Use of Oxygen during Resuscitation of Neonates A practical ...

Use of Oxygen during Resuscitation of Neonates A practical ...

Use of Oxygen during Resuscitation of Neonates John Baier March 5, 2007 Manitoba NRP Advisory Group Objectives Review CPS recommendations regarding use of oxygen during resuscitation of newborn infants Review the normal postnatal changes in oxygen saturation during transition to extrauterine life Review scientific evidence for oxygen being harmful during resuscitation Review clinical trials and experience with room air resuscitation

Provide a practical approach to CPS recommendations March 5, 2007 Manitoba NRP Advisory Group CPS Recommendations Positive-pressure ventilation should be initiated with air (21% oxygen). Supplemental oxygen should be used if the baby remains cyanotic or heart rate is less than 100 bpm at 90 seconds of age. Blended gases should be available in the delivery room and during transport to the NICU. To avoid hyperoxemia pulse oximetry should be available in rooms designated for delivery of babies <33 weeks gestation. Even though, there is no clear definition of what is hyperoxia for preterm infant, it seems reasonable to

avoid saturations above 95% when supplemental oxygen is used. March 5, 2007 Manitoba NRP Advisory Group Normal postnatal changes in oxygen saturation during transition to extrauterine life March 5, 2007 Manitoba NRP Advisory Group Transitions Fetal PaO2 is 20 mm Hg SaO2 ~60%

At birth Infant starts to breath Lungs expand Pulmonary vascular resistance decreases Pulmonary blood flow increases Removal of placental circulation Systemic vascular resistance increases Fetal circulatory pattern starts to convert to normal extra-uterine pattern PaO2 increases March 5, 2007 Manitoba NRP Advisory Group Transitions

How long does this take? How good are we at detecting cyanosis? March 5, 2007 Manitoba NRP Advisory Group Normal postnatal change in oxygen saturation Rabi et al J Pediatrics 2006 March 5, 2007 Manitoba NRP Advisory Group

Normal postnatal change in oxygen saturation Rabi et al J Pediatrics 2006 March 5, 2007 Manitoba NRP Advisory Group Normal postnatal change in oxygen saturation Kamlin et al J Pediatrics 2006 March 5, 2007 Manitoba NRP Advisory Group

Evidence that resuscitation with 100% oxygen may harm March 5, 2007 Manitoba NRP Advisory Group Abstracts on use of oxygen for Resuscitation at PAS-SPR Number of Abstracts 14 12 10 8 6

4 2 0 2000 March 5, 2007 2001 2002 2003 Manitoba NRP Advisory Group 2004

2005 2006 Animal Models: Cardiovascular Variety of species and models Compared to RA resuscitation with 100% results in: Increased pulmonary arterial contractility in vitro (newborn lambs) Similar effects on pulmonary and systemic vascular resistances (piglet) No difference in cardiac output (piglets) No differences in regional blood flow (piglets) Similar or less myocardial protection troponin (piglets) March 5, 2007

Manitoba NRP Advisory Group Animal Models: Pulmonary Compared to RA resuscitation with 100% results in: Increased time of apnea (rat) Slower resolution of acidosis (piglets) Similar resolution of acidosis (lambs) More rapid resolution of hyperlactatemia (piglets) Increased evidence of pulmonary injury (lamb, piglet)

March 5, 2007 Decreased anti-oxidant levels Increased lipid peroxidation Increased neutrophil activation (MPO) Increased MMP-2, MMP-9 Increased cytokines (IL-8) Increased gene expression (immunosupression) Manitoba NRP Advisory Group Animal Models: CNS Compared to RA resuscitation with 100% results in: No changes in regional blood flow (rabbits) Increased CNS lipid oxidation and worse neurological outcome (adult dogs) Increase in CNS apoptosis cell death (piglets)

Increased in CNS MMP-2 (piglets) Increase in CNS IL-1 and TNF (lambs) No improvement in neurobehavioural outcomes or brain histology (rats) No differences in brain pathology (piglets) March 5, 2007 Manitoba NRP Advisory Group Animal Models: Other effects Compared to RA resuscitation with 100% results in: Increased platelet aggregation (piglets) March 5, 2007 Manitoba NRP Advisory Group

