Delivery Room Stabilization of the ELBW InfantELBW Infant

Myra H Wyckoff , MDMyra H Wyckoff , MDProfessor of Pediatrics

Division of Neonatal Perinatal MedicineDivision of Neonatal Perinatal MedicineUT Southwestern Medical Center, Dallas, TX

2015 New AlgorithmAlgorithm

Impending Delivery of ELGAN Infant 36 yo G1P0 mom

– severe pre-eclampsiap p– membranes intact– no history of trauma– Received 1 dose steroids 1 hour ago

Bedside sono supports her 26 wk EGA datesBedside sono supports her 26 wk EGA dates– Estimated fetal weight 720g– Female, singletong

Category 2 Fetal Heart Rate Tracing and breech positionposition

C/S under combined spinal/epidural anesthesia

Outcomes for Inborn vs Outborn ELBW I fELBW Infants

Large body of literature from the mid 1990s ti i d t f ELBW’ b isuggesting improved outcomes for ELBW’s born in

tertiary care centers versus those that were out born and subsequently transferred inand subsequently transferred in.—Less IVH—Lower mortalityy

Could be due to… —Better maternal antepartum care (steroids and

antibiotics)—Presence of experienced neonatal resuscitation teams

in the delivery room to initiate appropriate resuscitationin the delivery room to initiate appropriate resuscitation—Improved resources for multidisciplinary care in the

NICU

ELBW Can Be Difficult to Stabilize inDifficult to Stabilize in

the DR Lose heat easier Immature tissues may be damaged more easily by oxygen Weak chest muscles can limit adequate ventilation Immature nervous system may not provide adequate

stimulation to breathstimulation to breath Lungs may be immature and deficient in surfactant making

lung expansion and ventilation more difficult Increased risk for infection Fragile capillaries within the immature brain that can rupture

S Small blood volume makes them more susceptible to hypovolemic effects of blood loss

In our case we are the regional care center In our case, we are the regional care center Due to both the maternal and fetal condition

delivery will be imminentdelivery will be imminent.

Antenatal CounselingAntenatal Counseling Meeting with parents before the birth of an

t l t b b i i t textremely preterm baby is very important – Parents

Medical Providers– Medical Providers

These discussions can be difficult– Large amount of complex information to convey– Parents very stressed

Need both national and local outcome data and to understand the limitations of each– If necessary consult with specialists at your regional

referral center to obtain up to date information

Antenatal Counseling Best to consider multiple factors

Gestational Age– Gestational Age– Estimated Fetal Weight– GenderGender– Singleton or Multiple– Has mother received antenatal steroids

Ideally, both the obstetric provider and the neonatal provider should be present to talk to theneonatal provider should be present to talk to the parents– Perspectives may differ– Such differences should be discussed BEFORE

meeting with parents so that information is consistent

United StatesELBW Outcome Calculator

Based on a prospectively studied cohort of 4446 extremely premature infants

T JE t l I t i C fTyson JE et al Intensive Care for Extreme Prematurity: Moving Beyond Gestational Age. N Engl J Med 2008;358:1672-81;

Parkland 2009‐2014 Survival and Survival without Severe Illness by OB EGA

23wk 24wk 25wk 26wk 27wk 28wk 29wk 30wk 31wk 32wk 33wk 34wkTotal 

Patients 10 46 66 79 83 110 121 164 200 330 406 786

Denominator: All patients with Comfort Care patients excluded.  Severe illness includes PDA ligation, Severe BPD (NIH consensus definition), Surgical NEC, Spontaneous intestinal perforation, Grade 3 or 4 IVH, IVH w/surgery for Hydrocephalus, Cystic PVL, Severe ROP (Stage>4, Avastin or Laser therapy)

Preparation for ELBW Delivery

Adequate trained personnel (basic team) Adequate trained personnel (basic team)– Neonatologist, Nurse, Respiratory therapist, Recorder

