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How Long is Too Long? Stopping resuscitation efforts in newborns.


kbarrington

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When a baby is unexpectedly born without a heart beat, and resuscitation is initiated, the outcome may be a failed resuscitation. Even if everything is done correctly. If you are doing everything correctly, and the baby doesn't respond right away, how long should you continue before you "call it off"?

The NRP, based on previous data which showed that survival was very rare after 10 minutes of asystole, and the few reported survivors were profoundly impaired, recommended in an older edition that  "if there is no heart rate after 10 minutes of complete and adequate resuscitation efforts, and there is no evidence of other causes of newborn compromise, discontinuation of resuscitation efforts may be appropriate. Current data indicate that, after 10 minutes of asystole, newborns are very unlikely to survive, or the rare survivor is likely to survive with severe disability".

ILCOR in 2010 came up with this "In a newly born baby with no detectable heart rate which remains undetectable for 10 minutes, it is appropriate to then consider stopping resuscitation. The decision to continue resuscitation efforts when the infant has a heart rate of 0 for longer than 10 minutes is often complex and may be influenced by issues such as the presumed etiology of the arrest, gestation of the baby, potential reversibility of the situation, and the parents' previously expressed feelings about acceptable risk of morbidity."

Two recent publications report outcomes of full-term babies who had a return of circulation after more than 10 minutes, many of whom were then treated with therapeutic hypothermia. Kasdorf E, et al. Improving infant outcome with a 10 min Apgar of 0. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2015;100(2):F102-F5Shah P, et al. Outcomes of infants with Apgar score of zero at 10 min: the West Australian experience. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2015. Another from the NICHD network a few years ago includes some similar data.
Laptook AR, et al. Outcome of Term Infants Using Apgar Scores at 10 Minutes Following Hypoxic-Ischemic Encephalopathy. Pediatrics. 2009;124(6):1619-26.

To be clear, none of these series include babies who were not successfully resuscitated. We can't tell from these data what percentage of babies with 10 minutes of asystole will eventually respond to resuscitation and survive to go home. All we can tell is that there some who arrive in (or are born in) tertiary care centers, and then get intensive care provided. A good proportion of those survivors (varying between studies) do not have very profoundly abnormal outcomes. Some with developmental scores within 2 SD of the population mean, some with moderate and some with severely impaired outcomes. In the NICHD network paper, for example, there were 13 survivors out of 25 babies in the 2 arms of the hypothermia trial. 54% had "moderately or severely disability", which means, obviously, that 46% did not.

Dominic Wilkinson and Ben Stenson in an editorial in the Archives accompanying the latest of these publications state the following:

An Apgar score of 0 at 10 min after birth is not a good enough predictor of outcome to be used as the main basis for decision-making about ongoing resuscitation. There is no clear answer to the question of how long resuscitation should continue after birth. We propose that in most circumstances, resuscitation at birth should continue until 20 min in the absence of a clinically detectable heartbeat. In the face of uncertainty about whether resuscitation should be discontinued, clinicians should opt to provide longer resuscitation, with later consideration of withdrawal of life-sustaining treatment if the clinical course indicates that the prognosis is poor.

I think in general I agree with that, I think we could perhaps curtail the resuscitation somewhat if there was a documented loss of heartbeat prior to delivery, and no response within perhaps 10 to 15 minutes. But it would be great to have some prospectively collected data, or even data from a well maintained database that included "failed" resuscitations, in order to know if there were characteristics that predicted failure before, or success after, 20 minutes.

I think the prior NRP recommendation which included an evaluation of whether the resuscitation was "complete and adequate" might also have some merit. I would hate to call off a resuscitation because it was being badly done.

In my own practice I must say that it has usually taken longer than 10 minutes to be fairly sure that it was not going to work, most failed resuscitations have lasted at least 15 minutes, and often longer. Especially the totally unexpected ones, where you hope that something very acute happened that might still give a chance of a response after the 3rd or 4th dose of epinephrine.

Stopping a resuscitation is a very difficult thing to do, personally, emotionally, professionally and for its impacts on the team. It's almost impossible to counsel parents about the decision to take during the process, some better data about return of a perfusing circulation, and longer term survival after prolonged asystole would make it a little bit easier.

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Thanks for a great post and interesting links. In fact, when I read the editorial by Dominic and Stenson I thought about the possibility of making an observational study based on the Swedish Medical Birth Register, where Apgar scores are available. The Swedish guidelines are (in contrast to the international) that full resusc is continued for 15 min before stopping is considered. I have some relatively recent examples in my own record where babies have been starting with normal hearts beats abrupt and just before 15 minutes, and their long-term outcomes has been far from good... So, my impression was that we may do some harm.

So, investigating what later diagnoses are given to survivors with degrees of really low Apgar scores at 10 minutes (by combining the Birth Registry with the Patient Registry) would give a hint on how late responders do.

But then of course, we have the group perspective and the perspective of the individual baby... regardless of what  a cohort study would show, we still need to consider each and one of these difficult and unusual situations individually.

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