scholarly journals Single versus continuous sustained inflations during chest compressions and physiological-based cord clamping in asystolic lambs

2021 ◽  
pp. fetalneonatal-2021-322881
Author(s):  
Georg M Schmölzer ◽  
Calum T Roberts ◽  
Douglas A Blank ◽  
Shiraz Badurdeen ◽  
Suzanne L Miller ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Diastolic Blood Pressure ◽  
Intermittent Positive Pressure Ventilation ◽  
Spontaneous Circulation ◽  
Positive Pressure ◽  
Chest Compressions ◽  
Delayed Cord Clamping ◽  
Fetal Sheep ◽  
Epinephrine Administration ◽  
Cord Clamping

BackgroundThe feasibility and benefits of continuous sustained inflations (SIs) during chest compressions (CCs) during delayed cord clamping (physiological-based cord clamping; PBCC) are not known. We aimed to determine whether continuous SIs during CCs would reduce the time to return of spontaneous circulation (ROSC) and improve post-asphyxial blood pressures and flows in asystolic newborn lambs.MethodsFetal sheep were surgically instrumented immediately prior to delivery at ~139 days’ gestation and asphyxia induced until lambs reached asystole. Lambs were randomised to either immediate cord clamping (ICC) or PBCC. Lambs then received a single SI (SIsing; 30 s at 30 cmH2O) followed by intermittent positive pressure ventilation, or continuous SIs (SIcont: 30 s duration with 1 s break). We thus examined 4 groups: ICC +SIsing, ICC +SIcont, PBCC +SIsing, and PBCC +SIcont. Chest compressions and epinephrine administration followed international guidelines. PBCC lambs underwent cord clamping 10 min after ROSC. Physiological and oxygenation variables were measured throughout.ResultsThe time taken to achieve ROSC was not different between groups (mean (SD) 4.3±2.9 min). Mean and diastolic blood pressure was higher during chest compressions in PBCC lambs compared with ICC lambs, but no effect of SIs was observed. SIcont significantly reduced pulmonary blood flow, diastolic blood pressure and oxygenation after ROSC compared with SIsing.ConclusionWe found no significant benefit of SIcont over SIsing during CPR on the time to ROSC or on post-ROSC haemodynamics, but did demonstrate the feasibility of continuous SIs during advanced CPR on an intact umbilical cord. Longer-term studies are recommended before this technique is used routinely in clinical practice.

Comparison of intraosseous and intravenous epinephrine administration during resuscitation of asphyxiated newborn lambs

2021 ◽  
pp. fetalneonatal-2021-322638
Author(s):  
Calum T Roberts ◽  
Sarah Klink ◽  
Georg M Schmölzer ◽  
Douglas A Blank ◽  
Shiraz Badurdeen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Flow ◽  
Systemic Blood Pressure ◽  
Spontaneous Circulation ◽  
Positive Pressure ◽  
Plasma Epinephrine ◽  
Intraosseous Access ◽  
Systemic Blood ◽  
Epinephrine Administration ◽  
Cord Clamping

ObjectiveIntraosseous access is recommended as a reasonable alternative for vascular access during newborn resuscitation if umbilical access is unavailable, but there are minimal reported data in newborns. We compared intraosseous with intravenous epinephrine administration during resuscitation of severely asphyxiated lambs at birth.MethodsNear-term lambs (139 days’ gestation) were instrumented antenatally for measurement of carotid and pulmonary blood flow and systemic blood pressure. Intrapartum asphyxia was induced by umbilical cord clamping until asystole. Resuscitation commenced with positive pressure ventilation followed by chest compressions and the lambs received either intraosseous or central intravenous epinephrine (10 μg/kg); epinephrine administration was repeated every 3 min until return of spontaneous circulation (ROSC). The lambs were maintained for 30 min after ROSC. Plasma epinephrine levels were measured before cord clamping, at end asphyxia, and at 3 and 15 min post-ROSC.ResultsROSC was successful in 7 of 9 intraosseous epinephrine lambs and in 10 of 12 intravenous epinephrine lambs. The time and number of epinephrine doses required to achieve ROSC were similar between the groups, as were the achieved plasma epinephrine levels. Lambs in both groups displayed a similar marked overshoot in systemic blood pressure and carotid blood flow after ROSC. Blood gas parameters improved more quickly in the intraosseous lambs in the first 3 min, but were otherwise similar over the 30 min after ROSC.ConclusionsIntraosseous epinephrine administration results in similar outcomes to intravenous epinephrine during resuscitation of asphyxiated newborn lambs. These findings support the inclusion of intraosseous access as a route for epinephrine administration in current guidelines.

