new concepts of newborn resuscitation – the new national protocol

New Concepts of Newborn Resuscitation – the new national protocol

D. Dobryanskyj Lviv National Medical University

< 1% require

complete resuscitation

Approx. 3-6% require initial help (lungs

ventilation with mask)

Approx. 5-10% require simple stimulation (drying and massage) in

order to start breathing independently

All the newborns require immediate condition assessment and standard medical measures

0.1% require ICM*

0.05% require medicines

administration

• Should follow to IC**

• LOW level of evidences of

effectiveness

≈ 1 million

children

Approx. 6 million

children

Approx. 10 million

children

130 million

children

S. Wall et al., Int J Gynaecol Obstet. 2009 107 (Suppl 1): S47

* - indirect cardiac massage

** - intensive care

≈ 5000

children ≈ 30000

children

≈ 50000 children

Ukraine

The most

important influence

population

Інші причини; 0,181 млн.

Природжені аномалії; 0,27

млн.

Неонатальні інфекції; 0,83 млн.; 27%

Інтранатальні ускладнення; 0,72 млн.;

23%

Ускладнення недоношеності;

1,08 млн.; 35%

Born too soon: the global action report on preterm birth, WHO, 2012.

Li Liu et al. The Lancet, 2012, V. 379, No. 9832: P. 2151-2161

Ukraine, 2009

7%

15%

8%

3%

12% 32%

8%

13% 2%

Інші Аномалії Інфекції

Сепсис Асфіксія Захв. легень

Пневмонії ВШК Пор цер. стат.

228 children

501-750 g 751-1000 g 1001-1250 g 1251-1500 g

Years

Body

weight

Data basedon 355 806 newborns with birth weight from 501to1500 g from 669 hospitals of the North America

J.D. Horbar et al.

Pediatrics 2012;129:1019

• 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

1996: Regulatory systematic recommendations as to the initial resuscitation of newborns. Amendment to Order No.4 of the Ministry of Healthcare from 05/01/1996

2003: Onapproval of branch program "Initial resuscitation of newborns for 2003-2006 ". 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 MH 08/06/2007.

2013: Immediate, resuscitative and post-resuscitative support of newborns: Unified clinical protocol

Official opening of Kyiv NMC of Newborns resuscitation, 1998

"Avoid hypothermia of a newborn"

«Fill their lungs with air»

«Do not give oxygen - it is toxic!»

1895

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])»3

1 Chitty H.E. et al., Wrapping is not sufficient to prevent hypothermia of preterm infants, PAS 2012 2 Wyllie J. et al., Resuscitation 81S (2010) e260 3 Davis P.G. et al., Lancet 2004; 364: 1329

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”!

Term newborn

Preterm newborn

Total blood volume in fetal/placental circulation for gestational period is 110-115 vl/kg

In case of urgent delivery 2/3 of this volume are in fetus blood vessels and ? stay in placenta

At 30 weeks of GA these volumes are about the same

Immediate clamping of umbilical cord leads to newborn blood volume ≈ 45 vl/kg ('loss'– 25-35 ml/kg)

15-20 ml is contained in the cord; 'half' of cord length – 10 ml

4 'wringings' give 40-50 ml of transfusion N. Aladangady et al. Pediatrics 2006;117;93

Rabe H. et al. Obstet Gynecol. 2011; 117(2 Pt 1):205

Blood volume

Less transfusions needed [ВР-0.61; 95% CI 0.46-0.81]

blood pressure and decreased need in inotropes administration [ВР-0,42; 95% CI 0.23-0.77]

Better circulation in upper hollow vein

Betteremission from left ventricle

Cerebral oxygenation index

Decreased 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

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

Put a child into a plastic bag (< 28 weeks); in case there is no independent respiration immediately* separate and transport….

