New Concepts of Newborn Resuscitation – the new national protocol D. Dobryanskyj Lviv National Medical University
May 27, 2015
New Concepts of Newborn Resuscitation – the new national protocol
D. Dobryanskyj Lviv National Medical University
< 1% require
complete resuscitation
Approx. 3-6% require initial help (lungs
ventilation with mask)
Approx. 5-10% require simple stimulation (drying and massage) in
order to start breathing independently
All the newborns require immediate condition assessment and standard medical measures
0.1% require ICM*
0.05% require medicines
administration
• Should follow to IC**
• LOW level of evidences of
effectiveness
≈ 1 million
children
Approx. 6 million
children
Approx. 10 million
children
130 million
children
S. Wall et al., Int J Gynaecol Obstet. 2009 107 (Suppl 1): S47
* - indirect cardiac massage
** - intensive care
≈ 5000
children ≈ 30000
children
≈ 50000 children
Ukraine
The most
important influence
population
Інші причини; 0,181 млн.
Природжені аномалії; 0,27
млн.
Неонатальні інфекції; 0,83 млн.; 27%
Інтранатальні ускладнення; 0,72 млн.;
23%
Ускладнення недоношеності;
1,08 млн.; 35%
Born too soon: the global action report on preterm birth, WHO, 2012.
Li Liu et al. The Lancet, 2012, V. 379, No. 9832: P. 2151-2161
Ukraine, 2009
7%
15%
8%
3%
12% 32%
8%
13% 2%
Інші Аномалії Інфекції
Сепсис Асфіксія Захв. легень
Пневмонії ВШК Пор цер. стат.
228 children
501-750 g 751-1000 g 1001-1250 g 1251-1500 g
Years
Body
weight
Data basedon 355 806 newborns with birth weight from 501to1500 g from 669 hospitals of the North America
J.D. Horbar et al.
Pediatrics 2012;129:1019
• During 2000-2009 mortality rate of newborns with birth weight 501-1500 g decreased from 14,3% to 12,4% (dynamics– 21,9%; 95% CI: 22,3-21,5%)
• Severe morbidity in newborns who survived decreased from46,4% to 41,4% (dynamics – 24,9%; 95% CI: 25,6-24,2%)
• In 2009 mortality rate varied from 36,6% (501-750 g) to 3,5% (1251-1500 g), and morbidity varied,from82,7% to 18,7%
• 49,2% of all newborns with VLBW 89,2%
of newborns with weighting at birth 501-
750 g either died or survived with severe
disability
1996: Regulatory systematic recommendations as to the initial resuscitation of newborns. Amendment to Order No.4 of the Ministry of Healthcare from 05/01/1996
2003: Onapproval of branch program "Initial resuscitation of newborns for 2003-2006 ". Order No. 194 of the MH from06/05/2003
2007: Initial resuscitation and post-resuscitation support of newborns: Clinical protocol on neonatal support provision . Order No. 312 of the MH 08/06/2007.
2013: Immediate, resuscitative and post-resuscitative support of newborns: Unified clinical protocol
Official opening of Kyiv NMC of Newborns resuscitation, 1998
"Avoid hypothermia of a newborn"
«Fill their lungs with air»
«Do not give oxygen - it is toxic!»
1895
51%of newborns born at < 28 weeks and 57% at ≥ 28 weeks (< 32 weeks) had body temperature < 36,5°С at the time of admission to NICU (2011)1
Ventilation, filling of lungs, РЕЕР, СРАР, intubation? 2
«We may come to a reasonable conclusion that in term and early-born infants -initial lungs ventilation should be performed with room air (relevant risk of mortality is 0.71 [95% CI 0.54-0.94])»3
1 Chitty H.E. et al., Wrapping is not sufficient to prevent hypothermia of preterm infants, PAS 2012 2 Wyllie J. et al., Resuscitation 81S (2010) e260 3 Davis P.G. et al., Lancet 2004; 364: 1329
differentiate between the interventions needed for 5-10 % of
newborns who really required resuscitation, and stabilization
measures which are standard for 90% of infants and are
taken to avoid further morbidity
• Stabilization of condition (a support for adaptation) is
necessary for all the newborns irrespective of their gestational
age, independent breathing or respiratory problems and heart
rate ≥ 100/min.