scholarly journals Sustained Inflation Reduces Pulmonary Blood Flow during Resuscitation with an Intact Cord

Children ◽  
2021 ◽  
Vol 8 (5) ◽  
pp. 353
Author(s):  
Jayasree Nair ◽  
Lauren Davidson ◽  
Sylvia Gugino ◽  
Carmon Koenigsknecht ◽  
Justin Helman ◽  
...  
Keyword(s):  
Blood Flow ◽  
Perinatal Asphyxia ◽  
Arterial Blood Flow ◽  
Positive Pressure ◽  
Optimal Timing ◽  
Delayed Cord Clamping ◽  
Arterial Blood ◽  
Cord Clamping ◽  
Sustained Inflation ◽  
Near Term

The optimal timing of cord clamping in asphyxia is not known. Our aims were to determine the effect of ventilation (sustained inflation–SI vs. positive pressure ventilation–V) with early (ECC) or delayed cord clamping (DCC) in asphyxiated near-term lambs. We hypothesized that SI with DCC improves gas exchange and hemodynamics in near-term lambs with asphyxial bradycardia. A total of 28 lambs were asphyxiated to a mean blood pressure of 22 mmHg. Lambs were randomized based on the timing of cord clamping (ECC—immediate, DCC—60 s) and mode of initial ventilation into five groups: ECC + V, ECC + SI, DCC, DCC + V and DCC + SI. The magnitude of placental transfusion was assessed using biotinylated RBC. Though an asphyxial bradycardia model, 2–3 lambs in each group were arrested. There was no difference in primary outcomes, the time to reach baseline carotid blood flow (CBF), HR ≥ 100 bpm or MBP ≥ 40 mmHg. SI reduced pulmonary (PBF) and umbilical venous (UV) blood flow without affecting CBF or umbilical arterial blood flow. A significant reduction in PBF with SI persisted for a few minutes after birth. In our model of perinatal asphyxia, an initial SI breath increased airway pressure, and reduced PBF and UV return with an intact cord. Further clinical studies evaluating the timing of cord clamping and ventilation strategy in asphyxiated infants are warranted.

Site of central chemosensitivity in fetal sheep

1975 ◽  
Vol 39 (1) ◽  
pp. 1-6 ◽  
Author(s):  
A. H. Jansen ◽  
V. Chernick
Keyword(s):  
Blood Pressure ◽  
Spinal Cord ◽  
Heart Rate ◽  
Respiratory Response ◽  
Fetal Sheep ◽  
Central Chemosensitivity ◽  
Cord Clamping ◽  
Chemosensitive Areas ◽  
Ventral Medullary Surface ◽  
Histotoxic Hypoxia

The heart rate, blood pressure, and respiratory response to topically applied cyanide on the ventrolateral medullary surface and upper spinal cord was studied on exteriorized sinaortic-denervated fetal lambs under pentobarbital anesthesia. On all sites tested cyanide produced a rapid increase in heart rate and blood pressure (P smaller than 0.05) which was most pronounced from the area adjacent to the nerve roots IX to XI (mean 32%). Respiratory efforts consisting of 1–8 gasps were induced in half the applications to the medulla but never when the pledgets were applied to the spinal cord. The mean delay to response was 43 s (range 13–102 s). After cautery of the chemosensitive areas, topical application of cyanide failed to stimulate gasping, whereas intravenous cyanide or cord clamping still produced a vigorous respiratory response. It is concluded that sympathetic stimulation of the heart and blood vessels can originate centrally in response to local histotoxic hypoxia of the ventral medulla and upper spinal cord. Furthermore, it is proposed that in the apneic fetus histotoxic hypoxia of the medulla initiates respiration possibly by stimulating a special gasping mechanism which is separate from the respiratory center responsible for rhythmic breathing after birth. The responsible neurons must be located at least 2 mm beneath the ventral medullary surface.

