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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
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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
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PVH-IVH RDS Circulatory Dysfunction EOS/LOS/NEC BPD/CLD Metabolic Disturbances Nutrition and Growth
GOLDEN HOURS: the difference in life and death
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LOW-TECH and LOW-COST Interventions
Pre-conception Folic acid supplementation
Antenatal Syphylis screening and treatment
Pre-eclapmsia and eclampsia prevention
Tetanus toxoid immunization
Preventive treatment of malaria
Detection and treatment of bacteriuria
Intrapartum (birth) Antibiotics - PROM
Steroids for preterm labor
Detection and management for breech
Clean delivery practices
Postnatal Resuscitation of newborn babies
Breasfeeding
Prevention and management of hypotermia
Kangaroo, skin to skin
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Factors May Injure Preterm Lung During Resuscitation P
regn
ancy
• Infection
• Steroids
• Delayed cord clamping
DR
/NIC
U M
anag
emen
t • High VT
• Oxygen
• Cold Gas
• Dry Gas
• No PEEP
• T Control
• Surfactant Post
nat
al C
are
• MV Strategy
• Infection
• Oxygen
• Nutrition
• PDA
Months Minutes/Hours Months
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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
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Validity of Newborn Examination at DR
Inaccurate value of Apgar score, skin perfusion and heart rate can lead to inappropriate treatment.
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Oxygen: how much is too much?
Vento et al: Pediatrics 2009, Aug 10
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The SpO2 value in preterm newborn in DR
Kamlin et al. Peduatrics 2006
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Intubation
• When is indicated?
• How we are successful?
• Who is best?
Carbine et al., Pediatr.106, 2000 O Donnell et al., Pediatr., 117, 2006
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Intubation at Delivery Room (elective, selective, prophylactic, urgent….)
78
90 9085
78
100
53
3943
18
54
29 27
58
23 24 25 26 27
VON 98-00 DR Trial 02-03 Columbia 99-02
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CURPAP Trial: Secondary outcomes
Prophylactic Surfactant (N = 105)
nCPAP (N = 103)
Risk Ratio
95% Confidence
Interval
ROP: n(%) Stage > 3: n(%)
30 (28.6) 7 (6.7)
30 (29.1) 7 (6.8)
0.98 0.98
0.65-1.48 0.36-2.70
NEC : n(%) 7 (6.7) 9(8.7) 0.76 0.30-1.90
Sepsis : n(%) 45 (42.9) 43 (41.7) 1.02 0.75-1.40
Mild BPD in survivors: n/N(%) 11 /98 (11.2)
12 /94 (12.8) 0.89 0.41-1.93
Moderate and Severe BPD in survivors: n/N(%)
14/98 (14.3)
11/94 (11.7)
1.22 0.58-2.50
Use of systemic steroids: n(%) 14
(13.3) 11
(10.7) 1.25 0.59-2.62
Sandri F, Stranak Z et al. Pediatrics 2010, June 125
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CURPAP Trial: Secondary outcomes
Prophylactic Surfactant (N = 105)
nCPAP (N = 103)
Risk Ratio
95% Confidence
Interval
Pneumothorax: n(%) 7 (6.7) 1 (1.0) 6.82 0.86-53.75
Pulmonary interstitial emphysema: n(%)
3 (2.9) 4 (3.9) 0.74 0.17-3.21
Pulmonary hemorrhage: n(%) 3 (2.9) 2 (1.9) 1.47 0.25-8.76
PVH-IVH: n(%) Grade 3-4: n(%)
21 (20.0) 6 (5.7)
19 (18.4) 8 (7.8)
1.08 0.73
0.62-1.89 0.27-2.03
PDA: n(%) Medically treated Surgically ligated
43 (41.0)
28 (26.7) 6 (5.7)
51 (49.5)
35 (34.0) 3 (2.9)
0.83 0.62-1.10
Sandri F, Stranak Z et al. Pediatrics 2010, June 125
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CURPAP Trial: Primary outcome - need for mechanical
ventilation within 5 days
Prophylactic Surfactant (N = 105)
nCPAP (N = 103)
Risk Ratio 95%
Confidence Interval
Gestational age 25-28+6 wk - n (%) 33 (31.4%) 34 (33.0%) 0.95 0.64-1.41
Gestational age 25-26 wk - n (%) 15 (47%) 12 (39%) 1.21 0.68-2.16
Gestational 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
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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
CONCLUSION
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The Golden Hour of Thermoregulation: Prevention of
Delivery Room-Associated Hypothermia
DR - Associated Hypothermia is any body temperature less than 36.50 degrees on admission to the NICU for inborn babies!
