Neonate resus update 2021

2021 Resuscitation Council UK Guidance: What’s new in neonates?

Cite this article as:
Anandi Singh, Jilly Boden and Vicki Currie. 2021 Resuscitation Council UK Guidance: What’s new in neonates?, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33461

We’ve looked at the changes in the paediatric resuscitation guidelines, here we take a closer look at neonatal guidelines.

Supporting transition at birth

There are no major changes for the newborns (just yet), but there is clarification on certain practices since the last 2015 update.

The umbilical cord: Leave it hanging?

We should delay clamping the cord for sixty seconds after the first cry. Researchers are looking at the benefit of beginning resuscitation whilst the cord still remains intact. Immediate cord clamping (ICC) has been shown to significantly reduce ventricular pre-load while simultaneously adding to left ventricular afterload.

If delayed cord clamping (DCC) is not possible, ‘milking of the cord’ can result in some transient benefits. There may be less need for inotropic support and fewer transfusions but no overall reduction in morbidity or mortality in the premature. There is insufficient data to suggest any benefit in babies 34 weeks to term. Milking of the cord is not recommended below 28 weeks as one large study was terminated early after babies were found to have higher risk of intraventricular haemorrhage.

Inflation and ventilation breaths: Increased pressure

When delivering inflation breaths, the resuscitation guidelines recommend slightly increased pressures than before

<32 weeks gestation, 25cm H2O for peak inspiratory pressure
>32 weeks, we should be using 30cm H2O initially slowly titrating up to achieve good chest wall movement.

Set the PEEP at at 5cm H2O for all babies that need assisted ventilation.

Laryngeal Mask Airways

LMAs are better than (in systematic review of 7 studies, N=794) bag-mask ventilation. Using them reduces the need for intubation and the duration of ventilation, though the evidence was low/moderate quality. The updated guidelines suggest more proactive use of an LMA in babies >34weeks and >2kgs.

Oxygen: Start low

  • For babies >32/40, the guidelines remains unchanged, start in air, monitor SpO2 and increase as needed. It can take several minutes to reach normal saturation levels.
  • For babies born between 28-32 weeks gestation, a small amount of supplemental oxygen (21-30% FiO2) may help with the effort of breathing and reduce mask ventilation time.
  • Start babies born before 28 weeks gestation on 30% FiO2.
  • Turn the FiO2 immediately up to 100% if you have to start chest compressions.

Thick Meconium: Don’t rush to suction

In the past, if a ‘non-vigorous’ baby (i.e. hasn’t cried yet), was delivered through thick meconium, you were supposed to visualise the cords with a laryngoscope and suction before providing inflation breaths. There wasn’t great evidence for this and the thought was that it simply delayed ventilation in an otherwise apnoeic baby.

What about adrenaline dosing?

There are still a few studies looking at the dosing of adrenaline in neonates but now the recommended dose is 20 micrograms/kg (0.2 mL/kg of 1:10,000 adrenaline (1000 micrograms in 10 mL)).  This should be repeated every 3-5 minutes as needed.

Focus on temperature: Aim for 36.5-37.5°C

The admission temperature of all (non-asphyxiated) babies across all settings and gestational ages, is a strong predictive factor for morbidity and mortality.

  • Use heated and humidified gases from the outset if you can, for babies born <32 weeks. A meta-analysis of 2 RCTs (N=476) suggested that this reduced the rate of hypothermia on admission by 36%.
  • Skin-to-skin care may be enough to keep >32 week babies warm, though a study focusing on 28-32+6 gestation babes suggested that this may be sub-optimal compared to conventional means of warming (a mix of radiant heaters, plastic bags, heated mattresses etc).

For each 1 degree Celsius decrease in admission temperature below the recommended range, an increase in the baseline mortality by 28% has been reported.

Emergency access: You know the drill

Umbilical catheterisation remains the prime means of vascular access.   If this is not an option, then use intraosseous access to give emergency drugs and volume.  Simulation studies suggest that the IO route may be quicker, though not without risk. Adverse events such as osteomyelitis, compartment syndrome and fractures have occurred.