Evidence of harmful effects of resuscitation with 100% oxygen in newborn infants March 5, 2007 Manitoba NRP Advisory Group Anti-oxidant status in resuscitated infants Vento, M. et al. Pediatrics 2001;107:642-647 Copyright 2001 American Academy of Pediatrics March 5, 2007 Manitoba NRP Advisory Group

Anti-oxidant status in resuscitated infants RA resuscitation resulted in less oxidant stress (GSH/GSSG ratio) at 48 hours of life than did resuscitation with 100% oxygen Superoxide dismutase (SOD) activity was less in infants resuscitated with room air than with 100% oxygen **p March 5, 2007

< 0.01 versus control; #p <0.05 versus RAR. Manitoba NRP Advisory Group Vento et al 2005 AJRCCM Renal injury in resuscitated infants NAG urine excretion expressed in IU/mmol creatinine, in the first 14 d of postnatal life in asphyxiated newborn infants resuscitated with room air (RAR) or 100% oxygen (OxR). *p < 0.05 versus RAR.

Normal values for non asphyxiated control infants are below the limit of 10 IU/mmol creatinine March 5, 2007 Manitoba NRP Advisory Group Vento et al 2005 AJRCCM Relationships between oxidant status and injury biomarkers Both troponin (myocardial injury) and NAG (renal injury) were

directly related to degree of oxidant stress (oxidized glutathione) March 5, 2007 Manitoba NRP Advisory Group Vento et al 2005 AJRCCM Clinical Trials and Experience with Room Air Resuscitation March 5, 2007 Manitoba NRP Advisory Group

Clinical Trials comparing Resuscitation with room air and 100% oxygen Vento et al 1991 Spain (40 infants) Ramji et al 1993 India (84 infants) Saugstad et al 1998, 2003 India and Europe (609 infants) Ramji et al 2003

India (431 infants) Bajaj et al 2005 India (204 infants) Vento et al 2005 Spain (39 infants) March 5, 2007 Manitoba NRP Advisory Group Vento et al 1991 Term Infants (40) Clinical and biochemical signs of asphyxia (moderate)

hypotonia and apnea, which were nonresponsive to external stimuli Apgar score at 1 minute in both groups ranged from 3 to 5 Resuscitating team was unaware of the type of gas (RA or 100%) March 5, 2007 Manitoba NRP Advisory Group Time needed for the onset of a sustained respiratory pattern ** p<0.01 vs. controls # p<0.05 vs. the RAR group. Vento, M. et al. Pediatrics 2001;107:642-647 Copyright 2001 American Academy of Pediatrics

March 5, 2007 Manitoba NRP Advisory Group Extended experience with Room Air Resuscitation (Vento 2001) March 5, 2007 Manitoba NRP Advisory Group Saugstad et al 1998 Multicenter Study Mainly in developing countries Entry criterion

apnea or gasping with heart rate <80 beats per minute at birth necessitating resuscitation Exclusion criteria Birth weight <1000 g Lethal anomalies Hydrops cyanotic congenital heart defects Stillbirth Quasi randomized

even dates were resuscitated with room air (room air group), and those born on odd dates were resuscitated with 100% oxygen (oxygen group) Not Blinded Infants in the room air group who had bradycardia (heart rate <80) and/or central cyanosis 90 seconds after birth was switched over to 100% March 5, 2007 Manitoba NRP Advisory Group Saugstad et al 1998 Treatment failure (ie cyanosis or HR<80 at 90 seconds

40 35 30 25 20 15 10 5 0 Room Air March 5, 2007 Manitoba NRP Advisory Group 100%

Saugstad et al 1998 Primary outcome: Death within 1 week and/or presence of grade II or III HIE March 5, 2007 Manitoba NRP Advisory Group Bajaj et al 2005 204 infants India Entry criterion apnea or gasping with heart rate <100 beats per minute at birth necessitating resuscitation Exclusion criteria

Birth weight <1000 g Lethal anomalies Hydrops Quasi randomized Odd dates were resuscitated with room air (room air group), and those born on even dates were resuscitated with 100% oxygen (oxygen group) Not Blinded Infants in the room air group who had bradycardia (heart rate <100) and/or central cyanosis 90 s after birth was switched over to 100% March 5, 2007