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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
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Intrauterine Thermal Homeostasis
Is 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
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Bhatt, D. et al. PAS 2007; E-PAS2007:617933.23
Admission Temperatures Across Birth-weight
Birthweight, g # < 36.5C
< 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%)
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Laptook, A. R. et al. Pediatrics 2007;119:e643-e649
Admission Temperatures - All Gestations
GA, Weeks N BW (M+SD),
Grams < 35C, % < 36C, %
<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
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For each 1°C decrease in admission temperature, chances of survival are decreased by 10%! (Nedrelow) For each 1°C decrease in admission temperature, late-onset sepsis is increased by 11% & odds of death are increased by 28%! (Laptook)
DR – Associated Hypothermia Consequences
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Clinical Consequences of Heat Loss
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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
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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
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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
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Reactions to Cold
Voluntary
• None • Adding clothing layers
• Posture:
Rubbing hands
Curling up
Crossing arms across chest
Involuntary
• Limited non-shivering thermogenesis
• “Goose-pimples”
• Shivering
• Peripheral vasoconstriction
• Non-shivering thermogenesis
INFANT ADULT
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Thermal Balance at the Beginning of Life
Convection Radiation
Conductive Heat Loss
Evaporation
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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 to compensate for heat loss •Sick, hypoxic babies will have limited ability to increase heat production
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FROM BIRTH TO THE NEONATAL UNIT: A COLD JOURNEY?
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Mannheim Study - Rationale
•Compared Giraffe OmniBed to traditional transport incubator
– Admission temperature
– Number of transfers between beds
– Time from DR to NICU
– Physiological/behavioral stress of subjects
Permissions on File
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Mannheim Study - Demographic characteristics
Characteristic (Range)
Traditional Transport
(N=50)
Giraffe OmniBed Transport
(N=50) Gender (M/F)
22/28
24/26
Average Gestational Age (weeks)
33+2 w (24+1to 41+4)
34+1 (24+3 to 41+1)
Average Weight (grams)
1780.2 g (530 to 4120)
1934.5 (470 to 3890)
Prematurity
28/50
31/50
Diaphragmatic Hernia (CDH)
18/50
17/50
Congenital Cystic Adenomatoid Malformation
(CCAM)
1/50
2/50
Other Diagnoses
3/50
0/50
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Mannheim Study - Summary
Characteristic (Range)
Traditional Transport
(N=50)
Giraffe OmniBed Transport
(N=50)
Total Transport Time (minutes,m) Team to
DR; Returns with Baby
56.3 m (Preterms)
42.7 m (Preterms) *
62.1 m (Others)
46.8 m (Others) *
Birth to NICU Admission Time
(minutes. m)
33.9 m (Preterms)
25.3 (Preterms) *
29.1 m (Others)
27.7 m (Others)
*p<0.0001, Welch-Satterthwaite t-test
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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
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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.“
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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“
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Delivery room management in 24-30 wks
„Well being“ infants
INSURE
„Bad“ infants
Spontaneously breathing
NCPAP
PPV with PEEP
INSURE
CPAP failure criteria for Early Surfactant
Success on NCPAP
Active weaning
Arteficial Ventilation
15 min
DR
NICU
75-80% patients 20-25% patients
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Strategy of Arteficial Ventilation
0
1
2
3
4
5
6
7
PTV+VG PTV IPPV
HFV
1970 1980 1990 2000
LLV HLV OLV
PEEP
Tidal Volume
SURFACTANT
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Optimal Lung Volume and Trigger Ventilation
Ventilatory Induced Lung Injury:
Role of Tidal Volume
Severe Respiratory Morbidity
58
47
12
4,4
0
10
20
30
40
50
60
70
2002-2005 2006-2009
BPD/CLD Air leak
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Ventilatory Strategy:
•NCPAP
•SIMV+VG
•A/C, SIMV
•HFOV •INO
Singapore Med 2008; 49(3) : 199
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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.“
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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.“
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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
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Necrotizing Enterocolitis
Early use of colostrum (3-6 hrs) after delivery in ELBW.
14
7
0
2
4
6
8
10
12
14
16
2002-2007 2008-2009
N=266 vs N=134
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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
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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
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Common serious complications in preemies
PVH-IVH/CP BPD/CLD/ROP Sepsis/NEC
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Thank you for your attention…