The Optimization of Preterm Newborn Resuscitation Ola Didrik Saugstad Dep of Pediatric Research University of Oslo Norway & Ann and Robert H. Lurie Children’s Hospital of Chicago / Northwestern University Feinberg School of Medicine USA 1 Outline 1. Need of ventilation 2. Resuscitation algorithms 3. Oxygen in DR 4. Recommendations for use of oxygen 5. SpO2 and HR at 5 min as predictors 6. Heat loss prevention DISCLOSURE STATEMENT Dr. Ola Didrik Saugstad has disclosed the following financial relationships. Any real or apparent conflicts of interest related to the content of this presentation have been resolved. Affiliation / Financial Interest Organization An unrestricted grant Chiesi Farmaceutici Reseach grants Laerdal Medical Interventions in term or near term newborn in the delivery room INTERVENTION FREQUENCY 130 mill Assess baby’s response to birth 100/100 Dry, keep baby warm, position correctly B Stimulate to breathe by drying A 20 mill Clear airways – only if needed 15/100 S I Establish effective bag & mask ventilation C 4-6 mill Start with air 3 – 5/100 2 mill Endotracheal intubation 2/100 A Provide chest compressions 0.8 mill D with oxygen < 1/1000 Adrenaline 6/10 000 V 0.8 mill A Volume N 0.1 mill expansion 1/12000 C E D Saugstad OD 2016 29-34 w Variable Routine O2/CPAP Bag/Mask ET CPR Level % 24 32.5 26.1 14.7 2.7 GA w OR 0.55 (0.51-0.59) 0.52 (0.48-0.55 0.37 (0.34-0.41) 0.41 (0.35-0.48 Multiples OR 1.29 (1.05-1.59) 0.95 (0.79-1.13) 0.69 (0.55-0.86) 0.40 (0.22-0.73) ANS OR 0.69 (0.53-0.89) 0.77 (0.58-1.01) 0.56 (0.41 -0.77) 0.22 (0.12-0.34) Death % 0.6 1.0 1.6 7.2 21.0 Bajaj M et al J Pediatr 2018;195:33-8 Need of CPR in 500-1500 g 6% with survival 63% Vs 89% not needing CPR Finer NN et al Pediatrics1999;104:428-34 eNewborn Summary of Data 2014-16 eNewborn: Networking with Modern Technology Dominique Haumont Brussels Decomposition of Infant Mortality GA Early Neonatal Late Neonatal Early Postneonatal Late Postneonatal Infant mortality Died Total Died Total Died Total Died Total Died Total 22 16 37 7 21 2 14 1 12 26 37 23 205 698 103 493 60 390 3 330 371 698 24 316 1700 167 1384 104 1217 4 1113 591 1700 25 235 2138 142 1903 93 1761 3 1668 473 2138 26 172 2602 115 2430 84 2315 5 2231 376 2602 27 119 3179 60 3060 56 3000 1 2944 236 3179 28 115 4049 62 3934 53 3872 2 3819 232 4049 29 91 4743 44 4652 25 4608 1 4583 161 4743 30 84 6111 38 6027 13 5989 1 5976 136 6111 31 78 7818 24 7740 24 7716 0 7692 126 7818 32 41 5272 34 5231 25 5197 0 5172 100 5272 Total 1472 38347 796 36875 539 36079 21 35540 2828 38347 D i s t r i b u t i o n p e r G e s t a t i o n a l W e e k 1 0 0 0 0 8 0 0 0 r e 6 0 0 0 b m u 4 0 0 0 n 2 0 0 0 0 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 G e s t a t i o n a l a g e w e e k s eNewborn: Total 38347 infants 22-32 Weeks Gestational Age 2014-16 European Data base – E newborn N e o n a t a l M o r t a l i t y 8 0 6 0 4 0 % 2 0 0 2 3 4 5 6 7 8 9 0 1 2 2 2 2 2 2 2 2 2 3 3 3 G e s t a t i o n a l a g e w e e k s R i s k