Neonatal Resuscitation Guidelines Research Articles

Use and Efficacy of I-Gel in Complicated Intubations in Newborn Infants: A Review of Case Reports in the Literature.

Current guidelines for neonatal resuscitation suggest the use of a laryngeal mask when ventilation with both facemask and endotracheal tube has failed in newborns weighing >2000 g or delivered ≥ 34 weeks of gestation age. Paediatric I-gel® is one of the latest supraglottic airway management devices suitable for children and newborns. I-gel® use was effective in guaranteeing adequate ventilation in patients with anatomic abnormalities in case of respiratory impairment or during surgical procedures after the induction of anaesthesia. The purpose of our review was to evaluate the use and efficacy of I-gel® in case of complicated intubations. In July 2023, two authors of this paper independently conducted searches of the MEDLINE, Web of Science, and Scopus databases without imposing any time constraints or other restrictions. Three case reports were included, each describing the use of I-gel® device in difficult intubations in newborns with anatomical abnormalities. No difficulties were reported in the insertion of the device, which was placed even by inexperienced clinicians. The data collected highlighted the possibility of using I-gel® not only as a rescue device after attempted and failed endotracheal placement but also as a first choice in selected patients. Studies on larger cohorts would be needed. Further research involving larger patient cohorts of multicentre NICUs is necessary to confirm the use of laryngeal masks in neonates weighing less than 2000 grams.

Updated Neonatal Resuscitation Guidelines from the American Academy of Pediatrics and the American Heart Association.

Updated Neonatal Resuscitation Guidelines from the American Academy of Pediatrics and the American Heart Association.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics.

Between 0.25% and 3% of admissions to the NICU, PICU, and PCICU receive cardiopulmonary resuscitation (CPR). Most CPR events occur in patients <1 year old. The incidence of CPR is 10 times higher in the NICU than at birth. Therefore, optimizing the approach to CPR in hospitalized neonates and infants is important. At birth, the resuscitation of newborns is performed according to neonatal resuscitation guidelines. In older infants and children, resuscitation is performed according to pediatric resuscitation guidelines. Neonatal and pediatric guidelines differ in several important ways. There are no published recommendations to guide the transition from neonatal to pediatric guidelines. Therefore, hospitalized neonates and infants can be resuscitated using neonatal guidelines, pediatric guidelines, or a hybrid approach. This report summarizes the current neonatal and pediatric resuscitation guidelines, considers how to apply them to hospitalized neonates and infants, and identifies knowledge gaps and future priorities. The lack of strong scientific data makes it impossible to provide definitive recommendations on when to transition from neonatal to pediatric resuscitation guidelines. Therefore, it is up to health care teams and institutions to decide if neonatal or pediatric guidelines are the best choice in a given location or situation, considering local circumstances, health care team preferences, and resource limitations.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Comparison of various vasopressin doses to epinephrine during cardiopulmonary resuscitation in asphyxiated neonatal piglets

BackgroundCurrent neonatal resuscitation guidelines recommend epinephrine for cardiac arrest. Vasopressin might be an alternative during asphyxial cardiac arrest. We aimed to compare vasopressin and epinephrine on incidence and time to return of spontaneous circulation (ROSC) in asphyxiated newborn piglets.Design/methodsNewborn piglets (n = 8/group) were anesthetized, intubated, instrumented, and exposed to 30 min of normocapnic hypoxia, followed by asphyxia and asystolic cardiac arrest. Piglets were randomized to 0.2, 0.4, or 0.8IU/kg vasopressin, or 0.02 mg/kg epinephrine. Hemodynamic parameters were continuously measured.ResultsMedian (IQR) time to ROSC was 172(103–418)s, 157(100–413)s, 122(93–289)s, and 276(117–480)s for 0.2, 0.4, 0.8IU/kg vasopressin, and 0.02 mg/kg epinephrine groups, respectively (p = 0.59). The number of piglets that achieved ROSC was 6(75%), 6(75%), 7(88%), and 5(63%) for 0.2, 0.4, 0.8IU/kg vasopressin, and 0.02 mg/kg epinephrine, respectively (p = 0.94). The epinephrine group had a 60% (3/5) rate of post-ROSC survival compared to 83% (5/6), 83% (5/6), and 57% (4/7) in the 0.2, 0.4, and 0.8IU/kg vasopressin groups, respectively (p = 0.61).ConclusionTime to and incidence of ROSC were not different between all vasopressin dosages and epinephrine. However, non-significantly lower time to ROSC and higher post-ROSC survival in vasopressin groups warrant further investigation.ImpactTime to and incidence of ROSC were not statistically different between all vasopressin dosages and epinephrine.Non-significantly lower time to ROSC and higher post-ROSC survival in vasopressin-treated piglets.Overall poorer hemodynamic recovery following ROSC in epinephrine piglets compared to vasopressin groups.Human neonatal clinical trials examining the efficacy of vasopressin during asphyxial cardiac arrest will begin recruitment soon.

