Journal of Perinatology (2010) 30, S57–S66 r 2010 Nature America, Inc. All rights reserved. 0743-8346/10 www.nature.com/jp REVIEW Neonatal resuscitation for the preterm infant: evidence versus practice

N Finer and W Rich Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of California San Diego Medical Center and School of Medicine, San Diego, CA, USA

room (DR) and that intensive resuscitation is required in 1% of all In an effort to determine the actual conduct of neonatal resuscitation and deliveries.1 Approximately 5 to 10% of the newly born population the errors that may be occurring during this process, we developed a requires some degree of active resuscitation at birth (for example, method of video recording neonatal resuscitations as an ongoing quality stimulation to breathe) and B1 to 10% of these infants are assurance project. We initiated video recordings of resuscitations using reported to receive assisted ventilation. Although there have been a simple video recorders attached to an overhead warmer and reviewed the number of small studies of various resuscitation interventions, resultant tapes during biweekly quality improvement meetings. We also there have been very few large prospective well-designed added the continuous recording of analog information such as heart rate, randomized trials. This probably reflects the difficulty of oximeter values, fraction of inspired oxygen and airway pressure. We performing prospective clinical research during neonatal subsequently developed a checklist that includes a preresuscitation briefing resuscitation and thus there is minimal high-grade evidence and a postresuscitation debriefing, all of which are reviewed at the same to support many currently recommended practices.2 time as the video recording. We have examined the use of oxygen in the In the late 1990s, our center decided to evaluate our adherence very preterm infant, the effectiveness of bag and mask ventilation, including to current resuscitation guidelines. A review of medical records the detection of airway obstruction during such ventilation, intubation in showed that the data were inconsistent and incomplete. In view of the delivery area and environment. In addition, we have trained our teams these observations, and our concern that errors may be occurring and leaders using Crew Resource Management and focused on improved during neonatal resuscitation, we developed a method of video communication. The availability of a dedicated room for resuscitation recording neonatal resuscitations as an ongoing quality assurance allows an increased ambient environment and the ability to provide a user- project. The initial results of that project demonstrated that there friendly setting similar to the neonatal intensive care unit to optimize were frequent deviations from practices as taught using the performance. There are numerous opportunities for improving team and National Resuscitation Program (NRP) guidelines. We chose video leader performance and outcomes following neonatal resuscitation. Further recording as the tool for assessing ongoing quality assurance and prospective studies are required to evaluate specific interventions. clinical competence because of the previous lack of objective data Journal of Perinatology (2010) 30, S57–S66; doi:10.1038/jp.2010.115 for the evaluation of actual neonatal resuscitations. The videotaped Keywords: neonatal resuscitation; resuscitation team training; recording of performances provides an unbiased documentation of 3 Crew Resource Management; oxygen use; ventilation; intubation clinical skills and judgments during actual resuscitation. We developed a quality assurance tool for reviewing the videotaped recordings, which allowed us to systematically identify and quantify variations in practice occurring in our resuscitation. The results of