ILCOR 2015 – neonatal summary

The International Liaison Committee on Resuscitation (ILCOR) is a collaboration between resuscitation groups worldwide. Every few years, they do an enormous evidence based review of resuscitation science which informs resuscitation guidelines all over the world.

The 2015 ILCOR consensus document (International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations) was published on 15^th October 2015 and covers all aspects of resuscitation for all patient populations.

If you’re anything like me, you’ll agree that wordy documents like this can’t be read quickly (in this case even the Executive Summary is 31 pages!) so to save us all some time, I’ve summarised the recommendations with a focus on neonates.

Important note: this is an international consensus document and does not constitute new guidelines. Over the coming months, all the national resuscitation groups will assimilate this information into updated resuscitation guidelines so please don’t change your practice until your national updated guidelines have been published!

TOP TIPS (summary of my summary of the executive summary!)

1. ECG is more accurate than auscultation immediately after delivery
2. Delayed cord clamping is suggested for preterm infants NOT requiring resuscitation at delivery
3. There is NOT sufficient data to support tracheal suction in a non-vigorous baby born through meconium as it delays ventilation
4. LMAs can be used in >34week infants if the clinician is unsuccessful with ventilating via face mask and/or tracheal intubation
5. There is not sufficient evidence for any delivery room prognostic score to help us make decisions about <25 week infants – presumed gestational age is the best guide
6. In late preterm and term infants, an APGAR of 0 after 10 minutes of effective resuscitation + undetectable heart rate should prompt consideration of stopping resuscitation. Each case must be considered individually and decisions should not be made. I know this isn’t a change to current practice, but it is confirmation that the evidence still supports current practice.

 Initial stabilisation

• ECG assessment
  • ECG is more accurate than auscultating HR in the first 3 minutes of life
  • No data to comment if it changes patient outcome
• Delayed cord clamping and milking the cord
  • Delayed clamping; increases placental transfusion, improves cardiac output, allows more stable BP – RCTs were small and had few extreme prems or infants needed resuscitation
  • Delayed clamping is suggested for prems NOT needing resuscitation – cannot comment on those needing resus
  • Some evidence that milking the cord has similar positive effects – insufficient published human evidence (especially in prems) therefore can be considered on individual basis. May improve initial MAP, haem indices but also increased intracranial haemorrhage

Temperature management

• Maintaining temperature
  • Admission temp of newborn non asphyxiated infant is strong predictor or mortality and morbidity in all gestations; should be recorded as prognostic and quality indicator
  • Target 36.5-37.5^oC
  • <32 weeks; use a combination of environmental temp 23-25^oC, warm blankets, plastic wrapping without drying, hat, thermal mattress. Effect of each individual intervention is unknown
  • Dose dependent increased in mortality for temps <36.5^oC. Prems x12 compared to term.
  • >30 weeks (in resource limited setting): once dried, put legs torso and arms in plastic bag and swaddled OR nurse skin to skin with mother OR kangaroo care (all better than swaddling, open cot, or incubator)

Respiratory support in delivery room

• If spontaneously breathing with respiratory distress then use CPAP. Evidence mostly based on babies with maternal antenatal steroids on board.
• Prem without spontaneous resps at birth; sustained positive-pressure inflation may reduce the need for intubation at 72 hours. Optimal method to administer sustained inflations and long term effects is unknown. Recommends against routine use of initial sustained breaths >5 secs – but may be considered on individual basis.
• PEEP should be used for prems (helps to establish FRC) – no evidence over specific device, not enough evidence for terms
• Intubation + tracheal suctioning in non-vigorous mec VS no intubation for tracheal suctioning
  • Insufficient published data to support routine tracheal intubation for suctioning of meconium because it likely delays ventilation
• O2 concentration to start prem resus
  • Prem = start at 21-30%
  • Term still = 21%
• Compressions
  • 2 thumb-encircling technique; generates higher BP and less fatigue in mannequins
  • 2 thumb-encircling technique, 3:1, lower 1/3 of sternum
• O2 delivery during CPR
  • Once compressions started = 100%, wean as per sats as soon as ROSC
  • No human data for this
• Assisted ventilation devices and CPR feedback devices
  • LMA may be used during resus of >34 weeks if unsuccessful with facemask/intubation
  • Not enough evidence re flow and capnography in resus setting
• Use of CPR feedback devices
  • Advice against using ETCO₂ or pulse ox to detect ROSC until more evidence available
• Induced hypothermia in resource-limited settings
  • Should be considered, initiated and conducted only under clearly defined protocols with treatment in neonatal care unit with multi-disciplinary care, IV therapy, respiratory support, pulse ox, antibiotics, anticonvulsants and pathology.
  • Standard cooling criteria

Prognostication

• Delivery room assessment at <25 weeks
  • Insufficient evidence to support any delivery room prognostic score over estimated gestational age alone
  • Consider each individual case; consider perceived accuracy of gestational age, chorioamnionitis, level of care available at the current delivery facility
  • Decisions re resus for <25 weeks will be influenced by regional guidelines
• APGAR 0 for 10+ minutes of resuscitation
  • Strong predictor of mortality and morbidity in late preterm and term infants
  • If APGAR 0 after 10 mins of resuscitation + HR remain undetectable = may be reasonable to stop resus HOWEVER the decision to continue or not should be individualised
  • Variables to consider – if resuscitation is optimal, availability of NICU treatments (e.g. cooling), circumstances pre delivery (e.g. if timing of insult is known) and family wishes
  • Evidence = cohort of 35 weeks, APGAR 0 at 10minutes – 50% death, 24% survival without mod/major disability at 18-24 months BUT the number of infants that died in delivery room is unknown
• Predicting death or disability in resource limited settings of >34 weeks based on APGAR score and/or absence of breathing
  • >34 weeks + detectable HR + (not breathing OR APGAR 1-2 at 20mins) = strong predictors of mortality or significant morbidity
  • If limited resources – may be reasonable to stop assisted breathing
  • Studies were in the setting in which cooling was likely to be available

Resus training

• Frequency
  • Recurrent
  • More than once per year
  • Specific task and/or behavioural skills
• Instructors
  • Training instructors should incorporate timely, objective, structured, individualised verbal and/or written feedback
  • No evidence found to show improvement in critical outcomes
  • Some evidence to show that training instructors improved some important outcomes
  • Training instructors must be based on specific learning objectives for skills necessary to facilitate learning

References/further reading:

• ILCOR website; https://www.ilcor.org/home/
• European Resuscitation Counsil website; https://www.cprguidelines.eu/
• American Heart Association, Circulation online;