Feasibility and safety of intact cord resuscitation in newborn infants with congenital diaphragmatic hernia (CDH)

Lefèbvre, Caroline; Rakza, Thameur; Weslinck, N.; Vaast, P.; Houfflin‐Debarge, V.; Mur, Sébastien; Storme, Laurent

doi:10.1016/j.resuscitation.2017.08.233

Cited by 44 publications

(55 citation statements)

References 21 publications

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“…Thus, although the reduction in PVR associated with lung aeration was delayed and diminished in DH lambs, by also delaying cord clamping there was sufficient time for PVR to fall, allowing left-to-right DA shunting and thereby minimising the increase in ventricular afterload caused by cord clamping. These findings suggest that the effect of delayed umbilical cord clamping in infants with CDH certainly warrants further research in experimental models, and feasibility studies for clinical trials have already commenced 25…”

Section: Discussionmentioning

confidence: 93%

Neonatal cardiopulmonary transition in an ovine model of congenital diaphragmatic hernia

Kashyap¹,

Crossley²,

DeKoninck³

et al. 2019

Arch Dis Child Fetal Neonatal Ed

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ObjectiveInfants with a congenital diaphragmatic hernia (CDH) are at high risk of developing pulmonary hypertension after birth, but little is known of their physiological transition at birth. We aimed to characterise the changes in cardiopulmonary physiology during the neonatal transition in an ovine model of CDH.MethodsA diaphragmatic hernia (DH) was surgically created at 80 days of gestational age (dGA) in 10 fetuses, whereas controls underwent sham surgery (n=6). At 138 dGA, lambs were delivered via caesarean section and ventilated for 2 hours. Physiological and ventilation parameters were continuously recorded, and arterial blood gas values were measured.ResultsDH lambs had lower wet lung-to-body-weight ratio (0.016±0.002vs0.033±0.004), reduced dynamic lung compliance (0.4±0.1mL/cmH2O vs1.2±0.1 mL/cmH2O) and reduced arterial pH (7.11±0.05vs7.26±0.05), compared with controls. While measured pulmonary blood flow (PBF) was lower in DH lambs, after correction for lung weight, PBF was not different between groups (4.05±0.60mL/min/gvs4.29±0.57 mL/min/g). Cerebral tissue oxygen saturation was lower in DH compared with control lambs (55.7±3.5vs67.7%±3.9%).ConclusionsImmediately after birth, DH lambs have small, non-compliant lungs, respiratory acidosis and poor cerebral oxygenation that reflects the clinical phenotype of human CDH. PBF (indexed to lung weight) was similar in DH and control lambs, suggesting that the reduction in PBF associated with CDH is proportional to the degree of lung hypoplasia during the neonatal cardiopulmonary transition.

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Section: Discussionmentioning

confidence: 93%

Neonatal cardiopulmonary transition in an ovine model of congenital diaphragmatic hernia

Kashyap¹,

Crossley²,

DeKoninck³

et al. 2019

Arch Dis Child Fetal Neonatal Ed

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“…This led to less cerebrovascular injury in PBCC lambs compared to ICC lambs, although clamping in the middle of rebound response appeared to make things worse. PBCC could also decrease the incidence of persistent pulmonary hypertension of the newborn in infants with a congenital diaphragmatic hernia [37]. PBCC decreased the pulmonary arterial pressure and the pulmonary vascular resistance in lambs with congenital hernia during transition and in the first hours of life [38].…”

Section: The Umbilical Cordmentioning

confidence: 99%

The Changing Landscape in Supporting Preterm Infants at Birth

2019

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Noninvasive ventilation for preterm infants at birth has been recommended and universally adopted. The umbilical cord is often clamped immediately in order to provide the support the infant needs for stabilization. However, recent scientific data from experimental studies that involve animals in transition and human studies using physiological measurements at birth have increased awareness as to how little we know about how these interventions interact and integrate with the infant’s changing physiology. It has become clear that in apneic infants the larynx is closed immediately after birth, which can completely negate the effect of noninvasive ventilation of the lung. For this reason, stimulating and supporting spontaneous breathing could enhance the success of noninvasive ventilation. Animal data also demonstrated that the large swings in blood pressure, blood flow, and oxygenation caused by immediate cord clamping can be avoided by postponing cord clamping until lung aeration has been established. In this review we will focus on these “game changers” that have the potential to completely change the approach used in stabilizing preterm infants at birth.