Abstract 279: Sustained Inflation and Chest Compression versus 3:1 Chest Compression to Ventilation Ratio During Cardiopulmonary Resuscitation of Asphyxiated Newborns A Cluster Randomized Controlled Trial

Background: Neonatal resuscitation guidelines recommend 3:1 compression to ventilation ratio (C:V) ratio during chest compression (CC). In piglets, continuous CC superimposed by sustained inflation (CC+SI) resulted in faster time to return of spontaneous circulation (ROSC), lower mortality, improved hemodynamics and ventilation compared to 3:1 C:V. Similar a pilot trial in preterm infants reported significant faster ROSC with CC+SI compared to 3:1 C:V. Objective: To test the hypothesis that in newborn infants receiving chest compression with CC+SI compared with 3:1 C:V time to ROSC will be reduced or increased. Design/Methods: Multicenter cluster randomized trial of CC+SI vs. 3:1 C:V in newborn infants receiving CC. Hospitals were randomized to CC+SI or 3:1 C:V for 12 months then switched to 2 nd intervention for another 12 months. Infants were eligible if bradycardic with heart rate &lt;60/min or asystolic. Primary outcome was time to ROSC (heart rate &gt;60 for one minute). Analysis was performed according to intention-to-treat. The trial was stopped to slow enrolment, Covid-19 pandemic, and funding constrains. Results: Four sites (Edmonton, Graz, Halifax, and Vienna) included infants, which were randomized to either CC+SI (n=11) and 3:1 C:V (n=14). The groups were balanced in relation to demographics and delivery room interventions.The median (IQR) time to ROSC with CC+SI was 90 (60-270)sec and with 3:1 C:V was 615 (174-780)sec (p=0.0502 - log rank, and 0.16 cox proportional hazards regression) (Figure).Survival was 9/11 (82%) with CC+SI and 7/14 (50%) with 3:1 C:V [relative risk (RR) 0.36, 95% Confidence interval (CI) 0.094 to 1.42]. There were no differences in secondary outcomes between groups. Conclusion: CC+SI resulted in a reduction in time to ROSC. There was a trend towards higher survival rates with CC+SI.

Professional Guidelines for the Care of Extremely Premature Neonates: Clinical Reasoning versus Ethical Theory.

AbstractProfessional statements guide neonatal resuscitation thresholds at the border of viability. A 2015 systematic review of international guidelines by Guillen et al. found considerable variability between statements' clinical recommendations for infants at 23-24 weeks gestational age (GA). The authors concluded that differences in the type of data included were one potential source for differing resuscitation thresholds within this "ethical gray zone." How statements present ethical considerations that support their recommendations, and how this may account for variability, has not been as rigorously explored. We performed a mixed-methods exploratory analysis of 25 current international guidelines for neonatal resuscitation at 22+0-25+0 weeks GA. Qualitative analysis using a modified grounded theory yielded 34 distinct codes, eight categories, and four overarching themes. Three themes, consequentialism, principlism, and rights-based, consisted of concepts central to these ethical frameworks. The fourth theme, clinical reasoning, described counseling practices, medical management, outcomes data, and prognostic uncertainty, without any ethical context. The theme of clinical reasoning appeared in 22 of 25 guidelines. Ten guidelines lacked any ethical theme. Guidelines with an identified ethical theme were more likely to recommend comfort care than guidelines without an identified ethical theme, and recommended it at a higher average GA (22.7 weeks vs. 22.0 weeks, p = 0.03). Thus, how ethical concepts are incorporated into guidelines potentially impacts resuscitation thresholds. We argue that inclusion of explicit discussion of ethical considerations surrounding resuscitation in the "gray zone" would clarify values that inform recommendations and facilitate discussions about how neonatology ought to approach periviability as outcomes continue to evolve.

