Initiating delivery room stabilization/resuscitation in very low birth weight (VLBW) infants with an FiO2 less than 100% is feasible

Abstract

Background:Oxygen exposure during delivery room (DR) resuscitation, even when brief, is potentially toxic. A practice plan (PP) was introduced for very low birth weight (VLBW) infants ⩽1500 g as follows: initial FiO2 from 0.21 to 1.0 using blenders, oxygen guided by oximetry to maintain saturation between 85% to 95% from birth.Objective:To determine whether the initiating FiO2 could be safely lowered, and by doing so whether the number of infants with a PaO2 >80 mm Hg could be minimized on admission, as well as lowering oxygen requirement at 24 h.Methods:In all, 53 infants admitted between June 2006 and June 2007 were evaluated and compared with 47 infants from 2004 managed with 100 % oxygen (historical comparison group (HC)).Result:Stabilization/Resuscitation included intubation (n=28) and continuous positive airway pressure (CPAP) (n=25); no cardiopulmonary resuscitation (CPR). The heart rate increased rapidly in all cases. The initiating FiO2 decreased from 0.42 to 0.28 over 12 months (P=0.00005); 14 (26%) were resuscitated with room air. Correspondingly, the pH increased from 7.24 to 7.30 (P=0.002) and PCO2 decreased from 53 to 41 (P=0.001). A comparison of infants during the PP with the HC revealed that 36/53 versus 21/47 had an initial PaO2 <80 mm Hg (P=0.02); the median PaO2, that is, 64 versus 86 and saturation, that is, 95% versus 99% on admission were significantly lower. The median FiO2 at 24 h was 0.25 versus 0.40.Conclusion:DR resuscitation of VLBW infants can be initiated with less oxygen even with room air without concomitant overt morbidity. This change was associated with more infants with an initial PaO2 <80 mm Hg and lower saturation values on admission as well as a lower FiO2 requirement at 24 h.

Nasal CPAP vs. mechanical ventilation in 28-32 weeks preterm infants with early surfactant administration

“…Las características demográficas y clínicas de los dos grupos de pacientes no eran estrictamente idénticas y, aunque las diferencias no eran muy acentuadas (por ejemplo, había más varones, hubo más necesidad de reanimación en el grupo que recibió respiración mecánica asistida, y mayor peso y edad de gestación al nacer en el grupo de CPAP), esto obligó a tenerlas en cuenta en el análisis e interpretación de los hallazgos, ya que podían influir en los resultados (1,25). Esta es quizá la principal debilidad del estudio, pues para resolver de la mejor forma la incertidumbre frente a las dos intervenciones se tendría que haber hecho un ensayo clínico controlado.…”

Why are we still using oxygen to resuscitate term infants?

“…Findings of a recent study indicate that it is feasible to initiate delivery room stabilization with <100% oxygen in very low birth weight infants when the FiO 2 is being adjusted according to postductal SaO 2 values. 48 In addition, preterm infants <35 weeks of gestation in need of resuscitation had evidence of lower levels of oxidative stress when FiO 2 was titrated according to pulse oximetry than when 100% O 2 was used. 49 From the emerging data it seems that an FiO 2 of 1.0 or 0.9 is too high for preterm infants in need of stabilization/ resuscitation at birth, whereas 0.21, in many cases, is too low.…”

Response to Drs Lanka and Cummings

“…Feeding blood-tinged expressed mother's milk in the NICU In the February 2009 issue 1 we reported results of an e-survey of neonatal intensive care unit (NICU) professionals at Intermountain Healthcare regarding feeding NICU patients blood-tinged expressed mother's milk. We received 421 survey responses; 7% of respondents would discard the milk shown as #1 (faintly red breast milk), 75% would discard milk #2 and 98% would discard milk #3 (very red sample) (see Figure 1 in Phelps et al 1 ).…”

“…We received 421 survey responses; 7% of respondents would discard the milk shown as #1 (faintly red breast milk), 75% would discard milk #2 and 98% would discard milk #3 (very red sample) (see Figure 1 in Phelps et al 1 ). The reasons given most frequently for not feeding blood-tinged milk were; (1) It would cause gastrointestinal upset and feeding intolerance (77% of respondents), (2) blood might appear in the stool and result in Abbreviations: GI, gastrointestinal; NEC, necrotizing enterocolitis.…”

“…1 Resuscitation of the very low birth weight infant has become complex. In addition to monitoring supplemental oxygen delivery, close attention to temperature control, the most appropriate and effective method of inflating the lung, and deciding whether to use early surfactant in the delivery room are all part of the intense attention to detail required in the early minutes following delivery.…”