1. Ola Didrik Saugstad MD, PhD, FRCPE Professor of Pediatrics Professor of Pediatrics Director Director Department of Pediatric Research Department of Pediatric Research Oslo University Hospital, Rikshospitalet University of Oslo University of Oslo NORWAY NORWAY Newborn Resuscitation: latest guidelines Newborn Resuscitation: latest guidelines Kiev, November 30th, 2011

2. 5-10% need help to breathe within «the golden minute»

3. Black RE, et al. Lancet. 2010 Jun 5;375(9730):1969-87. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Maternal, and intrapartum related deaths

4. Assess baby’s response to birth Keep baby warm Position, clear airway, stimulate to breathe by drying Establish effective ventilation bag & mask ventilation Start with air endotracheal intubation Provide chest compressions Adrenaline Volume expansion 3 – 5/100 1/100-1/700 < 1/1000 0.6/1000 1/12000 Interventions in term or near term newborn in the delivery room INTERVENTION FREQUENCY 4-6 mill 136 mill 1 mill 0.1 mill All B A S I C A D V A N C E D NUMBER 1 mill

5. Neonatal Resuscitation Is the amniotic fluid clear of meconium? Is the baby breathing or crying? Is there a good muscle tone? Is the color pink? Was the baby born at term? If the answer is no to any of these consider resuscitation The following questions should be answered after every birth: ILCOR/AHA 2000 XXXXXXXXXXXXXX AHA/ILCOR: 2005 XXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX AHA/ILCOR: 2010

6. ILCOR Guidelines Newborn Resuscitation Changes from 2005 -2010 Timing the first 60 seconds only Progression to the next step following initial evaluation is defined by heart rate and respiration For babies born at term it is best to begin resuscitation with air rather than 100% oxygen Evidence does not support or refute routine endotracheal suctioning of infants born through meconium-stained amniotic fluid, even when the newborn is depressed Chest compression- ventilation ratio 3:1 unless the arrest is known to be of cardiac etiology. Then higher ratio should be considered (15:2) Hypothermia in moderate to severe HIE Cord clamping late, in asphyxia not known

7. ILCOR Neonatal Resuscitation Guidelines 2010 Perlman J et al, Circulation 2010;122 (Suppl 2) S516-538 3 questions: Term, Breathing, Tone Timing: First 60 seconds only Start with air, consider SpO2 Start Ventilation: Heart rate < 100 bpm and or apnea/insufficent breathing

8. Newborns in Need of Resuscitation According to ILCOR Saugstad et al, data from Resair 2

10. Treatment Recommendation In term infants receiving resuscitation at birth with positive pressure ventilation, it is best to begin with air rather than 100% oxygen. If despite effective ventilation there is no increase in heart rate or if oxygenation (guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.

11. American Academy of Pediatrics 2010 Kattwinkel J et al Pediatrics, 2010

12. Dawson et al, Pediatrics 2010 Development of SaO2 first 10 min of life

13. X X X X X X X Need of Oxygen According to SpO2 – USA Guidelines

14. Initial steps of stabilisation (assess the airways, positioning, stimulating, dry and provide warmth) Ventilation (including bag-mask or bag -tube ventilation) Chest compressions Medications or volume expansion A B D C Airways Breathing Circulation Drugs ILCOR/AHA 2005 Four Categories

15. Suctioning of upper airways Routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born with clear or meconium stained amniotic fluid is no longer recommended ILCOR 2010 A: Airways Stabilisation and suctioning

16. A vigorous newborn who starts to breath within 10-15 seconds does not need suctioning routinely Deep suctioning should be avoided especially the first 5 min of life. It may induce apnea, bradycardia and bronchospasm If suctioning, always suction the mouth before through the nose to minimize risk of aspiration