Vasopressin versus epinephrine during cardiopulmonary resuscitation of asphyxiated newborns: A study protocol for a prospective, cluster, open label, single-center, randomized controlled phase 2 trial – The VERSE-Trial

IntroductionCurrent neonatal resuscitation guidelines recommend the use of epinephrine during neonatal cardiopulmonary resuscitation (CPR). However, newborns receiving epinephrine continue to have high rates of mortality and neurodevelopmental disability. The infrequent need for neonatal CPR, coupled with an inability to consistently anticipate which newborn infants are at risk of requiring CPR, explains the lack of high-quality evidence (i.e., large randomized clinical trials) to better guide healthcare providers in their resuscitative effort. Therefore, we need neonatal data to determine the optimal vasopressor therapy during neonatal CPR. The current pilot trial will examine the efficacy of vasopressin versus epinephrine during CPR of asphyxiated newborn infants. Methods and analysisThe trial will be a prospective, cluster, open label, single-center, randomized controlled trial on two alternative cardiovascular supportive medications. This study will assess the primary outcome of time to return of spontaneous circulation (ROSC) in newborns requiring CPR in the delivery room who were treated with either vasopressin (intervention) or epinephrine (control). Secondary outcomes such as infant mortality and other clinical outcome measures will also be collected. An estimated 20 newborns will be recruited, and comparisons will be made between asphyxiated infants treated with either drugs. Ethics and disseminationThis study has been approved by the Research Ethics Board at the University of Alberta (June 16, 2023). Study findings will be published in peer-reviewed journals, presented at conferences, and communicated to relevant participants and stakeholders.Trial registration: ClinicalTrial.gov Identifier: NCT05738148. Registered February 21, 2023.

Biomarkers of Oxidative Stress in Healthy Infants within the First Three Days after Birth.

The clinical relevance of stress biomarkers in newborns is well established. Currently, oxidative stress (OS) parameters are seen to play an important role in neonatal resuscitation guidelines, and a link has been observed between the amount of oxygen delivered and the level of OS and the development of various pathologies. The aim of the current study was to investigate changes in neonatal plasma and urine OS status during the first hours after birth. A lower antioxidant capacity (TAC) and higher levels of malondialdehyde in blood were observed in newborns at the time of birth compared with results 48 h postnatally. The urine revealed a significant and progressive increase in TAC and creatinine during the first 36 h of life, with a progressive decline thereafter. Meanwhile, malondialdehyde in urine samples showed no significant differences over time. Overall, the correlation between blood and urine parameters was poor, except for the relationship between umbilical vein glutathione reduced/oxidized ratio and urine malondialdehyde (r = 0.7; p = 0.004) and between TAC in the umbilical artery and urine (r = -0.547; p = 0.013). The biomarkers evaluated in this study could be established as reference values for neonatal OS.

Multicentre study protocol comparing standard NRP to deveLoped Educational Modules for Resuscitation of Neonates in the Delivery Room with Congenital Heart Disease (LEARN-CHD)

IntroductionInfants born with critical congenital heart defects (CCHDs) have unique transitional pathophysiology that often requires special resuscitation and management considerations in the delivery room (DR). While much is known about...

Basics and novelties of neonatal resuscitation

This recommendation summarizes the recent neonatal resuscitation guidelines of the European Resuscitation Council (ERC), but it takes into account the guidelines of the American Heart Association (AHA) and the statements of the International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations (CoSTR) for neonatal life support. The goal of the management of the newly born infants is to support the cardiorespiratory transition. Personnel and equipment should be prepared for neonatal life support before every delivery. After birth, the heat loss of the newborn must be prevented and, if possible, the clamping of the cord should be delayed. Initially the newborn must be assessed and, if possible, the baby should be kept with the mother in skin-to-skin contact. The infant must be placed under radiant warmer and the airways must be opened, if respiratory or circulatory support is needed. Decisions about the further steps of resuscitation are based on the evaluation of breathing, heart rate and oxygen saturation. If the baby is apnoeic or has a low heart rate, positive pressure ventilation must be started. The effectiveness of the ventilation must be checked, and failures are to be corrected if necessary. If the heart rate is <60/min despite effective ventilation, chest compressions should be started. Rarely, administration of medications is also necessary. After successful resuscitation, post-resuscitation care must be started. In the case of unsuccessful resuscitation, discontinuing management can be considered. Orv Hetil. 2023; 164(12): 474-480.

Masked Randomized Trial of Epinephrine versus Vasopressin in an Ovine Model of Perinatal Cardiac Arrest.

