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Stabilization of very low birth weight infants after delivery

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International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

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  • 1. Stabilization of very low birth weight infants after delivery Zbynek Stranak Institute for the Care of Mother and Child, Prague 3rd Medical Faculty, Charles University, Prague Czech Republic
  • 2. Priority in Extremely Low Birth Weight Infants• Decrease incidence of intraventricular haemorrhage• Optimal treatment of acute respiratory insufficiency• Minimalize circulatory dysfunction• Avoid early and late onset infection including NEC• Decrease chronic respiratory insufficiency rate• Appropriate solving of metabolic disturbances• Facilitate nutrition and growth
  • 3. PVH-IVH RDS Circulatory Dysfunction EOS/LOS/NEC BPD/CLD Metabolic Disturbances Nutrition and Growth GOLDEN HOURS:the difference in life and death
  • 4. LOW-TECH and LOW-COST InterventionsPre-conception Folic acid supplementationAntenatal Syphylis screening and treatment Pre-eclapmsia and eclampsia prevention Tetanus toxoid immunization Preventive treatment of malaria Detection and treatment of bacteriuriaIntrapartum (birth) Antibiotics - PROM Steroids for preterm labor Detection and management for breech Clean delivery practicesPostnatal Resuscitation of newborn babies Breasfeeding Prevention and management of hypotermia Kangaroo, skin to skin
  • 5. Factors May Injure Preterm Lung During Resuscitation Months Minutes/Hours Months • Infection • High VT • MV DR/NICU Management • Steroids • Oxygen Strategy Postnatal Care • Cold Gas • InfectionPregnancy • Dry Gas • Oxygen • No PEEP • Nutrition • Delayed • T Control • PDA cord • Surfactant clamping
  • 6. Background:• Resuscitation is one of the most frequently performed procedures in the neonatal period• Since the most recent guidelines from the ILCOR appeared in 2005. Revision: 2010• Experimental and clinical research has introduced changes regarding the different components of the procedure, with the common denominator being the least aggressive to the baby
  • 7. Validity of Newborn Examination at DR Inaccurate value of Apgar score, skin perfusion and heart rate can lead to inappropriate treatment.
  • 8. Oxygen: how much is too much? Vento et al: Pediatrics 2009, Aug 10
  • 9. The SpO2 value in preterm newborn in DR Kamlin et al. Peduatrics 2006
  • 10. Intubation• When is indicated?• How we are successful?• Who is best? Carbine et al., Pediatr.106, 2000 O Donnell et al., Pediatr., 117, 2006
  • 11. Intubation at Delivery Room (elective, selective, prophylactic, urgent….) VON 98-00 DR Trial 02-03 Columbia 99-02 100 90 90 8578 78 54 53 43 39 29 27 18 8 5 23 24 25 26 27
  • 12. CURPAP Trial: Secondary outcomes Prophylactic 95% nCPAP Risk Surfactant Confidence (N = 103) Ratio (N = 105) IntervalROP: n(%) 30 (28.6) 30 (29.1) 0.98 0.65-1.48Stage > 3: n(%) 7 (6.7) 7 (6.8) 0.98 0.36-2.70NEC : n(%) 7 (6.7) 9(8.7) 0.76 0.30-1.90Sepsis : n(%) 45 (42.9) 43 (41.7) 1.02 0.75-1.40 11 /98Mild BPD in survivors: n/N(%) 12 /94 (12.8) 0.89 0.41-1.93 (11.2)Moderate and Severe BPD in 14/98 11/94 1.22 0.58-2.50survivors: n/N(%) (14.3) (11.7) 14 11Use of systemic steroids: n(%) 1.25 0.59-2.62 (13.3) (10.7) Sandri F, Stranak Z et al. Pediatrics 2010, June 125
