Recent discussions
-
Jonathan Wyllie
Thank you Colin. You are of course correct. It is also an issue that they do not measure what flow actually occurs. We did think about this and will consider again. -
MARIA ALBERTINA REGO
We are grateful for this important initiative by ILCOR in enabling an expanded discussion on neonatal care at birth, based on the best recommendations available. Transforming accumulated knowledge into potentially better clinical practices is an arduous task for the healthcare team. The possibility of confounding in the evaluation of neonatal results from routine suctioning, oropharyngeal or nasopharyngeal, controlled other components of care - trained team to provide integrated and continuous care, seems great. In addition, it is a variable with precision and accuracy that are difficult to define/control, depending on the “technique” and the instrument used and who makes the intervention. It is important to implement well-designed studies to assess the influence of such an intervention, which, with the knowledge accumulated so far, points to adverse events. While knowledge is being produced, it is important to strengthen the concept of the neonatal care continuum, especially in low and middle income countries. Birth assistance is a component of the “continuum” of reproductive, maternal, newborn, child and adolescent health care. The neonatal results of birth care depend on the implementation of clinical protocols by an integrated and trained team, working in an environment that ensures care in all its stages. -
Richard Hearn
Dr Tinnion makes very good points and I am not going to repeat all of them in my own comments but I would like to reiterate one point he makes and to do this as one of the authors of Sproat et al. The ILCOR team need to make a very clear distinction between term and preterm infants. Our data showed a universally poor outcome (death) in prolonged resuscitation of preterm infants. With regards to term infants there are survivors between 10 and 20 minutes but with a high risk of significant impairment and little in the way of concrete markers as to what might be antecedent factors that will allow accurate prediction of outcome. I suspect, as Dr Tinnion writes, the better than previously published outcomes do relate to better antenatal care and particularly better ability to predict the moment where deliver must happen. There is reasonable evidence that resuscitation beyond 20 minutes has an incredibly poor outcome and therefore I do not think it is unreasonable to attach an upper time limit to term infants with a lack or response to 20 minutes with consideration of appropriateness of continuation from 10 minutes of age -
Rob Tinnion
I agree wholeheartedly with this statement. There have been some studies in adults regarding adrenaline administration which suggest this area (whether adrenaline should be used) requires study urgently in the neonatal population. -
rob tinnion
Thank you for updating this work. My only comment would be that in the treatment recommendations, before the clear advice to not delay getting intravenous access by giving intratracheal adrenaline, I would ask the group to consider adding that where you have said "we suggest administering endotracheal epinephrine at a larger dose" the rider 'where an endotracheal tube has already been placed' is added so that then treatment recommendation is not interpreted as 'we have no IV access and therefore need to place an ETT before IV access'. -
Rob Tinnion
Thank you for the work that has gone into this review. It is an important topic as the nuance of the information (balancing risk of outcome against ongoing resuscitative efforts) is often interpreted reductively by resuscitators as 'carry on regardless for 'x' minutes'. I would ask the ILCOR team please to consider a couple of things about the treatment recommendation: 1) There is a marked difference between outcomes in the preterm population as the GA decreases and term population in this situation. I personally feel this should be reflected more strongly in the wording of the treatment recommendations because as it stands currently the synopsis is perhaps could be interpreted as encouraging prolonged resuscitations of extremely preterm infants. This would not be supported by the evidence presented. 2) The evidence presented in the review shows that beyond 10 minutes of systole there is a waning chance of disability-free survival and quite rightly some difficulty in stratifying who might have this with ROSC after 10 minutes. Therefore, as a resuscitating team there is merit in considering cessation of resuscitative efforts based on the circumstances of the case in hand before 20 minutes. The potential problem with suggesting this thought process only happens around 20 minutes is that again it presents a threshold for resuscitators to 'aim for' and will be interpreted as 'you can't stop before 20 minutes' . In addition, recent evidence from Japan where prolonged resuscitative efforts are more frequent than in some places has shown that in cases of neonatal ROSC beyond 20 minutes of age there is a universal outcome of death (most likely) or severe disability in the few survivors. To this end, I would ask the committee to consider acknowledging the element of likely disastrous outcome beyond 20 minutes based on the available evidence, but refrain from effectively precluding the resuscitating team from stopping resuscitative efforts before 20 minutes with the wording as it is currently. I think the evidence should be stated as it is but the onus be on the resuscitating team to proceed with resuscitation between 10-20 minutes as appropriate according to their discretion. Again, I note this is only really relevant to term and very late preterm babies. 