Introduction our first 100 videotaped resuscitations revealed that there were 4 Neonatal resuscitation is required for B3% of births, and is the frequent repetitive deviations from the NRP guidelines. By most frequently recurring form of resuscitation performed in establishing a routine quality assurance program using the video hospitals. Currently, it is estimated that in the United States over tapes, we were able to virtually eliminate four of the six minor 400 000 infants each year require some assistance in the delivery errors that we recognized, including deep suctioning, excessive stimulation, not communicating the heart rate and not Correspondence: Dr N Finer, Division of Neonatal-Perinatal Medicine, Department of reevaluating bag–mask ventilation. Our observations were also Pediatrics, University of California San Diego Medical Center and School of Medicine, 402 Dickinson Street, MPF 1-140 San Diego, CA 92103-8774, USA. consistent with the types of problems described during trauma E-mail: nfi[email protected] resuscitation, which included poor teamwork, deficiencies in This paper resulted from the Evidence vs. Experience in Neonatal Practices Conference, leadership, poor communication and failure to adequately perform 5 19 to 20 June 2009, sponsored by Dey LP. assigned tasks. Video review combined with specifically defined Neonatal resuscitation for the preterm infant N Finer and W Rich S58 errors and acceptable deviations has been shown by Oakley et al.6 (126.3±21.8 versus 72.2±6.8 mm Hg). Ramji et al.10 reported to be better than chart review in recognizing management and the first randomized trial to compare air with 100% oxygen for leadership errors, although less effective in recognizing items such neonatal resuscitation of depressed term infants. This preliminary as dosing errors, which are not easily visible. This group also noted study reported that air was as effective as 100% oxygen for that the absolute number of management errors was high in their resuscitation. Saugstad et al.11 then reported on a subsequent trial trial because of the nature of video review and its superiority of 609 infants from 10 centers, the Resair 2 study, 288 of whom to clinician memory.6 We have continued to use actual video were resuscitated with air and 321 with 100% oxygen. Mortality in recordings of human resuscitations in our institutionFit is now a the first 7 days was 12.2 and 15.0% (odds ratio (OR) 0.79, 95% biweekly quality improvement activity in our hospitalFand this confidence interval (CI) 0.49 to 1.26) in the air and oxygen process continues to highlight for us many areas of potential groups, and neonatal mortality was 13.9 and 19.0% improvement. The current review focuses on our observations and (OR 0.60, 95% CI 0.44 to 1.06), respectively.11 Death within 7 days practices as they relate to the resuscitation of preterm infants. and/or moderate or severe hypoxic–ischemic encephalopathy, the primary outcome measure, was not significantly different. This study, which enrolled patients primarily from developing countries, Oxygen use in the DR reported that asphyxiated newborn infants can be resuscitated The practice of mouth-to-mouth resuscitation was the first natural with air as efficiently as with 100% oxygen. They noted that experiment using gas mixtures without supplemented oxygen for resuscitation with 100% oxygen might depress ventilation and artificial ventilation. Standard practice evolved to include the use of therefore delay the first breath. Saugstad et al.12, in 2003, reported pure oxygen for assisted ventilation, without any evidence to the 18- to 24-month follow-up of infants in the Resair 2 suggest that this would produce improved outcomes. Neonatal resuscitation trial. Of the original 591 enrolled infants, basic resuscitation is primarily directed toward establishing