The topic for this journal club on 12 January was 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 paper was 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
Here comes the transcript of the JC!
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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
- rate Population growth of the country
- The development level of the country
- Religious beliefs communities
- The ability of parents
- 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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