17. The most important is to ventilate the lungs. Training is needed B: ventilation Increasing heart rate is the primary sign of effective ventilation during resuscitation What is an adequate heart rate? Observe also: Improving color Spontaneous breathing Improving muscle tone Check these signs of improvement after 30 seconds of PPV. This requires the assistance of another person 50 percentile for heart rate is 99 bpm at one min Dawson et al, 2010

18. The 10th, 25th, 50th, 75th and 90th heart rate centiles for all infants with no medical intervention after birth. bpm, beats per minute. Dawson J et al. Arch Dis Child Fetal Neonatal Ed 2010;95:F177-F181 ©2010 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health

19. Assessment if resuscitation is stepped up 3 vital characteristics Heart rate Respirations State of oxygenation ”The most sensitive indicator of successful response to each step is an increase in heart rate”

20. Newborns in Need of Resuscitation According to ILCOR Saugstad OD in press

21. Initial breaths and pressures Initiation of intermittent positive- pressure ventilation at birth can be accomplished with either shorter or longer inspiratory times. Initial peak inflating pressures needed are variable- start with 20 cm H2O may be effective but 30-40 Cm H2O may be needed. PEEP is likely to be beneficial Heart rate increase is more Important to observe than chest rise Basic Newborn Resuscitation, WHO 1998

22. Sustained inflation (SI) ? ● In babies with GA < 29 weeks SI is tested out ● Different models for instance 5 seconds x 3 or 15 seconds with increasing PIP ● Still experimental

23. Assisted ventilation devices Ventilation of the newborn can be performed effectively with a flow-inflating, a self inflating bag or a pressure limited T- piece resuscitator

24. Self inflating (Laerdal) bag and mask with a manikin No PEEP P F V

25. Neopuff and mask with a mannequin PEEP P F V

26. C: Circulation Neonatal Resuscitation Chest compressions - indication Chest compressions should be performed if the heart rate is < 60 beats/minute, despite adequate ventilation start with a 3:1 ratio - that is 90:30 0.8 per 1000 term or near term infants 2-10% in preterm infants No human data have identified an optimal compression to ventilation ratio for cardiopulmonary resuscitation in any age Goals: Reperfuse the heart (obtain diastolic pressure) Reperfuse the Brain Wyckoff et al, Pediatrics 2005:115:950-955 Finer et al Pediatrics 1999;104:428-34 Wyckoff and Berg Seminars Fetal and Neonatal Med 2008;13:410-415

27. The two-thumb technique is superior to the two-finger method for administering chest compressions in a manikin model of neonatal resuscitation Depth of compressions and coefficient of variation (COV) utilising a 3:1 compression to ventilation ratio for 2 min using the two-thumb compared with the two-finger technique Two-thumb 3:1 (2 min) Two-finger 3:1 (2 min) p Value Depth (mm) 29±5.4 23.7±5.8 0.0009 Variability (COV) 6.1±2.9 9.8±3.1 0.00002 C Christman, RJ Hemway, MH Wyckoff,JM Perlman Arch Dis Childhood 2010

28. Chest compressions If no signs of life beyond 10 min: 83% mortality of survivors: 77% suffer severe disability 15% suffer moderate disability 8% mild disability No reported normal survivors Harrington et al Am J Obstet Gynecol 2007;196:463 e1-5 Fact sheet

29. Solevaag A et al Neonatology 2010 Newborn hypoxic piglets with cardiac arrest:

30. Solvaag A et al, Resuscitation 2010 Median and IQR P< 0.001

31. D: Drugs Neonatal Resuscitation Adenaline/Epinephrine dose If adequate ventilation and chest compressions have failed to increase heart rate to > 60 bpm, then it is reasonable to use adrenaline despite the lack of human neonatal data.

32. Adrenaline for newborn resuscitation 6:10 000 newborns 0.1-0.3 mL/kg 1:10 000 adrenaline solution 1st dose at earliest at 4-5 min of life IV recommended Barber et al Pediatrics 2006;118:1028-1034

33. Neonatal Resuscitation Volume expansion Volume expansion may be accomplished with (1) isotonic crystalloid such as normal saline or Ringer’s lactate or (2) O-negative blood. 10ml per kg, can be repeated Needed in 1:12000 term or near term infants (Perlman et al) Insufficient evidence to support routine use In infants with no blood loss.

