New Concepts of Newborn Resuscitation – the new national protocol

10,241 views

Published on

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

Published in: Health & Medicine
5 Comments
27 Likes
Statistics
Notes
No Downloads
Views
Total views
10,241
On SlideShare
0
From Embeds
0
Number of Embeds
17
Actions
Shares
0
Downloads
669
Comments
5
Likes
27
Embeds 0
No embeds

No notes for slide

New Concepts of Newborn Resuscitation – the new national protocol

  1. 1. D. Dobryanskyj Lviv National Medical UniversityNew Concepts of NewbornResuscitation – the new nationalprotocol
  2. 2. Ukraine 0.1% require ICM* 0.05% require medicines administration ≈ 1 million < 1% • Should follow to IC** ≈ 5000 children • LOW level of evidences of require children complete resuscitation effectiveness≈ 30000 * - indirect cardiac massage ** - intensive carechildren Approx. 6 million Approx. 3-6% The most children require initial help (lungs important influence ventilation with mask) population≈ 50000 children Approx. 10 million Approx. 5-10% require simple children stimulation (drying and massage) in order to start breathing independently130 million All the newborns require immediate condition children assessment and standard medical measures S. Wall et al., Int J Gynaecol Obstet. 2009 107 (Suppl 1): S47
  3. 3. Інші причини; 0,181 млн. Ukraine, 2009 Природжені 2% 7% аномалії; 0,27 13% млн. 15% Ускладнення недоношеності; 8% 8% 1,08 млн.; 35% Неонатальні інфекції; 0,83 млн.; 27% 3% Інтранатальні 12% 32% ускладнення; 0,72 млн.; 228 children 23% Інші Аномалії Інфекції Сепсис Асфіксія Захв. легеньBorn too soon: the global action report on preterm birth, WHO, 2012. Пневмонії ВШК Пор цер. стат.Li Liu et al. The Lancet, 2012, V. 379, No. 9832: P. 2151-2161
  4. 4. • During 2000-2009 mortality rate of newborns with birth weight 501-1500 g decreased from 14,3% to 12,4% (dynamics– 21,9%; 95% CI: 22,3-21,5%) • Severe morbidity in newborns who survived decreased from46,4% to 41,4% (dynamics – 24,9%; 95% CI: 25,6-24,2%) • In 2009 mortality rate varied from 36,6% (501-750 g) to 3,5% (1251-1500 g), and morbidity varied,from82,7% to 18,7% • 49,2% of all newborns with VLBW 89,2% of newborns with weighting at birth 501- 750 g either died or survived with severe disability Data basedon 355 806 newborns with birth weight from 501to1500 g from 669 hospitals of theYears J.D. Horbar et al.Body 501-750 g 751-1000 g 1001-1250 g 1251-1500 g North America Pediatrics 2012;129:1019
  5. 5.  1996: Regulatory systematic recommendations asresuscitation, 1998 Official opening of Kyiv NMC of Newborns to the initialresuscitation of newborns. Amendment to Order No.4 of the Ministry ofHealthcare from 05/01/19962003: Onapproval of branch program "Initial resuscitation of newborns for2003-2006 ". Order No. 194 of the MH from06/05/20032007: Initial resuscitation and post-resuscitation support of newborns:Clinical protocol on neonatal support provision . Order No. 312 of the MH08/06/2007.2013: Immediate, resuscitative and post-resuscitative support ofnewborns: Unified clinical protocol
  6. 6. "Avoid hypothermia of anewborn"«Fill their lungs with air»«Do not give oxygen - it istoxic!» 1895
  7. 7. 51%of newborns born at < 28 weeks and 57% at ≥ 28 weeks (< 32 weeks) had body temperature < 36,5°С at the time of admission to NICU (2011)1 Ventilation, filling of lungs, РЕЕР СРАР intubation? 2 , , «We may come to a reasonable conclusion that in term and early-born infants -initial lungs ventilation should be performed with room air (relevant risk of mortality is 0.71 [95% CI 0.54-0.94])»31 Chitty H.E. et al., Wrapping is not sufficient to prevent hypothermia of preterm infants, PAS 20122 Wyllie J. et al., Resuscitation 81S (2010) e2603 Davis P.G. et al., Lancet 2004; 364: 1329
  8. 8. differentiate between the interventions needed for 5-10 % of newborns who really required resuscitation, and stabilization measures which are standard for 90% of infants and are taken to avoid further morbidity• Stabilization of condition (a support for adaptation) is necessary for all the newborns irrespective of their gestational age, independent breathing or respiratory problems and heart rate ≥ 100/min.• “More” observation, and less “agression”!