early lung follow-up information was available for 213 of 323 surviving aeration and maintaining lung volume during expiration, which eligible infants from 7 of the original 10 centers. There was no will overcome the initial vagal bradycardia. It remains unclear significant difference in neurological handicap, somatic growth or whether oxygen facilitates this process, or contributes to potential developmental milestones when comparing infants who received reperfusion injury, inhibition of spontaneous breathing and 100% oxygen with those who received air for initial resuscitation. possible aggravation of atelectasis by the attenuation of nitrogen Saugstad et al.13 have reviewed the five trials that compared the splinting. At present, there is no agreement regarding the initial or use of air with 100% oxygen and reported that the use of air was optimal oxygen concentration for resuscitating the extremely low associated with a significant lowering of mortality from 13 to 8%, gestational age neonate. The current NRP guidelines indicate that P ¼ 0.0021, with an OR of 0.57 (95% CI 0.42, 0.78). No difference such resuscitation or stabilization may be performed with any was observed for infants with a 1 min Apgar score of <4 (OR 0.81; oxygen concentration and that a pulse oximeter should be applied 95% CI 0.54, 1.21). In term infants, neonatal mortality was 5.9% in and blenders available to facilitate the optimal saturation of the 21% O2 group and 9.8% in the 100% O2 group (OR 0.59; 95% 7 peripheral oxygen (SpO2) values during resuscitation. As recently CI 0.40 to 0.87). These results are similar to those reported in the as 2005, virtually all DR resuscitation for extremely low birth recent reviews by Tan et al. and Davis et al.14,15 Further analysis of weight (ELBW) infants in the United States was performed using the studies from Spain demonstrated a similar reduction in 100% oxygen. We published a survey of resuscitation practices in mortality from 3.5% in the 100% oxygen group to 0.5% in the air the United States that demonstrated that 42% of programs had group, suggesting that the reduction in mortality was not exclusive installed blenders in the DRs but 77% continued to begin to studies conducted in Third World environments.16 Of more resuscitation with 100% oxygen, ensuring that most preterm relevance, an analysis of preterm infants revealed an even greater infants would receive 100% oxygen as the initial resuscitating gas.8 reduction in mortality from 35 to 21% (OR 0.51 (95% CI 0.28 to It is understood that the intrauterine PaO2 levels in the fetus are 0.90), P<0.02) for infants receiving 100% oxygen compared 17 in the 15 to 30 mm Hg (2 to 4 kPa) range, resulting in fetal SpO2 with air. levels of 45 to 55%, and that, following delivery, these levels will Despite these trials, there is no agreement on the initial or gradually rise to between 50 and 80 mm Hg (an SpO2 of about optimal oxygen concentration for resuscitating the very low birth 90%) depending on the status of the lungs, the pulmonary weight and ELBW infant. The current NRP guidelines indicate that circulation and the presence of other stressors at delivery. Vento such resuscitation or stabilization may be performed with any et al.9 reported arterial blood gases obtained from the umbilical oxygen concentration between 21 and 100% and that a pulse artery during resuscitation in a blinded and randomized trial. oximeter should be applied and blenders available to facilitate 4 When infants were resuscitated with pure oxygen PaO2, levels were the optimal SpO2 values during resuscitation. above 100 mm Hg at 5 to 6 min, at 15 min, and thereafter, whereas Current evidence suggests that many morbid conditions infants resuscitated with air did not exceed 80 to 90 mm Hg associated with prematurity are potentiated by an excess of free