  • 13. CURPAP Trial: Secondary outcomes Prophylactic 95% nCPAP Risk Surfactant Confidence (N = 103) Ratio (N = 105) IntervalPneumothorax: n(%) 7 (6.7) 1 (1.0) 6.82 0.86-53.75Pulmonary interstitial emphysema: 3 (2.9) 4 (3.9) 0.74 0.17-3.21n(%)Pulmonary hemorrhage: n(%) 3 (2.9) 2 (1.9) 1.47 0.25-8.76PVH-IVH: n(%) 21 (20.0) 19 (18.4) 1.08 0.62-1.89Grade 3-4: n(%) 6 (5.7) 8 (7.8) 0.73 0.27-2.03PDA: n(%) 43 (41.0) 51 (49.5) 0.83 0.62-1.10Medically treated 28 (26.7) 35 (34.0)Surgically ligated 6 (5.7) 3 (2.9) Sandri F, Stranak Z et al. Pediatrics 2010, June 125
  • 14. CURPAP Trial: Primary outcome - need for mechanical ventilation within 5 days Prophylactic 95% nCPAP Surfactant Risk Ratio Confidence (N = 103) (N = 105) IntervalGestational age 25-28+6 wk - n (%) 33 (31.4%) 34 (33.0%) 0.95 0.64-1.41Gestational age 25-26 wk - n (%) 15 (47%) 12 (39%) 1.21 0.68-2.16Gestational age 27-28+6 wk - n (%) 18 (24.7%) 22 (30.6%) 0.81 0.47-1.37 Sandri F, Stranak Z et al. Pediatrics 2010, June 125
  • 15. CONCLUSION Our Patients are Resilient, Fortunately……• Most infants need only stabilisation and/or adaptation• A little or Oxygen/Air is all that is needed for infants needing the help Doctor, please do not harm !!! Adapted from Jobe A, Ipokrates - Prague 2009
  • 16. The Golden Hour of Thermoregulation: Prevention ofDelivery Room-Associated HypothermiaDR - Associated Hypothermia is any body temperature less than 36.50 degrees on admission to the NICU for inborn babies!
  • 17. WHO - Background• Prevention and management of hypothermia is one of the key interventions for reducing neonatal mortality and morbidity.• According to UNICEF, such interventions can help reduce neonatal mortality or morbidity by 18%–42%.• Improvement in Infant Mortality Rate last 10 years – 24 weeks: improved survival rate from 25% to 40% – 25 weeks: improved survival rate from 40% to 60% – No improvement in DR - associated mortality (Still impacts ~ 15% of the live-born) •No improvement in morbidity Annual Summary of Vital Statistics: 2006. Pediatrics, April 1, 2008
  • 18. Intrauterine Thermal HomeostasisIs the uterus a “bun-warmer” or an air conditioner? Factors which impact heat balance in utero:  Uterine wall temperature  Maternal-fetal blood temperature gradient  Placental vessel temperature  Amniotic fluid temperature  Fetal core ~ 0.5 ºC > maternal core temperature Graphic ©2002 Nucleus Communications
  • 19. Admission Temperatures Across Birth-weight Birthweight, g # < 36.5C < 750 g, n (%) 15/15 (100%) 751-1000 g, n (%) 20/25 (80%) 1001-1250 g, n (%) 23/28 (82%) 1251-1500 g, n (%) 16/22 (73%) 1501-2500 g, n (%) 71/164 (43%) > 2500 g, n (%) 57/258 (22%) Bhatt, D. et al. PAS 2007; E-PAS2007:617933.23
  • 20. Admission Temperatures - All Gestations BW (M+SD),GA, Weeks N < 35C, % < 36C, % Grams <24 187 598 + 118 43.9 71.1 24 397 655 + 100 33.8 64.2 25 468 751 + 130 20.5 57.1 26 539 840 + 163 13.2 44.2 27 609 977 + 182 10.7 41.5 28 643 1088 + 201 9.6 38.3 Laptook, A. R. et al. Pediatrics 2007;119:e643-e649
  • 21. DR – Associated Hypothermia ConsequencesFor each 1°C decrease in admission temperature, chances ofsurvival are decreased by 10%! (Nedrelow)For each 1°C decrease in admission temperature, late-onsetsepsis is increased by 11% & odds of death are increased by28%! (Laptook)
  • 22. Clinical Consequences of Heat Loss
  • 23. Potential risks of heat loss in infants• Depletion of surfactant• Hypoxia• Hypoglycaemia• Metabolic disorders• Increased utilisation of calorific reserves• Acidosis• Increased neonatal morbidity • Warm resuscitation surface • Warm transportation equipment • Plastic bags