  9. 9. Term newborn Preterm newborn
  10. 10. Total blood volume in fetal/placental circulation forgestational period is 110-115 vl/kgIn case of urgent delivery 2/3 of this volume are in fetusblood vessels and ? stay in placentaAt 30 weeks of GA these volumes are about thesameImmediate clamping of umbilical cord leads to newbornblood volume ≈ 45 vl/kg (loss– 25-35 ml/kg)15-20 ml is contained in the cord; half of cord length – 10ml4 wringings give 40-50 ml of transfusion et al. Pediatrics 2006;117;93 N. Aladangady Rabe H. et al. Obstet Gynecol. 2011; 117(2 Pt 1):205
  11. 11.  Blood volumeLess transfusions needed [ВР-0.61; 95% CI 0.46-0.81] blood pressure and decreased need in inotropesadministration [ВР-0,42; 95% CI 0.23-0.77]Better circulation in upper hollow veinBetteremission from left ventricle Cerebral oxygenation indexDecreased number of any IVH [ВР-0.59; 95% ДI 0.41-0.85] (no differences in the number of severe IVH)Decreased number of NEC [ВР-0.62; 95% ДI 0.43-0.90] Raju T.N.K., Singhal N. Clin Perinatol 2012;39:889 Rabe H. et al. Cochrane Database of Systematic Reviews 2012, Issue 8
  12. 12. 5 RCS(2008-2012)* 8 controlled studies Unfortunately, there is no systematic review and meta-analysis so far Preliminary finding: the same positive clinical results that were obtained after delayed cord clamping No negative effects of this clinical practice were observed for term and preterm infants* Hosono08, Minami08, Rabe11, Erickson-Owens12, Gotwal12
  13. 13. Put a child into a plastic bag (< 28 weeks); in casethere is no independent respiration immediately*separate and transport….Put a child into a plastic bag (< 28 тиж) and in caseof independent breathing hold below the placentalevel; clamp and cut the cord after 30-45 s** in case any delay is impossible, quickly wringblood out of the cord 3-4 times directing it to a child(A) Immediate, resuscitative and post-resuscitative support of newborns, Kyiv, 2013
  14. 14. Visual assessment of skin colour and adequateindependent breathing especially in deeply preterminfants is inacurate and subjectiveAssessment according to Apgar scale is also rathersubjective and especially complicated for deeplypreterm infantsStandard methods of heart rate measurement(auscultation and palpation) are inaccurate J. Wyllie et al. Resuscitation 81S (2010) e260
  15. 15. % of observers considering that a SpO2 corresponding to clinical child has cyanosis definition of pink colour SpO2% Maximum level of SpO2 during Results from 20 videoclips are indicated videorecording C. Kamlin et al. J Pediatr 2008;152:756
  16. 16. 1 min 60-65% 2 min 65-70%SpO2 (%) 3 min 70-75% 4 min 75-80% 5 min 80-85% 10 min 85-95% Minutes after delivery 10th 25th 50th 75th 90th Percentile J.A. Dawson et al. Pediatrics 2010;125;e1340
  17. 17. 0Median differences (95% CI) between clinical heart rate measurement and ECG data -5 Deviation from actual value -10 -15 -20 -25 -30 -35 Auscultation Palpation (n=26) (n=21) C. Kamlin et al. Resuscitation 2006; 71: 319
  18. 18. Prospective , randomized (heart rate measurementtechniques [auscultation or palpation] and scenario),controlled study64 experienced physicians3 training scenarios (SimNewB®, Laerdal Inc.,Stavangar, Norway)Heart rate measurement bias were observed at 26-48%initial and 26-52% follow-up assessmentsMeasurement method did not affect the resultClinical measurement of heart rate in case of RN isunreliable Chitkara R. et al., Resuscitation 2012, In press
