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Evidence Based Medicine Indian Pediatrics 2000;37: 1229-1233. |
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Guidelines 2000 for Neonatal Resuscitation |
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The International Liaison Committee on Resuscitation (ILCOR), formed in 1992, has addressed many important resuscitation issues including an advisory statement on pediatric resuscitation, and recommendations in the areas of pediatric basic life support (BLS), pediatric advanced life support (ALS), and BLS for the newly born(4,5). The present exercise was taken up to extend advisory recommendations beyond BLS to ALS for the newly born. The Neonatal Resuscitation Guidelines 2000 on advanced life support (ALS) of the newly born(6) emerged as a result of two years of intense labor put in a systematic process of careful review of current constituent organization guidelines and contemporary international literature, evidence evaluation, and formulation by the Neonatal Resuscitation Program Steering Committee (American Academy of Pediatrics), the Pediatric Working Group of the ILCOR, and the Pediatric Resuscitation Subcommittee of the Emergency Cardiovascular Care Committee (American Heart Association).
The Pediatric Working Group of ILCOR developed a consensus advisory statement on ‘resuscitation of newly born infant’ in 1999(7). The consensus process helped in identifying the issues and controversies shrouding the resuscitative management of the newly born. Subsequently, an exercise was taken up with the help of topic experts leading to assembly of most current scientific information related to these queries. A standard tool (a worksheet template) facilitated uniform evaluation of each topic. Each topic (e.g., basic steps, ventilation, chest compression, medication, etc.) was subsequently analyzed and evaluated on the basis of articles published in peer-reviewed journals for relevance and quality of the evidence. Accumulated evidence from different sources was integrated by formal panel presentations and debates at the Evidence Evaluation Conference (American Heart Association, September 1999). Based on the critical assessment of the quality and number of studies, consistency of conclusions, measured outcome and magnitude of the benefit, final recommendations were formulated and presented for endorsement at the Guidelines 2000 Conference held in February 2000. To facilitate decision making by the healthcare provider on the recommended guidelines, the Conference also provided a guide to the clinical interpretation of each class of recommendations (Table I). The class, accompanied by the highest level of evidence (LOE) supporting the recommendation, is mentioned alongside each revised guideline appearing in the text.
The basic principles as well as the sequence of events for neonatal resuscitation remain unchanged. Past guidelines, not originally formulated through evidence based review were retained unless there existed a lack of evidence to confirm effectiveness, new evidence to suggest harm or ineffectiveness, or evidence that superior approaches had become available. Only new incorporations or major guideline changes are being highlighted below: Definitions of Newly-born and Neonate: Newly born refers to the infant in the first minute to hours after birth. Though the guidelines for resuscitation focus on this group, the principles are applicable throughout the neonatal period, which is defined as an infant during the first 28 days of life. Personnel: Personnel capable of initiating resuscitation should attend every delivery. At least one such person should be responsible for care of the infant. A person capable of carrying out a complete resuscitation should be immediately available for normal low risk deliveries and in attendance for all deliveries considered high risk. Basic Steps–Warmth: Avoid hyperthermia, because it is associated with perinatal respiratory depression (Class III, LOE 3). Routine implementation of selective cerebral hypothermia to protect against brain injury was not recommended for lack of appropriate controlled studies in humans (Class Indeterminate, LOE 2). Meconium stained amniotic fluid (MSAF): Intrapartum suctioning (as soon as the head is delivered) from mouth, pharynx and nose is to be performed in all deliveries born through MSAF. Perform direct laryngoscopy for suctioning of meconium from the hypopharynx and intubation/suction of the trachea, if the infant has depressed or absent respiration, decreased muscle tone, or heart rate <100 bpm. Tracheal suctioning of the vigorous infant with MSAF does not improve outcome and may cause complications (Class I, LOE 1). Oxygenation and ventilation: If assisted ventilation is required, deliver 100% oxygen by positive pressure ventilation. If supple-mental oxygen is unavailable, initiate resuscitation of the newly born with PPV and room air (Class Indeterminate, LOE 2). Current clinical data do not justify routine practice of ventilating with room air. If bag and mask is ineffective or attempts at intubation have failed, laryngeal mask airway (LMA) may be an effective alternative for establishing airway (Class Indeterminate, LOE 5). Endotracheal intubation: An exhaled-CO2 monitor may be used to verify tracheal tube placement, particularly when clinical assessment is equivocal (Class Indeterminate, LOE 5). Chest compressions: Indications: Administer compressions, if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The previous indication of starting compression at heart rate of 60-80 bpm and not rising stands withdrawn. This recommendation is based on construct validity (ease of teaching and skill