scholarly journals Perinatal Outcomes of Subjects Enrolled in a Multicenter Trial with a Waiver of Antenatal Consent

2020 ◽  
Author(s):  
Anup C. Katheria ◽  
Phillip Allman ◽  
Jeff M. Szychowski ◽  
Jochen Essers ◽  
Waldemar A. Carlo ◽  
...  
Keyword(s):  
Perinatal Outcomes ◽  
Multicenter Trial ◽  
Institutional Review Boards ◽  
Positive Pressure ◽  
Minimal Risk ◽  
Delayed Cord Clamping ◽  
Clinical Trial Registration ◽  
Institutional Review ◽  
Cord Clamping ◽  
Waiver Of Consent

Objective This study aimed to determine whether outcomes differed between infants enrolled in the PREMOD2 trial and those otherwise eligible but not enrolled, and whether the use of waiver effected these differences. Study Design The multicenter PREMOD2 (PREmature infants receiving Milking Or Delayed cord clamping) trial was approved for waiver of antenatal consent by six of the nine sites institutional review boards, while three sites exclusively used antenatal consent. Every randomized subject delivered at a site with a waiver of consent was approached for postnatal consent to allow for data collection. Four of those six sites’ IRBs required the study team to attempt antenatal consent when possible. Three sites exclusively used antenatal consent. Results Enrolled subjects had higher Apgar scores, less use of positive pressure ventilation, a lower rate of bronchopulmonary dysplasia, and a less frequent occurrence of the combined outcome of severe intraventricular hemorrhage or death. A significantly greater number of infants were enrolled at sites with an option of waiver of consent (66 vs. 26%, risk ratio = 2.54, p < 0.001). At sites with an option of either approaching families before delivery or after delivery with a waiver of antenatal consent, those approached prior to delivery refused consent 40% (range 15–74% across six sites) of the time. Conclusion PREMOD2 trial demonstrated analytical validity limitations because of the variable mix of antenatal consent and waiver of consent. A waiver of antenatal consent for minimal risk interventional trials conducted during the intrapartum period will be more successful in enrolling a representative sample of low and high-risk infants if investigators are able to enroll all eligible subjects. Clinical Trial Registration ClinicalTrials.gov identifier: NCT03019367. Key Points

scholarly journals Influence of Cimetidine on Cardiovascular Parameters in Man

1979 ◽  
Vol 72 (12) ◽  
pp. 898-901 ◽  
Author(s):  
I O Samuel ◽  
J W Dundee
Keyword(s):  
Blood Pressure ◽  
Intensive Care Unit ◽  
Cardiac Output ◽  
Positive Pressure Ventilation ◽  
Intermittent Positive Pressure Ventilation ◽  
Positive Pressure ◽  
Dilution Method ◽  
Depressant Effect ◽  
Average Blood Pressure ◽  
Before And After

Cardiac output was measured in 10 patients using the dye dilution method, before and after the intravenous injection of 400 mg cimetidine. The subjects were in the intensive care unit and required intermittent positive pressure ventilation. There was no change in the average blood pressure, heart rate and cardiac output during the 60 minutes following the cimetidine, although one patient showed a marked fall in cardiac output. The results suggest that cimetidine is without a marked depressant effect on cardiovascular system.

27 ECG monitoring during NRP: A false sense of security?

2021 ◽  
Vol 26 (Supplement_1) ◽  
pp. e21-e21
Author(s):  
Laurence Gariépy-Assal ◽  
Ahmed Moussa ◽  
Michael-Andrew Assaad
Keyword(s):  
Controlled Trial ◽  
Neonatal Resuscitation ◽  
Pulseless Electrical Activity ◽  
Positive Pressure ◽  
Ecg Monitoring ◽  
Chest Compressions ◽  
Perinatal Medicine ◽  
Epinephrine Administration ◽  
Sense Of Security ◽  
False Sense