  19. 19. If PO shows heart rate < 100/min, thePO heart rate minus ECG heart rate probabilty of 2SD bradycardia is 83% 0 If PO shows heart 2SD rate > 100/min, the possibility that an infant has no bradycardia is 99% Mean heart rate C. Kamlin et al. J Pediatr 2008;152:756 + 2 SD (24 strikes/min.); 0: mean (-2 strikes/min.); - 2 SD (-28 strikes/min)
  20. 20. 90th 75th 50th 25th 10thHeart rate 50th percentile value is less than 100/min in 1 min after delivery! Minutes after delivery J.A. Dawson et al., Arch Dis Child Fetal Neonatal Ed 2010;95:F177
  21. 21. CONCLUSIONS: An improved delivery(24 weeks, ventilation with Case1 (term infant) Case 2 ETT) room score thatNumber of respondents Number of respondents decreases variability among medical care323 335 professionals participants is needed to accurately reflect the clinical status of participants preterm infants. CONCLUSIONS: An improved assessment scale is General Apgar score General Apgar score needed in(28 weeks, СРАР) unify and increase (28 weeks, ventilation with ETT) Case 3 order to Case 4 accuracy in defining clinical conditions of preterm infants betweenNumber of respondents 313 312 different medical professionals participants Number of respondents participants General Apgar score General Apgar score M.T. Bashambu et al. Pediatrics 2012;130;e982 1 min of life 5 min of life 10 min of life
  22. 22. Characteris 0 1 2 Timetic 1 min 5 min 10 min 15 min 20 min Bradycardia (HRHeart rate None (HR <100/min) ≥100/min) Bradypnoea,Respiration None Regular, cry irregular Dramatically ActiveMuscular tone Mild limb bending low movementReflex Cough, No reaction Spasmexcitability sneezing Cyanosis orColour Limbs cyanosis Pink paleness General scoreComments: Resuscitation Minutes 1 5 10 15 20 Oxygen Ventilation/CPAP Intubation IMCААР. Pediatrics, 2006,117,4:1444 Adrenalin
  23. 23. After initial help [(1) position ± airways sanitization[according to indications – meconium, ventilationneed (newborn does not breathe!) or obstructedrespiration]; 2) drying]Only 2 characteristics may evidence the need innresuscitative intervention after initial help – nobreathing (gasping ) or heart rate <100/minThe first minute is a «goldentime frame» and all theactions during this minute are standardized! J. Wyllie et al. Resuscitation 81S (2010) e260
  24. 24. Mechanisms that support Adults Primary effects of respiration Newborns increased lungs volume at with increased lings volume expiration at expiration FRC of lungs EERV1. Additional diaphragm and 1. Less energy loss larynx – lungs volume at rest at 2. Improvement of surfactant Vr muscles activity expiration phase effect2. Starting the following EERVDecrease of lungs vessels 3. – end-expiratory lungs volume Volume Moan inspiration before Vr "Supporting" resistance3. Inverse sequesnce of inspiration 4. Optimized ventilation- glottis opening and perfusion correlation diaphragm contraction EERV Better gas exchange EERV 5. Time Trachea intubation blocks all these physiological mechanisms!
  25. 25. FRC dynamics, CL, і RL after delivery ml Free lungs from fluid ml/kPa Create functional residual capacity of lungs (FRC) ≈ 30 ml/kg Stimulate independent breathing using lungs aeration Facilitate gas exchange Minimize risk of lungs damage hou min r Lungs resistance [RL] (ml*s/kPa) FRC (ml)Roehr C.C. et al. Neoreviews 2012;13;e343 Lungs pliability [CL] (ml/kPa)
  26. 26. СРАР only?"Filling of lungs"  with СРАР?"Filling of lungs"  with ventilation?Intubation and ventilation?INSURE?Surfactant without intubation?
