The transition from intrauterine to extrauterine life that occurs at the time of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transition is brought about by initiation of air breathing and cessation of the placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-welloxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the lowresistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting across the ductus arteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption.Approximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after positive-pressure ventilation (PPV), 2% will be intubated to support respiratory function, and 0.1% will require chest compressions and/or epinephrine to achieve this transition. [1][2][3] Although the vast majority of newborn infants do not require intervention to make these transitional changes, the large number of births worldwide means that many infants require some assistance to achieve cardiorespiratory stability each year.Newly born infants who are breathing or crying and have good tone immediately after birth must be dried and kept warm so as to avoid hypothermia. These actions can be provided with the baby lying on the mother's chest and should not require separation of mother and baby. This does not preclude the need for clinical assessment of the baby. For the approximately 5% of newly born infants who do not initiate respiratory effort after stimulation by drying, and providing warmth to avoid hypothermia, 1 or more of the following actions should be undertaken: providing effective ventilation with a face mask or endotracheal intubation, and administration of chest compressions with or without intravenous medications or volume expansion for those with a persistent heart rate less than 60/min or asystole, despite strategies to achieve effective ventilation (Figure 1).The 2 vital signs that are used to identify the need for an intervention as well as to assess the response to interventions are heart rate and respirations. Progression down the algorithm should proceed only after successful completion of each step, the most critical being effective ventilation. A period of only approximately 60 seconds after birth is allotted to complete each of the first 2 steps, ie, determination of heart rate and institution of effective ventilation. Subsequent progression to the next step will depend o...
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide ( https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100 ). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With TreatmentRecommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates.The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
The International Liaison Committee on Resuscitation uses the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group method to evaluate the quality of evidence and the strength of treatment recommendations. This method requires guideline developers to use a numerical rating of the importance of each specified outcome. There are currently no uniform reporting guidelines or outcome measures for neonatal resuscitation science. We describe consensus outcome ratings from a survey of 64 neonatal resuscitation guideline developers representing seven international resuscitation councils. Among 25 specified outcomes, 10 were considered critical for decision-making. The five most critically rated outcomes were death, moderate-severe neurodevelopmental impairment, blindness, cerebral palsy and deafness. These data inform outcome rankings for systematic reviews of neonatal resuscitation science and international guideline development using the GRADE methodology.
High PCO 2 levels attenuate reperfusion injury and ventilationinduced injury in isolated and perfused lungs. We asked whether premature lambs could tolerate 6 h of ventilation with a PCO 2 Ͼ80 mm Hg and whether the high PCO 2 modulated the ventilatorinduced injury. Preterm surfactant-treated lambs were ventilated for 30 min with a high tidal volume (VT) to induce lung injury. The lambs then were ventilated for 5.5 h with a VT of 6 -9 mL/kg to achieve a PCO 2 of 40 -50 mm Hg in the control group. CO 2 was added to the ventilator circuit of a high PCO 2 group to maintain an average PCO 2 of 95 Ϯ 5 mm Hg. The high PCO 2 lambs had heart rates, blood pressures, plasma cortisol values, and oxygenation equivalent to the control lambs. The lungs of the high PCO 2 group had significantly higher gas volumes and had less lung injury by histopathology. Indicators of inflammation (white blood cells, hydrogen peroxide production, and IL-1 and IL-8 cytokine mRNA expression in cells from the alveolar wash) qualitatively indicated less injury in the high PCO 2 group, although the differences were not significant. Preterm lambs tolerated a very high PCO 2 without physiologic compromise for 6 h. The high PCO 2 may attenuate ventilator-induced lung injury in the preterm. BPD in preterm infants is highly associated with the use of mechanical ventilation and supplemental oxygen (1, 2). Efforts to decrease the incidence of BPD have included attempts to avoid mechanical ventilation with the use of continuous positive airway pressure (3), different techniques for mechanical ventilation such as high-frequency oscillatory ventilation (4), and lower VT ventilation resulting in higher PCO 2 values (5). In the mature lung, ventilator-mediated injury increases if the lung is inadequately inflated at end-expiration or overinflated at end-inspiration (6, 7). Attempts to decrease lung distention by decreasing VT will result in increases in PCO 2 , referred to as "permissive hypercapnia" (8). Laffey et al. (9) recently extended this concept to "therapeutic hypercapnia" by demonstrating that reperfusion injury of the lung can be prevented if the injury and reperfusion occur in the presence of a PCO 2 of 80 mm Hg. This work demonstrates that high PCO 2 can protect the lung from reperfusion injury, most likely via attenuation of free radical damage. This effect has also been reported for reperfusion injury of other organ systems, such as the brain and heart in adult and newborn animal models (10, 11). Broccard et al. (12) recently reported that high PCO 2 also minimized ventilatorinduced lung injury in isolated and perfused lungs. However, a protective effect of high PCO 2 values has not been demonstrated for ventilator-induced injury in vivo in animals or for the preterm lung. Therefore, we ventilated surfactant-treated preterm lambs to achieve normal PCO 2 values or equivalently ventilated other lambs with supplemental CO 2 to evaluate the tolerance of the preterm to high PCO 2 and the effect of the high PCO 2 on indicators of lung injury. MET...
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