Put a child into a plastic bag (< 28 тиж) and in case of independent breathing hold below the placenta level; clamp and cut the cord after 30-45 s*

* in case any delay is impossible, quickly wring blood out of the cord 3-4 times directing it to a child (A)

Immediate, resuscitative and post-resuscitative support of newborns, Kyiv, 2013

Visual assessment of skin colour and adequate independent breathing especially in deeply preterm infants is inacurate and subjective

Assessment according to Apgar scale is also rather subjective and especially complicated for deeply preterm infants

Standard methods of heart rate measurement (auscultation and palpation) are inaccurate

J. Wyllie et al. Resuscitation 81S (2010) e260

SpO2 corresponding to clinical

definition of pink colour

SpO2%

% of observers considering that a

child has cyanosis

Results from 20 videoclips are indicated Maximum level of SpO2 during

videorecording C. Kamlin et al. J Pediatr 2008;152:756

J.A. Dawson et al. Pediatrics 2010;125;e1340

Minutes after delivery

Sp

O2

(%)

10th 25th 50th 75th 90th

Percentile

1 min

2 min

3 min

4 min

5 min

10 min

60-65%

65-70%

70-75%

75-80%

80-85%

85-95%

-35

-30

-25

-20

-15

-10

-5

0

Med

ian

diffe

renc

es (

95%

CI)

bet

wee

n cl

inic

al

hear

t rat

e m

easu

rem

ent a

nd E

CG

dat

a

Auscultation

(n=26)

Palpation

(n=21)

C. Kamlin et al. Resuscitation 2006; 71: 319

Deviation from actual

value

Prospective , randomized (heart rate measurement techniques [auscultation or palpation] and scenario), controlled study

64 experienced physicians

3 training scenarios (SimNewB®, Laerdal Inc., Stavangar, Norway)

Heart rate measurement bias were observed at 26-48% initial and 26-52% follow-up assessments

Measurement method did not affect the result

Clinical measurement of heart rate in case of RN is unreliable

Chitkara R. et al., Resuscitation 2012, In press

If PO shows heart rate < 100/min, the probabilty of bradycardia is 83%

If PO shows heart rate > 100/min, the possibility that an infant has no bradycardia is 99%

PO

hea

rt r

ate

min

us E

CG

hea

rt r

ate

Mean heart rate

2SD

0

2SD

C. Kamlin et al. J Pediatr 2008;152:756

+ 2 SD (24 strikes/min.); 0: mean (-2 strikes/min.); - 2 SD (-28 strikes/min)

90th

75th

50th

25th

10th

J.A. Dawson et al., Arch Dis Child Fetal Neonatal Ed 2010;95:F177

Hea

rt r

ate

Minutes after delivery

50th percentile value is less

than 100/min in 1 min after

delivery!

M.T. Bashambu et al. Pediatrics 2012;130;e982

1 min of life 5 min of life 10 min of life

Case1 (term infant) Case 2 (24 weeks, ventilation with ETT)

Case 3 (28 weeks, СРАР) Case 4 (28 weeks, ventilation with ETT)

335

participants

323

participants

313

participants

312

participants

General Apgar score General Apgar score

General Apgar score General Apgar score

Nu

mb

er o

f re

spo

nd

en

ts

Nu

mb

er o

f re

spo

nd

ents

Nu

mb

er o

f re

spo

nd

en

ts

Nu

mb

er o

f re

spo

nd

ents

CONCLUSIONS: An improved delivery room score that decreases variability among medical care professionals is needed to accurately reflect the clinical status of preterm infants.

CONCLUSIONS: An improved assessment scale is needed in order to unify and increase accuracy in defining clinical conditions of preterm infants between different medical professionals

Characteristic

0 1 2 Time

1 min 5 min 10 min 15 min 20 min

Heart rate None Bradycardia (HR <100/min)

(HR ≥100/min)

Respiration None Bradypnoea, irregular

Regular, cry

Muscular tone Dramatically low

Mild limb bending Active movement

Reflex excitability

No reaction Spasm Cough, sneezing

Colour Cyanosis or paleness

Limbs cyanosis Pink

General score

Comments: Resuscitation

Minutes 1 5 10 15 20

Oxygen

Ventilation/CPAP

Intubation

IMC

Adrenalin ААР. Pediatrics, 2006,117,4:1444

After initial help [(1) position ± airways sanitization [according to indications – meconium, ventilation need (newborn does not breathe!) or obstructed respiration]; 2) drying]

Only 2 characteristics may evidence the need inn resuscitative intervention after initial help – no breathing (gasping ) or heart rate <100/min

The first minute is a «goldentime frame» and all the actions during this minute are standardized!


