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What Is New in The European and UK Neonatal Resuscitation Guidance
What Is New in The European and UK Neonatal Resuscitation Guidance
What Is New in The European and UK Neonatal Resuscitation Guidance
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ADC-FNN Online First, published on April 28, 2016 as 10.1136/archdischild-2015-309472
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When to start compressions and what to do babies and equipment and staff requirements.31 These need to
Chest compressions will be performed when the heart rate be answered before this approach can be accepted or implemen-
remains less than 60/min after ve effective ination breaths and ted routinely.
30 s of effective ventilation. In the majority of babies, a slow
heart rate will usually increase within the time it takes to com-
plete these manoeuvres. This clarication to the guidelines means Sustained inations
that lung expansion and ventilation is established and minimises The ERC and UK guidelines advocate the use of initial ination
the potential compromise of ventilation by compressions. breaths sustained for 23 s duration based on human data which
Compressions and ventilations should be coordinated to is decades old.32 The sustained inations evaluated in the
avoid simultaneous delivery. A 3:1 compression to ventilation ILCOR/CoSTR process were even longer (520 s3335), and
ratio is used for resuscitation at birth where compromise of gas several studies had co-interventions that limited any direct com-
exchange is nearly always the primary cause of cardiovascular parisons. While the evidence of benet from animal studies is
collapse, but rescuers may consider using higher ratios (eg, persuasive,36 there are important differences (studied animals
15:2) if the arrest is believed to be of cardiac origin. The hand were non-breathing, intubated or tracheotomised), which limit
encircling technique with overlapping thumbs on the lower the immediate applicability to humans. Furthermore, variations
third of the sternum is recommended. This is a reinforcement in duration and number of breaths, as well as pressures, used
and development of previous advice.28 were considerable. Thus, the recommendation, until further
supportive evidence is available, was that sustained inations of
5 s duration should not be used unless in an individual clinical
Brieng/debrieng
situation or as part of a research study.
The importance of counselling and communicating with parents
and team brieng and debrieng has been highlighted in these
guidelines. They form the start and end of the mnemonic algo- Positive end expiratory pressure in term babies receiving
rithm and are covered in slightly more detail than previously. positive pressure ventilation
Although positive end expiratory pressure (PEEP) is widely used
ONGOING AREAS OF UNCERTAINTY in preterm babies both during resuscitation and in neonatal
While there have been some areas where newborn resuscitation units, there are scant data to support its use in term babies who
has become more evidenced based, there remain many areas require positive pressure ventilation at birth. Animal models
where the evidence is not yet strong enough to categorically would suggest that PEEP is benecial in helping to clear the
support a robust recommendation. This highlights that we still lung uid; however, there are major limitations to their applic-
do not know everything about the transition of babies. The fol- ability to human newborns, not least that most babies will
lowing are several areas where consensus could not be reached. respond to lung ination (with or without PEEP) due to Heads
paradoxical reex where ination of the lung triggers an inspira-
Umbilical cord milking (stripping) tory effort.37 Whether PEEP is more benecial than no PEEP in
While there is clear evidence that it is advantageous to allow infants who remain apnoeic is unknown. If a clear benet for
placental transfusion by delaying the clamping of the cord for using PEEP was found then, because self-inating bags are the
healthy babies of any gestation provided they can be kept warm, most common devices used for newborn resuscitation world-
less is known about what to do with those babies who appear to wide but cannot reliably deliver PEEP,38 there would be fairly
need immediate resuscitation. The milking (stripping) of the major resource implications.
