Gjenoppliving av nyfødte

Gjenoppliving av nyfødte Nye retningslinjer Ola Didrik Saugstad MD, PhD, FRCPE Pediatrisk Forskningsinstitutt Oslo Universitetssykehus, Rikshospitalet Universitetet i Oslo

Fødsels Asphyxia i globalt 136 mill nyfødte hvert år perspektiv Resuscitering 5-8 mill nyfødte trenger resusitering 5% moderat (6,6 mill) og 1% (1,3 million) omfattende Optimal resusitering kan redusere dødeligheten Team arbeid er nødvendig Lege- sykepleier - jordmor

Intrapartale dødsfall Black RE, et al. Lancet. 2010 Jun 5;375(9730):1969-87. Global, regional, and national causes of child mortality in 2008: a systematic analysis.

Sykepleierens rolle Tenk igjennom hva du kan og skal gjøre: Den som kan mest leder prosessen Suger, ventilerer, gir hjertekompressjon Trekker opp, sjekker og gir medikament. Skriver ned hva som er gitt, og når og av hvem Tar del i beslutningsprossessen underveis Må kjenne rutinene Må kjenne algoritmen Må kjenne utstyret hvordan det virker og hvor det er De-briefing oppsummering

Behovet for intervensjon hos termin eller nær n r termin barn ved fødselen f INTERVENTION FREQUENCY Assess baby s response to birth Keep baby warm Position, clear airway, stimulate to breathe by drying Give oxygen only if necessary Establish effective ventilation bag & mask ventilation endotracheal intubation Provide chest compressions Adrenaline 3 5/100 1/100-1/700 < 1/1000 6/10 000 Volume expansion 1/12000

Birth Term Gestation? Amniotic fluid clear? Breathing or crying? Good muscle tone? Color pink? Yes Provide warmth Clear airway if needed Dry Assess color A B No Evaluate respirations, heart rate and color Apneic or HR <100 HR> 100 Provide positive pressure ventilation HR < 60 HR > 60 Breathing Hr> 100 but cyanotic Persistant cyanosis Consider Supplementary O 2 C D Continue positive pressure ventilation Administer chest compression HR < 60 Administer Adrenaline and/or volume Tracheal intubation may be considered at several steps Saugstad 2006 Adapted from ILCOR 2005

ILCOR Guidelines for nyfødt resusitering Endringer fra 2005-2010 Timing the first 60 seconds only Progression to the next step following initial evaluation is defined by heart rate and respiration For babies born at term it is best to begin resuscitation with air rather than 100% oxygen Evidence does not support or refute routine endotracheal suctioning of infants born through meconium-stained amniotic fluid, even when the newborn is depressed Chest compression- ventilation ratio 3:1 unless the arrest is known to be of cardiac etiology. Then higher ratio should be considered (15:2) Hypothermia in moderate to severe HIE

AAP/AHA 2000/2005/2010 Neonatal Resuscitation The following questions should be answered after every birth: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Is the amniotic fluid clear of meconium? XXXXXXXXXXXXXXXXX Is the baby breathing or crying? Is there a good muscle tone? Is the color pink? Was the baby born at term? XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX AHA: 2010 AHA: 2005 If the answer is no to any of these: consider resuscitation

ILCOR Nyfødt guidelines 2011 3 spørsmål ved alle fødsler: Termin? Puster barnet? Muskel tonus? Bare første 60 sekunder skal «times» Perlman J et al, Circulation 2010;122 (Suppl 2) S516-538

ILCOR/AHA 2005 Fire Skritt i nyfødtresustering A Luftveier Initial stabilisering B Ventilasjon C sirkulasjon D Medikamenter Ventilasjon (bag-maske eller bag -tube ventilering) Hjerte kompressioner Medikamenter eller volum behandling

A: Airways - Luftveier Stabilisation and suctioning A vigorous newborn who starts to breath within 10-15 seconds does not need suctioning routinely Deep suctioning should be avoided especially the first 5 min of life. It may induce apnea, bradycardia and bronchospasm If suctioning, always suction the mouth before through the nose to minimize risk of aspiration

Suging av øvre luftveier Routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born with clear or meconium stained amniotic fluid is no longer recommended ILCOR 2010

B: ventilasjon Increasing heart rate is the primary sign of effective ventilation during resuscitation What is an adequate heart rate? 50 percentile for heart rate is 99 bpm at one min Dawson et al, 2010 Observe also: Improving color Spontaneous breathing Improving muscle tone Check these signs of improvement after 30 seconds of PPV. This requires the assistance of another person The most important is to ventilate the lungs. Training is needed