  27. 27. Indications No independent breathing Respiratory disfunctionGestational term < 32 weeksLungs ventilation with positive pressureVentilation frequency – 40-60/minPeak inspiratory pressure (РІР) – 40-20/25 cm Н2ОPositive end-expiratory pressure (РЕЕР) – 5 cm Н2ОMay be performed with relevantly long-term ("filling of lungs") or short-term (standard vetilation) tI J. Wyllie et al. Resuscitation 81S (2010) e260
  28. 28. Why it is so important to create РЕЕР for deeply preterminfants? Facilitates the development of FRC Facilitates aeration Improves oxygenation Protects lungs from damage (prevents pulmonary collapse)May be used with Resuscitation T-system Bag filled with airflow Self-filling bag (only in case additional valve and gas flow (connected gas source) are available!) Roehr C.C. et al. Neoreviews 2012;13;e343
  29. 29. Ventilation: Lower initial inspiratory pressure (20-25cm Н2О) for preterm infant compared to term infant(30-40 cm Н2О)Avoid excessive movement of chest, especially forpreterm infantsРЕЕР: will most likely benefit and is recommendedif technically possibleСРАР: may be used in ingants breathingindependently according to local protocols J. Wyllie et al. / Resuscitation 81S (2010) e260 © 2010 American Heart Association, Inc.
  30. 30. For infants with ≥ 32 weeks of gestational age it isrecommended to ventilate lungs with air (21% О2)For more immature infants (< 32 тиж) initial О2concentration should be  30%Start of ventilation, CPAP or additional oxygen useindicate the need in continuous pulse oximetryFurther on О2 concentration (FiO2) is changedaccording to SpO2Ventilation of lungs with 90-100% oxygen is shown forICM
  31. 31. Total number of death or BPD in 2 groups Intubation + СРАР from surfactant as birth onStudy preventive routine basis Relevant risk and 95% CI measure For СРАР For intubation Rojas-Reyes MX, Morley CJ, Soll R. Cochrane Database of Systematic Reviews 2012, Issue 3
  32. 32. Comparative namber of intubations in case of airbag ventilation using laryngeal (LM) or conventional (CM) mask LM Bag and mask Odds ratioStudy For LM For CM LM may be used for neonates with ≥ 34 weeks of GA and weight > 2000 g Georg M. Schmolzer et al. Resuscitation (2012). In press
  33. 33. T-systems or resuscitative bags filled with airflow orindependently may be used for respiratory support J. Wyllie et al. Resuscitation 81S (2010) e260T-systems are preferred in developed countries. It isrecommended by European Consensus onprevention and treatment of RDS31% in Ireland;  45% in Spain;80% in Austria;  41% in Germany;20% in Switzerland;  80% in Poland C.P. Hawkes et al. Resuscitation 83 (2012) 797 European Consensus Guidelines, Neonatology 2010; 97:402
  34. 34. Maximum proximity of real PIP, Insufficient control of РІР, РЕЕР and ТіPEEP and Ti values to desirable;minimum variability of these values  risk of volutrauma less risks of volutrauma (lower Better ability to feel the pliability ofand more stable VT ) lungs. Easier modification of ventilationLimited ability to feel the pliability of settingslungs. Less air leaks from under theSettings modification requires more masktime and skills Lower impact of flow rateIncreased air leak from under the changes to ventilation settingsmaskChange of flow rate significantlyalters ventilation settings C.P. Hawkes et al. Resuscitation 83 (2012) 797
  35. 35. ml cm Н2О p < 0,0005 p < 0,001 Self-filling bag Т-system Self-filling bag Т-system Respiratory volume (VT), ml Peak inspiratory pressure (РІР), cm Н 2О C.C. Roehr et al. Resuscitation 81 (2010) 202
  36. 36. Median, 25th- 75th percentilesSpO2 (%) and measurement limits are displayed p>0,05 Minutes after delivery Т-system Bag J. A. Dawson et al., J. Pediatr. 2011;158:912
  37. 37. Face masks Round masks are used more often Facilitate the use of ventilation, filling of lungs, РЕЕР і СРАР Their use may be often accompanied by airways obstruction and/or air leaksNasal prongs/ special cannula Shortened endotracheal tube Significant air leak May be more effective than mask
  38. 38. Equipment: Resuscitative bags of both types andT-systems may be usedNasal prongs/cannula may provide more effectiveventilation than maskMonitoring: to use pulse oximentry, insifficient datato recommend respiratory volume measurement J. Wyllie et al. / Resuscitation 81S (2010) e260 © 2010 American Heart Association, Inc.