Current neonatal resuscitation guidelines recommend the use of epinephrine for bradycardia/arrest not responding to ventilation and chest compressions. Vasopressin is a systemic vasoconstrictor and is more effective than epinephrine in postnatal piglets with cardiac arrest. There are no studies comparing vasopressin with epinephrine in newly born animal models with cardiac arrest induced by umbilical cord occlusion. Objective: To compare the effect of epinephrine and vasopressin on the incidence and time to return of spontaneous circulation (ROSC), hemodynamics, plasma drug levels, and vasoreactivity in perinatal cardiac arrest. Design/Methods: Twenty-seven term fetal lambs in cardiac arrest induced by cord occlusion were instrumented and resuscitated following randomization to epinephrine or vasopressin through a low umbilical venous catheter. Results: Eight lambs achieved ROSC prior to medication. Epinephrine achieved ROSC in 7/10 lambs by 8 ± 2 min. Vasopressin achieved ROSC in 3/9 lambs by 13 ± 6 min. Plasma vasopressin levels in nonresponders were much lower than responders after the first dose. Vasopressin caused in vivo increased pulmonary blood flow and in vitro coronary vasoconstriction. Conclusions: Vasopressin resulted in lower incidence and longer time to ROSC compared to epinephrine in a perinatal model of cardiac arrest supporting the current recommendations for exclusive use of epinephrine in neonatal resuscitation.

Survey on currently applied interventions in neonatal resuscitation (SCIN): A study protocol.

Around 140 million children are born every year and post-natal transition is uncomplicated in the vast majority. However, around 5%-15% of neonates receive supportive interventions during transition. Recent data on the interventions used is scarce. More data on the frequencies with which these interventions are used is needed to evaluate neonatal resuscitation, guide recommendations and to generate hypotheses for further research. The following protocol describes an international, multicentre survey on the interventions currently applied during neonatal resuscitation. To determine the frequencies at which different supportive interventions recommended by European Resuscitation Council (ERC) guidelines for neonatal resuscitation are used. To compare the frequencies between hospitals and patient groups and to investigate possible factors influencing any differences found. Participating hospitals will collect data on all interventions performed during neonatal resuscitation over a period of 6 months. All hospitals providing perinatal care are eligible regardless of size and designated level of neonatal care. Every neonate requiring more interventions than basic drying and tactile stimulation during the first 30 min of life will be included. The targeted sample size is at least 4,000 neonates who receive interventions. After anonymization, the data is pooled in a common database and descriptive and statistical analysis is performed globally and in subgroups. Possible correlations will be investigated with phi coefficient and chi square testing. Consent of the institutional review board of the Technical University Dresden was obtained for the local data collection under the number BO-EK-198042022. Additionally, approval of local ethical or institutional review boards will be obtained by the participating hospitals if required. Results will be published in peer-reviewed journals and presented at suitable scientific conferences.

Nurses’ and midwives’ knowledge regarding neonatal resuscitation in public hospitals of south wollo zone of Amhara Region, Northern Ethiopia

BackgroundNeonatal mortality is among major public health problems in developing nations with its major cause birth asphyxia. Birth asphyxia could be managed by Resuscitation of Neonates which is mainly implemented by nurses and midwives. This study aimed to assess nurses’ and midwives’ knowledge regarding Neonatal Resuscitation in the Public Hospitals of the South Wollo Zone of the Amhara Region, Northern Ethiopia. MethodsInstitution-based cross-sectional study design was used to recruit study participants working in the Labor and Neonatal Intensive Care Units of all public hospitals of the study zone. The sample size was calculated based on a single population proportion formula with the assumption of 95 % accuracy, 5 % error, 50 % previous estimated extent of knowledge towards Neonatal Resuscitation and 10 % non-response rate. Using the correction formula, the final calculated sample size was 143. Study participants were selected using a simple random sampling method from each public hospital of the study zone, after proportional allocation of calculated sample size to all public hospitals included in the study. The data collection tool was developed from similar literatures, guidelines, and training manuals. The internal validity of the study tool was attested by experts in the subject matter like neonatologists, expert nurses and midwives who specialized in neonatology care and researchers. Then, the content validity index of the study tool was calculated and rated at 0.89. A multivariable logistic regression model was used to attest statistically significant factors with the extent of knowledge towards Neonatal Resuscitation at a P-value < 0.05. ResultsA total of 143 nurses’ and midwives’ completed questionnaire was analyzed for this study with a 100 % response rate. Overall, about one third 54 (37.8 %) of the study participants had adequate knowledge towards Neonatal Resuscitation. The study revealed that study participants who took on job training [P < 0.01], presence of Neonatal Resuscitation guide in the working unit [P < 0.02], got supportive supervision within preceding six months of this study [P < 0.05] were found positively associated with knowledge level of the study participants towards Neonatal Resuscitation. ConclusionsThis study found the knowledge level of Neonatal Resuscitation among nurses and midwives who participated in this study is scarce. Getting on-job training, having a Neonatal Resuscitation guideline in the working unit and getting supportive supervision within preceding six months of this study were found statistically significantly associated with the knowledge level of the study participants towards Neonatal Resuscitation.