retention) rather on evidence. Technique: The 2 thumbs-encircling hands technique is preferred to 2 fingers on sternum method. The former may offer some advantages in generating peak systolic and coronary perfusion pressure (Class IIb, LOE 5). Depth of compression: Consensus of the ILCOR Working Group supports a relative rather than absolute depth of compression, i.e., compress to approximately one-third of the anterior-posterior dimension of the chest to generate a palpable impulse. A compression to relaxation ratio with a slightly shorter compression than relaxation phase offers theoretical advantages for blood flow in the young infant. Medications: Adrenaline: Administration of adrenaline is indicated when the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compression (Class I). High dose epinephrine is not recommended (Class Indeterminate, LOE 4). Volume expanders: Fluid of choice is an isotonic crystalloid solution, such as Normal saline or Ringer’s lactate (Class IIb, LOE 7). Administration of O-negative red blood cells may be indicated for replacement of large-volume blood loss (Class IIb, LOE 7). Albumin containing solutions are no longer the fluid of choice for initial volume expansion. Vascular access: Intraosseous access can be used as an alternative route for medication/volume expanders if umbilical or other direct venous access is not readily attainable (Class IIb, LOE 5). Post-resuscitation issues: Apgar scores: Continue to assign Apgar score at 1 and 5 minutes after birth and the sequentially every 5 minutes until vital signs have stabilized. The Apgar scores should not dictate resuscitative actions; these are essential for quantification and summarizing of response of the newly born to the extrauterine environment and resuscitation. Non-initiation of resuscitation: There are circumstances in which non-initiation or discontinuation of resuscitation in the delivery room may be inept. Non-initiation of resuscitation in the delivery room is apt for infants with confirmed gestation age <23 weeks or birth weight <400 g, anencephaly, or confirmed trisomy 13 or 18. Current data suggest that resuscitation of this group of infants is not likely to reduce the resulting mortality and neurodevelopmental morbidity (Class IIb, LOE 5). Discontinuation of resuscitation: Quit resuscitative efforts in an infant with cardiorespiratory arrest if spontaneous circulation is not achieved in 15 minutes. Resuscitation after 10 minutes of asystole is very unlikely to result in survival or survival without severe disability (Class IIb, LOE 5). Table I__Clinical Interpretation of Classes of Recommendation
We were not surprised when India, which crossed the one billion-population mark with much fanfare and gusto, returned from Sydney Olympics 2000 almost empty handed, except for a solitary bronze. Yes, it is now a routine. Why should then we be surprised to know that the country with maximum number of births per annum had no say in formulation of guidelines for resuscitation and delivery room management of the newly born infant! A horde of National Health Programs were launched in the post independence era but the policy makers failed to put the desired emphasis on essential newborn care (ENC). Realizing that appropriate and effective resuscitation at birth is a corner stone of neonatal care, the National Neonatology Forum has consistently focussed on this theme as a vital strategy for improving the neonatal survival in the country. The current scenario appears a shade better with recent health programs giving due importance to care of the asphyxiated newly born as an integral part of ENC(8). The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America provides a forum for liaison between resuscitation organizations in the developed world. The 2000 consensus document on advanced life support of the newly born converts the previously published ILCOR advisory statements in to a set of guidelines. Consensus was reached on almost all aspects of neonatal resuscitation, and areas of controversy and high priority for additional research were delineated. There was agreement that insufficient data exist to recommend changes to current guidelines regarding the use of 21% versus 100% oxygen, neuroprotective interventions such as cerebral hypothermia, use of a laryngeal mask versus endotracheal tube, and use of high-dose epinephrine. The document provides clear directions to initiate, withhold, or withdraw resuscitation and is going to be of tremendous utility to health provider as well as the parents in difficult situations; however, regional and hospital policies may have to be worked out for complex and difficult ethical issues. Fortunately, a high degree of uniformity exists in practice of guidelines for resuscitation of newly born infants at birth, with controversies arising mostly from local and regional preferences, training networks, customs, and equipment/medication avail-ability rather than scientific evidence. The new guidelines, backed by scientific evidence, should reinforce the need for their unanimous adaptation. It is to be kept in mind that though International guidelines 2000 originate from the consensus arrived through the evidence review process, use of these is not mandated or imposed upon an individual or organization. It is solely up to the national and local agencies to adopt or adapt these recommendations in future training programs on neonatal resuscitation. Evidence-based evaluation of these advisory statements and the impact of their implementation are destined to the future topics of discussion among those concerned with the care of the newly born. Piyush Gupta,
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