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Background and aim

In animal studies immediate cord clamping (ICC), prior to lung aeration or lung ventilation, was associated with hemodynamical disturbances and may be associated with brain damage in preterm infants. Cut-umbilical cord milking (C-UCM) may substitute these adverse effects by supplying additional placental blood to the infant.

Aim of the study was to analyse, whether C-UCM was associated with differences in cerebral oxygenation and perfusion during immediate neonatal transition measured with near-infrared spectroscopy (NIRS) compared to ICC.

Methods

A randomized controlled pilot trial including preterm neonates delivered by caesarean section. In the C-UCM group the umbilical cord was clamped within 30 seconds after delivery, cut long at least 30 cm and milked once towards the neonate. Within the first 15 minutes after birth continuous measurements of tissue oxygen saturation (t-rSO2) and cerebral blood volume (CBV) using NIRS (t-NIRS, Hamamatsu), heart rate and arterial oxygen saturation using pulse-oximetry were performed and compared to infants receiving ICC 30 seconds after birth.

Results

In total, 39 preterm infants (C-UCM n=19; ICC n=20) with median gestational age of 34+6 (IQR 2.57) weeks and mean birth weight of 2273 (SD±530) grams were included. Median t-rSO2 increased from and 19.2 (IQR 26.7) to 68.1 (IQR 9.9) and CBV decreased from 3.1 (IQR 0.8) to 2.9 (IQR 0.6) ml/100g brain from minute 3 to 15 without significant differences between groups. There were no differences in pulse-oximetry.

Conclusion

Preterm infants receiving C-UCM didn’t show differences in cerebral oxygenation and perfusion compared to infants receiving ICC.

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Infants with inadequate breathing at birth may be resuscitated with positive pressure ventilation (PPV). Giving prolonged sustained lung inflations (SLI) may help clear lung fluid and establish gas volume in the lungs.

We assessed the efficacy of an initial SLI (> one second duration) compared to standard inflations (≤ one second) in newly born infants receiving resuscitation with intermittent PPV. We searched Central, MEDLINE, EMBASE, CINAHL, clinical trials databases and conference proceedings.

Ten RCTs enrolling 1467 infants met our inclusion criteria. Investigators in 9 RCTs (1458 infants) administered SLI with no chest compressions. Use of SLI had no impact on the primary outcomes of this review - mortality in the delivery room (RR 2.66, 95% confidence interval (CI) 0.11 to 63.40; participants = 479; studies = 5) and mortality during hospitalisation (RR 1.09, 95% CI 0.83, 1.43; participants = 1458; studies = 9). The quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was low for death in the delivery room because of limitations in study design and imprecision of estimates (one death). For death before discharge the quality was moderate (limitations in study design).

Our meta-analysis shows that SLI was not better than intermittent ventilation for reducing mortality. However, the single largest RCT, which was well-conducted and had the greatest number of enrolled infants, was stopped early for higher mortality rate in the SLI group. There is no evidence to support the use of SLI based on evidence from our review.

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Background

Pediatric resuscitation guidelines recommend continuous chest compressions (CC) with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation (CPR) once an airway has been secured. However, the optimal CC technique remains unknown.

Aim

To determine if CCs during sustained inflations (SI) improves return of spontaneous circulation (ROSC) of asphyxiated pediatric piglets compared to CCaV.

Intervention and measurements

Piglets (age 20-23 days) were anesthetized, intubated, instrumented, and asphyxiated. Protocolized resuscitation was initiated when mean arterial blood pressure was <25mmHg with bradycardia. Piglets (n=12/group) were randomized to receive CCaV resuscitation (CCaV group) according to the current resuscitation guidelines, or CC during SI (CC+SI group). The CC+SI group received a SI with a peak inflating pressure of 25 cmH₂O for 30sec, CCs were provided at a rate of 100/min, and SI was interrupted after 30 sec for one second before a further 30sec SI was provided. CC and SI were continued until ROSC. Respiratory parameters, carotid blood flow, systemic artery pressures, and cerebral oxygenation were measured.