Neonatal perioperative resuscitation (NePOR) protocol-An update.

Unexpected cardiac arrest in the perioperative period is a devastating complication. Owing to immaturity of organ systems, and presence of congenital malformations, morbidity and mortality are higher in neonates. There is abundant literature about early recognition and management of perioperative adverse events in children, but similar data and guidelines for surgical neonates is lacking. The current neonatal resuscitation guidelines cater to a newborn requiring resuscitation at the time of birth in the delivery room. The concerns in a newborn undergoing transition from intrauterine to extra uterine life is significantly different from a neonate undergoing surgery. This review highlights the causes and factors responsible for peri-arrest situations in neonates in the perioperative period, suggests preoperative surveillance for prevention of these conditions, and finally presents the resuscitation protocol of the surgical neonate. All these are comprehensively proposed as Neonatal Peri-operative Resuscitation (NePOR) protocol.

NEW-BORN RESUSCITATION

These guidelines are planned for Health care workers who are dedicated to giving neonatal resuscitation in the health care facilities. These guidelines are designed to keep in mind the complete process from the intrauterine to the extrauterine life of a new-born. In Other words, we can say the transition from intrauterine to extrauterine life. Updated neonatal resuscitation guidelines Included the latest knowledge in neonatal resuscitation also important changes from older guidelines and sanctions by the government of India for practice in health care facilities.

Perinatal management: Lessons learned from the neonatal research network

Recent contributions of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) regarding obstetrical perinatal interventions and neonatal delivery room practices include the following: the impact of multiple antepartum factors including maternal diabetes, hypertension, obesity and mode of delivery on outcomes of extremely preterm newborns, effects of delayed delivery interval for extremely preterm multiples, effects of antenatal steroids on preterm newborn outcomes and the impact of antenatal magnesium sulfate therapy on neurodevelopmental outcomes for extremely preterm infants. NRN studies also contribute important evidence for neonatal delivery room resuscitation guidelines including umbilical cord management and maintenance of euthermia immediately after birth. The updated NRN outcome calculator helps better counsel families regarding possible outcomes for the most immature newborns if resuscitation is attempted at birth. Thus, the NRN provides substantial information regarding effects of perinatal management on newborn infants.

Special consideration in neonatal resuscitation

Delivery room resuscitation of neonates is performed according to evidence-based neonatal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation of newborns suffering from perinatal asphyxia. Special considerations are needed when resuscitating newborns in locations other than the delivery room and for newborns with congenital anomalies. In this review, we examine the resuscitation of newborns at home and in the emergency department and highlight special considerations for resuscitating newborns with specific congenital anomalies. In addition, we explore the resuscitation of neonates in the neonatal intensive care unit and discuss the potential use of pediatric advanced life support guidelines. Finally, we highlight the importance of simulation to prepare teams for neonatal resuscitations. This review aims to prepare healthcare professionals in all disciplines caring for neonates at risk for requiring resuscitation under special circumstances.1Evidence-based neonatal resuscitation guidelines focus on resuscitation newborns suffering from perinatal asphyxia in the delivery room.2Modification of neonatal resuscitation guidelines is needed for newborn resuscitations outside the delivery room and to address certain congenital anomalies.3When resuscitating critically ill neonates in the intensive care unit suffering from arrest etiologies not covered in neonatal guidelines, teams may consider using pediatric advanced life support guidelines.4Simulation is a central part of neonatal resuscitation training and should be used to prepare for neonatal resuscitation in all circumstances.5With preparation and practice for special circumstances, healthcare teams can improve the quality of resuscitation for all neonates.

State-of-the art training in neonatal resuscitation

Healthcare training has traditionally emphasized acquisition and recall of vast amounts of content knowledge; however, delivering care during resuscitation of neonates requires much more than content knowledge. As the science of resuscitation has progressed, so have the methodologies and technologies used to train healthcare professionals in the cognitive, technical and behavioral skills necessary for effective resuscitation. Simulation of clinical scenarios, debriefing, virtual reality, augmented reality and audiovisual recordings of resuscitations of human neonates are increasingly being used in an effort to improve human and system performance during this life-saving intervention. In the same manner, as evidence has accumulated to support the guidelines for neonatal resuscitation so, too, has affirmation of training methodologies and technologies. This guarantees that training in neonatal resuscitation will continue to evolve to meet the needs of healthcare professionals charged with caring for newborns at one of the most vulnerable times in their lives.