• “More” observation, and less “agression”!
Term newborn
Preterm newborn
Total blood volume in fetal/placental circulation for gestational period is 110-115 vl/kg
In case of urgent delivery 2/3 of this volume are in fetus blood vessels and ? stay in placenta
At 30 weeks of GA these volumes are about the same
Immediate clamping of umbilical cord leads to newborn blood volume ≈ 45 vl/kg ('loss'– 25-35 ml/kg)
15-20 ml is contained in the cord; 'half' of cord length – 10 ml
4 'wringings' give 40-50 ml of transfusion N. Aladangady et al. Pediatrics 2006;117;93
Rabe H. et al. Obstet Gynecol. 2011; 117(2 Pt 1):205
Blood volume
Less transfusions needed [ВР-0.61; 95% CI 0.46-0.81]
blood pressure and decreased need in inotropes administration [ВР-0,42; 95% CI 0.23-0.77]
Better circulation in upper hollow vein
Betteremission from left ventricle
Cerebral oxygenation index
Decreased number of any IVH [ВР-0.59; 95% ДI 0.41-0.85] (no differences in the number of severe IVH)
Decreased number of NEC [ВР-0.62; 95% ДI 0.43-0.90]
Raju T.N.K., Singhal N. Clin Perinatol 2012;39:889
Rabe H. et al. Cochrane Database of Systematic Reviews 2012, Issue 8
5 RCS(2008-2012)*
8 controlled studies
Unfortunately, there is no systematic review and meta-analysis so far
Preliminary finding: the same positive clinical results that were obtained after delayed cord clamping
No negative effects of this clinical practice were observed for term and preterm infants
* Hosono08, Minami08, Rabe11, Erickson-Owens12, Gotwal12
Put a child into a plastic bag (< 28 weeks); in case there is no independent respiration immediately* separate and transport….
Put a child into a plastic bag (< 28 тиж) and in case of independent breathing hold below the placenta level; clamp and cut the cord after 30-45 s*
* in case any delay is impossible, quickly wring blood out of the cord 3-4 times directing it to a child (A)
Immediate, resuscitative and post-resuscitative support of newborns, Kyiv, 2013
Visual assessment of skin colour and adequate independent breathing especially in deeply preterm infants is inacurate and subjective
Assessment according to Apgar scale is also rather subjective and especially complicated for deeply preterm infants
Standard methods of heart rate measurement (auscultation and palpation) are inaccurate
J. Wyllie et al. Resuscitation 81S (2010) e260
SpO2 corresponding to clinical
definition of pink colour
SpO2%
% of observers considering that a
child has cyanosis
Results from 20 videoclips are indicated Maximum level of SpO2 during
videorecording C. Kamlin et al. J Pediatr 2008;152:756
J.A. Dawson et al. Pediatrics 2010;125;e1340
Minutes after delivery
Sp
O2
(%)
10th 25th 50th 75th 90th
Percentile
1 min
2 min
3 min
4 min
5 min
10 min
60-65%
65-70%
70-75%
75-80%
80-85%
85-95%
-35
-30
-25
-20
-15
-10
-5
0
Med
ian
diffe
renc
es (
95%
CI)
bet
wee
n cl
inic
al
hear
t rat
e m
easu
rem
ent a
nd E
CG
dat
a
Auscultation
(n=26)
Palpation
(n=21)
C. Kamlin et al. Resuscitation 2006; 71: 319
Deviation from actual
value
Prospective , randomized (heart rate measurement techniques [auscultation or palpation] and scenario), controlled study
64 experienced physicians
3 training scenarios (SimNewB®, Laerdal Inc., Stavangar, Norway)
Heart rate measurement bias were observed at 26-48% initial and 26-52% follow-up assessments
Measurement method did not affect the result
Clinical measurement of heart rate in case of RN is unreliable
Chitkara R. et al., Resuscitation 2012, In press
If PO shows heart rate < 100/min, the probabilty of bradycardia is 83%
If PO shows heart rate > 100/min, the possibility that an infant has no bradycardia is 99%
PO
hea
rt r
ate
min
us E
CG
hea
rt r
ate
Mean heart rate
2SD
0
2SD
C. Kamlin et al. J Pediatr 2008;152:756
+ 2 SD (24 strikes/min.); 0: mean (-2 strikes/min.); - 2 SD (-28 strikes/min)
90th
75th
50th
25th
10th
J.A. Dawson et al., Arch Dis Child Fetal Neonatal Ed 2010;95:F177
Hea
rt r
ate
Minutes after delivery
50th percentile value is less
than 100/min in 1 min after
delivery!
