Recent discussions
-
ILCOR Staff
Thank you for the review. Our work with ECEB has a big task of encouraging delayed cord clamping, while starting resuscitations. This is the biggest resistance I find when working globally, including the global north. There could be inclusive diagrams of babies being resuscitated on the maternal abdomen, for fast recovery within the golden minute. I have gotten into the 'teaching habit' of timing how long it takes for providers to 'cut and tie' the cord. This exercise while adding a lot of humor to class, also adds reality for the providers responsible for resuscitation. The lengthy time taken to cut/tie makes an impression and reinforces that starting the stimulation, bag and mask (after suctioning if that is indicated), can be done so effectively with room air, on maternal abdomen, while calling for help, hoping that an additional set of hands shows up to assist when it is time to cut the cord, or change location for better access to surveillance and continued care. -
ILCOR Staff
I agree with the recommendations. I especially like the statement: "In still suggesting to start with low oxygen concentrations, we place value on avoiding exposure of preterm babies to additional oxygen without proven benefit for critical or important outcomes, as we are cognizant of harms in preterm animals and increased neonatal mortality in term infants exposed to high initial O2 concentration." -
ILCOR Staff
Thank you for the review. I agree with the recommendations. -
ILCOR Staff
Thank you for the review. It would be useful to have specific comments on populations that are expected to have high mortality, such as congenital diaphragmatic hernia. Many guidelines (example - see citation) comment on risks, but do not provide specific guidance. Snoek KG, Reiss IK, Greenough A, Capolupo I, Urlesberger B, Wessel L, Storme L, Deprest J, Schaible T, van Heijst A, Tibboel D; CDH EURO Consortium. Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update. Neonatology. 2016;110(1):66-74. doi: 10.1159/000444210. Epub 2016 Apr 15. PubMed PMID: 27077664. -
ILCOR Staff
Thanks to the authors of this well-written statement. 1) Presumably the format for presentation of results has been mandated, but strictly speaking the evidence is "inconclusive"; evidence that shows "no benefit or harm" is something different. 2) I agree that in the absence of evidence it is not possible to say if starting in air is better or worse than 30-40% but I am sympathetic to the concerns expressed above about use of air. I wonder if the second paragraph of the justification could be expanded to say something like "until further evidence is available, we recommend that individual units decide on a starting concentration between 21-30% based on local practice considerations and ongoing audit of care". 3) Second point in knowledge gaps: "Further evidence is needed from randomized studies about long term NDI outcomes". -
ILCOR Staff
I agree with the recommendations. -
ILCOR Staff
Congrats to authors on the comprehensive job done, however the jury is still out. We are still in need of more compelling evidence to rescue ELGANs in 21% FiO2. While the partial pressure of oxygen in utero is quite low, and therefore brain is likely not significantly damaged from brief episode of hypoxia at birth, it has not yet been proven by any of the studies sited here. I agree that without compelling evidence some O2 (30-40%) would be best in this vulnerable group, at least until better long-term neurodevelopmental follow-up can be evaluated. First, do no harm. -
ILCOR Staff
I certainly agree with recommendation for starting with Room Air oxygen for Term Neonates. As a Neonatologist have following this recommendation for term newborns since NRP 5th edition was released, and now we have definite science to show that is good practice to start resuscitation in term newborn with room air. Oxygen free radicals can cause much more harm, than transient hypoxia. -
ILCOR Staff
Agree with starting in Air in term and near term infants Problem is it gets turned up slowly or not at all.... I would suggest if starting CPR t turn I up to 100% and then titrate down if Sats >95% -
ILCOR Staff
I agree with your well researched conclusions. Locally we have been using 40% start and reduced to 30% 2 years ago. Your recommended range of 21% to 30% could be interpreted as 21% or 30% . I would favour the latter as this seems to offer good transition in practice. One practical problem with starting in air is that people 'forget' to turn it up in a crisis, or turn up in very small increments, once they get distracted by intubation, CPR etc, whereas when the saturations are too high people usually notice and turn it down. So would pragmatically agree with the principle Start lower rather than start higher, but might still recommend 30% rather than air. I agree with others that once starting CPR should consider 100% oxygen.