Journal of Perinatology Neonatal resuscitation for the preterm infant N Finer and W Rich S59 radicals occurring in infants who are intrinsically deficient in very smallest of infants, we continue to continuously monitor the enzymatic antioxidants such as superoxide dismutase, catalase heart rate using auscultation until the oximeter is operational. and glutathione peroxidase.18–20 Preterm rabbits are unable to The evaluation of oxygenation in the minutes after birth has upregulate deficient antioxidants,21 and Silvers et al.22 have largely been through examination of color. There is now reported that low plasma antioxidant activity at birth in premature significant information regarding the increase in SpO2 following infants was an independent risk factor for mortality. It is known delivery for infants, including extremely low gestational age that, during hypoxia, metabolic alterations prime cells to produce neonates, who did not require any resuscitation.37,38 Fetal arterial free oxygen radicals when the cells are subsequently exposed to oxygen saturation levels are known to be lower than neonatal oxygen. This reoxygenation/reperfusion injury, in addition to arterial oxygen saturation levels, with an average of 50% in fetal increasing the production of free oxygen radicals, is associated with lambs,39 and may be <30% in a stressed fetus. The first studies other potentially toxic metabolic changes. Recent experimental using fetal pulse oximetry demonstrated that fetal SpO2 was studies have shown that pulmonary arterial contractility increases B58±10% during labor.40 The rate of change from fetal to with the use of 100% oxygen on reoxygenation and that previous neonatal values after birth has been demonstrated by multiple exposure to 100% oxygen decreased responsiveness to inhaled nitric investigators to be more gradual than previously believed, with 23 24 oxide. Kumar et al. showed that resuscitation with air decreased actual SpO2 values reaching the expected neonatal levels after 5 to oxidative stress in asphyxiated newborn lambs without increasing 15 min of life.41–45 House et al.46 reported that average oxygen metabolic acidosis. There are now at least six small prospective saturation was 59% at 1 min, 68% at 2 min, 82% at 5 min and 90% randomized trials comparing the use of lower and higher at 15 min. Oxygen saturation was <30% in 12 neonates and <50% oxygen concentrations during neonatal resuscitation in preterm in 26 neonates at some time during the 15-min monitoring period. 25–30 infants using targeted SpO2. These trials have compared lower In term infants, preductal SpO2 values have been reported to be versus higher initial oxygen concentrations and all evaluated B5 to 10% higher than postductal values in the first 5 min of short-term neonatal outcomes. In the Vento et al.28 study, there life47,48. Mariani et al.49 confirmed the presence of such gradients was a reported decrease in bronchopulmonary dysplasia in their for the first 15 min of life. Rabi et al.50 reported that infants low inspired oxygen group, a benefit not reproduced in the other delivered by cesarean delivery had a 3% lower SpO2 than infants prospective trials. None of these trials were powered to evaluate delivered by vaginal delivery and took longer to reach a stable SpO2 survival without significant neurodevelopmental disability. X85%. At 5 min of age, vaginally delivered infants had an SpO2 of Along with others, we have now planned two large randomized, 87% (80 to 95%) versus 81% (75 to 83%) for infants delivered 51 blinded, prospective trials that would use targeted SpO2 to by cesarean section. Kamlin et al. reported that infants of <37 compare initial fraction of inspired oxygen (FiO2) levels, and weeks who did not require resuscitation reached an SpO2 of 75% would be powered to evaluate survival without significant after 4.2 min, and an SpO2 of 90% at 6.5 min, whereas these values neurodevelopmental impairment at 2 years of age. We are were reached at 2.5 and 4.7 min for term infants. We have hopeful that these trials will provide evidence to improve the initial suggested that the initial SpO2 following delivery can be assumed to resuscitation of very preterm infants.31 be around 50% and increases B5 to 6% per min for the very preterm infant. This will result in an SpO2 of 65 to 70% at 3 min, 75 to 80% at 5 min and 85 to 90% by 7 to 8 min of age. Pulse oximeters Pulse oximetry has been shown to provide useful information Bag and mask ventilation during the neonatal transition from fetal life,32–36 and has become Approximately 85 to 90% of the most immature infants require the standard for preterm deliveries. Once operational, a pulse intubation as part of their neonatal care and almost all such oximeter provides a continuous heart rate, which is more helpful infants will require some form of assisted ventilation or continuous in assessing the benefit of any intervention than the currently positive airway pressure. The standard approaches to provision of recommended infrequent checking of heart rate. We have found this support include bag and mask ventilation, followed if that a useful signal is not always available within 1 min of birth in necessary by endotracheal intubation. The design of the bag and depressed infants, even when applied by a trained respiratory mask used for neonatal resuscitation has changed very little. The therapist using proper techniques. This delay is the result of the standard 500 ml Jackson/Rees-type anesthesia bag or the self- sensitivity of the individual oximeter, poor peripheral perfusion and inflating bag has been used for decades. Masks, whether round or the pulse oximeter averaging algorithm. We recommend the anatomically shaped, have also changed little. Recently, some use of the right hand or wrist to monitor preductal SpO2 values. changes have occurred in the provision of positive pressure Continuous palpation/auscultation of the heart rate during ventilation. The existence of a commercial T-piece has changed the resuscitation is vital to gauge the effects of resuscitation process of manual ventilation, providing a more consistent delivery interventions, and even though we find it to be inconsistent in the device,52,53 and masks that are appropriately sized for infants under

