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Found 10 results

  1. I think my first training in resuscitation began with the principles outlined in the NRP 3rd edition program. As we have moved through subsequent editions with the current edition being number 7, I can’t help but think about how many changes have occurred over that time. One such change has been the approach to using medications as part of a resuscitation. Gone are such things as calcium gluconate, naloxone and sodium bicarbonate but something that has stood the test of time is epinephrine. The dosing and recommendations for administering epinephrine have changed over time as well with the dose of endotracheal medication increasing from 0.01 to 0.03 and now to 0.05 – 0.1 mg/kg. While this dosing has increased, that of IV administration has remained the same at 0.01 to 0.03 mg/kg. The change in dosing for the ETT route was due to an increasing awareness that this route just isn’t as effective as IV. Having said that with only 0.1% of resuscitations requiring such support the experience with either route is fairly limited. What is the concern? Giving a medication directly via the IV route ensures the dose reaches the heart in the amount desired. In the case of ETT administration there are a few potential issues along the way. The first is that one needs to push the dose down the ETT and this presumes the ETT is actually in the trachea (could have become dislodged). Secondly, if the medication is sent to the lung what effect does the liquid component in the airways have in terms of dilution and distribution of the medication? Lastly, even if you get the epinephrine to the lung it must be picked up at the capillary level and then returned to the left side of the heart. In the absence of significant forward pulmonary blood flow this is not assured. What is the evidence? In terms of human clinical research it remains fairly limited. Barber published a retrospective review of 47 newborns who received epinephrine via the endotracheal route. The study Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room found that spontaneous circulation was restored in 32% of this cohort. Following the first dose, a subsequent dose of intravenous epinephrine restored circulation in 77%. This study provided the first suggestion that the IV route may be better than endotracheal. Keep in mind though that this study was retrospective and as the authors conclude in the end, prospective studies are needed to confirm these findings. The question really is what is the likelihood of restoring circulation if the first dose is given IV? Eleven years later we have a second study that attempts to answer this question although once again it is retrospective. Efficacy of Intravenous and Endotracheal Epinephrine during NeonatalCardiopulmonary Resuscitation in the Delivery Room by Halling et al. This study really was designed to answer two questions. The study group looked at the period from July 2006 to July 2014. During this period the dose of IV epinephrine remained unchanged as per NRP recommendations but the dose of endotracheal epinephrine increased from 0.01 to 0.03 and then to 0.05 mg/kg endotracheally. The increase was in response to both NRP and site observations that the lower doses were not achieving the effect they were hoping for. The Results ETT epinephrine IV Epinephrine Number 30 20 Return of circulation 23 15 1 dose 6 4 2 dose 5 8 3 doses 9 0 4 doses 3 3 In the ETT group all doses except for 3 after the first dose were given as IV. There was no difference in the response rate over time suggesting that higher doses do not truly increase the chance of a better response. The authors noted that the effectiveness of the two arms were not that different despite a significantly higher dose of epinephrine being administered to the group receiving ETT epinephrine first which is not surprising given the higher recommended dosages. What I find interesting though is that giving the first dose of epinephrine was given IV in 20 of the paitents, if it is indeed the better route one might expect a better response than in the ETT group. The response from one dose of ETT epi was 20% while that from the IV first group was in fact also only 20%! We do indeed need to be careful here with small numbers but the results at least to me do not suggest strongly that giving IV epi first ensures success. What the study suggests to me is that two doses of epinephrine may be needed to restore circulation. If you choose to start with IV it certainly does not seem unwise but if you have any delays I don’t see any reason to avoid ETT epinephrine as your first line. The reality is that for many individuals a UVC is a procedure that while they may have learned in an NRP class they may have never actually placed one. Having an ETT in place though seems like a good place to start. I doubt we will ever see a randomized trial of ETT vs IV epinephrine in Neonatology at this point given the stance by the NRP so these sorts of studies I suspect will be the best we get. For now, based on what is out there I suggest use the route that you can get first but expect to need additional doses at least one more time to achieve success. Lastly remember that even if you do everything correct there will be some that cannot be brought back. Rest assured though that if the first dose was given via ETT you have still done your best if that was the route you had.
