Pulseless electrical activity: a misdiagnosed entity during asphyxia in newborn infants?

BackgroundThe 2015 neonatal resuscitation guidelines added ECG as a recommended method of assessment of an infant’s heart rate (HR) when determining the need for resuscitation at birth. However, a recent case report raised concerns about this technique in the delivery room.ObjectivesTo compare accuracy of ECG with auscultation to assess asystole in asphyxiated piglets.MethodsNeonatal piglets had the right common carotid artery exposed and enclosed with a real-time ultrasonic flow probe and HR was continuously measured and recorded using ECG. This set-up allowed simultaneous monitoring of HR via ECG and carotid blood flow (CBF). The piglets were exposed to 30 min normocapnic alveolar hypoxia followed by asphyxia until asystole, achieved by disconnecting the ventilator and clamping the endotracheal tube. Asystole was defined as zero carotid blood flow and was compared with ECG traces and auscultation for heart sounds using a neonatal/infant stethoscope.ResultsOverall, 54 piglets were studied with a median (IQR) duration of asphyxia of 325 (200-491) s. In 14 (26%) piglets, CBF, ECG and auscultation identified asystole. In 23 (43%) piglets, we observed no CBF and no audible heart sounds, while ECG displayed an HR ranging from 15 to 80/min. Sixteen (30%) piglets remained bradycardic (defined as HR of <100/min) after 10 min of asphyxia, identified by CBF, ECG and auscultation.ConclusionClinicians should be aware of the potential inaccuracy of ECG assessment during asphyxia in newborn infants and should rather rely on assessment using a combination of auscultation, palpation, pulse oximetry and ECG.

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Effects of varying chest compression depths on carotid blood flow and blood pressure in asphyxiated piglets

Archives of Disease in Childhood - Fetal and Neonatal Edition ◽

10.1136/archdischild-2020-319473 ◽

2021 ◽

pp. fetalneonatal-2020-319473

Author(s):

Marlies Bruckner ◽

Megan O’Reilly ◽

Tze-Fun Lee ◽

Mattias Neset ◽

Po-Yin Cheung ◽

...

Keyword(s):

Blood Pressure ◽

Blood Flow ◽

Systolic Blood Pressure ◽

Neonatal Resuscitation ◽

Chest Compressions ◽

Carotid Blood Flow ◽

Newborn Piglets ◽

Resuscitation Guidelines ◽

Registration Number ◽

Anterior Posterior

BackgroundCurrent neonatal resuscitation guidelines recommend chest compressions (CCs) should be delivered to a depth of approximately 1/3 of the anterior–posterior (AP) chest diameter. The aim of the study was to investigate the haemodynamic effects of different CC depths in a neonatal piglet model.MethodsCCs were performed with an automated CC machine with 33%, 40% and 25% AP chest diameter in all piglets in the same order for a duration of 3 min each.ResultsEight newborn piglets (age 1–3 days, weight 1.7–2.3 kg) were included in the study. Carotid blood flow (CBF) and systolic blood pressure were the highest using a CC depth of 40% AP chest diameter (19.3±7.5 mL/min/kg and 58±32 mm Hg).ConclusionCC depth influences haemodynamic parameters in asphyxiated newborn piglets during cardiopulmonary resuscitation. The highest CBF and systolic blood pressure were achieved using a CC depth of 40% AP chest diameter.Trial registration numberPCTE0000148.

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Cardiac arrest with pulseless electrical activity rhythm in newborn infants: a case series

Archives of Disease in Childhood - Fetal and Neonatal Edition ◽

10.1136/archdischild-2018-316087 ◽

2019 ◽

Vol 104 (6) ◽

pp. F572-F574 ◽

Cited By ~ 10

Author(s):

Deandra Luong ◽

Po-Yin Cheung ◽

Keith J Barrington ◽

Peter G Davis ◽

Jennifer Unrau ◽

...