Main results

Median (IQR) time to ROSC was significantly decreased in the CC+SI group compared to CCaV with 248 (41-346)sec vs. 720 (167-720)sec (p=0.049), respectively. CC+SI had a 100% higher rate of ROSC compared to CCaV with 10(83%) vs. 5(42%) (p=0.089), respectively. Piglets in the CC+SI group received a median (IQR) 3.5 (0-5.8) intravenous epinephrine boluses compared to 8.0 (1.8-11) in the CCaV group (p=0.123).

Conclusions

Combining CC and SI significantly improved time to ROSC and survival in asphyxiated pediatric piglets when compared to the current standard of CCs with CCaV during pediatric CPR.

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Background and aims:

The recommendations for ventilation rate (VR) during bag mask ventilation (BMV) is not consistent in current guidelines, with a variation from 30/minute to 40-60/minute. As there is limited research to underpin recommendations, we aimed to study whether VR predicted survival and total duration of BMV.

Methods:

Ventilation data for newborns who received BMV immediately after birth between 1.7.2013-1.7.2018 at Haydom Lutheran Hospital, Tanzania, were recorded using a ventilation monitor. Among 18,997 live-born, 1,379 (7.3%) received BMV. Complete data on VR were available from 1,220. Main outcomes were survival at 24 hours and time from first to last inflation by categories for VR (<40, 40-60 and >60/minute) the first 5 minutes of BMV.

Results:

The median VR the first 5 minutes of ventilation was 50.2 (IQR 40.7-63.4). The mortality was lowest in the group with ventilation rate <40/min (5.9, 8.6 and 9.5%, respectively). In regression analyses adjusted for differences in birth weight and delivery mode the differences were not significantly different (relative risk 1.36 (95% CI 0.78-2.39) for highest vs lowest, p_trend=0.32).

Duration of BMV was shortest in the group with ventilation rate <40/min (Figure, median duration 95, 143 and 134 seconds, respectively, p=0.03 in logrank test). The difference was not significant in unadjusted and adjusted Cox regression analyses (HR 1.08, 95%CI 0.92-1.26 for lowest vs highest VR).

Conclusions:

VR in the lower range of the spectrum of recommendations were non-significantly associated with improved survival and shorter need for BMV in newborns.

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Background:Worldwide, the most common neonatal resuscitation method is face-mask (FM) ventilation performed by midwives. The aim of this trial was to investigate whether the use of a cuffless laryngeal mask airway (LMA) compared to FM could reduce mortality and morbidity in asphyxiated neonates.

Methods:A phase III open-label superiority randomized controlled trial was conducted at Kawempe National Referral Hospital, Uganda, constituting a high-risk population. Neonates needing positive pressure ventilation at birth, gestation ≥34 weeks and/or expected birth weight≥2000 g, were eligible. Randomization was done to LMA (intervention) or FM (control). The primary outcome was a composite of 7-day mortality and hypoxic-ischemic encephalopathy (HIE). Secondary outcomes were early neonatal death and admission to NICU.

Results:1163 babies were included between 08.05.18-12.08.19 (Fig 1). 298 (25.8%) neonates died within 7 days (n=231) or were alive with HIE (n=67). In the LMA arm, 19 neonates were switched to FM. In the FM arm, 63 neonates were switched to LMA. Primary outcome was not statistically different between LMA (n=154/563) vs. FM (n=144/591) arms (RR 1.17, 95% CI 0.95 to 1.44; p=0.14) according to intention-to-treat analysis. Secondary outcomes were similar between the 2 groups (Table 1) No other adverse events occurred (Table 2).

Conclusion:LMA was not superior to FM in reducing early neonatal mortality and moderate/severe morbidity in this population and do not support LMA as a primary device in this setting.However, the LMA was safe in the hands of midwives. Further studies are needed to clarify if these results apply to hospitals with less sick infants.

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Objectives

Five randomised controlled trials (n=307) have shown that surfactant can be given through a laryngeal mask airway (LMA) to treat respiratory distress syndrome avoiding the need for laryngoscopy, intubation and ventilation. It is reported as easy to learn and well tolerated by infants. We describe the first 60 infants who received LMA surfactant in two UK neonatal units.