M.T. Bashambu et al. Pediatrics 2012;130;e982
1 min of life 5 min of life 10 min of life
Case1 (term infant) Case 2 (24 weeks, ventilation with ETT)
Case 3 (28 weeks, СРАР) Case 4 (28 weeks, ventilation with ETT)
335
participants
323
participants
313
participants
312
participants
General Apgar score General Apgar score
General Apgar score General Apgar score
Nu
mb
er o
f re
spo
nd
en
ts
Nu
mb
er o
f re
spo
nd
ents
Nu
mb
er o
f re
spo
nd
en
ts
Nu
mb
er o
f re
spo
nd
ents
CONCLUSIONS: An improved delivery room score that decreases variability among medical care professionals is needed to accurately reflect the clinical status of preterm infants.
CONCLUSIONS: An improved assessment scale is needed in order to unify and increase accuracy in defining clinical conditions of preterm infants between different medical professionals
Characteristic
0 1 2 Time
1 min 5 min 10 min 15 min 20 min
Heart rate None Bradycardia (HR <100/min)
(HR ≥100/min)
Respiration None Bradypnoea, irregular
Regular, cry
Muscular tone Dramatically low
Mild limb bending Active movement
Reflex excitability
No reaction Spasm Cough, sneezing
Colour Cyanosis or paleness
Limbs cyanosis Pink
General score
Comments: Resuscitation
Minutes 1 5 10 15 20
Oxygen
Ventilation/CPAP
Intubation
IMC
Adrenalin ААР. Pediatrics, 2006,117,4:1444
After initial help [(1) position ± airways sanitization [according to indications – meconium, ventilation need (newborn does not breathe!) or obstructed respiration]; 2) drying]
Only 2 characteristics may evidence the need inn resuscitative intervention after initial help – no breathing (gasping ) or heart rate <100/min
The first minute is a «goldentime frame» and all the actions during this minute are standardized!
J. Wyllie et al. Resuscitation 81S (2010) e260
Moan Volume
Adults Newborns
Time
"Supporting"
inspiration
FRC of
lungs EERV
EERV EERV
EERV – end-expiratory lungs volume
Vr – lungs volume at rest
Primary effects of respiration with increased lings volume
at expiration
1. Less energy loss
2. Improvement of surfactant
effect
3. Decrease of lungs vessels
resistance
4. Optimized ventilation-
perfusion correlation
5. Better gas exchange
Mechanisms that support
increased lungs volume at
expiration
1. Additional diaphragm and
larynx muscles activity at
expiration phase
2. Starting the following
inspiration before Vr
3. Inverse sequesnce of
glottis opening and
diaphragm contraction
Trachea intubation blocks all these physiological
mechanisms!
Free lungs from fluid
Create functional residual capacity of lungs (FRC)
Stimulate independent breathing using lungs aeration
Facilitate gas exchange
Minimize risk of lungs damage
min hou
r
Roehr C.C. et al. Neoreviews 2012;13;e343
Lungs resistance [RL] (ml*s/kPa)
FRC dynamics, CL, і RL after delivery
FRC (ml) Lungs pliability [CL] (ml/kPa)
≈ 30 ml/kg
ml
ml/kPa
СРАР only?
"Filling of lungs" with СРАР?
"Filling of lungs" with ventilation?
Intubation and ventilation?
INSURE?
Surfactant without intubation?
Indications No independent breathing
Respiratory disfunction
Gestational term < 32 weeks
Lungs ventilation with positive pressure Ventilation frequency – 40-60/min
Peak inspiratory pressure (РІР) – 40-20/25 cm Н2О
Positive end-expiratory pressure (РЕЕР) – 5 cm Н2О
May be performed with relevantly long-term ("filling of lungs") or short-term (standard vetilation) tI
J. Wyllie et al. Resuscitation 81S (2010) e260
Why it is so important to create РЕЕР for deeply preterm infants?