Keyword(s):

Heart Rate ◽

Cardiopulmonary Resuscitation ◽

Electrical Activity ◽

Activity Rhythm ◽

Healthcare Providers ◽

Newborn Infants ◽

Case Series ◽

Neonatal Resuscitation ◽

Pulseless Electrical Activity ◽

Resuscitation Guidelines

The 2015 neonatal resuscitation guidelines added ECG to assess an infant’s heart rate when determining the need for resuscitation at birth. However, a recent case report raised concerns about this technique in the delivery room. We report four cases of pulseless electrical activity during neonatal cardiopulmonary resuscitation in levels II–III neonatal intensive care units in Canada (Edmonton [n=3] and Winnipeg [n=1]).Healthcare providers should be aware that pulseless electrical activity can occur in newborn infants during cardiopulmonary resuscitation. We propose an adapted neonatal resuscitation algorithm to include pulseless electrical activity. Furthermore, in compromised newborns, heart rate should be assessed using a combination of methods/techniques to ensure accurate heart rate assessment. When ECG displays a heart rate but the infant is unresponsive, pulseless electrical activity should be suspected and chest compression should be started.

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Delivery Room Management of Asphyxiated Term and Near-Term Infants

Neonatology ◽

10.1159/000516429 ◽

2021 ◽

pp. 1-13

Author(s):

Marlies Bruckner ◽

Gianluca Lista ◽

Ola D. Saugstad ◽

Georg M. Schmölzer

Keyword(s):

Preterm Infants ◽

Newborn Infants ◽

Neonatal Resuscitation ◽

Birth Asphyxia ◽

Delivery Room ◽

Temperature Management ◽

Term Infants ◽

Term Newborn ◽

Resuscitation Guidelines ◽

Delivery Room Management

Approximately 800,000 newborns die annually due to birth asphyxia. The resuscitation of asphyxiated term newly born infants often occurs unexpected and is challenging for healthcare providers as it demands experience and knowledge in neonatal resuscitation. Current neonatal resuscitation guidelines often focus on resuscitation of extremely and/or very preterm infants; however, the recommendations for asphyxiated term newborn infants differ in some aspects to those for preterm infants (i.e., respiratory support, supplemental oxygen, and temperature management). Since the update of the neonatal resuscitation guidelines in 2015, several studies examining various resuscitation approaches to improve the outcome of asphyxiated infants have been published. In this review, we discuss current recommendations and recent findings and provide an overview of delivery room management of asphyxiated term newborn infants.

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Abstract 170: Temperature Maintenance and Oxygen Use in Newborns at Birth: A Surveillance of Clinical Practice and Compliance with Neonatal Resuscitation Guidelines

Circulation ◽

10.1161/circ.130.suppl_2.170 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Georg M Schmölzer ◽

Roxanne Pinson ◽

Marion Molesky ◽

Heather Chinnery ◽

Karen Foss ◽

...

Keyword(s):

Body Temperature ◽

Knowledge Transfer ◽

Oxygen Saturation ◽

Neonatal Resuscitation ◽

Positive Pressure ◽

Respiratory Therapists ◽

Vaginal Deliveries ◽

Resuscitation Guidelines ◽

The Right ◽

Continuous Positive Pressure

Background: Guidelines of neonatal resuscitation are revised regularly. Gaps in knowledge transfer commonly occur when the guidelines are communicated to the clinical practitioners. Maintaining body temperature and supporting oxygenation are main goals that clinical practitioners aim to achieve in assisting newborns during the feto-neonatal transition at birth. Objectives: In this study, we aim to examine the compliance to guidelines in neonatal resuscitation regarding the temperature maintenance and oxygen use in newborns at birth. Methods: From October to November 2013, a prospective questionnaire surveillance was conducted in all attended deliveries at all four hospitals in Edmonton, Alberta, Canada. All clinical practitioners (registered nurses, physicians and respiratory therapists) were requested to complete the questionnaires immediately after the attended delivery regarding temperature maintenance and oxygenation monitoring. Descriptive statistics were used with mean±SD (range) and % presented. Results: During the 14-days study period, data was obtained in 518 of 712 (73%) attended deliveries of newborns with gestational age 38.6±2.0 (23-42) weeks and birth weight 3324±589 (348-6168) g. Of these deliveries, 58% were normal vaginal deliveries and 29% were cesarean sections. There were 8.8% and 8.4% newborns who required positive pressure ventilation and continuous positive pressure, respectively. Radiant warmer heat was used in 81% (419/518) with 63% (266/419) turned to full power. Room temperature was 21.6±1.6 (17-31)°C. Body temperature at 30-60 min after birth was 36.8±0.5 (32.4-38.1)°C with hypothermia (<36.5°C) in 17%. Percutaneous oxygen saturation was measured in 15% newborns and 96% had sensors placed at the right wrist. At the initiation of resuscitation, 21% oxygen was used in 76% and the oxygen concentration was adjusted according to an oxygen saturation chart in 17%. In 70% of the cases, clinical practitioners commented that this chart was not helpful. Conclusions: Gaps in knowledge transfer contribute to non-compliance in the guidelines of neonatal resuscitation for temperature maintenance and oxygen use. Caution is needed to avoid hypothermia and hyperoxia in at-risk populations such as prematurity.