Design/Methods

A protocol was written and staff training carried out using simulation and videos. Included infants weighed ≥ 1.2Kg and had RDS confirmed on X-Ray, with an oxygen requirement of ≥30% on CPAP. Exclusion criteria included previous or imminent need for intubation and large pneumothorax. An LMA (iGel) was inserted, placement confirmed by colormetric CO₂ detector and connected to a neopuff circuit that delivered PEEP plus IPPV if needed during the procedure. Up to 200mg/kg of surfactant was administered slowly by surfactant giving catheter through a duckbill port of the circuit.

Results

From 13/12/18 to 18/04/20, 60 infants were treated. Median (range) gestational age and weight were 33+2 weeks (29+0-39+2) and 2100g (1200-4440g). All procedures were completed and well tolerated by the infants. All infant’s oxygen requirements reduced and by four hours afterwards, 40 (66%) had weaned to air. Ten infants had a persistent oxygen requirement and were intubated for further surfactant (17%). Three infants needed treatment for pneumothorax. Four infants diagnosed with Chronic Lung Disease

Conclusions

Our experience is that LMA surfactant in infants >1.2kg is efficacious, well tolerated by infants and easily learned by staff.

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The objective of the study was to investigate if a lung ultrasound (LUS) score in premature newborn with a respiratory distress syndrome (RDS) may allow an earlier surfactant therapy (within the first 3 hours of life) comparing to FiO₂ criteria. This was a randomized not blinded clinical trial conducted in a neonatal intensive care unit. The inclusion criteria were newborn ≤32 gestational age with RDS. Patients who met the inclusion criteria were randomly assigned to two groups: Experimental group, in which surfactant was administered based on LUS score and/or oxygen threshold; and control group, guided by oxygen threshold only. Fifty-six patients were included. Newborn in the experimental group (n=29) received surfactant earlier (1 hour of life vs. 6 hours), with lower FiO₂ requirements (25% vs. 30%), lower CO₂ (48 vs. 54), and greater SpO_2, Saturation/FiO₂ ratio and pH (all p<0.05). The need of mechanical ventilation was lower in the experimental group (n=5, 17.2%) than in the control group (n=10, 37.0%), with p=0.095.

Conclusions: LUS score allowed an earlier surfactant therapy with lower oxygen requirements determined by FiO2, Saturation/FiO₂ ratio and blood gases. The early surfactant replacement can suppose a reduction in the need of mechanical ventilation

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Background: Current guidelines recommend an initial management of respiratory distress (RD) in the delivery room (DR) with nasal continuous positive airways pressure (NCPAP) and, if later required, nasal intermittent positive pressure ventilation, less-invasive surfactant administration (LISA) and tracheal intubation.

Aims: To evaluate early factors (within the first 3h of life) associated with an initial NCPAP failure in moderate and late preterm infants.

Methods:

Sub analysis from a multicentric prospective observational study (NEOBS study) performed in 46 French NICUs

Inclusion: preterm infants between 32+0/7 and 36+6/7 weeks of gestational age (GA) with RD requiring ventilatory support between H0 and H24 from the NEOBS study were included. Non-inclusion criteria: ventilatory support for other indication than RD; tracheal intubation in the DR before NCPAP attempt, death within H24.

NCPAP failure defined as need for intubation < 72h. Uni- and multi-variate analyses were performed.

Results:

demographic and clinical details( fig 1 )

When surfactant was administered, LISA use was lower in the NCPAP failure group (10.3%) compared to the control group (60%; p<0.0001).

In the multivariate analysis, severe RD, Apgar score at 5 min < 7 and FiO2 ≥ 30 % at H3 were significant factors associated with an increased risk of early NCPAP failure (Area Under the Curve (AUC)=0,75).

Conclusion:

In moderate and late preterm infants, Apgar score at 5 min < 7, FiO2 level at H3 > 30% and severe RD were associated with NCPAP failure. Surfactant administration by LISA was associated with CPAP success.