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  • Journal Club 12 Jan 2016: Outcomes of infants with Apgar score of zero at 10 min


    Stefan Johansson

    We have set the date for the next Journal Club to Tuesday 12 January 2016, at 7 PM (GMT).

    The topic this time is outcomes of infants with Apgar score of zero at 10 min.

    Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.

    The report is accompanied by an interesting editorial.

    Both articles are available as Editor's Choices at the ADC web site:

    http://fn.bmj.com/content/100/6/F492.full

    http://fn.bmj.com/content/100/6/F476.full

    ADC also produced a podcast that you can listen to here:

    https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat

     

    Please read those articles and join the Journal Club in the Chat room. Note that you need to log in to enter the chat room.

    Edited by Stefan Johansson

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    Very interesting.  Many families in Hope for HIE have experienced APGARS after 10 minutes of zero and have come through.  Some with lasting impacts, some not.  

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    Guest safaa5@hotmail.com

    Posted

    It is results of the case series are  very interesting and I think  RCCT is needed .

    We had previous experience regarding AAP recommendation of  use  100% oxygen during  resuscitation that was changed after RCCT of room air versus 100% oxygen . 

      

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    Here's the transcript of this journal club.

    Stefan Johansson
    Hi everyone and welcome to the 2nd 99nicu JC! The topic this time is outcomes of infants with Apgar score of zero at 10 min.

    Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.

    You find the original article and the and the editorial: http://fn.bmj.com/content/100/6/F476.full

    What was your general impressions reading the article and editorial?

    Fcardona
    It was definitely an eye-opener for me. I mostly considered APGAR of 10 as sure predictor of death or terrible outcome

    Jonathan Davis
    My overall impression that is that this is an important topic area and one that is currently under justifiable scrutiny.

    I too was surprised at the survival potential

    Stefan Johansson
    What is your current (or previous) guidelines about resusc when the Apgar is /was zero at 10 minutes?

    amirmasoud2012
    The decision is difficult

    Jonathan Davis
    In Bristol where I currently work we don't have a specific guideline

    Fcardona
    neither do we here in vienna have a guideline

    Stefan Johansson
    The Swe guidelines has been to continue resusc until 15 min if there is asystole

    Jonathan Davis
    it is generally accepted that one would stop resuscitation once a consultant has at least been present

    dracunculus
    In Ulm where I currently work we dont have a guideline, but I think nobody would stop resuscitation here after 10 minutes

    Stefan Johansson
    I have felt discomforted about this (as the international guidelines are evaluation at 10 min). Have had cases with apgar0 at 10' who started going at >14 minutes... and outcomes were quite bad (severe CP)

    Jonathan Davis
    if out of hours that should be at max 20 minutes

    Stefan Johansson
    Do you generally use chest electrodes to monitor heart beats?

    Jonathan Davis
    I agree Stefan the push for longer resus is definitely one that shouldn't be made with haste

    amirmasoud2012
    Several issues must be considered

    1. rate Population growth of the country
    2. The development level of the country
    3. Religious beliefs communities
    4. The ability of parents
    5. The health system support

    If the above condition is better we continue to resuscitation.

    In our country under the above conditions there and I 'd rather stop after ten minutes of resuscitation

    Stefan Johansson
    @Amir - valid points, the context matters                  

    Jonathan Davis                  
    I certain agree that all the above must be taken consideration... the evidence base of survival and with or without disability is also important

    Dracunculus
    We are starting to use ECG electrodes.

    Stefan Johansson
    One thing about the case series in ADC - how certain where the authors that apgar was really zero? It does not say how heart beats were monitored.

    Could the babies be Apgar=1 at 10 min?                    

    Jonathan Davis
    That is the flaw in these papers, the apgar is a subjective measure

    who listened... and for how long and how practised where they    

    fcardona
    I agree stefan, it is unclear how objective heart rate was assessed

    Jonathan Davis
    ECG is the new european rests council guidance fcardona?            

    Stefan Johansson
    Thanks for support  I just think there is some problem with the internal validity of this report

    After the JC I can recommend this blog post by MichaelN (All Things Neonatal) ; http://99nicu.org/blogs/entry/169-apgar-score-of-0-at-10-minutes-why-the-new-nrp-recommendations-missed-the-mark/

    How do you handle the contact with parents in a situation like this? Do you give a "trial of life" on mechanical ventilation etc and discuss options thereafter? (In Sweden, we generally (I think) do not listen enough to the voices of the parents)             

    Jonathan Davis                 
    If heart rate was achieved, a trial of life is appropraite                  
    early measures of brain injury are difficult and poorly predictive    

    fcardona
    yes, jonathan - ecg is suggested for use during neonatal resuscitation in the 2015 guidelines 

    Jonathan Davis
    parents wishes extremely important and the context as above essential

    fcardona
    i agree about parents wishes

    Jonathan Davis                  
    I had a recent case of no heart rate at 10, baby extremely unwell. Trial of life with EEG and discussion with parents at the bedside

    additional colleague opinion sought also for second brain

    Stefan Johansson
    This is just an impression but in the "pre-cooling days" (when I was fulltime at a level3 unit) I think babies were more often given palliative care if the asphyxia was very severe. Now we are more active, start cooling shortly after birth (usually within 2-3 hours), and then there is a rolling stone of activity.