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500 g have made it possible to get even the smallest infant out of required after delivery for absent or inadequate respirations; the DR without intubation. Assurance of a patent airway is critical (2) bag and mask ventilation is not effective or will have to be irrespective of the ventilation device used. Chest wall movement is prolonged; and (3) surfactant needs to be administered. Our own the most common method of determining the adequacy of experience in evaluating and attempting to improve neonatal ventilation with a bag and mask. The visualization of chest rise is intubation is based on our ongoing quality improvement program often difficult because of operator position, a crowded bed space involving the video and analog data recording of high-risk and infant size. Adequate chest rise in the very low birth weight deliveries and the subsequent review of such resuscitations,62 and a infant may be a subtle finding and may be confused with prospective database of all neonatal intubations, which we abdominal rise; thus, the ability to detect adequate chest rise maintain in our Neonatal Program.63 From our video reviews, we requires experience to develop. Tracy et al.54 have shown that demonstrated that the overall success rate for neonatal intubation hypocarbia and hyperoxia occur frequently in the intubated during resuscitation was B33% within the allotted 20 s stated ventilated preterm infant during resuscitation when chest rise is in current guidelines and overall 56% using a 30 s duration.64 used as a marker for determining appropriate ventilatory pressures. We, along with others, have subsequently reported that the failure We have introduced the use of a colorimetric semiquantitative rate using a 30 s interval is substantially greater for infants of carbon dioxide detector to assist in the recognition of airway <28-week gestation.65,66 A detailed review of the last 5 years of our patency during bag and mask ventilation of the ELBW infant.55 intubation database has demonstrated that, on an average, at least We have found that over 80% of such infants receiving bag and three attempts are required for the successful intubation of infants mask breaths have evidence of airway obstruction during the initial of <1000 g birth weight, and we have reviewed resuscitations in breaths and that such airway obstruction may persist for 37 or which 10 or more attempts were required by experienced operators more breaths over a period of a minute or longer.56 These for such infants. This is especially true for infants <700 g at obstructed breaths may often go unrecognized in the absence of a birth or of <25-week gestation. Each attempt is associated with CO2 detection device and may lead to bradycardia and hypoxia, physiological instability, including hypoxia, bradycardia and blood and, in time, to further, more aggressive and hazardous pressure changes (Figure 1). Infants who are very immature with procedures, such as increased pressure compressions, intubation or birth weights <1000 g have very small airways and even the larynx medications, if not rapidly recognized and relieved. at term is small in its gross size compared with the mouth and upper pharynx;67 furthermore, the size of the cricoid ring and that of other cartilaginous components vary directly with gestational Intubation age.68,69 The neonatal larynx is more anterior and newborns and Our current practice is to provide weekly resuscitation training for especially premature infants have a shorter neck than the older residents rotating through the neonatal intensive care unit (NICU). child.70 In the preterm infant, the larynx is very small and vocal An analysis of this process by Garey et al.57 has shown that cords not as well defined. The size of the larynx and oral airway is repeated training improved resuscitation skills. There does not, a very important component of the difficulty encountered in however, seem to be a clear relationship between manikin practice intubation of such infants. The small size and anterior location of and successful intubation skills; hence we also provide feedback for the larynx in such infants markedly decrease the ability to clearly all intubations that occur during resuscitation by way of video visualize the larynx of the smallest infants. Because of the small review. Although a review of the video provides significant details size of the infant’s mouth and the current design of even the regarding an operator’s approach and skill and will increase the smallest blades, once an ETT is placed in the mouth, there is often understanding of what needs to occur if performed consistently, the too little available space to see the larynx. Thus, it can be difficult acquisition of such a skill requires significant real-world to position the ETT at the laryngeal opening, and the tube is experience.58–60 Successful intubation in such infants typically often incorrectly placed in the much larger posterior esophagus. requires multiple attempts because of the small size of such Postintubation airway injury is more frequent with increasing infants’ airways and the difficulty in visualizing the larynx. From immaturity, which may be the result of the difficulty of the our evaluations and ongoing practice, it is clear that intubation procedure and the need to have repetitive attempts at intubation.71 during resuscitation and in the NICU is increasingly difficult with Indeed, a finger intubation technique that avoids the need to decreasing gestational age and birth weight. use instrumentation was one of the first descriptions of neonatal We, along with others, have demonstrated that the placement of intubation described by Woody and Woody in 196872, and although an endotracheal tube (ETT) in a newborn infant is associated seemingly simple and effective, this technique has not been with significant adverse physiological effects, including accepted by the great majority of practitioners, even though a bradycardia, fluctuations in blood pressure, hypoxia and increases recent small clinical trial from Brazil for infants >1000 g in intracranial pressure.61 The most common indications for demonstrated its effectiveness.73 This technique, however, is not intubation in the ELBW infant are when (1) resuscitation is effective for the small and very immature infant.