Facilitates the development of FRC
Facilitates aeration
Improves oxygenation
Protects lungs from damage (prevents pulmonary collapse)
May be used with
Resuscitation T-system
Bag filled with airflow
Self-filling bag (only in case additional valve and gas flow (connected gas source) are available!)
Roehr C.C. et al. Neoreviews 2012;13;e343
Ventilation: Lower initial inspiratory pressure (20-25 cm Н2О) for preterm infant compared to term infant (30-40 cm Н2О)
Avoid excessive movement of chest, especially for preterm infants
РЕЕР: will most likely benefit and is recommended if technically possible
СРАР: may be used in ingants breathing independently according to local protocols
J. Wyllie et al. / Resuscitation 81S (2010) e260
© 2010 American Heart Association, Inc.
For infants with ≥ 32 weeks of gestational age it is recommended to ventilate lungs with air (21% О2)
For more immature infants (< 32 тиж) initial О2 concentration should be 30%
Start of ventilation, CPAP or additional oxygen use indicate the need in continuous pulse oximetry
Further on О2 concentration (FiO2) is changed according to SpO2
Ventilation of lungs with 90-100% oxygen is shown for ICM
Total number of death or BPD in 2 groups СРАР from
birth on
routine basis
Intubation +
surfactant as
preventive
measure
Study Relevant risk and 95% CI
Rojas-Reyes MX, Morley CJ, Soll R. Cochrane Database of Systematic Reviews 2012, Issue 3
For СРАР
For intubation
Comparative namber of intubations in case of airbag ventilation using laryngeal (LM) or conventional (CM) mask
Study LM Bag and mask Odds ratio
Georg M. Schmolzer et al. Resuscitation (2012). In press
For CM For LM
LM may be used for neonates with ≥ 34 weeks of GA and weight > 2000 g
T-systems or resuscitative bags filled with airflow or independently may be used for respiratory support
T-systems are preferred in developed countries. It is recommended by European Consensus on prevention and treatment of RDS 31% in Ireland; 45% in Spain;
80% in Austria; 41% in Germany;
20% in Switzerland; 80% in Poland
C.P. Hawkes et al. Resuscitation 83 (2012) 797
European Consensus Guidelines, Neonatology 2010; 97:402
J. Wyllie et al. Resuscitation 81S (2010) e260
Maximum proximity of real PIP, PEEP and Ti values to desirable; minimum variability of these values
less risks of volutrauma (lower and more stable VT )
Limited ability to feel the pliability of lungs.
Settings modification requires more time and skills
Increased air leak from under the mask
Change of flow rate significantly alters ventilation settings
Insufficient control of РІР, РЕЕР and Ті
risk of volutrauma
Better ability to feel the pliability of lungs.
Easier modification of ventilation settings
Less air leaks from under the mask
Lower impact of flow rate changes to ventilation settings
C.P. Hawkes et al. Resuscitation 83 (2012) 797
Т-system Self-filling bag
C.C. Roehr et al. Resuscitation 81 (2010) 202
Т-system Self-filling bag
Respiratory volume (VT), ml
ml cm Н2О
Peak inspiratory pressure (РІР), cm Н2О
p < 0,0005 p < 0,001
Sp
O2
(%)
Т-system Bag Minutes after delivery
J. A. Dawson et al., J. Pediatr. 2011;158:912
Median, 25th-
75th
percentiles
and
measurement
limits are
displayed
p>0,05
Face masks Round masks are used more often
Facilitate the use of ventilation, filling of lungs, РЕЕР і СРАР
Their use may be often accompanied by airways obstruction and/or air leaks
Nasal prongs/ special cannula Shortened endotracheal tube
Significant air leak
May be more effective than mask
Equipment: Resuscitative bags of both types and T-systems may be used
Nasal prongs/cannula may provide more effective ventilation than mask
Monitoring: to use pulse oximentry, insifficient data to recommend respiratory volume measurement
J. Wyllie et al. / Resuscitation 81S (2010) e260
© 2010 American Heart Association, Inc.