  2. I have written about respectful communication before in Kill them with kindness. The importance of collaborating in a respectful manner cannot be overemphasized, as a calm and well prepared team can handle just about anything thrown their way. This past week I finally had the opportunity to take the 7th ed NRP instructor course. What struck me most about the new version of the course was not the approach to the actual resuscitation but the preparation that was emphasized before you even start! It only takes 30 seconds to establish who is doing what in a resuscitation and while it would seem logical to divide up the roles each will take on it is something that has not been consistently done (at least in our institution). When a baby is born and responds to PPV quickly, this may not seem that important but in a situation where a team is performing chest compressions, placing an emergency UVC and moving on to epinephrine administration it certainly is nice to know in advance who is doing what. The Golden Hour We and many other centres have adopted this approach to resuscitation and at least here developed a checklist to ensure that everyone is prepared for a high risk delivery. While teams may think they have all the bases covered, when heart rates are racing it may surprise you to see how many times crucial bits of information or planning is missed. As I told you in another post I will be releasing a series of videos that I hope others will find useful. The video in this case is of a team readying itself for the delivery of a preterm infant that they anticipate will have respiratory distress. Ask yourself as you watch the film whether your team is preparing to this degree or not. Preparing in such a fashion certainly reduces the risk of errors caused by assumptions about who is doing what or what risk factors are present. As you can tell I am a big fan of simulation in helping to create high functioning teams! More of these videos can be accessed on my Youtube channel at All Things Neonatal YouTube To receive regular updates as new videos are added feel free to subscribe! Lastly a big thank you to NS, RH and GS without whom none of this would have been possible!
  3. The other day I met with some colleagues from Obstetrics and other members from Neonatology to look at a new way of configuring our delivery suites. The question on the table was which deliveries which were always the domain of the high risk labour floor could be safely done in a lower acuity area. From a delivery standpoint they would have all the tools they need but issues might arise from a resuscitation point of view if more advanced resuscitation was needed. Would you have enough space for a full team, would all the equipment you need be available and overall what is in the best interests of the baby and family? We looked at a longstanding list of conditions both antenatal and intrapartum and one by one tried to decide whether all of these were high risk or if some were more moderate. Could one predict based on a condition how much resuscitation they might need? As we worked our way through the list there was much discussion but in the end we were left with expert opinion as there was really no data to go by. For example, when the topic of IUGR infants came up we pooled our collective experience and all agreed that most of the time these babies seem to go quite well. After a few shoulder shrugs we were left feeling good about our decision to allow them to deliver in the new area. Now several days later I have some concern that our thinking was a little too simple. You see, conditions such as IUGR may present as the only risk factor for an adverse outcome but what if they also present with meconium or the need for a instrument assisted delivery. We would presume the risk for advanced resuscitation (meaning intubation or chest compressions and/or medication need) would be increased but is there a better way of predicting the extent of this risk? Indeed there might just be An interesting approach to answer this question has been taken by an Argentinian group in their paper Risk factors for advanced resuscitation in term and near-term infants: a case–control study. They chose to use a prospective case control study matching one case to 4 control infants who did not require resuscitation. The inclusion criteria were fairly straightforward. All babies had to be 34 weeks gestational age or greater and free of congenital malformations. By performing the study in 16 centres they were able to amass 61953 deliveries and for each case they found (N=196) they found 784 deliveries that were matched by day of birth. The idea here was that by matching consecutive patients who did not require resuscitation you were standardizing the teams that were present at delivery. The antepartum and intrapartum risk factors that were then examined to determine strengths of association with need for resuscitation were obtained from the list of risks as per the NRP recommendations. A Tool For All of Us? What came out of their study was a simple yet effective tool that can help to predict the likelihood of a baby needing resuscitation when all factors are taken into account. By resuscitation the authors defined this as intubation, chest compressions or medications. This is pretty advanced resuscitation! In essence this is a tool that could help us answer the questions above with far better estimation than a shoulder shrug and an “I think so” response. The table can be found by clicking on this link to download but the table looks like this. By inserting checks into the applicable boxes you get a calculated expected need for resuscitation. Let’s look at the example that I outlined at the start of the discussion which was an IUGR infant. It turns out that IUGR itself increases the background risk for infants 34 weeks and above from 6% to 55% with that one factor alone. Add in the presence of fetal bradycardia that is so often seen with each contraction in these babies and the risk increases to 97%! Based on these numbers I would be hesitant to say that most of these kids should do well. The majority in fact would seem