Resuscitation before Cord Clamping · Katheria AC et al Acceptability of Bedside Resuscitation With...
Transcript of Resuscitation before Cord Clamping · Katheria AC et al Acceptability of Bedside Resuscitation With...
Feasibility of Resuscitation (Apnoeic Babies) before Cord Clamping
Lindsay MildenhallANZCOR
Plan
• Physiology of the transition
• ?Benefit of breathing with delayed cord clamping
• Equipment (no commercial interest!)
• Trials assessing feasibility of assisting breathing before cord clamping: ?Results
• Parents / Medical Staffs views
• Ongoing Trials
• Video
The Physiology• Fetus LV preload
• Placental blood delivered via UV →DV → FO → LV
• Fetal P Vein (preload) return to LV negligible
(Can increase somewhat with in utero fetal breathing movements)
• Early Cord Clamping:
1. Low resistance placental circuit• (LV exposed to ↑afterload)
2. 30-50% of venous return cut off → period of flow fluctuations
• ?bad for you…..Preterm baby and IVH
• May explain newborn initial low HR on HR normograms
Dilemmas remain
• DCC seems beneficial*; + breathing may add benefit
• Majority DCC trials exclude pre term babies that needed resus
• Apnoeic infants: ICC → Removed to Resuscitaire
• Unsure of best CC strategy during CS delivery• 70% premature babies delivered by CS (US 2008)
* Fogarty M et al, Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis. Am J Obstet Gynecol. 2018 .
Evidence Suggesting Advantage of
Breathing before CC
AnimalsHumans
Experimental Evidence for Advantage of DCC + Breathing (Animals)
• CVS changes in Preterm lamb model 26-28 w; • 2 groups:
-●- UCC 2min before vent commenced -○- Vent commenced. UCC av ∼4min PBF
Bhatt S et al J Physiol. 2013 Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs.
An aside: HR Normograms
• HR graphs
Blank et al (RWH) Aust
Humans: Observational Studies: Breathing before CC
Ersdal et.al. 2014
Term and pretermn > 15 000
CC before onset of breathing
• More likely to die
• The longer delay from SR onset to CC,
the better outcome
• Beyond 2 mins DCC risk minimised
Nevill, Meyer 2015
Preterm infants < 30 weeks
Breathing DCC vs Non breathing DCC:
• Less intubation
• Reduced CLD
• Reduced severe IVH
• Increased day 1 Haemoglobin
• Death rate similar
Breathing before Cord Clamping seems advantageous
1. Is it feasible to assist breathing during the transition with the cord unclamped?
2. Does it provide clinical benefit to the baby?
Questions to be Answered
The Equipment needs to provide respiratory support
1. Does not restrict providing full standard of care
2. Able to monitor the infant
3. Prevent kinking / stretching of cords
4. Unhindered care to the mother
5. Acceptable to all parties
T piece DeviceHeated gel platform Respiratory
function module:HR, Sat’s FiO2, TV
Concord
Lifestart
Feasibility Studies using these
and other devices during DCC
RCTs: LIFESTART
Katheria et.al. 2016
23 – 31w
n = 150
CS (85%) / NVD delivered to LIFESTART
• All 60 seconds DCC
• V-DCC: If Apnoeic → CPAP +/- PPV
• DCC: If Apnoeic → stimulation
• Only 13 didn’t breathe before DCC!
• 78% to LIFESTART for resus (Obs nervous)
Katheria et.al. 2017
Term (at Risk)
Vaginal deliveries only
n = 60
• 5 min DCC (Apnoeic to LIFESTART)
• 1 min DCC (If apnoea immediate clamp)
• 13/30 5 min DCC to Lifestart
• 8/13 just stimulation +/- Ox, 2 PPV, 1 intubate
• 5 mins DCC achieved in all 30
CONCORD and others
Brouwer E et al 2016
Holland
26 - 35w
n = 37
ObservationalFeasibility
CONCORD
• Baby stabilised(+/- PPV) then Cord ClampingStable = HR >100, TV ≥ 4mls /kg on CPAP, Sat’s > 25% FiO2 < 0.4
• Cord clamp time: median 4min 23 secs• Temp 36.0
• Learning curve: 89% successful (33/37)
• No post clamping bradycardia at any gestation
Duley L et al2018
UK
28-29w
n = 276 babies
Multicentred RCT
• DCC at 2 minutes + resus if needed• Cord clamped within 20secs + resus if needed
DCC Group:• 50-70 % of respiratory support beside mother
including 50% intubations• Median DCC 120 secs
Medical Staff / Patients Satisfaction UK• Parents: Generally positive
• By watching resus, reassured staff doing best they could
• Having baby close less distressing than taken away
• Clinicians: Generally positive
• Improved parental communication
• Less experienced staff insecure about being watched
• Sterility in theatre an issue
Yoxall CW et al Providing immediate neonatal care and resuscitation at birth beside the mother: clinicians' views, a qualitative study. BMJ Open. 2015
Medical Staff / Patients Satisfaction USAVaginal delivery only
• Parents: Generally positive
• Good to see and make contact with baby in first minutes
• Positive impression of resus by bedside and of radiant warmer
• Clinicians: Generally negative
• 50% concerns regarding suboptimal access to baby
• Uncomfortable with interventions by bedside
Katheria AC et al Acceptability of Bedside Resuscitation With Intact Umbilical Cord to Clinicians and Patients' Families in the United States. Front Pediatr. 2018
Prem Vent First: Pilot Study Feasibility / Safety (USA)
• Instructional video • Simulations• Coordinator at each
delivery
• Problems Identified:
• ECG leads not sterile
• Crowding.
Winter Jet al. Ventilation of Preterm Infants during Delayed Cord Clamping (VentFirst): A Pilot Study of Feasibility and Safety. Am J Perinatol. 2017
CS
X
X
Vaginal
Hard with Short cord
Summary
• Is it feasible?
•Yes!
• Is there a clinical benefit?
•On-going research topic
2 Ongoing studies
ABC Study ACTRN126150010226516
01VentFirstNCT0274245
02
Primary Outcome: RBC tx rates (Echo data)NDT @ 2 years for ≤ 29wWraps and Sterile CPAP circuits
Single Centre RCT – Intervention with those performing outcome assessment masked
n = 120 < 31 w NVD and CS
If no regular breathing at 15 secs randomised
Control: DCC: 50 secs + wrap / position / stimulate
Intervention: DCC: 50 secs + resp support (CPAP/PPV)
Primary Outcome: Incidence of IVH at 7-10 day Head USS
Multicentre RCT – Intervention with those performing outcome assessment masked
n = 940 23 – 28.6 w NVD and CS
Control: DCC: For 30 seconds if not breathing;
60 seconds if breathing
Intervention: DCC: For 120 seconds:
Assessed at 30 seconds. If neededCPAP or PPV given for 90 secs
Chest Compressions with Intact Cord
• If the resuscitation extends to chest compressions
does it make physiological sense to leave the cord
unclamped?
ABC Study: ‘ Assisted Breathing before Cord Clamping’