Neonatal resuscitation updates

Stopping resuscitation should be considered by the team if there is no response after 20 minutes and reversible (e.g. tension pneumothorax, hypovolaemia, equipment failure) have been discounted.

Selected references

Resuscitation Council UK Guidelines 2021 https://www.resus.org.uk/library/2021-resuscitation-guidelines

Madar J et al European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). https://doi.org/10.1016/j.resuscitation.2021.02.014

ERC Guidelines 2021: https://cprguidelines.eu/

Wyckoff MH, ET AL. Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187.  https://doi.org/10.1016/j.resuscitation.2020.09.015 Epub 2020 Oct 21. PMID: 3309891

How to… set up the resuscitaire

Cite this article as:
Taryn Miller. How to… set up the resuscitaire, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31358

Check that the resuscitaire is plugged in and connected to the oxygen and air 

  • On button 
  • Light button 

Top to bottom run through 

Top panel  

  • Clock or timer to time your resuscitation – (start, stop and reset) 
  • Temperature settings 
    • Pre-warm – The machine will automatically set to pre-warm
    • Manual – Use the up button to change to manual 
    • Up and down buttons – Dial up the temperature using these buttons in the manual setting  
    • Baby – If using a manual continuous saturation monitor plug into here and then set to baby 

Key locks the settings so it cannot be changed again unless you press it again

Blender 1:13

This blender corresponds to the Fio2 of the gas coming out of the auxiliary gas port
You can dial it up or down
Most people set the initial FIO2 to 0.21 so that you are resuscitating on air 

Suction 1:25

Turn on suction using the switch
Increase pressure by turning the suction dial 
When you occlude the suction device the needle on the dial will move up and down to show how much negative pressure is exerted 

Ventilation settings 1:40

Autobreath

T piece is attached to auxiliary gas port shown 

Working from left to right 

  • Rate – most people start with an initial rate of 40 breaths per minute 
  • PEEP – If you are not setting the peep with valve on top of the T piece device you can set it using the PEEP dial 
  • On and off switch for autobreath 
  • Airway pressure relief – also known as the peak inspiratory pressure – most people like to set this at a maximum of 30 to begin with 

Testing pressures: 2:13 

To test the pressures when the T-piece is connected to the gas outlet:  

  • PEEP = Occlude the valve inside the mask, the needle will move to the desired level of peep 
  • Peak inspiratory pressure – occlude the valve at the top of the T-piece

Flow rate 2:31

  • This dial controls the flow rate through the gas outlet 
  • Most people set it at 8 litres per minute 

Gas outlet 

  • Below this you have an alternative gas outlet that always runs on 100% oxygen 
  • You can attach a water or anaesthetic circuit here and adjust the flow rate in the same way as above using this dial 

Gas Supply 

  • These dials show much how air and oxygen are in the tanks behind the resuscitaire 
  • This switch should be used whenever the gases are in use

Resuscitaire run through 

There is a baby being born – get your resuscitaire ready and primed 

  1. Plug the resuscitaire in 
  2. Connect to the gases – black to air, white to oxygen 
  3. Turn the resuscitaire on and turn the light on 
  4. Select manual and turn the temperature all the way up 
  5. Set your blender to an fi02 of 21 
  6. Check your suction – one end connects underneath the resuscitaire, the other end connects to the yanker. Check it is working by occluding the end 
  7. Set your Autobreath settings – 
    • Rate of 40 breaths per minute 
    • Peep of 4 or 5 and turn the peep on  
    • Flow rate of 8 
    • Connect the tubing to the outlet
  8. Test the pressures  
    • Occlude the mask to check PEEP isn’t too high 
    • Occlude the valve at the top of the T-piece to check your peak inspiratory pressure 
  9. You should have a 250ml bag-valve-mask to attach in case you need to manually bag the baby 
  10. Have lots of towels 
  11. Oxygen saturation probe and stick it to the edge of the resuscitaire  
  12. Airway trolley near by 

Neonatal intubation: Shabs Rajapaksa at DFTB18

Cite this article as:
Team DFTB. Neonatal intubation: Shabs Rajapaksa at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17490

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

A short story about death…

Cite this article as:
Andrew Tagg. A short story about death…, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16636

This is the first of a two-part post based on my talk for FIX18 entitled A short story about death and life… We’ll publish the second part tomorrow.