o f N e o n a t a l M o r t a l i t y 6 0 ) I 4 0 C % 5 9 ( 2 0 R O 0 2 0 2 2 2 4 2 6 2 8 3 0 3 2 3 4 G e s t a t i o n a l a g e w e e k s I n f a n t M o r t a l i t y 8 0 6 0 4 0 % 2 0 0 2 3 4 5 6 7 8 9 0 1 2 2 2 2 2 2 2 2 2 3 3 3 G e s t a t i o n a l a g e w e e k s M o r t a l i t y 8 0 N e o n a t a l I n f a n t 6 0 4 0 % 2 0 0 2 3 4 5 6 7 8 9 0 1 2 2 2 2 2 2 2 2 2 3 3 3 G e s t a t i o n a l a g e w e e k s R e s u s c i t a t i o n p e r g e s t a t i o n a l w e e k 1 0 0 B a s i c R e s u s c i t a t i o n 8 0 6 0 % 4 0 2 0 0 2 2 2 4 2 6 2 8 3 0 3 2 3 4 w e e k s G A R e s u s c i t a t i o n p e r g e s t a t i o n a l w e e k 1 0 0 A d v a n c e d R e s u s c i t a t i o n 8 0 B a s i c R e s u s c i t a t i o n 6 0 % 4 0 2 0 0 2 2 2 4 2 6 2 8 3 0 3 2 3 4 w e e k s G A R e s u s c i t a t i o n p e r g e s t a t i o n a l w e e k 1 0 0 9 1 % A d v a n c e d R e s u s c i t a t i o n 8 0 B a s i c R e s u s c i t a t i o n 5 9 % 6 0 4 9 % % 4 0 2 0 5 % 8 % 0 2 2 2 4 2 6 2 8 3 0 3 2 3 4 w e e k s G A R e s u s c i t a t i o n p e r g e s t a t i o n a l w e e k 1 0 0 8 0 6 0 % 4 0 2 0 0 2 2 2 4 2 6 2 8 3 0 3 2 3 4 w e e k s G A R e s u s c i t a t i o n p e r g e s t a t i o n a l w e e k 1 0 0 8 0 6 0 % 4 0 2 0 9 2 9 6 9 7 9 6 9 5 9 2 8 8 8 2 7 3 5 7 0 2 2 2 4 2 6 2 8 3 0 3 2 3 4 w e e k s G A R i s k o f D e a t h : R e s u s c i t a t i o n 3 ) I O R : 1 . 9 5 9 5 % C I ( 2 . 4 3 - 1 . 5 7 ) C 2 % 5 9 ( R 1 O A d v a n c e d B a s i c 0 ILCOR 2015 ILCOR changes 2010 -2015 1.Support of transition, not automatically resuscitation 2.Cord clamping For uncompromised infants, a delay of cord clamping ≥ 1 min 3. Body temperature For non-asphyxiated infants 36.5-37.5oC 4.Maintenance of temperature < 32 wk 36.5-37.5oC maintained by warmed humidified resp gases, increased room temperature (< 28 wk >25oC, plastic wrapping, cap, thermal mattress ) 5. Optimal assessment of heart rate Suggest use of ECG in resuscitation 6. Meconium stained amniotic fluid –non-vigerous infant Intubation only for suspected tracheal obstruction 7. Air/Oxygen Term infants start with 21%. Preterm 21- 30% 8. Continuous Positive Airways Pressure (CPAP) CPAP rather than intubation for spontaneously breathing preterm infants 9. Hypothermia therapy in low income settings cooling with ice packs Saugstad OD, 2016 The Premature Infant CPAP and IPPV Treatment Recommendation For spontaneously breathing preterm infants with respiratory distress requiring respiratory support in the delivery room, we suggest initial use of CPAP rather than intubation and IPPV weak recommendation, moderate-quality evidence. ILCOR 2015 Ventilation Strategies in the Delivery Room Treatment Recommendation • We suggest against the routine use of initial sustained inflation (greater than 5 seconds duration) for preterm infants without spontaneous respirations immediately after birth, but an SI may be considered in individual clinical circumstances or research settings weak recommendation, low-quality evidence.