Thermal Protection (Radiant warmer plastic wrap

AAP-NRP photo

Thermal Protection (Radiant warmer, plastic wrap, thermal mattress)

PPV device that can provide PEEP/CPAP PPV device that can provide PEEP/CPAP Zero blade and 2.5 Endotracheal tube Adjust starting O concentration (FiO 0 21 0 3) Adjust starting O2 concentration (FiO2 0.21-0.3) Pulse Oximetry Discussion with OB regarding plans for delayed Discussion with OB regarding plans for delayed

cord clamping if infant active at delivery

At birth must help obstetrical team decide whether to performteam decide whether to perform

delayed cord clamping

Delayed Cord Clamping (DCC)P I f ?Preterm Infants?

Outcomes examined: mortality, severe IVH, any y, , yIVH, hemodynamic stability, hyperbilirubinemia, neurodevelopment

Sixteen articles included– RCTs 12 articles (691 cases)

Non RCTs 4 articles (811 cases)– Non-RCTs 4 articles (811 cases)– Excluded 230 articles

No difference in mortality or severe IVHNo difference in mortality or severe IVH No data for neurodevelopment DCC improved any IVH, hemodynamic stabilityp y , y y

Washington DC 2014Outcome: PVH/IVH (gr I-IV)

<RCT>

2015 Guidelines for Delayed Cord ClampingCord Clamping

D l d d l i i t d f 30 60 d Delayed cord clamping is suggested for 30-60 seconds for most preterm newborns showing some signs of vigor (some respiratory effort, some tone/movement)(some respiratory effort, some tone/movement)– Place skin to skin with mom or OB securely hold in a warm, dry

towel or blanketV t b b d i bl k t– Very preterm newborns may be wrapped in a warm blanket or polyethylene plastic

N d l if i f lif l l l i l i No delay if infant appears lifeless or placental circulation disrupted (abruption, cord avulsion, bleeding placenta previa bleeding vasa previa)previa, bleeding vasa previa)

Need good communication and teamwork with OBs

Please NotePlease Note….

Time of birth is still the time when the babyTime of birth is still the time when the baby emerges from the mother, not the time of cord clampingcord clamping.

At Delivery: Our baby is very limp and not breathingand not breathing

Delayed Cord Clamping not attempted due to the poor Delayed Cord Clamping not attempted due to the poor condition of the infant

Infant brought to the radiant warmer

2015 Neonatal Resuscitation Guidelines: Increased Focus onGuidelines: Increased Focus on

Maintaining Normal Temperature

Provision of Warmth Affects Ventilation!

Cold Stress is associated with Cold Stress is associated with– Increased Apnea

Decreased S rfactant F nction– Decreased Surfactant Function– Increased metabolic acidosis, which may lower

pH and thus may reduce pulmonary arterypH and thus may reduce pulmonary artery relaxation

– Increased mortality– Increased mortality

Why Prematures Are at Particular Ri k f H th iRisk for Hypothermia

Immature epidermal barrier- High evaporative heat lossg e apo at e eat oss

Limited subcutaneous fat Limited subcutaneous fat

Increased surface area/weight ratio

Ineffective non-shivering thermogenesis

ILCOR Systematic Reviews R di T S bili iRegarding Temperature Stabilization 36 observational studies demonstrate increased36 observational studies demonstrate increased

risk of mortality associated with hypothermia at admission

Hypothermic infants have increased morbidity– Hypoglycemia Respiratory Distress IVH Late onset– Hypoglycemia, Respiratory Distress, IVH, Late onset

sepsis

Temperature should be monitored and maintainedTemperature should be monitored and maintained between 36.5-37.5ºC after delivery

Admission Temperature of LBW Infants: P di t d A i t d M biditiPredictors and Associated Morbidities

15 NICHD Neonatal Network Centers15 NICHD Neonatal Network Centers Jan 2002-Dec 2003 401-1499g Admitted to NICU directly from delivery roomAdmitted to NICU directly from delivery room

No major congenital anomalies

Site of temperature measurement recorded (rectal, axillae, skin)( , , )

Laptook et al. Pediatrics 2007;119:e643-e649

Admission Temperatures

N=527747%!!47%!!

