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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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BetsyP

Member

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.  

Guest safaa5@hotmail.com

Guest safaa5@hotmail.com

Guests

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 . 

  

Stefan Johansson

Administrators

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!

sselim

Member

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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