Exp
irat
ion
vo
lum
e (m
l/kg
)
D.A. Poulton et al., Resuscitation 82 (2011) 175
Resuscitation teams could not give visual assessment of chest excursion adequacy for EPNs!
• «No movements» - 4.4 (3.0-7.0) ml/kg
• «Uncertain movements» - 3.7 (3.0-5.6) ml/kg
• «Proper movements» - 5.2 (2.9-8.9) ml/kg
• «Excessive movements» - 5.8 (2.4-8.6) ml/kg
• «Insufficient movements» - 7.8 (3.6-10.3) ml/kg
20 newborns at ≈ 27
weeks of gestation
Royal Women Hospital, Melbourne, Australia
Non-invasive respiratory support optimization
Detection of airways obstruction
Providing of proper RV
Independent breathing diagnostics
Assessment of ventilation frequency
Inspiration and expiration duration
Correct ETT position and gas leak availability
G. Lista et al., Neoreviews 2012;13;e364
Pressure
(cm Н2О)
Flow
(ml/s)
Volume
(ml)
G. Lista et al., Neoreviews 2012;13;e364
Inspiratory flow
Expiratory flow
G. Lista et al., Neoreviews 2012;13;e364
Uncontrolled ventilation Controlled ventilation
Pressure
(cm Н2О)
Flow
(ml/s)
Volume
(ml)
K. Schilleman et al. J. Pediatr. 2012. In press
No flow – obstruction
Gas leak
UC San Diego Medical Center, USA
Finer N. et al. Clin Perinatol 39 (2012) 931
Covers all the new regulations of International Scientific Consensus of 2010.
Includes the concept of initial stabilization of preterm infants condition
Proposes the necessity to use modern methods of respiratory support and monitoring (resuscitative T-system, laryngeal mask, СО2 detectors, pulsoxymeters)
Includes separate detailed rules of preterm infants care and expanded Apgar scale
Reprecents the concept of palliative care
Contains a separate protocol on therapeutic hypothermia
To leave with mother
BIRTH
30 s
60 s
Term delivery? Breathing or crying?
Muscular tone is good?
Provide warming and free airways, dry, and stimulate
Routine care • Provide warming • Free airways • Dry • Assess condition in dynamic
state
Yes
Apnoea, gasping or heart rate<100? Complicated breathing or stable
cyanosis?
Ventilation, need in SpO2 monitoring Free airways, need in SpO2 monitoring, CPAP
No
No
No
Yes Yes
Heart rate < 100?
Necessity of intubation Start ICM, coordinate with ventilation
Adequate ventilation control
Yes
Yes
Post-resuscitative care
1 min
2 min
3 min
4 min
5 min
10
min
60-65%
65-70%
70-75%
75-80%
80-85%
85-95%
EffectiveSpO.
norms2%
Adrenalin IV
Correct ventilation Intubate if no movements observed!
Possibility of: • Hypovolemia • Pneumothorax
No
Heart rate < 60?
Heart rate < 60?
© 2010 American Heart Association, Inc.
J. Wyllie et al. / Resuscitation 81S (2010) e260
Yes
≥ 32
weeks!
BIRTH
30 s
60 s
• Transfer to resuscitation table • Provide warming and free airways, dry, and stimulate • Attach pulsoximeter sensor to the right hand (preductively) • Assess the ability to breathe independently, heart rate and SpO2
• Sanitate upper airways (upon indication)
• Apnoea, gasping OR • Heart rate<100 OR • SpO2 < 40%
Independent breathing
• «Lungs filling** 10 s (РІР 20-25 cm Н2О; FiO2 30-40%) СРАР (5 cm Н2О; FiO2 30-40%) OR
• ventilation(РІР 20-25 cm Н2О, РЕЕР 5 cm Н2О, FiO2 30%)
СРАР 5-7 cm Н2О****
Yes Yes
HR increased?
• Continue ventilation(РІР 20-25 cm Н2О; РЕЕР 5 cm Н2 О; FiO2****)
Yes
N
o
Apnoea, gaspings
< 32 weeks!
Independent breathing (IB): hold a newborn below placenta level; clamp and cut the cord after 30-45 s*; provide thermal protection
No independent breathing (IB)*...