    @Jonathan - good point about intercollegial support and discussion                   

    Jonathan Davis
    Very true re activity. Early marker of severity of asphyxia can often mislead and none are perfect... some work done by the Brain group in cork... will look for link

    on early predictors from umbilical cord samples

    Stefan Johansson              
    One problem is the lack of models that can predict bad outcomes with good precision. How could we do better?

    Jonathan Davis                  
    https://clinicaltrials.gov/ct2/show/NCT02019147

    fcardona
    I agree, do we know anything about the EEG and MRI in the survivors of this study?

    Stefan Johansson
    @Francesco - I cannot find this info in the paper only that "All eight deaths were because of withdrawal of life support in view of severe encephalopathy on clinical exam- ination, electrocortical inactivity on electroencephalogram (EEG) and extensive damage to the brain on MRI”

    Jonathan Davis                  
    the group in cork appear to be collaborating with the Karolinska Institutet

    Stefan Johansson              
    @Jonathan - I see that. The current head of the Karolinska Neo Dep (Boubou Hallberg) is a co-investigator

    fcardona      
    in the study: i am still concerned about selection bias in the study. what is the denominator of the study population?

    Stefan Johansson              
    @Francesco - you mean, where is the epidemiologist  :)

    fcardona
    I guess

    Jonathan Davis                  
    I think the study represents a pragmatic interrogation of the data that is routinely collected and submitted to the ANZNN

    fcardona      
    and how many cases with apgar 10 of zero were not included because they didnt make it into the database

    Jonathan Davis                  
    I think we are back to the antithesis of the 'were they sure it was zero' argument

    where there miscounted apgars?

    Stefan Johansson              
    Valid point, if we are to study outcomes, we need to know about the population base. If you look into the blog post I linked to above, I non-secretely display one of my fancy research ideas...

    Jonathan Davis                  
    The population as far as I can tell is all babies who were admitted to KEMH and PMH in WA..

    Interesting that APGAR is now being used or certainly reported as a predictor.

    In my training the APGAR score was always derided as an unreliable subjective measures

    I need to confess that I will soon be a consultant in the unit that authored the paper in Australia. I haven't had anything to do with the paper however... nor any other particular bias

    Stefan Johansson              
    @Jonathan -  But in 2001 even NEJM had an article about that Apgar was not entierly wrong

    @Jon - are you moving to Australia?!   

    Jonathan Davis
    The first question.... Yes I have come to the conclusion that my mentors had an anti APGAR bias... a subjective measure but potentially a useful one.. experienced hand quiet useful..

    the second question.. yes starting hopefully next month... fellowship in oz previously and now appointed in Perth..

    Stefan Johansson
    This is off-topic... but Perth sounds great!                  

    Jonathan Davis                  
    yes... sorry.. needed to disclose that fact                    

    Stefan Johansson              
    @Jonathan - no worries!  

    @all: what can we learn from the paper and editorial?

    I think one important thing raised in the editorial is that "Clinicians must be guided primarily by the best interests of the infant."

    Jonathan Davis                  
    I think personally we can learn that perhaps 10 minutes may not be long enough... the resuscitation needs to be effective and all reversible causes need to be excluded                   

    Also the suppose to me was that the outcomes are still not great but they are better then I expected and that needs to influence what we discuss with parents.        

    Stefan Johansson
    another important message it seems, is that noone with Apgar=0 at 20 min did survive

    +1 on that last comment

    Jonathan Davis
    I will have to duck out of the conversation at this stage... but although involved in the podcast... the discussion with Ben Stenson and Dominic Wilkinson makes interesting listening... expands on the editorial a little..

    Stefan Johansson              
    And here is the link to the podcast:
    https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat

    Jonathan Davis
    thanks for the great discussion.. I tweeted along the way!!            

    Stefan Johansson
    I will also need to leave now. Any final thoughts ?

    amirmasoud2012
    thanks

    Stefan Johansson              
    Thanks all for a another great experience!
    Meet you next time!

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    I believe to continue resuscitation after 10 minutes a systole especially in term & near term newborn & up to 20 minutes maximum as mentioned in the original study in ADC.

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