The 10th, 25th, 50th, 75th and 90th heart rate centiles for all infants with no medical intervention after birth. bpm, beats per minute. Dawson J et al. Arch Dis Child Fetal Neonatal Ed 2010;95:F177-F181 2010 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health

The 10th, 25th, 50th, 75th and 90th heart rate centiles for infants <37 weeks gestation with no medical intervention after birth. bpm, beats per minute. Dawson J et al. Arch Dis Child Fetal Neonatal Ed 2010;95:F177-F181 2010 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health

The 10th, 25th, 50th, 75th and 90th heart rate centiles for term infants with no medical intervention after birth. bpm, beats per minute. X Dawson J et al. Arch Dis Child Fetal Neonatal Ed 2010;95:F177-F181 2010 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health

Initial breaths and pressures Initiation of intermittent positivepressure ventilation at birth can be accomplished with either shorter or Heart rate increase is more Important to observe than chest rise longer inspiratory times. Initial peak inflating pressures needed are variable- start with 20 cm H2O may be effective but 30-40 Cm H2O may be needed. PEEP is likely to be beneficial

Sustained inflation (SI)? In babies with GA < 29 weeks SI is tested out Different models for instance 5 seconds x 3 or 15 seconds with increasing PIP Still experimental

Assisted ventilation devices Ventilation of the newborn can be performed effectively with a flow-inflating, a self inflating bag or a pressure limited T- piece resuscitator

Ventilating with a T-piece Index finger Thumb

Self inflating (Laerdal) bag and mask with a mannequin P F No PEEP V

Neopuff and mask with a mannequin P PEEP F V

Vurdering for å trappe opp resusiteringen 3 vitale tegn Puls Respirasjon Oksygenering The most sensitive indicator of successful response to each step is an increase in heart rate

C: Circulation - Sirkulasjon Indikasjon for hjertekompresjoner Chest compressions should be performed if the heart rate is < 60 beats/minute, despite adequate ventilation for 30 seconds. 3:1 ratio - that is 90:30 ILCOR 2005 0.8 per 1000 term or near term infants 2-10% in preterm infants No Human data have identified an optimal compression to ventilation ratio for cardiopulmonary resuscitation in any age 2 thumb technique is more efficient than the 2 finger technique Lower 1/3 of sternum, pressure to one third of posterior anterior diameter to generate pulses Goals: Reperfuse the heart (obtain diastolic pressure) Reperfuse the Brain Wyckoff et al, Pediatrics 2005:115:950-955 Finer et al Pediatrics 1999;104:428-34 Wyckoff and Berg Seminars Fetal and Neonatal Med 2008;13:410-415

D: Drugs - medikamenter Adenalin If adequate ventilation and chest compressions have failed to increase heart rate to > 60 bpm, then it is reasonable to use adrenaline despite the lack of human neonatal data. The recommended dose of adrenaline is 0.1 to 0.3 ml/kg IV of a 1:10,000 solution (0.01 to 0.03 mg/kg) repeated every 3 to 5 minutes as indicated. Not evidence based Higher doses cannot be recommended and may be harmful. If the Endotracehal route is chosen use higher doses (0.05-0.1 mg/kg) No different dose for premature infants

Volum behandling 1)Fysiologisk saltvann eller Ringer s lactate 2)0-negativt blood. 10ml per kg, kan gjentas Needed in 1:12000 term or near term infants (Perlman et al) Insufficient evidence to support routine use In infants with no blood loss.

Luft eller oksygen?

Before 1998 Resuscitation World Map Term or Near Term infants 100% O2

2009 Resuscitation World Map According to O 2 Supplementation Term and Near Term Infants 21% national guidelines Australia Belgium Canada Finland Russia Sweden Spain The Netherlands UK WHO 100% 30-40% mixed 21-30%

Resuscitation of Newborn Piglets with 21% or 100% Oxygen Rootwelt, Løberg, Moen, Øyasæter, Saugstad, Pedaitr Res 1992;32:107

Neonatal Mortality after 21% or 100% O2 resusctiation 10 studies incuding 2134 infants Saugstad, Ramji, Soll, Vento. Neonatology 2008

Treatment Recommendation In term infants receiving resuscitation at birth with positive pressure ventilation, it is best to begin with air rather than 100% oxygen. If despite effective ventilation there is no increase in heart rate or if oxygenation (guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.