Journal of Perinatology Neonatal resuscitation for the preterm infant N Finer and W Rich S61

200.0

150.0

100.0 BPM

Pulse Rate 50.0

0.0 100.0

75.0

50.0 Sat Sat 25.0

0.0 60.0

45.0

30.0

15.0 cmH20 Bag Pressure 0.0 100.0

75.0

50.0 FiO2 25.0 Percent

0.0 0.0 6.012.0 18.0 minutes Figure 1 Multiple intubation attempts with significant decreases in oxygen saturation (Sat) in an extremely low birth weight infant. BPM, beats per minute; FiO2, fraction of inspired oxygen.

Current instrumentation is not designed specifically for ELBW can markedly improve the visualization of the inlet and the infants and is inadequate because it requires infant manipulation successful passage of the ETT. Failure to adequately visualize to acquire adequate visualization of the larynx, provides the laryngeal inlet will almost always result in the tube passing insufficient space for visualization of the larynx during the passage into the much larger and posterior esophagus. As different of an ETT, does not provide optimal visualization or magnification individuals need different levels of magnification, depending of the larynx and does not allow other team members to visualize on the properties of their eyes, not all operators find the use of and confirm the actual intubation. magnifying lenses or loupes useful and many are reluctant to The short length of the smallest laryngoscope blades and the use them. short horizontal distance of the airway in the ELBW infant present Video laryngoscopes have been developed primarily for adult use a unique challenge in visual accommodation, which may be dealt to facilitate the intubation of patients with challenging airways. with by stress accommodation in younger individuals. In fact, the This device uses a video camera mounted either on the blade of a near point of visual accommodation increases with age and is laryngoscope or in the handle, which provides a view into the B14 cm for 30-year olds, increasing to 22 cm by the age of 40, larynx for examination, intubation and the removal of foreign and by 50 years of age this distance is at least 40 cm.74 The bodies. Conventional direct-viewing laryngoscopes require the smallest available laryngoscope blades, Miller 00, are B6cmin operator to use a line of sight and necessitate a direct view of the length and most operators place their eye very close to the larynx. Video laryngoscopes have been developed with a charge- proximal end of the blade. From the review of video recordings coupled device or complementary metal oxide semiconductor during intubations of ELBW infants, we have found that the camera placed at a point on the blade, either at or back from the distance from the operator’s eye to the proximal end of the tip, and the camera can be angled to assist in viewing the anterior laryngoscope blade can be as short as 6 cm, resulting in a focal larynx behind the tongue.75 These devices can facilitate the distance of B12 cm, well below the near point for almost all intubation process by providing a much clearer and larger image. individuals who actually perform this procedure. Although younger We have evaluated the pediatric and neonatal video laryngoscopes operators may be able to accommodate at this distance, older that are available at present (DCI Video Laryngoscope, Storz, Culver individuals have decreased accommodation (presbyopia), and they City, CA, USA; Cobalt, Verathon, Bothell, WA, USA). The Storz has a cannot make such a visual accommodation. We have placed Miller 0 blade and in our experience does not provide adequate magnifying glasses and loupes in our DRs and they are also visualization for infants <700 g. The Glidescope Cobalt has a available in our NICU. These can improve the clarity and perceived newer smaller blade but it is too large for the small oral airway size of the larynx. As the laryngeal inlet is very small of infants <700 g and does not provide, in our hands, adequate in the ELBW infant, usually p3 mm in diameter, magnification visualization, nor enough space to pass an ETT in such infants.