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“…Our study adds to the growing consensus that a physiological approach to umbilical cord clamping, which includes resuscitation on the cord if required, is preferable to immediate, or even time-based delayed cord clamping 5 11 22 25–29 33. The majority of our PBCC lambs did not achieve their target V T , so umbilical cord clamping was delayed until our arbitrary maximum of 10 min.…”

Section: Discussionmentioning

confidence: 93%

“…Despite improved pulmonary perfusion, PBCC lambs had persistent hypoxia and hypercapnia, similar to ICC lambs, suggesting that gas exchange remained impaired by the underlying lung hypoplasia. Indeed, in infants with CDH with relatively mild lung hypoplasia, resuscitation with an intact umbilical cord for ~7 min increased pH and reduced pCO 2 levels in the first 30 min after birth 22. While survival rates and length of hospital stay were similar, the study only assessed feasibility in infants with relatively mild lung hypoplasia.…”

Section: Discussionmentioning

confidence: 98%

“…Although our lambs were delivered via caesarean section in a controlled environment, the feasibility of replicating this approach clinically in the delivery room is slowly being realised 25 26. Several studies have now assessed the feasibility of assessing, resuscitating and ventilating infants at the maternal bedside in preterm27 and very preterm28 29 infants, as well as infants with CDH 22 30. However, other confounding factors such as labour and oxytocin administration and their potential effects on umbilical blood flow and cardiopulmonary haemodynamics have not been assessed 31.…”

Section: Discussionmentioning

confidence: 99%

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Physiologically based cord clamping improves cardiopulmonary haemodynamics in lambs with a diaphragmatic hernia

Kashyap

Hodges

Thió

et al. 2019

Arch Dis Child Fetal Neonatal Ed

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ObjectiveLung hypoplasia associated with congenital diaphragmatic hernia (CDH) results in respiratory insufficiency and pulmonary hypertension after birth. We have investigated whether aerating the lung before removing placental support (physiologically based cord clamping (PBCC)), improves the cardiopulmonary transition in lambs with a CDH.MethodsAt ≈138 days of gestational age, 17 lambs with surgically induced left-sided diaphragmatic hernia (≈d80) were delivered via caesarean section. The umbilical cord was clamped either immediately prior to ventilation onset (immediate cord clamping (ICC); n=6) or after achieving a target tidal volume of 4 mL/kg, with a maximum delay of 10 min (PBCC; n=11). Lambs were ventilated for 120 min and physiological changes recorded.ResultsPulmonary blood flow (PBF) increased following ventilation onset in both groups, but was 19-fold greater in PBCC compared with ICC lambs at cord clamping (19±6.3 vs 1.0±0.5 mL/min/kg, p<0.001). Cerebral tissue oxygenation was higher in PBCC than ICC lambs during the first 10 min after cord clamping (59%±4% vs 30%±5%, p<0.001). PBF was threefold higher (23±4 vs 8±2 mL/min/kg, p=0.01) and pulmonary vascular resistance (PVR) was threefold lower (0.6±0.1 vs 2.2±0.6 mm Hg/(mL/min), p<0.001) in PBCC lambs compared with ICC lambs at 120 min after ventilation onset.ConclusionsCompared with ICC, PBCC prevented the severe asphyxia immediately after birth and resulted in a higher PBF due to a lower PVR, which persisted for at least 120 min after birth in CDH lambs.

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Feasibility and safety of intact cord resuscitation in newborn infants with congenital diaphragmatic hernia (CDH)

Cited by 44 publications

References 21 publications

Neonatal cardiopulmonary transition in an ovine model of congenital diaphragmatic hernia

Neonatal cardiopulmonary transition in an ovine model of congenital diaphragmatic hernia

The Changing Landscape in Supporting Preterm Infants at Birth

Physiologically based cord clamping improves cardiopulmonary haemodynamics in lambs with a diaphragmatic hernia

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