Moan Volume

Adults Newborns

Time

"Supporting"

inspiration

FRC of

lungs EERV

EERV EERV

EERV – end-expiratory lungs volume

Vr – lungs volume at rest

Primary effects of respiration with increased lings volume

at expiration

1. Less energy loss

2. Improvement of surfactant

effect

3. Decrease of lungs vessels

resistance

4. Optimized ventilation-

perfusion correlation

5. Better gas exchange

Mechanisms that support

increased lungs volume at

expiration

1. Additional diaphragm and

larynx muscles activity at

expiration phase

2. Starting the following

inspiration before Vr

3. Inverse sequesnce of

glottis opening and

diaphragm contraction

Trachea intubation blocks all these physiological

mechanisms!

Free lungs from fluid

Create functional residual capacity of lungs (FRC)

Stimulate independent breathing using lungs aeration

Facilitate gas exchange

Minimize risk of lungs damage

min hou

r

Roehr C.C. et al. Neoreviews 2012;13;e343

Lungs resistance [RL] (ml*s/kPa)

FRC dynamics, CL, і RL after delivery

FRC (ml) Lungs pliability [CL] (ml/kPa)

≈ 30 ml/kg

ml

ml/kPa

СРАР only?

"Filling of lungs" with СРАР?

"Filling of lungs" with ventilation?

Intubation and ventilation?

INSURE?

Surfactant without intubation?

Indications No independent breathing

Respiratory disfunction

Gestational term < 32 weeks

Lungs 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


Why it is so important to create РЕЕР for deeply preterm infants?

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

Ventilation: Lower initial inspiratory pressure (20-25 cm Н2О) for preterm infant compared to term infant (30-40 cm Н2О)

Avoid excessive movement of chest, especially for preterm infants

РЕЕР: will most likely benefit and is recommended if technically possible

СРАР: may be used in ingants breathing independently according to local protocols

J. Wyllie et al. / Resuscitation 81S (2010) e260

© 2010 American Heart Association, Inc.

For infants with ≥ 32 weeks of gestational age it is recommended to ventilate lungs with air (21% О2)

For more immature infants (< 32 тиж) initial О2 concentration should be 30%

Start of ventilation, CPAP or additional oxygen use indicate the need in continuous pulse oximetry

Further on О2 concentration (FiO2) is changed according to SpO2

Ventilation of lungs with 90-100% oxygen is shown for ICM

Total number of death or BPD in 2 groups СРАР from

birth on

routine basis

Intubation +

surfactant as

preventive

measure

Study Relevant risk and 95% CI

Rojas-Reyes MX, Morley CJ, Soll R. Cochrane Database of Systematic Reviews 2012, Issue 3

For СРАР

For intubation

Comparative namber of intubations in case of airbag ventilation using laryngeal (LM) or conventional (CM) mask

Study LM Bag and mask Odds ratio

Georg M. Schmolzer et al. Resuscitation (2012). In press

For CM For LM

LM may be used for neonates with ≥ 34 weeks of GA and weight > 2000 g

T-systems or resuscitative bags filled with airflow or independently may be used for respiratory support

T-systems are preferred in developed countries. It is recommended by European Consensus on prevention 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


Maximum proximity of real PIP, PEEP and Ti values to desirable; minimum variability of these values

less risks of volutrauma (lower and more stable VT )

Limited ability to feel the pliability of lungs.