Abstract Primary Subject area Neonatal-Perinatal Medicine Background During neonatal resuscitation, use of an electrocardiogram (ECG) provides a more reliable measurement of heart rate than auscultation or pulse oximetry. Having an ECG monitor may, however, provide a false sense of security in the unlikely scenario of a newborn with pulseless rhythms. This could delay critical resuscitative steps during neonatal resuscitation. Objectives The aim of this study is to evaluate whether the presence of ECG monitoring has an impact on the resuscitative steps of neonatal resuscitation providers. Design/Methods We conducted a prospective crossover randomized controlled trial, which took place at Sainte-Justine University Health Center in Montreal, Quebec, Canada. Residents, fellows, attending physicians, transport nurses, and respiratory therapists were recruited in teams of three. They participated in two simulation scenarios (pulseless electrical activity [PEA] with and without ECG monitoring). Teams were randomized to one of the scenarios and then crossed over. A debriefing session followed the two scenarios. All sessions were video-recorded. The primary outcome was the time to pulse check once the simulated mannequin was programmed to become pulseless. Secondary outcomes were the number of pulse checks, time to intubation, time to start of chest compressions, and time to administration of epinephrine. Results Preliminary results (n=5 groups, 10 scenarios) showed that the time to check the pulse once the mannequin was pulseless was longer when ECG electrodes were used (98.0 vs 55.6 sec, p = 0.07). There was a statistically significant decreased number of pulse checks with the ECG compared to without (2.4 vs 5.6, p = 0.004). Time to start of positive pressure ventilation (31.3 vs 27 sec), intubation (182.4 vs 179.2 sec), chest compressions (235.2 vs 227.6 sec), and epinephrine administration (340.8 vs 241.5 sec), were all increased in the presence ECG monitoring, but the difference between groups was not statistically significant. Conclusion ECG monitoring may alter the behaviour of individuals and delay recognition of a pulseless state, but preliminary data suggest that clinical endpoints are not affected.

Abstract 249: Association of Diastolic Blood Pressure and Myocardial Perfusion Pressure with Survival During Pediatric Cardiopulmonary Resuscitation

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Jill L Sorcher ◽  
Donald H Shaffner ◽  
Caitlin OBrien
Keyword(s):  
Blood Pressure ◽  
Cardiac Arrest ◽  
Myocardial Perfusion ◽  
Diastolic Blood Pressure ◽  
Chest Compression ◽  
Life Support ◽  
Perfusion Pressure ◽  
Diastolic Pressure ◽  
Secondary Analysis ◽  
Epinephrine Administration

Introduction: Myocardial perfusion pressure (MPP), defined as the aortic diastolic pressure minus the central venous diastolic pressure, is an important determinant of return of spontaneous circulation (ROSC) in cardiac arrest. However, measuring MPP requires both arterial and venous catheters and is often not possible. When only invasive arterial monitoring is available, diastolic blood pressure (DBP) is suggested as a surrogate for MPP during resuscitation and is also associated with survival after cardiac arrest. Hypothesis: We hypothesized that DBP measured during chest compression delivery would mirror MPP during resuscitation and both would be associated with survival. Methods: We performed a retrospective, secondary analysis of 102 swine resuscitations. Pediatric swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS). MPP and DBP were recorded every 30 s during chest compression delivery. Results: For both survivors and non-survivors, DBP mirrored MPP throughout resuscitation ( Figure 1A, B ). During BLS, both MPP and DBP were significantly greater in survivors (MPP: 8.5 0.6 vs. 1.1 0.5 mmHg; p < 0.0001; DBP 17.3 0.6 vs. 8.7 0.5 mmHg; p < 0.0001). During ALS, MPP and DBP were greater in survivors than non-survivors (MPP: 20.5 1.0 vs. 0.7 0.3 mmHg; p < 0.0001; DBP 32.3 0.9 vs. 8.8 0.2 mmHg; p < 0.0001). During ALS, the magnitude of change in both MPP and DBP after the first epinephrine administration in survivors was greater than in non-survivors (MPP: 24.4 3.3 vs. 4.8 0.9 mmHg; p < 0.0001; DBP: 24.5 3.1 vs. 5.4 0.8 mmHg; p < 0.0001). Conclusion: These observations confirm that both DBP and MPP are associated with survival in cardiac arrest and validate the use of DBP as a surrogate for MPP. Figure 1: Myocardial perfusion pressure (MPP) and diastolic blood pressure (DBP) during BLS and ALS in survivors (A) and non-survivors (B). Arrows indicate administration of epinephrine during ALS.