  • 24. What is “Normal” Temperature?•A single, discrete value is mythical!•Definition of “normal” : – Normal range: 36.5 - 37.5oC – Potential cold stress: 36.0 to 36.5oC • Have concern – Moderate hypothermia: 32.0 to 36.0oC • Danger, immediately warm infant – Severe hypothermia: < 32.0oC • Outlook grave • Skilled care urgently needed World Health Organization, 1997
  • 25. Delayed cord clamping/milking• Rationale: – Improve circulatory parameters during transitional period• For uncompromised babies, a delay in cord clamping of at least 1min from the complete delivery of the infant, is now recommended• As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in babies who are severely compromised at birth
  • 26. Reactions to Cold INFANT ADULT • None • Adding clothing layers • Posture: Rubbing handsVoluntary  Curling up Crossing arms across chest • Limited non-shivering • “Goose-pimples” thermogenesis • ShiveringInvoluntary • Peripheral vasoconstriction • Non-shivering thermogenesis
  • 27. Thermal Balance at the Beginning of Life Convection Radiation Conductive Evaporation Heat Loss
  • 28. Why are Newborns Prone to Heat Loss?•Increased insensible water loss•Thin epidermis in preterms•Large surface area compared to body mass•Lack of insulating and brown fat•Extended posture•Non-shivering thermogenesis may be insufficient tocompensate for heat loss•Sick, hypoxic babies will have limited ability toincrease heat production
  • 29. FROM BIRTH TO THE NEONATAL UNIT: A COLD JOURNEY?
  • 30. Mannheim Study - Rationale•Compared Giraffe OmniBed to traditional transportincubator – Admission temperature – Number of transfers between beds – Time from DR to NICU – Physiological/behavioral stress of subjects Permissions on File
  • 31. Mannheim Study - Demographic characteristics Characteristic Traditional Giraffe OmniBed (Range) Transport Transport (N=50) (N=50) Gender (M/F) 22/28 24/26 Average Gestational 33+2 w 34+1 Age (weeks) (24+1to 41+4) (24+3 to 41+1) Average 1780.2 g 1934.5 Weight (grams) (530 to 4120) (470 to 3890) Prematurity 28/50 31/50 Diaphragmatic 18/50 17/50 Hernia (CDH) Congenital Cystic Adenomatoid 1/50 2/50 Malformation (CCAM) Other Diagnoses 3/50 0/50
  • 32. Mannheim Study - Summary Characteristic Traditional Giraffe OmniBed (Range) Transport Transport (N=50) (N=50) 56.3 m 42.7 m (Preterms) * Total Transport Time (Preterms) (minutes,m) Team toDR; Returns with Baby 62.1 m (Others) 46.8 m (Others) * 33.9 m 25.3 (Preterms) * Birth to NICU (Preterms) Admission Time (minutes. m) 29.1 m (Others) 27.7 m (Others) *p<0.0001, Welch-Satterthwaite t-test
  • 33. Hypothermia - Conclusion•Hypothermia is preventable!•Know your facility data•Adopt actions that attenuate admission hypothermia – Raise the room temperature – Place occlusive wrap @ point of delivery • Consider chemical blankets, if staff stuggles with polyethylene wrap – Use developmental care from birth • Swaddling, appropriate handling – Consider use of a single device from DR to NICU to further improve thermal stability
  • 34. Resuscitation of babies at birth: ILCOR 2010• „For uncompromised babies, a delay in cord clamping of at least 1min from the complete delivery of the infant, is now recommended.“• „As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in babies who are severely compromised at birth.“• „For term infants, air should be used for resuscitation at birth. If, despite effective ventilation, oxygenation (ideally guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.“