Settings modification requires more time and skills

Increased air leak from under the mask

Change of flow rate significantly alters ventilation settings

Insufficient control of РІР, РЕЕР and Ті

risk of volutrauma

Better ability to feel the pliability of lungs.

Easier modification of ventilation settings

Less air leaks from under the mask

Lower impact of flow rate changes to ventilation settings

C.P. Hawkes et al. Resuscitation 83 (2012) 797

Т-system Self-filling bag

C.C. Roehr et al. Resuscitation 81 (2010) 202

Т-system Self-filling bag

Respiratory volume (VT), ml

ml cm Н2О

Peak inspiratory pressure (РІР), cm Н2О

p < 0,0005 p < 0,001

Sp

O2

(%)

Т-system Bag Minutes after delivery

J. A. Dawson et al., J. Pediatr. 2011;158:912

Median, 25th-

75th

percentiles

and

measurement

limits are

displayed

p>0,05

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 leaks

Nasal prongs/ special cannula Shortened endotracheal tube

Significant air leak

May be more effective than mask

Equipment: Resuscitative bags of both types and T-systems may be used

Nasal prongs/cannula may provide more effective ventilation than mask

Monitoring: to use pulse oximentry, insifficient data to recommend respiratory volume measurement



Exp

irat

ion

vo

lum

e (m

l/kg

)

D.A. Poulton et al., Resuscitation 82 (2011) 175

Resuscitation teams could not give visual assessment of chest excursion adequacy for EPNs!

• «No movements» - 4.4 (3.0-7.0) ml/kg

• «Uncertain movements» - 3.7 (3.0-5.6) ml/kg

• «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/kg

20 newborns at ≈ 27

weeks of gestation

Royal Women Hospital, Melbourne, Australia

Non-invasive respiratory support optimization

Detection of airways obstruction

Providing of proper RV

Independent breathing diagnostics

Assessment of ventilation frequency

Inspiration and expiration duration

Correct ETT position and gas leak availability

G. Lista et al., Neoreviews 2012;13;e364

Pressure

(cm Н2О)

Flow

(ml/s)

Volume

(ml)


Inspiratory flow

Expiratory flow


Uncontrolled ventilation Controlled ventilation

Pressure

(cm Н2О)

Flow

(ml/s)

Volume

(ml)

K. Schilleman et al. J. Pediatr. 2012. In press

No flow – obstruction

Gas leak

UC San Diego Medical Center, USA

Finer N. et al. Clin Perinatol 39 (2012) 931

Covers all the new regulations of International Scientific Consensus of 2010.

Includes the concept of initial stabilization of preterm infants condition

Proposes the necessity to use modern methods of respiratory support and monitoring (resuscitative T-system, laryngeal mask, СО2 detectors, pulsoxymeters)

Includes separate detailed rules of preterm infants care and expanded Apgar scale

Reprecents the concept of palliative care

Contains a separate protocol on therapeutic hypothermia

To leave with mother

BIRTH

30 s

60 s

Term delivery? Breathing or crying?

Muscular tone is good?

Provide warming and free airways, dry, and stimulate

Routine care • Provide warming • Free airways • Dry • Assess condition in dynamic

state

Yes

Apnoea, gasping or heart rate<100? Complicated breathing or stable

cyanosis?

Ventilation, need in SpO2 monitoring Free airways, need in SpO2 monitoring, CPAP

No

No

No

Yes Yes

Heart rate < 100?

Necessity of intubation Start ICM, coordinate with ventilation

Adequate ventilation control

Yes

Yes

Post-resuscitative care

1 min

2 min

3 min

4 min

5 min

10

min

60-65%

65-70%

70-75%

75-80%

80-85%

85-95%

EffectiveSpO.

norms2%

Adrenalin IV

Correct ventilation Intubate if no movements observed!

Possibility of: • Hypovolemia • Pneumothorax

No

Heart rate < 60?

Heart rate < 60?



Yes

≥ 32

weeks!