 

“Someone will be along in a minute to explain what is going on”

Then a minute became two, three, five, until fifteen silent minutes had passed, each one seemingly longer than the last. Then footsteps…

It must have taken her an hour to cross the floor, or maybe just 30 seconds, I don’t know. I was no longer there.

I’m sorry, Mr. Tagg, I’ve got some bad news for you….Despite our best efforts, we were unable….

Her words disappeared and floated away with our dreams and I was lost.

That was how I had found out that my daughter had died. It was a tragic accident, the result of an unexpected antepartum haemorrhage and  an unsuccessful neonatal resuscitation. Something happened that day that fundamentally changed me, not just as a person, but as a doctor.

Flashbulb memories

Memory is imprecise – even in times of extreme emotion when it feels like every frame is burnt into your retina like the after image of photograph. These flashbulb memories have been heavily studied by psychologists and Malcolm Gladwell gives an easy to understand rundown in this episode of Revisionist History. What is most fascinating to me is that they are not always correct. So what does that mean of my recollection of the events that August?

The rarity of neonatal resuscitation

According to the Australian Bureau of Statistics a baby is born every 1 minute 42 seconds. That equates to around 8000 babies a day. Unfortunately, 7.2 per 1000 babies are stillborn and there are 2.4 neonatal deaths per 1000 live births. So in the whole of Australia, there are up to 19 neonatal deaths every single day.*

Most of us attend a delivery and never expect to resuscitate an infant. When we do a waft of oxygen is often all that is required. A Dutch study showed that around 2.6% of all births via elective caesarean required supplemental oxygen, around 1% require bag-valve-mask ventilation of some sort and only 0.1% require any more intensive resuscitation. The rates are much higher in lower/middle income countries.

Because they are such a rare event most doctors never expect to have to deal with a fatal outcome. Just as most emergency physicians obsess over the rarest of events, the surgical airway, perhaps those of us that may potentially be present at birth should be prepared to do what is necessary?

*A neonatal death is one that occurs within 28 days of birth

 

Absence does not make the heart grow fonder

A lot has already been written about the benefits and challenges of parental presence during the management of a critically ill child. To get you up to speed then read this post from Natalie May over on St Emlyns. The Resuscitation Council (UK) seems to think it is a good idea and most literature focuses on parental presence in either the ICU or ED setting and in an older cohort.

An exploratory interview study by Harvey and Pattison identified four key concerns surrounding the presence of the father during neonatal resuscitation in the delivery suite.

  • Whose job is it to support them?
  • What should they say or do?
  • The importance of teamwork
  • Impact on the healthcare practitioner

Think about the last time you did any neonatal life support training? No doubt you focussed on the core clinical skills – airway, breathing, circulation – with very little if no mention of dealing with the parents.

Medicine has moved on from beneficient paternalism to a more patient/parent-centred approach. It can be a hard decision to make – stay or go – but it doesn’t have to be the clinician’s choice.

Being present at a neonatal resuscitation can also be distressing for the staff involved and so one can understand how medical teams might want to shield parents from the hurt. There is concern that caregivers might interfere or get in the way with treatment. A skilled guide, such as a social worker or trained nurse, can help explain what is going on and translate the complex medical into plain English.

