Recent discussions
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Sean Michael
I wonder whether there may be an opportunity to mention the idea of rapid response systems and their role in mitigating failure to rescue among admitted patients boarding in an emergency department setting while awaiting a hospital bed. There is a very large body of literature about harms and consequences of this practice, and one systematic review citation is below.
Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PloS one. 2018 Aug 30;13(8):e0203316.
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Dr Sreenivasarao Surisetty
Injury while CPR may be rib fractures, if the victim survives, rib fractures are not a major issue, they can be treated simply by immobilization along with analgesic medications. So please encourage CPR outside by layman.
moreover, if you train the lay people their technique may be improved without harming they can survive the victims
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Dr Sreenivasarao Surisetty
CPR outside hospital by a layman is highly recommended,thats why as IRCF instructor we are promting training to layman-COMPRESSION ONLY LIFE SUPPORT (COLS),only compression no breath support…30 each like 5 sets in a nonresponding victims after calling help
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Tim van Hasselt
The review is clear and summarises a great deal of evidence. There appears to be clear evidence for increased success at intubation for videolaryngoscopy vs direct, with RCT evidence which is encouraging. However the review also clearly demonstrates the gaps in other important outcomes including adverse events. Given this, I think the conclusions are justified and I would be happy to see incorporated into newborn courses.
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Jeff Perlman
We appreciate the ability to comment on this upcoming ILCOR statement . Our discussions involved Neonatal Fellows and Faculty, frontline providers at high-risk deliveries. Below represents a consensus of opinion.
We urge ILCOR to consider rewording their recommendation “begin resuscitation with more than 30% oxygen” for < 32 wk infants. A distinct change from 2020 recommendations for initiating resuscitation in <35 wk infants with 21-30% O2, this seems to be primarily based on the NETMOTION meta-analysis. This intriguing network & IPD meta-analyses showed lower mortality in >90% compared to the other 2 groups <30% & 50-65% (weak/very weak recommendations). While thought provoking, individual study limitations remain, such as heterogeneity in setting (both well and poorly resourced, with/without availability of oxygen blenders) and patient population (AGA/SGA infants etc.). Except for one study, (Oei et al) the cause/s and timing of mortality is unclear. Trying to link a few minutes of starting O2 to mortality in the absence of such data is difficult.
Practically, clinicians here have initiated preterm resuscitation with 30% O2. In most other DR`s, clinicians likely start at 21% or 30%, as recommended.. “More than 30%” implies that a clinician who starts resuscitation at 30% would not be adhering to recommendations while starting at 31% would be compatible. Could rewording the statement to “30% or higher” support current science while being less of a drastic and unclear change?
The third statement “Subsequent titration of O2 using pulse oximetry is advised” could be more impactful if included with the initial sentence as “Among newborn infants <32 wks’, it is reasonable to begin resuscitation with 30% or higher O2 with subsequent titration using pulse oximetry”. When using higher oxygen, titrating O2 delivery based on pulse oximetry is critical. If used as currently formulated, we consider the word “advise” weak. We would suggest using “recommended”. If blenders are unavailable, the word “recommended” should force guiding councils to consider making them available.
Physiologically, heart rate response is as important as O2 saturations in a resuscitation. A lower HR, eg 60-100/min, could lead to the clinician turning up the O2 even if the saturations are near target range. Is this a knowledge gap that could be explored with existing data or in future studies?
Nair J, Ahn E, DeBenedictis N, Hartman C, Lee Y, Mansfield J, Muthalaly R, Kim J, Perlman J.
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massimo m. alosi
When aspirating the newborn's trachea at birth, fluid rich in surfactant is aspirated, whether it is stained with meconium or not. The management of the newborn born with meconium-stained fluid is always and in any case beneficial only if the resuscitation maneuvers are performed with the umbilical cord intact. Our mentality must change radically and understand that an intact umbilical cord in an emergency is always an advantage, in any case and at any gestational age. It is important to leave the umbilical cord intact for hours and not for minutes or worse for a few seconds.
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Jayasree Nair
We appreciate the ability to comment on this upcoming ILCOR statement . Our discussions involved Neonatal Fellows and Faculty, frontline providers at high-risk deliveries. Below represents a consensus of opinion.