Manitoba NRP Advisory Group Bajaj et al 2005 Primary Outcome: HIE and/or death before discharge March 5, 2007 Manitoba NRP Advisory Group Blood Gases March 5, 2007 Manitoba NRP Advisory Group Overall Mortality in studies

Mortality (% ) RA Number of Resuscitated 100% Oxygen 20 Source 18 Number Died Room Air

Oxygen Room Air Oxygen Ramji 1993 42 42 3 4 16

Saugstad 1998 288 321 40 61 14 Vento 2001 19 21

0 0 12 Vento 2001 16 1 14 6 10

Ramji 2003 210 221 26 40 8 Bajaj 2005 107 97

17 17 6 Vento 2005 17 22 2 4 4

Totals 657 683 99 128 15.1% 18.7% 2 0 Mortality

March 5, 2007 Manitoba NRP Advisory Group Metanalysis of Trials: Death at 1 week March 5, 2007 Manitoba NRP Advisory Group Rabi et al 2007 (in press) Metanalysis of Trials: Death at 1 month March 5, 2007 Manitoba NRP Advisory Group

Rabi et al 2007 (in press) Metanalysis of Trials: HIE March 5, 2007 Manitoba NRP Advisory Group Practical Considerations CPS Guideline: Supplemental oxygen should be used if the baby remains cyanotic or heart rate is less than 100 bpm at 90 seconds of age. March 5, 2007

Manitoba NRP Advisory Group How much Oxygen???? How to switch between RA and Oxygen???? March 5, 2007 Manitoba NRP Advisory Group How much Oxygen?? No Data Clinical Trials switched back to 100% oxygen if poor response after 90 seconds

of room air resuscitation 40 35 30 25 20 15 10 5 0 Room Air March 5, 2007 Manitoba NRP Advisory Group

100% How much Oxygen?? No Data Clinical Trials switched back to 100% oxygen if poor response after 90 seconds of room air resuscitation CPS recommendation is to use 100% oxygen March 5, 2007 Manitoba NRP Advisory Group Resuscitation using an Anesthesia Bag Situation 1: Blended oxygen is

available in delivery suite: Bag is connected to a blender and FiO2 turned to 21% If no response, then FiO2 is increased using blender. March 5, 2007 Manitoba NRP Advisory Group Resuscitation with Self Inflating Bag Situation 1: Blended oxygen is available in delivery suite: Bag (with reservoir attached) is connected to blender and FiO2 turned to

21% If no response after 90 seconds, then FiO2 is increased using the blender. March 5, 2007 Manitoba NRP Advisory Group Resuscitation with Self Inflating Bag Situation 2: Only 100% oxygen is available Bag (with reservoir attached) is connected to 100% oxygen source and flow is turned off If no response after 90 seconds, then flow is turned on March 5, 2007

Manitoba NRP Advisory Group What if there is no medical air in the delivery room? A compressor in the delivery room could be used to deliver room air Still needs to be blended with 100% oxygen source March 5, 2007 Manitoba NRP Advisory Group What if there is no blender CPS Guideline: Blended gases should be available in the delivery room and during

transport to the NICU This means all deliveries. Not recommended but gases can be teed together to adjust effective FiO2 March 5, 2007 Manitoba NRP Advisory Group Blending gases without blender March 5, 2007 Manitoba NRP Advisory Group Additional Considerations Infants <33 weeks gestation

Resuscitation in patients in NICU who are ventilated or already receiving oxygen March 5, 2007 Manitoba NRP Advisory Group CPS recommendation To avoid hyperoxemia pulse oximetry should be available in rooms designated for delivery of babies <33 weeks gestation. Even though, there is no clear definition of what is hyperoxia for preterm infant, it seems reasonable to avoid saturations above 95% when supplemental oxygen is used. How to titrate oxygen in preterm infants?

March 5, 2007 Manitoba NRP Advisory Group Oxygen administration Pulse oximetry must be considered an essential component of resuscitation Should be placed as soon as possible in an infant who requires resuscitation or appears in need of supplemental oxygen Consider use of new technology signal extraction monitors that will perform adequately in low perfusion situations.