  • 35. Resuscitation of babies at birth: ILCOR 2010• „Preterm babies less than 32 weeks gestation may not reach the same transcutaneous oxygen saturations in air as those achieved by term babies. Therefore blended oxygen and air should be given judiciously and its use guided by pulse oximetry. If a blend of oxygen and air is not available use what is available“
  • 36. Delivery room management in 24-30 wksDR „Well being“ infants „Bad“ infants Spontaneously breathing PPV with PEEP NCPAP INSURE 15 minNICU CPAP failure criteria for Early Surfactant Arteficial Ventilation INSURE Active weaning Success on NCPAP 75-80% patients 20-25% patients
  • 37. Strategy of Arteficial Ventilation LLV HLV OLV7 IPPV PTV PTV+VG65 HFV Tidal4 Volume32 PEEP1 SURFACTANT0 1970 1980 1990 2000
  • 38. Optimal Lung Volume and Trigger VentilationVentilatory Induced Lung Injury: Severe Respiratory Morbidity Role of Tidal Volume 70 60 58 50 47 40 30 20 12 10 4,4 0 2002-2005 2006-2009 BPD/CLD Air leak
  • 39. Singapore Med 2008; 49(3) : 199 Ventilatory Strategy: •NCPAP •SIMV+VG •A/C, SIMV •HFOV •INO
  • 40. Resuscitation of babies at birth: ILCOR 2010• „Preterm babies of less than 28 weeks gestation should be completely covered up to their necks in a food-grade plastic wrap or bag, without drying, immediately after birth. They should then be nursed under a radiant heater and stabilised. They should remain wrapped until their temperature has been checked after admission. For these infants delivery room temperatures should be at least 26 ◦C.“
  • 41. Resuscitation of babies at birth: ILCOR 2010• „If adrenaline is given then the intravenous route is recommended using a dose of 10–30 μg/kg. If the tracheal route is used, it is likely that a dose of at least 50–100 μg/kg will be needed to achieve a similar effect to 10 μg/kg intravenously.“
  • 42. Resuscitation of babies at birth: ILCOR 2010• Detection of exhaled carbon dioxide in addition to clinical assessment is recommended as the most reliable method to confirm placement of a tracheal tube in neonates with spontaneous circulation• Newly born infants born at term or near-term with evolving moderate to severe hypoxic–ischaemic encephalopathy should, where possible, be treated with therapeutic hypothermia. This does not affect immediate resuscitation but is important for postresuscitation care
  • 43. Necrotizing Enterocolitis Early use of colostrum (3-6 hrs) after delivery in ELBW. N=266 vs N=134 16 14 14 12 10 8 7 6 4 2 0 2002-2007 2008-2009
  • 44. Conclusion I• Babies should be kept warm, avoiding suctioning as a general rule• Adjusting pressure, volume and oxygen to the minimum to achieve stabilisation without causing harm to the airways or oxidative stress• Applying all the available technology in the delivery room before transportation to the neonatal intensive care unit• The response to ventilation should primarily be assessed by the heart rate Vento et al. Semin Fetal Neonatal Med. 2010 May 5
  • 45. Conclusion II• Babies of gestational age ≥ 32 weeks should be ventilated initially with 21% oxygen• Babies of gestational age and if <32 weeks should be ventilated initially with 21-30% oxygen• Intubation, chest compressions, use of drugs or volume therapy are rarely needed in term or near term babies in need of resuscitation• The first minutes of life are decisive, and what we do during these minutes will have unequivocal influence later on Vento et al. Semin Fetal Neonatal Med. 2010 May 5
  • 46. Common serious complications in preemiesSepsis/NEC PVH-IVH/CP BPD/CLD/ROP
  • 47. Thank you for your attention…