to need some help to transition into this world. Some words of caution The definition here of resuscitation was intubation, chest compressions or medications. I would like to presume that the practioners in these centres were using NRP so with respect to chest compressions and medication use I would think this should be comparable to a centre such as ours. What I don’t know for sure is how quickly these centres move to intubate. NRP has always been fairly clear that infants may be intubated at several time points during a resuscitation although recent changes to NRP have put more emphasis on the use of CPAP to establish FRC and avoid intubation. Having said that this study took place from 2011 – 2013 so earlier than the push for CPAP began. I have to wonder what the effect of having an earlier approach to intubating might have had on these results. I can only speculate but perhaps it is irrelevant to some degree as even if in many cases these babies did not need intubation now they still would have likely needed CPAP. The need for any respiratory support adds a respiratory therapist into the mix which in a crowded space with the additional equipment needed makes a small room even smaller. Therefore while I may question the threshold to intubate I suspect these results are fairly applicable in at least picking out the likelihood of needing a Neonatal team in attendance. Moreover I think we might have a quick tool on our hands for our Obstetrical colleagues to triage which deliveries they should really have us at. A tool that estimates the risk may be better than a shoulder shrug even if it overestimates when the goal is to ensure safety.
  4. Ask almost anyone who has worked in the field of Neonatology for some time and they will tell you that babies are not as sick as they once were. We can give a lot of credit to better antenatal steroid use, maternal nutrition and general management during pregnancy. Additionally, after birth we now rush to place infants on CPAP and achieve adequate expansion of the lungs which in many cases staves off intubation. The downside to our success though is that the opportunities to provide positive pressure ventilation (PPV) and moreover intubation are becoming less and less. How then do we perform when we are asked to do such procedures on an infrequent basis? The answer as you might expect is not that well. Dr. Schmolzer et al studied the ability of people to keep a good seal and found a 29% leak on average with as high as 63% in one patient. As this was a study in which people were being observed one might think the Hawthorne Effect might artificially decrease the percentage leak compared to real world scenarios when you know you aren't being watched. What is the cause of the leak? Leaks most commonly occur on either side of the nasolabial folds. Although at least in my experience we educate trainees about this issue it remains a problem. I would also speculate that at the times when we need to be at our best during an advanced resuscitation involving chest compressions we may well function at our worst. This is the effect of the adrenalin rushing through our system as our sympathetic system turns into overdrive. The question therefore is one of getting around human error in particular when we need to minimize such inefficiency the most. The Solution? If the masks are prone to leaking and with it the ability to properly ventilate compromised, how could we minimize such human error. The answer may lie in what I consider to be an ingenious way to apply a mask. The concept and it is just that at the moment is to use suction to apply the mask to the face without risk of leak. Lorenz L et al have just published a proof of concept study utilizing a mannequin with a "seal skin" layer applied to the face to simulate human skin. The article is entitled A new suction mask to reduce leak during neonatal resuscitation: a manikin study. In this study, the mask was applied to the face of the mannequin and 100 cm H2O pressure was applied through a side port on the mask. There is an inner and outer ring such that the internal 41 mm diameter mask is surrounded by a double wall in which the suction is applied to the space between the two walls leading to the mask seating itself firmly against the face. The authors then studied the amount of leak found when using a Neopuff set to deliver 40 - 60 breaths per minute at pressures of 25/5. For this study 60 courses were tested. How did it do compared to PPV through a traditional mask? As you might expect (since you can feel my excitement!) it did very well. The average leaks using a conventional approach were quite good at 12.1% but the suction mask was only 0.7% leak. Importantly the ranges were quite different. PPV through a conventional mask had a range of 0.6 - 39% leak while with the suction version it was 0.2 - 4.6%. These results were statistically different. What does the future hold? As mentioned this study is what one would consider a proof of concept study. We do not know how this would fare in the real world and that of course is the next step. In terms of harm, the authors did note that when applied to the forearm of an adult it caused some mild redness from the suction that vanished quickly on breaking of the seal but we do not know if there could be greater harm in a newborn in particular one who is quite small. Such testing will be needed as part of any further study. Having said that I think this rethink of the mask for PPV could be transformative to those who perform neonatal resuscitation infrequently. If this mask is found not only to be effective in a clinical trial but safe as well I would suggest a change to this type of mask could quite literally be life saving. Placed in the hands of those who are inexperienced in keeping a seal, PPV would become much more effective and in particular for rural sites the infants being transported in much more stable than some are at present. Keep your eyes peeled for future work using this mask. Something tells me if it proves to be efficacious outside of a seal skin covered mannequin, your toolkit for providing NRP may be in for a change.