March 5, 2007 Manitoba NRP Advisory Group Infants <33 weeks gestation Start resuscitation with room air as for term infants If bradycardic/cyanotic at 90 sec increase oxygen incrementally Gradual increase in saturation to 90% Avoid saturation >95% How? March 5, 2007 Manitoba NRP Advisory Group Titrating oxygen in infants < 33 weeks

PPV with room air HR <100 or Sat<80 60 secs Increase FiO2 to 0.40 HR <100 or Sat<80 60 secs Increase FiO2 to 0.60 HR <100 or

Sat<80 60 secs etc March 5, 2007 Manitoba NRP Advisory Group Blended oxygen source Titrate FiO2 to saturation and heart rate HR >100 Slow increase to ~90%

Saturation <90% Titrating oxygen in infants < 33 weeks PPV with no reservoir and no flow HR <100 or Sat<80 60 secs Turn on flow (40%) HR <100 or Sat<80

60 secs Attach reservoir March 5, 2007 Manitoba NRP Advisory Group Self inflating bag attached to 100% oxygen Endpoints HR >100 Slow increase to ~90% Saturation <90% Infants who need resuscitation

on ventilators or on oxygen Most likely have pulse oximetry already established Start with oxygen concentration patient was receiving before need for resuscitation occurred Example: Infant was on 30% oxygen for resolving HMD and has a severe apnea and profound bradycardia needing bag mask ventilation Start at 30% and provide adequate ventilation for 90% before increasing oxygen March 5, 2007 Manitoba NRP Advisory Group

Recently Viewed Presentations

  • Allocating Security Analysts to Cyber Alerts Using Markov Games

    Allocating Security Analysts to Cyber Alerts Using Markov Games

    Allocating Security Analysts to Cyber Alerts Using Markov Games. Noah Dunstatter. Joint work with: Dr. Mina . Guirguis, Alireza . Tahsini. Hello everyone! My name is Noah Dunstatter and today I'll be presenting my paper "Allocating security analysts to cyber...
  • The I/T and Telecom Sector in NYC - Ammannato
  • Elizabethan England and Shakespeare - Kenwood Academy

    Elizabethan England and Shakespeare - Kenwood Academy

    Tudors come to power, England is united under one monarchy End of the War of the Roses (English Civil War) King Henry VIII (1509-1547) can't decide on a wife, has six. ... Poor people wore simple, loose-fitting clothes made from...
  • Which crustal feature is located at approximately 150N

    Which crustal feature is located at approximately 150N

    The seismogram was recorded at a seismic station and shows the arrival times of the first P-wave and S-wave from an earthquake. When does the P wave arrive? 08:08:00. When does the S wave arrive? 08:11:25. ... Travel time chart...
  • Arthropods Chapter 28 Characteristics of Arthropods 1. Arthropods

    Arthropods Chapter 28 Characteristics of Arthropods 1. Arthropods

    (Uniramia) One pair. Unbranched appendages (Insects have three sections) Jaws. Organism. Group. How do you Know? Spiders and Relatives (Chelicerates. Two Body section. Crustaceans (Crustacea) Two pair antennae. Insects and Relatives (Uniramia) Three body sections.
  • PD Lecture 1999 - University of Pittsburgh

    PD Lecture 1999 - University of Pittsburgh

    Dalen Fuchs' nodule - histiocytes, prolif epithelial cells like cannon balls seen in all inflamm uveitis including TB, characteristic of SO Benign acquired melanosis Unilateral flat pigmentation of conj and periph cornea - completely flat pigmentation rarely is malignant Stains...
  • Recommended 2009 Marketing Investments

    Recommended 2009 Marketing Investments

    Summary of Enhancements: The Robust Search Engine will replace the existing Message Center user interface New user interface screens: Daily Reports and Advanced Claim Search Report data will now be retained for twelve months instead of seven Reports include Provider...
  • Cost of Care Overview - Maine.gov

    Cost of Care Overview - Maine.gov

    Aetna, Anthem, Cigna, Harvard Pilgrim, Maine Community Health Options, Maine Association of Health Plans. Behavioral Healthcare Cost subgroup has met twice, with approximately 20 stakeholders at each meeting; last met on October 8, next meets on December 17