3) There has been no fundamental change in the approach to resuscitation of the newborn in the last 20 years. The evidence coming out suggesting improved outcomes at after 10 minutes of systole on a population basis, therefore, must reflect factors of improved care elsewhere. I suspect the this is (a) better antenatal care and detection of a fetus in distress (so that at the time of delivery the effective 'down time' is less; analogous to a witnessed arrest in children/adults vs not witnessed) and (b) better and more immediately available neonatal intensive care. The evidence presented, though few studies, shows a positive effect of therapeutic hypothermia in this regard. This then, in context of point 2 above, suggests that place of delivery and attempted resuscitation is likely to contribute to the success of that process. So when making a statement about duration of resuscitative efforts it cannot be ignored that where this effort is taking place must be taken into account in terms of likely success and decisions to continue, and I think there is enough uncertainty in this respect that the treatment recommendations should acknowledge the likely variation in outcome based on place of treatment and resources available to help the clinician on the ground consider better when resuscitative attempts should continue or not. Lastly, I would note that the title of the piece is 'duration of intensive resuscitation'. I think the word intensive is misplaced as what is reported in all the studies is 'resuscitation' and no measure of 'intensive' or otherwise is needed or can be extrapolated. If 'poor' resuscitation (define this how you wish) goes on for 20 minutes or more before 'intensive' resuscitation starts, the outcome will be the same as if there has been no reponse to 'standard' resuscitation as the time passed is the same and the physiological effect therein. As with all arrests, the length of duration of resuscitation starts at point of arrest and not at point of 'effective' resuscitation starting and I worry that the use of the word 'intensive' may encourage resuscitators to try 20+ minutes of what they view as 'intensive' resuscitation after prolonged resuscitation has already occurred but not to their satisfaction. Thank you for considering these comments. -
MARIA ALBERTINA REGO
Briefing and debriefing is one of the components of the process of improving the quality of birth care as part of the qualification program for perinatal hospital care in the State of Minas Gerais-Brazil. The training included assistance to extreme premature infants, severe asphyxiation, stabilization during transport and approach of shock, in robotic and semi-robotized mannequins, in the simulation laboratory of the Faculty of Medicine of the Federal University of Minas Gerais. Leaders of the multidisciplinary teams of around 50 maternity hospitals that assist the flow of high-risk pregnant women participated in the process. The program as a whole was implemented in 160 maternity hospitals, including 3,500 professionals, for whom a resuscitation and transportation course was offered in the model of Brazilian Society of Pediatrics. The entire process is documented in technical reports from State Health Secretariat –Minas Gerais, under the technical coordination of the Faculty of Medicine-Medical Sciences of Minas Gerais, and registered at the Ministry of Education - MEC- Brazil, as a specialization course. This program as a whole significantly impacted perinatal indicators in the State, with a significant drop in infant mortality rates. Debriefing allows reflection on actions, view on different perspectives and solutions, reinforcement on good practices and learning from mistakes and successes, within the clinical context. Perinatal results depend on improving care throughout the clinical course of pregnant women, parturients, mothers and newborns, at birth and in the neonatal period, to achieve a positive impact on childhood mortality. -
Patrícia Pinto
The use of the T-piece can reduce the need for orotracheal intubation in newborns. T-piece facilitates the ventilation in the delivery room. We need to use in others services in the world. I believe that we need studies in hospitals with have less conditions too. -
Celso Rebello
Although there is evidence that manual ventilation using T-Piece resuscitator is superior to self-inflating bag regarding to the delivered tidal-volume and inspiratory pressure, some questions still need to be addressed, including the advantage of using PEEP valve in the self-inflating bag compared to this equipment without the PEEP valve and compared with the T-piece. -
Colin Morley
I think it may be important to point out that there are many different self inflating bags and they do not function in the same way. See refs: Arch Dis Child Fetal Neonatal Ed. 2019 Jul;104(4):F403-F408. Newborn self-inflating manual resuscitators: precision robotic testing of safety and reliability. Tracy MB, Halliday R, Tracy SK, Hinder MK. In particular this paper shows that of 20 tested 10 did not work at all well. Also: "Born not breathing: A randomised trial comparing two self-inflating bag-masks during newborn resuscitation in Tanzania. Thallinger M, Ersdal HL, Francis F, Yeconia A, Mduma E, Kidanto H, Linde JE, Eilevstjønn J, Gunnes N, Størdal K. Resuscitation. 2017 Jul;116:66-72. Also the different T piece devices work in different ways see: Arch Dis Child Fetal Neonatal Ed. 2019 Mar;104(2):F122-F127. T-piece resuscitators: how do they compare? Hinder M, McEwan A, Drevhammer T, Donaldson S, Tracy MB.