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Physical stimulation of newborn infants in the delivery room

Archives of Disease in Childhood - Fetal and Neonatal Edition ◽

10.1136/archdischild-2016-312311 ◽

2017 ◽

Vol 103 (2) ◽

pp. F132-F136 ◽

Cited By ~ 9

Author(s):

Vincent D Gaertner ◽

Sophie A Flemmer ◽

Laila Lorenz ◽

Peter G Davis ◽

C Omar Farouk Kamlin

Keyword(s):

A Priori ◽

Newborn Infants ◽

Neonatal Resuscitation ◽

Physical Stimulation ◽

Very Preterm Infants ◽

Infant Cry ◽

Transition Outcomes ◽

Very Preterm ◽

Video Recordings ◽

Resuscitation Guidelines

ObjectiveNeonatal resuscitation guidelines recommend that newborn infants are stimulated to assist with the establishment of regular respirations. The mode, site of application and frequency of stimulations are not stipulated in these guidelines. The effectiveness of stimulation in improving neonatal transition outcomes is poorly described.MethodsWe conducted a retrospective review of video recordings of neonatal resuscitation at a tertiary perinatal centre. Four different types of stimulation (drying, chest rub, back rub and foot flick) were defined a priori and the frequency and infant response were documented.ResultsA total of 120 video recordings were reviewed. Seventy-five (63%) infants received at least one episode of stimulation and 70 (58%) infants were stimulated within the first minute after birth. Stimulation was less commonly provided to infants <30 weeks’ gestation (median (IQR) number of stimulations: 0 (0–1)) than infants born ≥30 weeks’ gestation (1 (1–3); p<0.001). The most common response to stimulation was limb movement followed by infant cry and facial grimace. Truncal stimulation (drying, chest rub, back rub) was associated with more crying and movement than foot flicks.ConclusionLess mature infants are stimulated less frequently compared with more mature infants and many very preterm infants do not receive any stimulation. Most infants were stimulated within the first minute as recommended in resuscitation guidelines. Rubbing the trunk may be most effective but this needs to be confirmed in prospective studies.

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Global and regional cerebral blood flow in neonatal piglets undergoing pulsatile cardiopulmonary bypass with continuous perfusion at 25°C and circulatory arrest at 18°C

Perfusion ◽

10.1177/026765910101600610 ◽

2001 ◽

Vol 16 (6) ◽

pp. 503-510 ◽

Cited By ~ 7

Author(s):

Akif Ündar ◽

Takafumi Masai ◽

Shuang-Qiang Yang ◽

Harald C Eichstaedt ◽

Mary Claire McGarry ◽

...

Keyword(s):