We urge ILCOR to consider rewording their recommendation “begin resuscitation with more than 30% oxygen” for < 32 wk infants. A distinct change from 2020 recommendations for initiating resuscitation in <35 wk infants with 21-30% O2, this seems to be primarily based on the NETMOTION meta-analysis. This intriguing network & IPD meta-analyses showed lower mortality in >90% compared to the other 2 groups <30% & 50-65% (weak/very weak recommendations). While thought provoking, individual study limitations remain, such as heterogeneity in setting (both well and poorly resourced, with/without availability of oxygen blenders) and patient population (AGA/SGA infants etc.). Except for one study, (Oei et al) the cause/s and timing of mortality is unclear. Trying to link a few minutes of starting O2 to mortality in the absence of such data is difficult.
Practically, clinicians here have initiated preterm resuscitation with 30% O2. In most other DR`s, clinicians likely start at 21% or 30%, as recommended.. “More than 30%” implies that a clinician who starts resuscitation at 30% would not be adhering to recommendations while starting at 31% would be compatible. Could rewording the statement to “30% or higher” support current science while being less of a drastic and unclear change?
The third statement “Subsequent titration of O2 using pulse oximetry is advised” could be more impactful if included with the initial sentence as “Among newborn infants <32 wks’, it is reasonable to begin resuscitation with 30% or higher O2 with subsequent titration using pulse oximetry”. When using higher oxygen, titrating O2 delivery based on pulse oximetry is critical. If used as currently formulated, we consider the word “advise” weak. We would suggest using “recommended”. If blenders are unavailable, the word “recommended” should force guiding councils to consider making them available.
Physiologically, heart rate response is as important as O2 saturations in a resuscitation. A lower HR, eg 60-100/min, could lead to the clinician turning up the O2 even if the saturations are near target range. Is this a knowledge gap that could be explored with existing data or in future studies?
Nair J, Ahn E, DeBenedictis N, Hartman C, Lee Y, Mansfield J, Muthalaly R, Kim J, Perlman J.
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massimo m. alosi
Dear colleagues, the management of the emergency of childbirth will always fail until we consider the clamping of the umbilical cord as a bias and until we consider a placenta attached to the uterus as an ECMO. So clamping is always a bias and is always harmful, the placenta is a life-saving resource. Clear! What happens in the emergency of the newborn at birth: asphyxia? acidosis? shock? What is needed for asphyxia? A vector of oxygen and carbon dioxide, i.e. hemoglobin, i.e. blood. What is the main buffer system of the organism to deal with acidosis? Hemoglobin, blood. What is needed as an anti-shock? Blood, an isogroup with hemoglobin F that has the characteristics to transport oxygen from where it is at low pressure and release it where it is even lower, a miracle!! The solution to the neonatal emergency is only and exclusively the umbilical cord intact for as long as possible at least until the placenta is delivered and even beyond. While maintaining the umbilical cord intact, the resuscitation maneuvers and sequences that are deemed most useful will be performed, even immediately without waiting. With the umbilical cord intact, it is never necessary to perform cardiac massage because with correct ventilation, even in the most serious cases, between 5 and 10 minutes the newborn is as if he were turned on with a switch and the Apgar Index reaches 9-10 without problems. Then the baby is born seriously depressed, he must be kept below the placental level, positioned, stimulated and dried, if he regains vitality when he has a good Moro reflex he can do "skin to skin", otherwise he remains lower than the placental level, the heart rate is evaluated, below 100 beats per minute, positive pressure ventilation is started and below 60 beats per minute, complete CPR is started. All strictly and obligatorily with the umbilical cord intact. I've been saying this for years (at least since 2013). I'm speechless. Best regards.
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Pâmella Lugon
The installation of NIRs in the delivery room environment can delay resuscitation maneuvers and more studies are needed to guarantee their benefit.
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Sofia Cuevas-Asturias
Such important work. It would be informative to see whether dose of adrenaline, timing relative to cycle time/total time in OHCA, dosage and whether any other agents used had pooled analysis outcomes of significance. are the any comparable pool of data for in-hospital paediatric cardiac arrests to see if vasoactives had specific results in types of arrests.