  5. Every now and then I come across an instance when I discover that something that I have known for some time truly is not as well appreciated as I might think. Twice in my career I have come across the following situation which has been generalized to eliminate any specific details about a patient. In essence this is a fictional story but the conclusions are quite real. Case of the Flat Baby A mother arrives at the hospital with severe abdominal pain and in short order is diagnosed with a likely abruption at 26 weeks gestational age. Fetal monitors are attached and reveal a significant fetal bradycardia with a prolonged period of minutes below 100 and sometimes below 60 beats per minute. She is rushed to the OR where an emergency c-section is performed. A live born infant is handed to the resuscitation team after cord clamping is stopped at 30 seconds due to significant cyanosis and no respirations. After placing the infant in a polyethylene wrap and performing the initial steps of ventilation there is no respiratory effort and the baby is given PPV. After no heart rate is noted chest compressions commence followed by intubation and then epinephrine when a heart rate while detected remains below 60. The team gives a bolus of saline followed by another round of epinephrine and by 10 minutes a pulse of 80 BPM is detected. While a pulse is present it remains borderline and the baby shows no sign of any respiratory efforts. The care providers at this point have a decision to make about continuing resuscitative efforts or not. One of the team members performs a physical exam at this stage and notes that the pupils are unresponsive to light with a 3 mm pupillary diameter. The team questions whether based on this finding irreversible neurological damage has occurred. Pupillary Reactions in Preterm Infants It turns out that much like many organs in the body which have yet to fully mature the same applies to the eye or more specifically in this case the pupil. Robinson studied 50 preterm infants in 1990 and noted that none of the infants under 30 weeks gestational age demonstrated any reaction to light shone in the eye. After 30 weeks the infants gradually realized this function until by 35 weeks all infants had attained this pupillary reaction to light. Isenberg in the same year when examining 30 preterm infants under 30 weeks noted that in addition to the lack of pupillary constriction to light, as the gestational age decreased the pupillary diameter enlarged. The youngest infants in this study at 26 weeks had a mean pupillary diameter of 4.7 mm while by 29 weeks this number decreased to 2.9 mm. This means that the smaller the infant the larger the pupillary size and given that these are also the highest risk infants one can see how the appearance of a "fixed and dilated pupil" could lead one down the wrong path. Conclusion Deciding when to stop a resuscitation is never an easy decision. Add to this as I recently wrote, even after 10 minutes of resuscitation outcomes may not be as bad as we have thought; Apgar score of 0 at 10 minutes: Why the new NRP recommendations missed the mark. What I can say and obviously was the main thrust of this piece is that at least when you are resuscitating an infant < 30 weeks gestational age, leave the eyes out of the decision. The eyes in this case "do not have it".
  6. I switched hospital ~2 years ago and even if our resuscitation tables are equipped exactly the same as in the previous hospital, I have noticed that fellows here use laryngeal masks more often during resuscitation, instead of going directly from mask (+NeoPuff ventilation) to intubation. I must say that my experience has grown very positive, laryngeal masks can be applied with little training and gives good airway support. EBNEO has published a review here : https://ebneo.org/2015/09/airway-support-during-neonatal-resuscitation-how-effective-is-a-laryngeal-mask/ on a RCT on this specific question, laryngeal mask vs face-mask-ventilation. I fully agree with the conclusion that: Do you have similar or other experiences to share?
