborn Care, Division of Women and Children, University of Bristol, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.,Newborn Care, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Andrew William Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
4
|
Sankaran D, Chandrasekharan PK, Gugino SF, Koenigsknecht C, Helman J, Nair J, Mathew B, Rawat M, Vali P, Nielsen L, Tancredi DJ, Lakshminrusimha S. Randomised trial of epinephrine dose and flush volume in term newborn lambs. Arch Dis Child Fetal Neonatal Ed 2021; 106:578-583. [PMID: 33687959 PMCID: PMC8543198 DOI: 10.1136/archdischild-2020-321034] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Neonatal resuscitation guidelines recommend 0.5-1 mL saline flush following 0.01-0.03 mg/kg of epinephrine via low umbilical venous catheter for persistent bradycardia despite effective positive pressure ventilation (PPV) and chest compressions (CC). We evaluated the effects of 1 mL vs 3 mL/kg flush volumes and 0.01 vs 0.03 mg/kg doses on return of spontaneous circulation (ROSC) and epinephrine pharmacokinetics in lambs with cardiac arrest. DESIGN Forty term lambs in cardiac arrest were randomised to receive 0.01 or 0.03 mg/kg epinephrine followed by 1 mL or 3 mL/kg flush after effective PPV and CC. Epinephrine (with 1 mL flush) was repeated every 3 min until ROSC or until 20 min. Haemodynamics, blood gases and plasma epinephrine concentrations were monitored. RESULTS Ten lambs had ROSC before epinephrine administration and 2 died during instrumentation. Among 28 lambs that received epinephrine, 2/6 in 0.01 mg/kg-1 mL flush, 3/6 in 0.01 mg/kg-3 mL/kg flush, 5/7 in 0.03 mg/kg-1 mL flush and 9/9 in 0.03 mg/kg-3 mL/kg flush achieved ROSC (p=0.02). ROSC was five times faster with 0.03 mg/kg epinephrine compared with 0.01 mg/kg (adjusted HR (95% CI) 5.08 (1.7 to 15.25)) and three times faster with 3 mL/kg flush compared with 1 mL flush (3.5 (1.27 to 9.71)). Plasma epinephrine concentrations were higher with 0.01 mg/kg-3 mL/kg flush (adjusted geometric mean ratio 6.0 (1.4 to 25.7)), 0.03 mg/kg-1 mL flush (11.3 (2.1 to 60.3)) and 0.03 mg/kg-3 mL/kg flush (11.0 (2.2 to 55.3)) compared with 0.01 mg/kg-1 mL flush. CONCLUSIONS 0.03 mg/kg epinephrine dose with 3 mL/kg flush volume is associated with the highest ROSC rate, increases peak plasma epinephrine concentrations and hastens time to ROSC. Clinical trials evaluating optimal epinephrine dose and flush volume are warranted.
Collapse
Affiliation(s)
- Deepika Sankaran
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Praveen K Chandrasekharan
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Sylvia F Gugino
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Carmon Koenigsknecht
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Justin Helman
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Bobby Mathew
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Lori Nielsen
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | | |
Collapse
|
5
|
Vali P, Weiner GM, Sankaran D, Lakshminrusimha S. What is the optimal initial dose of epinephrine during neonatal resuscitation in the delivery room? J Perinatol 2021; 41:1769-1773. [PMID: 33712718 DOI: 10.1038/s41372-021-01032-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/29/2021] [Accepted: 02/25/2021] [Indexed: 01/25/2023]
Abstract
The neonatal resuscitation program recommends a wide dose range of epinephrine for newborns who receive chest compressions (endotracheal tube [ET] dose of 0.05-0.1 mg/kg or intravenous [IV] dose of 0.01-0.03 mg/kg), which presents a challenge to neonatal care providers when attempting to determine the optimal initial dose. Dosing errors are common when preparing epinephrine for neonatal resuscitation. Based on animal data, we suggest preparing 0.1 mg/kg or 1 ml/kg of 1 mg/10 ml epinephrine in a 5 ml syringe for ET administration. For IV epinephrine, we suggest preparing an initial dose of 0.02 mg/kg or 0.2 ml/kg of 1 mg/10 ml epinephrine in a 1 ml syringe. A dose of 0.02 mg/kg enables use of a 1 ml syringe for a wide range of birth weights from 500 g to 5 kg. The use of a color-coded syringe may decrease errors in dose preparation.
Collapse
Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA.
| | - Gary M Weiner
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Deepika Sankaran
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | | |
Collapse
|