  39. 39. • «No Resuscitation teams could not give visual movements» - 4.4 (3.0-7.0) assessment of chest excursion adequacy for ml/kg EPNs! • «Uncertain movements» - Expiration volume (ml/kg) 3.7 (3.0-5.6) 20 newborns at ≈ 27 ml/kg weeks of gestation • «Proper movements» - 5.2 (2.9-8.9) ml/kg • «Excessive movements» - 5.8 (2.4-8.6) ml/kg • «Insufficient movements» - 7.8 (3.6-10.3) ml/kgRoyal Women Hospital, Melbourne, Australia D.A. Poulton et al., Resuscitation 82 (2011) 175
  40. 40. Non-invasive respiratory support optimizationDetection of airways obstructionProviding of proper RVIndependent breathing diagnosticsAssessment of ventilation frequencyInspiration and expiration durationCorrect ETT position and gas leak availability G. Lista et al., Neoreviews 2012;13;e364
  41. 41. Pressure(cm Н2О) Inspiratory flow Flow (ml/s) Expiratory flow Volume (ml) G. Lista et al., Neoreviews 2012;13;e364
  42. 42. Uncontrolled ventilation Controlled ventilation G. Lista et al., Neoreviews 2012;13;e364
  43. 43. Pressure(cm Н2О) Gas leak Flow (ml/s) No flow – obstructionVolume (ml) K. Schilleman et al. J. Pediatr. 2012. In press
  44. 44. UC San Diego Medical Center, USA Finer N. et al. Clin Perinatol 39 (2012) 931
  45. 45. Covers all the new regulations of International ScientificConsensus of 2010.Includes the concept of initial stabilization of preterminfants conditionProposes the necessity to use modern methods ofrespiratory support and monitoring (resuscitative T-system, laryngeal mask, СО2 detectors, pulsoxymeters)Includes separate detailed rules of preterm infants careand expanded Apgar scaleReprecents the concept of palliative careContains a separate protocol on therapeutic hypothermia
  46. 46. BIRTH Term delivery? Yes Routine care Breathing or crying? • Provide warming To leave with Muscular tone is good? • Free airways mother • Dry No • Assess condition in dynamic Provide warming and free airways, state dry, and stimulate No No Complicated breathing or stable30 s Apnoea, gasping or heart rate<100? cyanosis? Yes Yes Ventilation, need in SpO2 monitoring Free airways, need in SpO2 ≥ 3260 s Heart rate < 100? monitoring, CPAP weeks! Yes No Adequate ventilation control Post-resuscitative EffectiveSpO. care norms2% Heart rate < 60? 1 min 60-65% Correct ventilation Yes 2 min 65-70% Intubate if no Necessity of intubation 3 min 70-75% movements Start ICM, coordinate with ventilation 4 min 75-80% observed! 5 min 80-85% Possibility of: Heart rate < 60? 10 85-95%• Hypovolemia Yes min © 2010 American Heart Association, Inc.• Pneumothorax Adrenalin IV J. Wyllie et al. / Resuscitation 81S (2010) e260
  47. 47. No independent Independent breathing (IB): hold a newborn below placenta level;BIRTH breathing clamp and cut the cord after 30-45 s*; provide thermal protection (IB)*... • Transfer to resuscitation table • • Provide warming and free airways, dry, and stimulate Attach pulsoximeter sensor to the right hand (preductively) < 32 weeks! • Assess the ability to breathe independently, heart rate and SpO2 • Sanitate upper airways (upon indication) • Monitoring: 1. IB available • Independent 2. Complicated • Apnoea, gasping OR respiration Conditi breathing • Heart rate<100 OR 3. SpO2 on • Heart rate ≥ 100 4. Heart rate • SpO2 < 40% assess • SpO2 ≥ 40% 5. Skin colour ment Yes 6. Activity Yes30 s • Transfer to NICU • «Lungs filling** 10 s (РІР 20-25 cm СРАР • Surfactant (in case Н2О; FiO2 30-40%)  СРАР (5 cm 5-7 cm of intubation Initial RS Н2О; FiO2 30-40%) OR Н2О**** FiO2>0,3) • ventilation(РІР 20-25 cm Н2О, РЕЕР 5 cm Н2О, FiO2 30%) Independent breathing60 s Assessment: Yes Apnoea, HR increased? HR, SpO2, IB N gaspings • o Adequate filling/ventilation? • Continue ventilation(РІР 20-25 cm Н2О; РЕЕР 5 cm Н2 О; • Repeat filling of lungs, start ventilation FiO2****)