  7. We are back with the 99nicu Polls! Inspired by the EBNEO review on ventilation through a laryngeal masks during resuscitation, we started a poll here! Find the interesting review on the EBNEO website: https://ebneo.org/2015/09/airway-support-during-neonatal-resuscitation-how-effective-is-a-laryngeal-mask/ So now... visit go to our poll on http://99nicu.org/forums/topic/1878-laryngeal-masks-should-be-available-for-neonatal-resuscitation/ and share your comments on laryngeal mask ventilation!
  8. Three recent-(ish) articles examining how we should ventilate babies and monitor what we are doing. Milner A, Murthy V, Bhat P, Fox G, Campbell ME, Milner AD, et al. Evaluation of respiratory function monitoring at the resuscitation of prematurely born infants. Eur J Pediatr. 2014:1-4. In this study, respiratory function monitoring with tidal volume, airway pressure and exhaled CO2 was routinely introduced in 2 London hospitals. The authors then asked trainees whether they found it useful, and what they thought the right tidal volume should be. As you might imagine the answers were quite variable, and integrating more than one sign, such as a lack of exhaled CO2 despite measured tidal volumes, was quite variable. van Vonderen JJ, Hooper SB, Hummler HD, Lopriore E, Te Pas AB. Effects of a Sustained Inflation in Preterm Infants at Birth. The Journal of pediatrics. 2014. Tony Milner was one of the authors of that previous article; many years ago he demonstrated that standard ventilation techniques led to an apparent 'opening pressure', where a substantial positive pressure was required to get air into the lungs, and that the end-expiratory volume of the lungs in the first few breaths remained very low. In contrast a long slow inflation (3 to 5 seconds) eliminated the opening pressure, in intubated babies, and led to establishment of an FRC. This new article used a pressure of 25 cmH2O and duration of 10 seconds, delivered by face mask, but was unable to show the establishment of an FRC, unless the babies were breathing. Murthy V, Creagh N, Peacock J, Fox G, Campbell M, Milner A, et al. Inflation times during resuscitation of preterm infants. Eur J Pediatr. 2012;171(5):843-6. This observational study during resuscitation, using the same respiratory function set up as in the first article, could not show that the variation in inflation times which occurred by chance during resuscitation (from 0.3 to 3 seconds) did not affect inspiratory flow duration. Neil Finer reviews the current state of the art of prolonged inflations, his conclusion: 'not ready for prime time'. Schilleman K, Witlox RS, van Vonderen JJ, Roegholt E, Walther FJ, te Pas AB. Auditing documentation on delivery room management using video and physiological recordings. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2014. If you video record resuscitations, and then compare the tapes to what is actually written in the patients chart, this is what you get: Hmmm.. maybe we need cameras everywhere and make the recordings part of the patients chart... or maybe not!
  9. Go to www.neonatalpneumologynaples.it and check the program !! We welcome you to join a high rank scientific meeting in a world class tourist destination Latest updates in Resuscitation Ventilation Lung ultrasound ... and much more !! Naples, Italy APRIL 11th and 12th, 2014
  10. European Neonatal Ethics Conference 1st and 2nd May 2014 Venue: Chilworth Manor Hotel Southampton United Kingdom Simulation Neonatal Ethics & Difficult Situations Workshops 1st May 2014 The first day challenges participants to address challenging issues, ethical dilemmas, and difficult clinical circumstances in a safe simulated environment. Simulations cover decision making regarding difficult ethical scenarios, limits of viability, neonatal death, and serious medical errors. Workshop 1 Neonatal Ethics 15 places Workshop 2 Difficult Situations 15 places Conference 2nd May 2014 The second day allows neonatal staff from different European centers to interact and share with each other practices governing Rights of the newborn Withdrawal of intensive care Extremes of viability Issues of Faith, Pain Conflict within the team about decisions When/How to approach your ethics committee Providing Expert opinions The first day of the conference is limited to 30 delegates in two workshops. Participants from all over Europe are welcome For more information visit the website www.wonepedu.com Contact: Dr Alok Sharma Consultant Neonatologist Lead Wessex Oxford Neonatal Education Programme Lead Neonatal Education Simulation Training (NEST) Princess Anne Hospital University Hospital Southampton SO16 5YA Tel: 07725868090 Email: aloksharma@nhs.net Web: www.wonepedu.com European_Sim_Flyer.doc