• Independent breathing
• Heart rate ≥ 100 • SpO2 ≥ 40%
• Monitoring: 1. IB available 2. Complicated
respiration 3. SpO2
4. Heart rate 5. Skin colour 6. Activity
• Transfer to NICU • Surfactant (in case
of intubation FiO2>0,3)
• Adequate filling/ventilation? • Repeat filling of lungs, start ventilation
Assessment: HR, SpO2, IB
Initial RS
Condition
assessment
• Continue ventilation(РІР 20-25 cm Н2О; РЕЕР 5 cm Н2 О; FiO2****)
• Adequate filling/ventilation? • Repeat filling of lungs, start ventilation
HR<60
• Trachea intubation*** • Start ICM • Continue ventilation (РІР
20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 90%)
• Coordinate ICM and ventilation
60<HR<100 HR>100
• Trachea intubation*** • Continue ventilation (РІР
20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 40%)
Assessment: HR, SpO2
HR<60 60<HR<100
HR>100
• Inject adrenalin into trachea • Continue ventilation (РІР 20-25
cm Н2О; РЕЕР 5 cm Н2О; FiO2 90%)
• Continue ICM • Catheterize cord vein
Assessment:
HR, SpO2
• Administer adrenalin IV • Continue ventilation (РІР 20-25 cm
Н2О; РЕЕР 5 cm Н2О; FiO2 90%) • Continue ICM • Administer physiological
solution IV*****
HR<60
< 32 weeks!
BIRTH
30 s
60 s
• Transfer to resuscitation table • Provide warming and free airways, dry, and stimulate • Attach pulsoximeter sensor to the right hand (preductively) • Assess the ability to breathe independently, heart rate and SpO2
• Sanitate upper airways (upon indication)
• Apnoea, gasping OR • Heart rate<100 OR • SpO2 < 40%
Independent breathing
• «Lungs filling** 10 s (РІР 20-25 cm Н2О; FiO2 30-40%) СРАР (5 cm Н2О; FiO2 30-40%) OR
• ventilation(РІР 20-25 cm Н2О, РЕЕР 5 cm Н2О, FiO2 30%)
СРАР 5-7 cm Н2О****
Yes Yes
HR increased?
• Continue ventilation(РІР 20-25 cm Н2О; РЕЕР 5 cm Н2 О; FiO2****)
Yes
N
o
Apnoea, gaspings
IB: hold a newborn below placenta level; clamp and cut the cord after 30-45 s*
No independent breathing...
• Independent breathing
• Heart rate ≥ 100 • SpO2 ≥ 40%
• Monitoring: 1. IB available 2. Complicated
respiration 3. SpO2
4. Heart rate 5. Skin colour 6. Activity
• Transfer to NICU • Surfactant (in case
of intubation)
• Adequate filling/ventilation? • Repeat filling of lungs, start ventilation
Assessment: HR, SpO2, IB
Initial RS
Condition
assessment
< 28 weeks!
• Put a child into a plastic bag
• Continue ventilation(РІР 20-25 cm Н2О; РЕЕР 5 cm Н2 О; FiO2****)
• Adequate filling/ventilation? • Repeat filling of lungs, start ventilation
HR<60
• Trachea intubation*** • Start ICM • Continue ventilation (РІР
20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 90%)
• Coordinate ICM and ventilation
60<HR<100 HR>100
• Trachea intubation***
• Continue ventilation (РІР 20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 40%)
Assessment: HR, SpO2
HR<60 60<HR<100
HR>100
• Inject adrenalin into trachea • Continue ventilation (РІР 20-25
cm Н2О; РЕЕР 5 cm Н2О; FiO2 90%)
• Continue ICM • Catheterize cord vein
Assessment: HR, SpO2
• Administer adrenalin IV • Continue ventilation (РІР 20-25
cm Н2О; РЕЕР 5 cm Н2О; FiO2 90%)
• Continue ICM • Administer physiological
solution IV*****
HR<60
< 28 weeks! GA < 25 weeks
GA ≥ 25 weeks
• Stop resuscitation
• Start palliative care
Resuscitation refuse or its discontinuation do not mean that no medical care is provided to the patient. It means a transfer to the so-called palliative or "comforting" care if a newborn still stays alive
PC for a newborn infant means complete set of measures that prevent or alleviate additional suffering and improve conditions of the last period of infant's life
PC is prescribed to a newborn in 3 cases: lethal developmental abnormalities;
resuscitation does not correspond to the best interests of a child;
obvious useless on intensive care
Catlin A. J. Perinat. 2002; 22:184
Palliative care. Nuffield Council on Bioethics, London, 2006: 97
0
100
200
300
400
500
600
<5% 5-9% 10-14% 15-24% 25-32% 33-49% 50-66% >66%
395
221
140 139 95 94
52 36
591
378
238
303
210 204
140 114
Тривалість ШВЛ Тривалість госпіталізації Hospitalization term
Days
Likelihood of survival without severe disability (%)
J.E. Tyson et al., N Engl J Med 2008;358:1672
N.A. Parikh et al., Pediatrics 2010;125;813
25
weeks
>60%
22 weeks, <10%
* EPN – extremely preterm newborn
USA, 4446 infants of 22-25 weeks, 2008
Ventilation term
Meadow W. et al. Clin Perinatol 39 (2012) 941
• Survival of newborns with < 600 g depends on gestational age, according to data from NICHD
• "Intact" survival in NICU is relevantly independent of GA!