 

‘They’ll always remember how you made them feel”

In a time when infant death was a common occurrence, the prevailing thought was that grief could be avoided by preventing mothers from seeing their stillborn children. Psychologists would later theorize that an attachment bond had not been formed and so whisking the baby away without ceremony would cause no harm. By the 1970s this theory had been thrown out the window and grieving parents were offered the opportunity to see their children. Perhaps now the attachment bond is formed even earlier, through the use of antenatal screening, regular ultrasound scans and midwife visits making grief even more palpable.

 

The traditional (if flawed) Kubler-Ross model of grief

There will always be questions after an unexpected death – some can be answered and some can never be. But is important for parents to have the opportunity to ask. A qualitative study by Bakhbahki and colleagues in the South West of England identified a number of parental concerns centred around the framework of transparency, flexibility, inclusivity, and positivity.

We want to know that there is a perinatal mortality review process and how it works. As one of the interviewed stated, they wanted to know “this is how your child died and this is how we investigate it“. Parents wanted to know that this process was multidisciplinary involving not just neonatologists or paediatricians but also the obstetricians in order to identify any factors that may future tragic events.

We want our children to be treated like any child should be treated – with respect – regardless of whether they are alive or dead.

“The most distressing thing for me was knowing that she had been stripped of her blanket and photographed before I even had the chance to hold her.”

E.T. – a bereaved mother

There is a stigma attached to the death of a child. Society, whether it means to or not, sees the death of a child as a failure on the part of the mother. She must have done something wrong in pregnancy, she must have broken the rules. Then, these women are isolated from other newborns and their parents to the extent that they may even receive sub-optimal care.

An alternate view

It has been 8 years now and I have progressed far enough in my career to be the one bearing bad news. As an emergency physician who deals with a lot of sick and critically unwell adults, I have gone out of my way to seek formal training on breaking bad news. Specialties, such as obstetrics and paediatrics, are not exposed to death and dying on such a routine basis and very few have received formal training.

So what could be done better?

Whilst being an emotionally distant automaton may afford some protection for the clinician it is important that those breaking bad news are humans first, doctors second. I’ve written before about the power of kindness and this is one of those moments when we need to stop, look, listen and think. The death of a child, any child, is a devastating event and should be acknowledged as such.

 

With thanks to Tess (for letting me share our story) and my big-hearted cheer squad (Tessa, Ben, Henry, Tanya, Genevieve, Ian, and Ross)

Selected References

The rarity of neonatal resuscitation

*De Luca R, Boulvain M, Irion O, Berner M, Pfister RE. Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics. 2009 Jun 1;123(6):e1064-71.

Kerber KJ, Mathai M, Lewis G, Flenady V, Erwich JJ, Segun T, Aliganyira P, Abdelmegeid A, Allanson E, Roos N, Rhoda N. Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby. BMC pregnancy and childbirth. 2015 Dec;15(2):S9.

Knight M, Draper ES, Kurinczuk JJ. Key messages from the UK Perinatal Confidential Enquiry into term, singleton, intrapartum stillbirth and intrapartum-related neonatal death 2017.

Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum‐related stillbirths and neonatal deaths: where, why, and what can be done?. International Journal of Gynecology & Obstetrics. 2009 Oct 1;107(Supplement):S5-19.

Lee AC, Cousens S, Wall SN, Niermeyer S, Darmstadt GL, Carlo WA, Keenan WJ, Bhutta ZA, Gill C, Lawn JE. Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC public health. 2011 Dec;11(3):S12.

Richmond S, Wyllie J. European resuscitation council guidelines for resuscitation 2010 section 7. Resuscitation of babies at birth. Resuscitation. 2010 Oct 1;81(10):1389-99.

Wilmink FA, Hukkelhoven CW, Lunshof S, Mol BW, van der Post JA, Papatsonis DN. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American journal of obstetrics and gynecology. 2010 Mar 1;202(3):250-e1.

Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B. European Resuscitation Council Guidelines for Resuscitation 2015: Section 7. Resuscitation and support of transition of babies at birth. Resuscitation. 2015 Oct 1;95:249-63.

 

Absence does not make the heart grow fonder

Boie ET, Moore GP, Brummett C, Nelson DR. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Annals of emergency medicine. 1999 Jul 1;34(1):70-4.