En endret holdning til bruk av oksygen ved gjenoppliving av nyfødte 1992 (ILCOR): 100% O 2 should be used, it is not toxic- no reason to be concerned 2000 (ILCOR/AAP): 100% O 2 should be used, however if O 2 is not available use room air 2005 (ILCOR/AAP): The optimal O 2 conc is not known for newborn resuscitation There is no reason to change the initial O 2 concentration 2010 (ILCOR/AAP)...that adverse outcomes may result from even brief exposure to excessive oxygen during and following resusctitation (AAP) In term infants receiving resuscitation at birth with positive- pressure ventilation, it is best to begin with air rather than 100% O 2 (ILCOR)

American Academy of Pediatrics 2010 Kattwinkel J et al Pediatrics, 2010

Utviklingen i SaO 2 hos normale terminbarn 0-10 minutter Dawson et al 2010

X X X X X X

Meta analyse luft Vs 100% O 2 for nyfødt resusitering All studies show better outcome with 21% O 2 N= 10, Infants 2134 Neonatal Mortality 12.8 Vs 8.2% p < 0.001 RR Neonatal death 0.69 (0.54-0.82) Randomised studies better outcome with 21% O 2 N= 4, Infants 449 Neonatal Mortality 3.9 Vs 1.2 % p < 0.01 RR Neonatal death 0.32 (0.12-0.82) Saugstad, Ramji, Soll, Vento, Neonatology 2008

Ressucitation World Map 2010 Term or Near term Infants ILCOR and AAP October 18th 2010 Low oxygen approach

Current practice of oxygen use during delivery room resuscitation for respondents 70 % 60 % % of respondents 50 % 40 % 30 % 20 % Term Neonates Preterm Neonates 10 % 0 % Pure Oxygen Room Air Blended oxygen The Use of Oxygen for Delivery Room Resuscitation of Newborn Infants in Non-Western Countries KOH J,,YEO CL, WRIGHT,I LUI K,,SAUGSTAD OD,,TARNOW-MORDI W,,OEI JE

Effect of Some Therapies Therapy Estimated Potential Saved Lives Antenatal steroids 500, 000 Surfactant* 250,000 650 000 Respirator** 625,000 Air resuscitation*** 250, 000 550 000 300 000 Hypothermia**** 40,000 40 000 Oral Rehydration Therapy 2000, 000 *0,5% < 29 weeks, 50 % survival without surfacant, 90% survival with ** 1% in need of ventilator 50% survival *** fresh still births 1mill x 30% survival = 300,000 *** 1 per 10000 needs hypothermia, 30% reduction in mortality

Do we need a new Apgar Score? Virginia Apgar 0 1 2 Heart rate 0 <100 >100 Respiration 0 Weak, irregular Good cry Reaction* 0 Slight Good Colour Blue or pale All pink, limbs blue Body pink Tone Limp Some movement Active movements limbs well flexed * Reaction to suctioning

Team arbeid og undervisning Gjenoppliving av nyfødte er team arbeid mellom leger og sykepleier/jordmor Hver enkelt må kjenne sine oppgaver Hver enkelt må kjenne algoritmen og behandlingspunktene Norske retningslinjer kommer Kontinuerlig utdanning er nødvendig

Nyfødt gjenoppliving Utfordringer Optimal Hjerteaksjon-respons er ikke kjent Optimal Ratio ventilasjon:kompresjon er ikke kjent Optimal adrenalin dose er ikke kjent Optimal FiO 2 for barn med ekstrem lav fødselsvekt er ikke kjent Bygge opp team Kontinuerlig utdannelse

Takk for oppmerksomheten! Spørsmål?

Oxygen From Bench to Bedside in Newborn Resuscitation ATP Hypoxia Hypoxanthine O 2 Birth asphyxia 4 million newborn per year O 2 _ 100% 21% Reoxygenation Mortality 12.8 Vs 8.2% Corresponds to > 100,000 lives potentially saved with room air Neonatal mortality % 15 10 5 0 1 Saugstad OD, The Lancet in press 1 100% 21%

1 Oxygen From Bench to Bedside in Newborn Resuscitation ATP Hypoxia Hypoxanthine O 2 O 2 _ 100% 21% Reoxygenation 15 Saugstad OD, The Lancet in press Neonatal mortality % 10 5 0 1 Neonatal mortality 100% 21%