scholarly journals Safety and Ergonomic Challenges of Ventilating a Premature Infant During Delayed Cord Clamping

Children ◽  
2019 ◽  
Vol 6 (4) ◽  
pp. 59 ◽  
Author(s):  
Wannasiri Lapcharoensap ◽  
Allison Cong ◽  
Jules Sherman ◽  
Doug Schwandt ◽  
Susan Crowe ◽  
...  
Keyword(s):  
Preterm Infants ◽  
Airway Pressure ◽  
Intraventricular Hemorrhage ◽  
Positive Pressure Ventilation ◽  
Positive Airway Pressure ◽  
Professional Organizations ◽  
Positive Pressure ◽  
Delayed Cord Clamping ◽  
Cord Clamping ◽  
Simulation Based

Delayed cord clamping (DCC) is endorsed by multiple professional organizations for both term and preterm infants. In preterm infants, DCC has been shown to reduce intraventricular hemorrhage, lower incidence of necrotizing enterocolitis, and reduce the need for transfusions. Furthermore, in preterm animal models, ventilation during DCC leads to improved hemodynamics. While providing ventilation and continuous positive airway pressure (CPAP) during DCC may benefit infants, the logistics of performing such a maneuver can be complicated. In this simulation-based study, we sought to explore attitudes of providers along with the safety and ergonomic challenges involved with safely resuscitating a newborn infant while attached to the placenta. Multidisciplinary workshops were held simulating vaginal and Caesarean deliveries, during which providers started positive pressure ventilation and transitioned to holding CPAP on a preterm manikin. Review of videos identified 5 themes of concerns: sterility, equipment, mobility, space and workflow, and communication. In this study, simulation was a key methodology for safe identification of various safety and ergonomic issues related to implementation of ventilation during DCC. Centers interested in implementing DCC with ventilation are encouraged to form multidisciplinary work groups and utilize simulations prior to performing care on infants.

Delayed Cord Clamping Versus Cord Milking In Preterm Neonates

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Mohamed N El-barbary ◽  
Mariam JA Ibrahim ◽  
Mai M Khalifa
Keyword(s):  
Umbilical Cord ◽  
Statistical Difference ◽  
Positive Pressure Ventilation ◽  
Laboratory Data ◽  
Preterm Neonates ◽  
Positive Pressure ◽  
Similar Amount ◽  
Delayed Cord Clamping ◽  
Cord Clamping ◽  
Increased Risk