BIRTH

30 s

60 s

• 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)

• Apnoea, gasping OR • Heart rate<100 OR • SpO2 < 40%

Independent breathing

• «Lungs filling** 10 s (РІР 20-25 cm Н2О; FiO2 30-40%) СРАР (5 cm Н2О; FiO2 30-40%) OR

• ventilation(РІР 20-25 cm Н2О, РЕЕР 5 cm Н2О, FiO2 30%)

СРАР 5-7 cm Н2О****

Yes Yes

HR increased?

• Continue ventilation(РІР 20-25 cm Н2О; РЕЕР 5 cm Н2 О; FiO2****)

Yes

N

o

Apnoea, gaspings

< 32 weeks!

Independent breathing (IB): hold a newborn below placenta level; clamp and cut the cord after 30-45 s*; provide thermal protection

No independent breathing (IB)*...

• Independent breathing

• Heart rate ≥ 100 • SpO2 ≥ 40%

• Monitoring: 1. IB available 2. Complicated

respiration 3. SpO2

4. Heart rate 5. Skin colour 6. Activity

• Transfer to NICU • Surfactant (in case

of intubation FiO2>0,3)

• Adequate filling/ventilation? • Repeat filling of lungs, start ventilation

Assessment: HR, SpO2, IB

Initial RS

Condition

assessment



HR<60

• Trachea intubation*** • Start ICM • Continue ventilation (РІР

20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 90%)

• Coordinate ICM and ventilation

60<HR<100 HR>100

• Trachea intubation*** • Continue ventilation (РІР


Assessment: HR, SpO2

HR<60 60<HR<100

HR>100

• Inject adrenalin into trachea • Continue ventilation (РІР 20-25

cm Н2О; РЕЕР 5 cm Н2О; FiO2 90%)

• Continue ICM • Catheterize cord vein

Assessment:

HR, SpO2

• Administer adrenalin IV • Continue ventilation (РІР 20-25 cm

Н2О; РЕЕР 5 cm Н2О; FiO2 90%) • Continue ICM • Administer physiological

solution IV*****

HR<60

< 32 weeks!

BIRTH

30 s

60 s

• 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)

• Apnoea, gasping OR • Heart rate<100 OR • SpO2 < 40%

Independent breathing

• «Lungs filling** 10 s (РІР 20-25 cm Н2О; FiO2 30-40%) СРАР (5 cm Н2О; FiO2 30-40%) OR

• ventilation(РІР 20-25 cm Н2О, РЕЕР 5 cm Н2О, FiO2 30%)

СРАР 5-7 cm Н2О****

Yes Yes

HR increased?


Yes

N

o

Apnoea, gaspings

IB: hold a newborn below placenta level; clamp and cut the cord after 30-45 s*

No independent breathing...

• Independent breathing

• Heart rate ≥ 100 • SpO2 ≥ 40%

• Monitoring: 1. IB available 2. Complicated

respiration 3. SpO2

4. Heart rate 5. Skin colour 6. Activity

• Transfer to NICU • Surfactant (in case

of intubation)


Assessment: HR, SpO2, IB

Initial RS

Condition

assessment

< 28 weeks!

• Put a child into a plastic bag



HR<60

• Trachea intubation*** • Start ICM • Continue ventilation (РІР


• Coordinate ICM and ventilation

60<HR<100 HR>100

• Trachea intubation***

• Continue ventilation (РІР 20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 40%)


HR<60 60<HR<100

HR>100

• Inject adrenalin into trachea • Continue ventilation (РІР 20-25


• Continue ICM • Catheterize cord vein


• Administer adrenalin IV • Continue ventilation (РІР 20-25


• Continue ICM • Administer physiological

solution IV*****

HR<60

< 28 weeks! GA < 25 weeks

GA ≥ 25 weeks

• Stop resuscitation

• Start palliative care

Resuscitation refuse or its discontinuation do not mean that no medical care is provided to the patient. It means a transfer to the so-called palliative or "comforting" care if a newborn still stays alive