cord has been proposed as an alternative when the cord must be
clamped immediately to allow treatment of either the baby or
T-piece resuscitator versus self-inating bags
the mother. It involves transfer of blood from a segment of the
Both T-piece resuscitators and self-inating bags are widely used
cord by actively milking the blood towards the baby three to
but the former is becoming more commonplace, in part,
ve times. It can be completed in around 20 s29 and produces
because of its ease of use and its ability to deliver PEEP. Using a
improved short-term haematological outcomes, admission tem-
T-piece resuscitator with an air/oxygen blender also allows for
perature and urine output when compared with delayed cord
better control of inspired oxygen. A major disadvantage is that
clamping (>30 s) in babies born by caesarean section, although
they require a pressurised gas source whereas self-inating bags
these differences were not observed in infants born vaginally.30
do not. For reasons discussed previously both devices are effect-
The ILCOR/CoSTR process examined the evidence for this
ive in resuscitating the apnoeic term baby, while PEEP may be
procedure in preterm babies (<29 weeks gestation) and felt that
advantageous, present evidence is not sufciently compelling to
there was currently insufcient evidence of any long-term bene-
recommend one over the other.39 40
ts for this to be recommended routinely without further
studies, particularly of the longer term neurological outcomes.
Laryngeal mask airways
Resuscitation before cord clamping Laryngeal mask airways (LMAs) are widely used for advanced
While there is a signicant amount of animal data favouring airway management in adult and paediatric resuscitation instead
delaying clamping the cord until after the lungs are aerated, of tracheal intubation. The LMA has been suggested as an alter-
there is as yet insufcient human evidence to determine whether native, either as a primary device (replacing facemask ventila-
resuscitation can be safely accomplished while the cord remains tion) or as a secondary device (for failed or not-possible
unclamped and placental gas exchange and transfusion can still tracheal intubation).41 They can be reliably used in babies of
occur. In many instances, existing equipment is not designed for >34 weeks gestation as an alternative to intubation; but costs
this and in some cases placental abruption or maternal condi- and the fact that effective facemask ventilation can resuscitate
tions will prevent it. While the potential clearly exists, many most term and near-term babies probably limits their applicabil-
questions remain about the impact especially on mothers and ity as a primary device.
Wyllie J, Ainsworth S. Arch Dis Child Fetal Neonatal Ed 2016;0:F1F5. doi:10.1136/archdischild-2015-309472 F3
Downloaded from http://fn.bmj.com/ on April 29, 2016 - Published by group.bmj.com
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Chest compressions: ratio and to synchronise or not to the continued lack of human evidence to justify change. It is
The 3:1 ratio of synchronised ventilations to chest compressions appropriate for all aspects of the pragmatic unied approach,
is unique to newborn resuscitation and is unchanged from previ- which guidelines represent, be subject to examination by
ous guidelines. This ratio allows for more ventilation breaths research studies. It is vital that such studies are not prevented
per minute than either the paediatric (15:2) or adult (30:2) purely on the basis of historical practice without any true evi-
ratios and is a reection of need to rst address the hypoxic dential support. The challenge for the future is to provide that
state of the newborn baby requiring resuscitation. That said, the evidence to ensure that babies at birth get the best and most
ratio providing the best combination of ventilation and both effective care.
cardiac and cerebral perfusion in the newborn baby requiring
Contributors JW and SA had joint responsibility writing the rst draft, editing the
resuscitation is unknown.
manuscript and approval of the nal draft.
Non-synchronised ventilations and compressions may be used
Competing interests JW is an unpaid co-chair of the ILCOR newborn task force
in adult resuscitations, especially following tracheal tube place-
and a member of the European Resuscitation Council developing guidelines for
ment. Adult tracheal tubes are cuffed whereas neonatal ones are newborn resuscitation, both JW and SA are unpaid members of the Newborn Life
not, meaning compressions performed at the time of a breath Support Subcommittee of the Resuscitation Council (UK) developing the UK
may limit the volume of that breath. Nonetheless in a manikin guidelines for newborn resuscitation.
model, because asynchronous ventilations and compressions Provenance and peer review Commissioned; externally peer reviewed.
allow for more breaths per minute, the minute volume can be
greater.42 It remains unclear whether this is advantageous in REFERENCES
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Arch Dis Child Fetal Neonatal Ed published online April 28, 2016
These include:
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Notes