  48. 48. • Continue ventilation(РІР 20-25 • Adequate filling/ventilation? cm Н2О; РЕЕР 5 cm Н2 О; • Repeat filling of lungs, start ventilation FiO2****)Assessment: HR, SpO2 HR<60 60<HR<100 HR>100 • Trachea intubation*** • Trachea intubation*** < 32 weeks! • Start ICM • Continue ventilation (РІР • Continue ventilation (РІР 20-25 cm Н2О; РЕЕР 5 cm 20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 40%) Н2О; FiO2 90%) • Coordinate ICM and ventilation HR>100 Assessmen HR<60 60<HR<100 t: HR, SpO2 • Inject adrenalin into trachea • Administer adrenalin IV • Continue ventilation (РІР 20-25 • Continue ventilation (РІР 20-25 cm cm Н2О; РЕЕР 5 cm Н2О; FiO2 HR<60 Н2О; РЕЕР 5 cm Н2О; FiO2 90%) 90%) • Continue ICM • Continue ICM • Administer physiological • Catheterize cord vein solution IV*****
  49. 49. • Put a child into a plastic bagBIRTH No independent IB: hold a newborn below placenta level; clamp and cut the cord after breathing... 30-45 s* < 28 weeks! • Transfer to resuscitation table • Provide warming and free airways, dry, and stimulate • Attach pulsoximeter sensor to the right hand (preductively) • Assess the ability to breathe independently, heart rate and SpO2 • Sanitate upper airways (upon indication) • Monitoring: 1. IB available • Apnoea, gasping OR • Independent 2. Complicated Conditi breathing respiration • Heart rate<100 OR 3. SpO2 on • Heart rate ≥ 100 • SpO2 < 40% 4. Heart rate assess • SpO2 ≥ 40% 5. Skin colour ment Yes Yes 6. Activity30 s • «Lungs filling** 10 s (РІР 20-25 cm СРАР • Transfer to NICU Н2О; FiO2 30-40%)  СРАР (5 cm 5-7 cm • Surfactant (in case Initial RS Н2О; FiO2 30-40%) OR Н2О**** of intubation) • ventilation(РІР 20-25 cm Н2О, РЕЕР 5 cm Н2О, FiO2 30%) Independent breathing60 s Assessment: Yes Apnoea, HR increased? HR, SpO2, IB N gaspings • o Adequate filling/ventilation? • Continue ventilation(РІР 20-25 cm Н2О; РЕЕР 5 cm Н2 О; • Repeat filling of lungs, start ventilation FiO2****)
  50. 50. • Continue ventilation(РІР 20-25 • Adequate filling/ventilation? cm Н2О; РЕЕР 5 cm Н2 О; • Repeat filling of lungs, start ventilation FiO2****)Assessment: HR, SpO2 HR<60 60<HR<100 HR>100 GA < 25 GA ≥ 25 < 28 weeks! weeks weeks • Trachea • Trachea intubation*** intubation***• Stop • Start ICM • Continue resuscitatio • Continue ventilation (РІР ventilation (РІР n 20-25 cm Н2О; РЕЕР 5 cm 20-25 cm Н2О;• Start Н2О; FiO2 90%) РЕЕР 5 cm Н2О; palliative • Coordinate ICM and FiO2 40%) care ventilation HR>100Assessment: HR<60 60<HR<100 HR, SpO2 • Administer adrenalin IV • Inject adrenalin into trachea • Continue ventilation (РІР 20-25 • Continue ventilation (РІР 20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 cm Н2О; РЕЕР 5 cm Н2О; FiO2 HR<60 90%) 90%) • Continue ICM • Continue ICM • Administer physiological • Catheterize cord vein solution IV*****
  51. 51. Resuscitation refuse or its discontinuation do not mean thatno medical care is provided to the patient. It means atransfer to the so-called palliative or "comforting" care if anewborn still stays alivePC for a newborn infant means complete set of measuresthat prevent or alleviate additional suffering and improveconditions of the last period of infants lifePC is prescribed to a newborn in 3 cases: lethal developmental abnormalities; resuscitation does not correspond to the best interests of a child; obvious useless on intensive care Catlin A. J. Perinat. 2002; 22:184 Palliative care. Nuffield Council on Bioethics, London, 2006: 97
