Recent discussions
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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.
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Thomas Sather
As all studies involved healthcare providers and/or healthcare trainees, recommend that the CoSTR treatment recommendation specify the population this applies to. Suggest that the recommendation read as “We suggest the use of high-fidelity manikins be used by healthcare providers and/or healthcare trainees…”
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Susan Niermeyer
Should deferred umbilical cord clamping and its interaction with administered oxygen concentration be highlighted as a significant gap in knowledge and explored deliberately in future analyses?
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ANA PAULA PAES
I do not have experiencie on this subject to give an opinion
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ANA PAULA PAES
the glucose management would be a care monitoring after ressucitacion In delivery room as that it is possible to achieve better neurological development
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Juliana de Araujo
The use of low-concentration oxygen can be beneficial for premature babies, always being within the target saturation.
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Hannah Shore
I would be anxious about NIRS use in the delivery room as it is not standard practice on many NICUs, it would be hard to apply and interpret and would detract from key treatment areas that we know have benefit and we need to focus on e.g. thermoregulation