Cacciatore J, Rådestad I, Frederik Frøen J. Effects of contact with stillborn babies on maternal anxiety and depression. Birth. 2008 Dec;35(4):313-20.

Fulbrook P, Latour JM, Albarran JW. Paediatric critical care nurses’ attitudes and experiences of parental presence during cardiopulmonary resuscitation: a European survey. International journal of nursing studies. 2007 Sep 1;44(7):1238-49.

Harvey ME, Pattison HM. The impact of a father’s presence during newborn resuscitation: a qualitative interview study with healthcare professionals. BMJ open. 2013 Jan 1;3(3):e002547.

Nederstigt I, Van Tol D. Parental presence during resuscitation. Resuscitation. 2008 May 1;77:S61.

Offord RJ. Should relatives of patients with cardiac arrest be invited to be present during cardiopulmonary resuscitation?. Intensive and Critical Care Nursing. 1998 Dec 1;14(6):288-93.

Sawyer A, Ayers S, Bertullies S, Thomas M, Weeks AD, Yoxall CW, Duley L. Providing immediate neonatal care and resuscitation at birth beside the mother: parents’ views, a qualitative study. BMJ open. 2015 Sep 1;5(9):e008495.

Tripon C, Defossez G, Ragot S, Ghazali A, Boureau-Voultoury A, Scépi M, Oriot D. Parental presence during cardiopulmonary resuscitation of children: the experience, opinions and moral positions of emergency teams in France. Archives of disease in childhood. 2014 Jan 6:archdischild-2013.

 

‘They’ll always remember how you made them feel”

Badenhorst W, Riches S, Turton P, Hughes P. The psychological effects of stillbirth and neonatal death on fathers: Systematic review. Journal of Psychosomatic Obstetrics & Gynecology. 2006 Jan 1;27(4):245-56.

Bakhbakhi D, Siassakos D, Burden C, Jones F, Yoward F, Redshaw M, Murphy S, Storey C. Learning from deaths: Parents’ Active Role and ENgagement in The review of their Stillbirth/perinatal death (the PARENTS 1 study). BMC pregnancy and childbirth. 2017 Dec;17(1):333.

Bonanno GA, Kaltman S. The varieties of grief experience. Clinical psychology review. 2001 Jul 1;21(5):705-34.

Boyle FM, Vance JC, Najman JM, Thearle MJ. The mental health impact of stillbirth, neonatal death or SIDS: prevalence and patterns of distress among mothers. Social science & medicine. 1996 Oct 1;43(8):1273-82.

Flenady V, Boyle F, Koopmans L, Wilson T, Stones W, Cacciatore J. Meeting the needs of parents after a stillbirth or neonatal death. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Sep;121:137-40.

Flenady V, King J, Charles A, Gardener G, Ellwood D, Day K, et al.PSANZ Clinical practice guideline for perinatal mortality. Perinatal Mortality Group https:// www.psanzpnmsig.org.au. Perinatal Society of Australia and New Zealand, April 2009; Vol. Version 2.2.

Koopmans L, Wilson T, Cacciatore J, Flenady V. Support for mothers, fathers and families after perinatal death. Cochrane database of systematic reviews. 2013(6).

Mills TA, Ricklesford C, Cooke A, Heazell AE, Whitworth M, Lavender T. Parents’ experiences and expectations of care in pregnancy after stillbirth or neonatal death: a metasynthesis. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jul 1;121(8):943-50.

Nuzum D, Meaney S, O’donoghue K. The impact of stillbirth on consultant obstetrician gynaecologists: a qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jul 1;121(8):1020-8.

 

ABC, easy as 1-2-3: neonatal resus by Helen Liley

Helen outlines the updates to the neonatal resuscitation guidelines and provides some background on how these came about.

Don't Forget the Bubbles
Don't Forget the Bubbles
ABC, easy as 1-2-3: neonatal resus by Helen Liley







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