• % of all infants of < 26 weeks of GA, which survived with severe neurological results depending on GA
• Most infants who survived with these results were born at GA, as the survival
depends on the GA while the % of affected infant does NOT!
Gestation week
% of survivals
% of general "acceptable" survival
% of "acceptable" survival in NICU
week
s week
s week
s week
s
Time and money
Prenatal consulting
Resuscitatio
n
Treatment
attempt
Discharg
e from
NICU
Refusal from
resuscitation
Death in the delivery
room
Death in NICU
GA; ACS; multiple
gestation, SGA
GA; ACS; multiple
gestation, SGA, Apgar
SNAP, intuition,
NSG
RN, BPD, cerebral
palsy
Meadow W. et al. Clin Perinatol 39 (2012) 941
Prognostic criteria GA - gestational age; ACS – antenatal corticosteroids; SGA – small
for gestational age; SNAP – the scale for evaluation of condition
severety; NSG - neurosonography
0
10
20
30
40
50
60
70
80
90
Вижили Вижили без важких наслідків
Припинення ШВЛ до смерті
6 0
82
16
8
77
55
9
66 72
20
68
%
B.J. Stoll et al. Pediatrics 2010;126;443 9575 infants of GA 22-28 weeks, 2003-2007
Long-term ventilation (> 60 s) or complete * resuscitation
Short-term ventilation using mask and air (≤ 60 s)
• Apgar score at 5 min ≥ 7 • Within 15 min after ventilation was discontinued
– HR>100/min – SpO2 > 85%, no central cyanosis (without supportive
О2) – No respiratory disfunctions – Acceptable or lightly decreased muscle tone – No other pathological characteristics
• Put a hat and socks on • Return infant to the mother's chest, providing skin-
to-skin contact • Cover with cloth and blanket • Continue observation (amendment 4)
Stable condition with N monitoring values
Unstable condition with deviation of any
valuefrom N
• Complete objective inspection immediately after resuscitation
• Urgent transfer to neonatal intensive care unit (following the rules of "warm chain")
• Administration of additional oxygen or CPAP in case of relevant indication
• Provision of access to vessels and intravenous fluid introduction in case of indications
• Monitoring and maintenance of main life functions • Consultation with regional centre* • Call of transport team in case of indications*
• Immediate complete objective inspection
• Standard clinical measures
Eligibility to participate in therapeutic hypothermia programme (art. 4.19)**
• Start of passive cooling (art. 4.5)
Yes
No Yes No
resuscitative support given to newborns often 'deviates' from the requirements, and description of interventions provided in clinical documents differs from real practice of medical staff»
Organization
Video registration, self-assessment and debriefing
Training in simulated environment
Monitoring of the results
Documentation
M. Rudiger et al. Early Human Development 87 (2011) 749
W.D. Rich et al. Clin Perinatol 37 (2010) 189
Finer N. & Rich W.D. Journal of Perinatology (2010) 30, S57
«No other medical profession gives this unique privilege – not
only preventing the last breath but presenting the first
inspiration…» D.Vidyasagar