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For larger infants, both instruments produce a very useful image the provision of blow-by oxygen or cricoid pressure during and can facilitate intubation when used by experienced operators.76 intubation; and poorly coordinated or completely uncoordinated compressions and ventilation. Robert Helmreich,81 one of the original designers of the process, Environment describes the fifth generation of Crew Resource Management All of the above interventions can be better accomplished in an (CRM), established in 1997, as an error management tool with environment conducive to critical care. The resuscitation suite three fundamental countermeasures. These are avoidance, trapping should be thought of as a place where the very best equipment is and mitigation. The use of CRM fundamentals in the DR needed. Vento et al.77 described the appropriate NICU environment environment to manage errors and improve outcomes can and as requiring at least one bed equipped with a blender and the should include all of these measures. capability of monitoring a variety of clinical variables, which he We developed team and leader ideal qualities and functions referred to as a DR intensive care unit bed. The delivery using the observations of Cooper and Wakelam.82 These included environment for most infants requiring resuscitation is not adequate preparation, having resuscitation team members who conducive to maintaining adequate temperature after birth. The were adaptable and who coordinated their activities and standard for preterm and nonasphyxiated term infants is an interventions using acknowledged clear and concise environment that provides for minimal heat loss and metabolic communication, under the direction of a calm and knowledgeable oxygen consumption. In randomized controlled trial of 55 infants leader.83 Communication is the primary framework of CRM, a of <28-week gestation, Vohra et al.78,79 demonstrated that methodology developed for the training of air crews from the late a polyethylene occlusive wrap in very low birth weight infants 1970s that evolved from a careful evaluation of the role of human is associated with a significant increase in mean temperature error in air crashes,84 and of resuscitation leadership as well. (0.9 1C P<0.002) and survival (P<0.001). In a meta-analysis A good leader has the ability to clearly and succinctly provide of trials involving occlusive wraps, the same author found that commands, while encouraging and integrating the suggestions wrapped infants were admitted with a significantly higher of other team members. CRM is the basis for much of the team temperature but were not significantly less likely to die.80 When and leader training used in a variety of medical areas, which used together, an occlusive wrap, a warm room and an efficient include the operating room, the emergency room and, in our radiant warmer can combine to make an ELBW infant too institution, the DR. warm. Therefore, close monitoring of temperature is recommended Avoiding errors requires some system of pre-event by both groups. To avoid inappropriate warming or cooling, communication, based on an established procedure. Knowing what a temperature probe should be applied in the DR. In addition, each team member is supposed to do while in the DR and we recommend that one member of the team be assigned to providing consistent training to ensure that they know how to note the infants actual temperature every 5 min. In very perform each of those tasks eliminate errors such as multiple immature infants, especially those below 500 g at birth, the individuals performing one task and, almost by definition, omit addition of a chemical warmer may be needed, especially if the others. A prebriefing ensures that roles are understood, that the room temperature is too low. specifics of a given delivery are provided for and that each member is reminded that they are expected to speak up if they see something that concerns them. Planning and carrying The team out a prebrief for all resuscitations will go a long way toward Having a functioning team is critical to managing DR outcomes. avoidance of errors. Neonatal resuscitation of the preterm infant requires a team of Trapping errors is accomplished in the cockpit by crosschecking, individuals who are well versed in their roles. There are at least two which is the process of checking information using a second distinct outcomes that can be measured. These include evaluating source. For instance, in the DR, an oximeter registering a heart whether the actual intervention was the correct one and, second, rate that is slow in an infant who seems otherwise stable can be whether the intervention was performed correctly. The most cross-checked with a stethoscope. difficult outcome to evaluate is whether the chosen interventions Mitigation occurs when an error, already defined as an are associated with improved survival without morbidity. An initial inevitable part of human interaction, is minimized by recognizing video review of resuscitations at the University of California at San it quickly. Every team member sees the process from a different Diego revealed a number of problems in the conduct of the perspective and the information provided by them should be resuscitation involving the team, the leader or both. As examples of acknowledged and processed. Empowering each team member such problems, we noted more than one person doing a single task; to verbalize any concern during resuscitation will increase the other tasks that were not performed at all, such as providing a likelihood that such an error is recognized and either avoided or at continuous communication of the infant’s heart rate, the lack of least mitigated.