  52. 52. J.E. Tyson et al., N Engl J Med 2008;358:1672 N.A. Parikh et al., Pediatrics 2010;125;813Days * EPN – extremely preterm newborn 591600 Ventilation term Тривалість ШВЛ Hospitalization term Тривалість госпіталізації500 USA, 4446 infants of 22-25 weeks, 2008 395 378400 25 303 weeks300 221 238 210 >60% 204200 140 139 140 95 94 114100 52 36 0 <5% 5-9% 10-14% 15-24% 25-32% 33-49% 50-66% >66% 22 weeks, <10% Likelihood of survival without severe disability (%)
  53. 53. % of survivals % of general "acceptable" survival • Survival of newborns with < % of "acceptable" survival in NICU 600 g depends on gestational age, according to data from NICHD • "Intact" survival in NICU is relevantly independent of GA! Gestation week• % of all infants of < 26 weeks of GA, week which survived with severe neurological s week results depending on GA s week s week• Most infants who survived with these s results were born at  GA, as the survival depends on the GA while the % of affected infant does NOT! Meadow W. et al. Clin Perinatol 39 (2012) 941
  54. 54. Time and money Refusal from Death in the delivery Death in NICU resuscitation room Prenatal Treatment Discharg Resuscitatio consulting attempt e from n NICUGA; ACS; multiple GA; ACS; multiple SNAP, intuition, RN, BPD, cerebral gestation, SGA gestation, SGA, Apgar NSG palsy Prognostic criteria GA - gestational age; ACS – antenatal corticosteroids; SGA – small for gestational age; SNAP – the scale for evaluation of condition severety; NSG - neurosonography Meadow W. et al. Clin Perinatol 39 (2012) 941
  55. 55. 90 82% 72 77 80 66 68 70 55 60 50 40 30 20 16 20 8 9 6 10 0 0 Вижили Вижили без важких Припинення ШВЛ до наслідків смерті9575 infants of GA 22-28 weeks, 2003-2007 B.J. Stoll et al. Pediatrics 2010;126;443
  56. 56. Short-term ventilation using mask and air (≤ 60 s) Long-term ventilation (> 60 s) or complete * resuscitation • Apgar score at 5 min ≥ 7 • Complete objective inspection immediately • Within 15 min after ventilation was discontinued after resuscitation – HR>100/min – SpO2 > 85%, no central cyanosis (without supportive О2 ) Eligibility to participate in – No respiratory disfunctions therapeutic hypothermia – Acceptable or lightly decreased muscle tone programme (art. 4.19)** – No other pathological characteristics Yes • Start of passive cooling No Yes No (art. 4.5)• Put a hat and socks on• Return infant to the mothers chest, providing skin- to-skin contact • Urgent transfer to neonatal intensive care unit• Cover with cloth and blanket (following the rules of "warm chain")• Continue observation (amendment 4) • Administration of additional oxygen or CPAP in case of relevant indication Unstable condition with • Provision of access to vessels and intravenous fluidStable condition with N introduction in case of indications deviation of any monitoring values • Monitoring and maintenance of main life functions valuefrom N • Consultation with regional centre* • Call of transport team in case of indications*• Standard clinical • Immediate complete measures objective inspection
  57. 57. resuscitative support given to newborns oftendeviates from the requirements, and description ofinterventions provided in clinical documents differsfrom real practice of medical staff»OrganizationVideo registration, self-assessment and debriefingTraining in simulated environmentMonitoring of the resultsDocumentation M. Rudiger et al. Early Human Development 87 (2011) 749 W.D. Rich et al. Clin Perinatol 37 (2010) 189 Finer N. & Rich W.D. Journal of Perinatology (2010) 30, S57
  58. 58. «No other medical profession gives this unique privilege – not only preventing the last breath but presenting the first inspiration…» D.Vidyasagar

×