Blood Flow ◽

Cerebral Blood Flow ◽

Cardiopulmonary Bypass ◽

Regional Cerebral Blood Flow ◽

Negative Impact ◽

Circulatory Arrest ◽

Deep Hypothermic Circulatory Arrest ◽

Regional Cerebral Blood ◽

Neonatal Piglets ◽

The Right

To investigate the influence of hypothermic cardiopulmonary bypass (HCPB) at 25°C and circulatory arrest at 18°C on the global and regional cerebral blood flow (CBF) during pulsatile perfusion, we performed the following studies in a neonatal piglet model. Using a pediatric physiologic pulsatile pump, we subjected six piglets to deep hypothermic circulatory arrest (DHCA) and six other piglets to HCPB. The DHCA group underwent hypothermia for 25 min, DHCA for 60min, cold reperfusion for 10 min, and rewarming for 40 min. The HCPB group underwent 15 min of cooling, followed by 60 min of HCPB, 10min of cold reperfusion, and 30 min of rewarming. The following variables remained constant in both groups: pump flow (150 ml/kg/min), pump rate (150 bpm), and stroke volume (1 ml/kg). During the 60-min aortic crossclamp period, the temperature was kept at 18°C for DHCA and at 25°C for HCPB. The global and regional CBF (ml/100g/min) was assessed with radiolabeled microspheres. The CBF was 48% lower during deep hypothermia at 18°C (before DHCA) than during hypothermia at 25°C (55.2± 14.3 ml/100 g/min vs 106.4±19.7 ml/100 g/min; p < 0.05). After rewarming, the global CBF was 45% lower in the DHCA group than in the HCPB group 48.3±18.1 ml/100 g/min vs (87±35.9 ml/100 g/min; p<0.05). Fifteen minutes after the termination of CPB, the global CBF was only 25% lower in the DHCA group than in the HCPB group (42.2±20.7 ml/100 g/min vs 56.4±25.8 ml/100 g/min; p=NS). In the right and left hemispheres, cerebellum, basal ganglia, and brain stem, blood flow resembled the global CBF. In conclusion, both HCPB and DHCA significantly decrease the regional and global CBF during CPB. Unlike HCPB, DHCA has a continued negative impact on the CBF after rewarming. However, 15 min after the end of CPB, there are no significant intergroup differences in the CBF.

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Is Chest Compression Superimposed with Sustained Inflation during Cardiopulmonary Resuscitation an Alternative to 3:1 Compression to Ventilation Ratio in Newborn Infants?

Children ◽

10.3390/children8020097 ◽

2021 ◽

Vol 8 (2) ◽

pp. 97

Author(s):

Seung Yeon Kim ◽

Gyu-Hong Shim ◽

Georg M. Schmölzer

Keyword(s):

Cardiopulmonary Resuscitation ◽

Chest Compression ◽

Newborn Infants ◽

Neonatal Resuscitation ◽

Spontaneous Circulation ◽

Delivery Room ◽

Sustained Inflation ◽

Resuscitation Guidelines ◽

High Incidence ◽

Reduced Time

Approximately 0.1% for term and 10–15% of preterm infants receive chest compression (CC) in the delivery room, with high incidence of mortality and neurologic impairment. The poor prognosis associated with receiving CC in the delivery room has raised concerns as to whether specifically-tailored cardiopulmonary resuscitation methods are needed. The current neonatal resuscitation guidelines recommend a 3:1 compression:ventilation ratio; however, the most effective approach to deliver chest compression is unknown. We recently demonstrated that providing continuous chest compression superimposed with a high distending pressure or sustained inflation significantly reduced time to return of spontaneous circulation and mortality while improving respiratory and cardiovascular parameters in asphyxiated piglet and newborn infants. This review summarizes the current available evidence of continuous chest compression superimposed with a sustained inflation.

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How do different brands of size 1 laryngeal mask airway compare with face mask ventilation in a dedicated laryngeal mask airway teaching manikin?

Archives of Disease in Childhood - Fetal and Neonatal Edition ◽

10.1136/archdischild-2017-312766 ◽

2017 ◽

Vol 103 (3) ◽

pp. F271-F276 ◽

Cited By ~ 6

Author(s):

Mark Brian Tracy ◽

Archana Priyadarshi ◽

Dimple Goel ◽

Krista Lowe ◽

Jacqueline Huvanandana ◽

...