Abstract Background Current guidelines suggest delayed cord clamping (DCC)as it reduces mortality and allows more placental transfusion. Another technique, umbilical cord milking (UCM), provides a placental transfusion without delaying resuscitation and can be completed as quickly as immediate cord clamping Objective To Investigate clinical and laboratory effects of UCM compared to DCC in preterm neonates. Subjects & Methods Preterm neonates &lt;37 weeks were randomized into two groups DCC for 6o seconds and UCM (stripping 20 cm of umbilical cord 4 times at a speed of 10 cm /second towards the baby then cord was clamped. After stabilization of neonates, blood samples were taken after two hours for all neonates for assessment of hemoglobin, hematocrit and bilirubin. Results Most of the neonates included in our study were born through lower segment caesarean section (LSCS) 73(73%) in DCC group and 86(86%) in UCM group. On the other hand, 27(27%) of neonates in DCC group and 14 (14%) in milking group were delivered by vaginal delivery (VD). There was statistical significance increase of LSCS than VD. (p = 0.023) Instrument used during delivery was forceps 3% for DCC and 2% for UCM group and ventose was not used on any of our neonates. Tactile stimulation and warming were performed for all our neonates. Some neonates required interventions for resuscitation like oxygen supplementation (31 % DCC and 36% UCM), positive pressure ventilation (23%DCC, 28 %UCM), fluid bolus (none in DCC group and 2% in UCM group) or intubation (7% DCC, 9% UCM) noting that no cases required any drug e.g. adrenaline intervention. Positive pressure ventilation without intubation included ambu bag or neopuff was used in 23% and 28 % in DCC group and UCM group respectively. No statistical difference was found in the abovementioned data. Apgar score was recorded for every neonate at 1 and 5 minutes of resuscitation to assess transition and any need for further resuscitation measures. Apgar at 1minute median 6 in DCC and CM group(p = 0.346). Apgar at 5minutes median 8.5 in DCC group and 9 in CM group(p = 0.646). No statistical difference was found in Apgar scores between two groups. Laboratory data including serum hemoglobin, hematocrit and bilirubin level were recorded from a blood sample taken within 2 hours of delivery. The mean hemoglobin, hematocrit in the DCC group was 17.06 (2.35) mg/dl, 48.32 (6.86) mg/dl respectively. The UCM group hemoglobin and hematocrit mean was 17.16 (2.34) mg/dl and 49.11(6.55) mg/dl respectively. Mean for serum bilirubin in DCC group was 3.15(3.02) g/dl and for UCM group was 2.91(2.43) mg/dl. No statistical difference was found between DCC and UCM in the laboratory data. Conclusion UCM and DCC resulted in comparable clinical and laboratory results including resuscitating maneuvers used, hemoglobin, hematocrit bilirubin at 2 hours of life implying that similar amount of placental transfusion occurs in both the groups with no increased risk in UCM group. UCM can be performed in any low resource setting and provides adequate placental transfusion to the premature newborn without delay of resuscitation, making it feasible for depressed neonates as well.

Cardiopulmonary Resuscitation 

1999 ◽  
Vol 90 (4) ◽  
pp. 1078-1083 ◽  
Author(s):  
Zoltan G. Hevesi ◽  
David N. Thrush ◽  
John B. Downs ◽  
Robert A. Smith
Keyword(s):  
Cardiopulmonary Resuscitation ◽  
Airway Pressure ◽  
Positive Pressure Ventilation ◽  
Minute Ventilation ◽  
Intermittent Positive Pressure Ventilation ◽  
Positive Pressure ◽  
Chest Compressions ◽  
Aortic Blood Pressure ◽  
To Receive ◽  
Co2 Elimination

Background Conventional cardiopulmonary resuscitation (CPR) includes 80-100/min precordial compressions with intermittent positive pressure ventilation (IPPV) after every fifth compression. To prevent gastric insufflation, chest compressions are held during IPPV if the patient is not intubated. Elimination of IPPV would simplify CPR and might offer physiologic advantages, but compression-induced ventilation without IPPV has been shown to result in hypercapnia. The authors hypothesized that application of continuous positive airway pressure (CPAP) might increase CO2 elimination during chest compressions. Methods After appropriate instrumentation and measurement of baseline data, ventricular fibrillation was induced in 18 pigs. Conventional CPR was performed as a control (CPR(C)) for 5 min. Pauses were then discontinued, and animals were assigned randomly to receive alternate trials of uninterrupted chest compressions at a rate of 80/min without IPPV, either at atmospheric airway pressure (CPR(ATM)) or with CPAP (CPR(CPAP)). CPAP was adjusted to produce a minute ventilation of 75% of the animal's baseline ventilation. Data were summarized as mean +/- SD and compared with Student t test for paired observations. Results During CPR without IPPV, CPAP decreased PaCO2 (55+/-28 vs. 100+/-16 mmHg) and increased SaO2 (0.86+/-0.19 vs. 0.50+/-0.18%; P &lt; 0.001). CPAP also increased arteriovenous oxygen content difference (10.7+/-3.1 vs. 5.5+/-2.3 ml/dl blood) and CO2 elimination (120+/-20 vs. 12+/-20 ml/min; P &lt; 0.01). Differences between CPR(CPAP) and CPR(ATM) in aortic blood pressure, cardiac output, and stroke volume were not significant. Conclusions Mechanical ventilation may not be necessary during CPR as long as CPAP is applied. Discontinuation of IPPV will simplify CPR and may offer physiologic advantage.

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