PC for a newborn infant means complete set of measures that prevent or alleviate additional suffering and improve conditions of the last period of infant's life

PC 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

0

100

200

300

400

500

600

<5% 5-9% 10-14% 15-24% 25-32% 33-49% 50-66% >66%

395

221

140 139 95 94

52 36

591

378

238

303

210 204

140 114

Тривалість ШВЛ Тривалість госпіталізації Hospitalization term

Days

Likelihood of survival without severe disability (%)

J.E. Tyson et al., N Engl J Med 2008;358:1672

N.A. Parikh et al., Pediatrics 2010;125;813

25

weeks

>60%

22 weeks, <10%

* EPN – extremely preterm newborn

USA, 4446 infants of 22-25 weeks, 2008

Ventilation term

Meadow W. et al. Clin Perinatol 39 (2012) 941

• Survival of newborns with < 600 g depends on gestational age, according to data from NICHD

• "Intact" survival in NICU is relevantly independent of GA!

• % of all infants of < 26 weeks of GA, which survived with severe neurological results depending on GA

• Most infants who survived with these results were born at GA, as the survival

depends on the GA while the % of affected infant does NOT!

Gestation week

% of survivals

% of general "acceptable" survival

% of "acceptable" survival in NICU

week

s week

s week

s week

s

Time and money

Prenatal consulting

Resuscitatio

n

Treatment

attempt

Discharg

e from

NICU

Refusal from

resuscitation

Death in the delivery

room

Death in NICU

GA; ACS; multiple

gestation, SGA

GA; ACS; multiple

gestation, SGA, Apgar

SNAP, intuition,

NSG

RN, BPD, cerebral

palsy

Meadow W. et al. Clin Perinatol 39 (2012) 941

Prognostic criteria GA - gestational age; ACS – antenatal corticosteroids; SGA – small

for gestational age; SNAP – the scale for evaluation of condition

severety; NSG - neurosonography

0

10

20

30

40

50

60

70

80

90

Вижили Вижили без важких наслідків

Припинення ШВЛ до смерті

6 0

82

16

8

77

55

9

66 72

20

68

%

B.J. Stoll et al. Pediatrics 2010;126;443 9575 infants of GA 22-28 weeks, 2003-2007

Long-term ventilation (> 60 s) or complete * resuscitation

Short-term ventilation using mask and air (≤ 60 s)

• Apgar score at 5 min ≥ 7 • Within 15 min after ventilation was discontinued

– HR>100/min – SpO2 > 85%, no central cyanosis (without supportive

О2) – No respiratory disfunctions – Acceptable or lightly decreased muscle tone – No other pathological characteristics

• Put a hat and socks on • Return infant to the mother's chest, providing skin-

to-skin contact • Cover with cloth and blanket • Continue observation (amendment 4)

Stable condition with N monitoring values

Unstable condition with deviation of any

valuefrom N

• Complete objective inspection immediately after resuscitation

• Urgent transfer to neonatal intensive care unit (following the rules of "warm chain")

• Administration of additional oxygen or CPAP in case of relevant indication

• Provision of access to vessels and intravenous fluid introduction in case of indications

• Monitoring and maintenance of main life functions • Consultation with regional centre* • Call of transport team in case of indications*

• Immediate complete objective inspection

• Standard clinical measures

Eligibility to participate in therapeutic hypothermia programme (art. 4.19)**

• Start of passive cooling (art. 4.5)

Yes

No Yes No

resuscitative support given to newborns often 'deviates' from the requirements, and description of interventions provided in clinical documents differs from real practice of medical staff»

Organization

Video registration, self-assessment and debriefing

Training in simulated environment

Monitoring of the results

Documentation

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

«No other medical profession gives this unique privilege – not

only preventing the last breath but presenting the first

inspiration…» D.Vidyasagar

new concepts of newborn resuscitation – the new national protocol

Health & Medicine

mortality rate of newborns

preterm birth

501to1500 g

hypothermia of preterm

birth weight

umbilical cord

severe morbidity

weeks of ga