Keyword(s):

Laryngeal Mask Airway ◽

Newborn Infants ◽

Neonatal Resuscitation ◽

Peak Inspiratory Pressure ◽

Face Mask ◽

Ease Of Use ◽

Laryngeal Mask ◽

Mask Ventilation ◽

Resuscitation Guidelines ◽

Bag Mask Ventilation

BackgroundInternational neonatal resuscitation guidelines recommend the use of laryngeal mask airway (LMA) with newborn infants (≥34 weeks’ gestation or >2 kg weight) when bag-mask ventilation (BMV) or tracheal intubation is unsuccessful. Previous publications do not allow broad LMA device comparison.ObjectiveTo compare delivered ventilation of seven brands of size 1 LMA devices with two brands of face mask using self-inflating bag (SIB).Design40 experienced neonatal staff provided inflation cycles using SIB with positive end expiratory pressure (PEEP) (5 cmH2O) to a specialised newborn/infant training manikin randomised for each LMA and face mask. All subjects received prior education in LMA insertion and BMV.Results12 415 recorded inflations for LMAs and face masks were analysed. Leak detected was lowest with i-gel brand, with a mean of 5.7% compared with face mask (triangular 42.7, round 35.7) and other LMAs (45.5–65.4) (p<0.001). Peak inspiratory pressure was higher with i-gel, with a mean of 28.9 cmH2O compared with face mask (triangular 22.8, round 25.8) and other LMAs (14.3–22.0) (p<0.001). PEEP was higher with i-gel, with a mean of 5.1 cmH2O compared with face mask (triangular 3.0, round 3.6) and other LMAs (0.6–2.6) (p<0.001). In contrast to other LMAs examined, i-gel had no insertion failures and all users found i-gel easy to use.ConclusionThis study has shown dramatic performance differences in delivered ventilation, mask leak and ease of use among seven different brands of LMA tested in a manikin model. This coupled with no partial or complete insertion failures and ease of use suggests i-gel LMA may have an expanded role with newborn resuscitation as a primary resuscitation device.

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Randomized Trial of Oxygen Saturation Targets during and after Resuscitation and Reversal of Ductal Flow in an Ovine Model of Meconium Aspiration and Pulmonary Hypertension

Children ◽

10.3390/children8070594 ◽

2021 ◽

Vol 8 (7) ◽

pp. 594

Author(s):

Amy L. Lesneski ◽

Payam Vali ◽

Morgan E. Hardie ◽

Satyan Lakshminrusimha ◽

Deepika Sankaran

Keyword(s):

Blood Flow ◽

Pulmonary Hypertension ◽

Oxygen Saturation ◽

Ductus Arteriosus ◽

Neonatal Resuscitation ◽

Meconium Aspiration Syndrome ◽

Ovine Model ◽

Neurodevelopmental Outcomes ◽

Meconium Aspiration ◽

Blood Flows

Neonatal resuscitation (NRP) guidelines suggest targeting 85–95% preductal SpO2 by 10 min after birth. Optimal oxygen saturation (SpO2) targets during resuscitation and in the post-resuscitation management of neonatal meconium aspiration syndrome (MAS) with persistent pulmonary hypertension (PPHN) remains uncertain. Our objective was to compare the time to reversal of ductal flow from fetal pattern (right-to-left), to left-to-right, and to evaluate pulmonary (QPA), carotid (QCA)and ductal (QDA) blood flows between standard (85–94%) and high (95–99%) SpO2 targets during and after resuscitation. Twelve lambs asphyxiated by endotracheal meconium instillation and cord occlusion to induce MAS and PPHN were resuscitated per NRP guidelines and were randomized to either standard (85–94%) or high (95–99%) SpO2 targets. Out of twelve lambs with MAS and PPHN, six each were randomized to standard and high SpO2 targets. Median [interquartile range] time to change in direction of blood flow across the ductus arteriosus from right-to-left, to left-to-right was significantly shorter with high SpO2 target (7.4 (4.4–10.8) min) compared to standard SpO2 target (31.5 (21–66.2) min, p = 0.03). QPA was significantly higher during the first 10 min after birth with higher SpO2 target. At 60 min after birth, the QPA, QCA and QDA were not different between the groups. To conclude, targeting SpO2 of 95–99% during and after resuscitation may hasten reversal of ductal flow in lambs with MAS and PPHN and transiently increase QPA but no differences were observed at 60 min. Clinical studies comparing low and high SpO2 targets assessing hemodynamics and neurodevelopmental outcomes are warranted.

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