34. Air versus Oxygen

35. Defining the reference range for oxygen saturation for infants after birth. Dawson JA, Kamlin COF, Vento M, Wong C, Cole TJ, Donath SM, Davis PG, Morley CJ. PEDIATRICS 2010

36. Term Neonates > 37 weeks gestation Dawson Ja et al Pediatrics 2010

37. Preterm < 37 weeks gestation Dawson Ja et al Pediatrics 2010

38. SpO2 polynomial adjustment curve (± SD) in “control” ELGA neonates (≤ 28 weeks gestation (n=29). Vento M, Saugstad OD SFNM 2010 Optimal FiO2 for ELBWI Is not known !

39. How could SpO2 centiles be used to inform decision making in the DR? Dawson, Vento, Finer, Rich, Saugstad, Morley, Davis J Pediatrics 2011

40. TRANSITIONAL OXYGEN TRACKING SYSTEM Allowing to individualize FiO2 avoiding hyper/hypoxia Rich W et al unpublished data, 2010 50% 10%

41. Guidelines for optimizing oxygenation after birth in ELBW infants Place preductal S P O 2 sensor (60-90 sec) Place preductal S P O 2 sensor (60-90 sec) Start in 21%-30% FiO 2 with adequate flow (4-8 l/min) and always use an O 2 /air blender. Start in 21%-30% FiO 2 with adequate flow (4-8 l/min) and always use an O 2 /air blender. Aerate lungs to promptly achieve Functional Residual Capacity (FRC) Aerate lungs to promptly achieve Functional Residual Capacity (FRC) Dawson, Vento, Finer, Rich, Saugstad, Morley, Davis J Pediatrics 2011

42. Guidelines for optimizing oxygenation after birth in ELBW infants At 90s review the infants HR, SpO 2 and breathing efforts At 90s review the infants HR, SpO 2 and breathing efforts If the baby is breathing, or is well ventilated, and HR is rising, and the SpO 2 > 10 th  O 2 is not required If the baby is breathing, or is well ventilated, and HR is rising, and the SpO 2 > 10 th  O 2 is not required If O 2 is needed, FiO 2 should be titrated against SpO 2 to keep it >10 th and 10 th and < 90 th SpO 2 10 th and 10 th and < 90 th Wait at least 30 sec after each change until HR improves and SpO 2 between 10 to 90 th Wait at least 30 sec after each change until HR improves and SpO 2 between 10 to 90 th If SpO 2 > 90 th reduce FiO 2 If SpO 2 > 90 th reduce FiO 2 Continue titrating FiO 2 according to infant’s response Continue titrating FiO 2 according to infant’s response Dawson, Vento, Finer, Rich, Saugstad, Morley, Davis J Pediatrics 2011

43. Do we need a new Apgar Score ? 0_______1__________ 2_____ 0_______1__________ 2_____ Heart rate 0 100 Respiration 0 Weak, irregular Good cry Reaction* 0 Slight Good Colour Blue or pale All pink, limbs blue Body pink Tone Limp Some movement Active movements limbs well flexed limbs well flexed Virginia Apgar * Reaction to suctioning

44. What about PCO 2 ? PCO 2 is high in asphyxia Hypercapnia restores cerebral circulation faster than normocapnia Hypocapnia increases risk of brain injury Perhaps we need to be more careful in the DR ventilating even term babies? Routine monitoring of PCO2 is needed

45. Newborn resuscitation Current challenges Optimal heart rate response not established Ratio ventilation:chest compession not established Sustained inflation? Optimal PEEP not established Optimal pCO 2 not established Optimal adrenaline dose not established Optimal FiO 2 and other procedures for ELGANS not established

46. Thank you for your attention! Comments – Questions?