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The leader processes that include checking environmental factors such as bed It is the primary role of the leader to bring together the first two temperature, technical problems such as not properly assessing processes we have discussed: ensuring that correct interventions are heart rate, and communication issues such as not repeating back chosen and ensuring that they are carried out correctly. To orders, all the while assessing the status of the infant, predicting accomplish this, the leader must have what is referred to in CRM the future course and determining the appropriate next step. We 85 as ‘situational awareness’, the process of reviewing, monitoring and have taken our previously validated resuscitation scoring tool and predicting, and this is the single most important function of the added a component to measure leadership skills based on CRM leader during DR resuscitations. If the team has chosen the wrong fundamentals. intervention, or someone is not skilled in a particular task, or they We have developed a preresuscitation checklist, which allows are too busy to carry out a particular intervention, it is up to the each team member to be prepared and review their own functions leader to recognize this fact while still maintaining an awareness of during the upcoming resuscitation, while providing a time for the status of the infant. This requires a skill called scanning, questions during the preresuscitation briefing held by the whereby the leader goes through a mental checklist of critical team leader (Figure 2). The resuscitation is followed by a

Figure 2 The checklist used at University of California San Diego (UCSD) Medical Center for all neonatal resuscitations.

Journal of Perinatology Neonatal resuscitation for the preterm infant N Finer and W Rich S64 postbriefing, which is meant to answer three simple 5 MacKenzie CF, Jeffries NJ, Hunter WA, Bernhard WN, Xiao Y, and the LOTAS group. questionsFWhat did we do well, what could we do better Comparison of self-reporting of deficiencies in airway management with video analysis and how could we do it better? of actual performance. Hum Factors 1996; 38: 623–635. 6 Oakley E, Stocker S, Staubli G, Young S. Using video recording to identify management errors in pediatric trauma resuscitation. Pediatrics 2006; 117: 658–664. 7 Kattwinkel J (ed). Neonatal Resuscitation Textbook, 5th edn, American Academy Physiological data recordings of Pediatrics: Elk Grove Village, IL, 2006. The use of real-time collection of physiological measurements in 8 Leone TA, Rich W, Finer NN. A survey of delivery room resuscitation practices in the DR, especially in conjunction with video recording, has been the United States. Pediatrics 2006; 117(2): e164–e175. shown to be useful in reviewing resuscitations.86 Our current 9 Vento M, Asensi M, Sastre J, Lloret A, Garcı´a-Sala F, Vin˜a J. Oxidative stress in asphyxiated term infants resuscitated with 100% oxygen. J Pediatr 2003; 142: practice is to gather oxygen saturation, pulse rate, FiO2, airway 240–246. pressure, end-tidal CO2 and audio on all recordings, with an option 10 Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth G, Saugstad OD. Resuscitation of to collect electrocardiogram (EKG) using the BioPac data asphyxic newborn infants with room air or 100% oxygen. Pediatr Res 1993; 34(6): acquisition and Acqknowledge 4.0 software (Biopac Systems, 809–812. Goleta, CA, USA). All data are collected at 30 Hz, except for EKG, 11 Saugstad OD, Rootwelt T, Aalen O. Resuscitation of asphyxiated newborn infants with which is collected at 60 Hz. Analysis includes maximum and room air or oxygen: An international controlled trial: the Resair 2 study. Pediatrics 1998; 102(1): E11–E17. minimum values for peak inspiratory pressure and positive end 12 Saugstad OD, Ramji S, Irani SF, El-Meneza S, Hernandez EA, Vento M. Resuscitation of expiratory pressure, respiratory and heart rates and an oxygen newborn infants with 21 or 100% oxygen: follow-up at 18 to 24 months. Pediatrics saturation histogram. However, at present, there is little evidence 2003; 112: 296. available to determine the optimal values for many of these 13 Saugstad OD, Ramji S, Vento M. Resuscitation of depressed newborn infants with parameters. We are able to evaluate whether the interventions were ambient air or pure oxygen: a meta-analysis. Biol Neonate 2005; 87(1): 27–34. 14 Tan A, Schulze A, O’Donnell CPF, Davis PG. Air versus oxygen for resuscitation of appropriate and were performed correctly (that is, an increase in infants at birth. The Cochrane Database of Systematic Reviews 2005, Issue 3. Art. 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