Admission Temp by for Infants ≤ 28 wks Gestational AgeGestational Age

Gestational Age ( k )

n Birth Weight Admission Temp (wks) (g) < 35 ºC < 36 ºC

28 643 1088 ± 201 10% 38%27 609 977 182 11% 42%27 609 977 ± 182 11% 42%26 539 840 ± 163 13% 44%25 468 751 ± 130 21% 57%25 468 751 ± 130 21% 57%24 397 655 ± 100 34% 64%

<24 187 598 ± 118 44% 72%<24 187 598 ± 118 44% 72%

For every 1°C decrease in admission temperature— Odds of late onset sepsis ↑ by 11% (OR 1.11; CI:1.02-1.20)

From Laptook et al. Pediatrics 2007;119:e643-e649 with permission from the AAP

Odds of late onset sepsis ↑ by 11% (OR 1.11; CI:1.02 1.20)— Odds of death ↑ by 28% (OR 1.28; CI: 1.16-1.41)

Polyethylene Occlusive WrappingImproves Admission Temperature for ELBW < 28 wks

2004-HELP (Heat Loss Prevention) trial ( )<28wks EGATotal N=55

ControlTemp (C)

N=27

WrapTemp (C)

N=28

Difference in Means (C)

N=27 N=28

Temperature 35.6± 1.3 36.5 ± 0.80.9

p = 0.002

Did not prevent all hypothermia No difference in mortality but not powered for this

or other morbidities

Adapted from Vohra et al. J Pediatr 2004;145:750-753.

or other morbidities Subsequent Systematic Reviews have consistent findings

Warming Mattress vs Plastic Wrap on Admission

Temperature for ≤ 28 wk InfantsTemperature for 28 wk Infants

Warming Plastic Wrap P valuegMattress

p

(n=17) (n=19)Admit Temp (°C)*

36.5 ± 0.7 36.1 ± 0.7 0.04

Hypothermic 41% 68% 0.10(<36.5°C)

N diff i biditi b t i ifi tl d d f thi

Simon et al. J Perinatol 2010

No differences in morbidities but significantly underpowered for this

The Addition of a Warming Mattress to Plastic Wrap on

ELBW Admission TemperatureELBW Admission Temperature

Traditional Plastic Wrap Plastic Wrap +TraditionalCare

Plastic Wrap Plastic Wrap + Warming Mattress

(n=230) (n=48) (n=97)Admit Temp (°C) 35.8 (35.0, 36.2) 36.0 (35.4, 36.6) 36.9 (36.4, 37.7)Hypothermic 192 (84%) 33 (69%) 25 (26%)Hypothermic(<36.5°C)

192 (84%) 33 (69%) 25 (26%)

Hyperthermic(>37 5°C)

1 (0.4%) 2 (4.2%) 27 (27.8%)(>37.5 C)

Singh et al. J Perinatol 2009

Plastic Caps and Admission Temperature

Pastic Cap Plastic Wrap Control(dried)

(n=32) (n=32) (n=32)Admit Temp (°C)* 36.1 ± 0.8 35.8 ± 0.9 35.3 ± 0.8Hypothermic 43% 62% 92%Hypothermic(<36.4°C)*

43% 62% 92%

Intubation in DR 43% 53% 53%Major Brain Injury 9% 6% 5%Mortality 9% 6% 6%

Trevisanuto et al. J Pediatr 2010.

*p<0.01

Increased Ambient Temperature in DR Improves Infant TemperaturesImproves Infant Temperatures

Will Likely Need Combination of Strategies to Provide Warmth

For all newborns– Environmental Temperature at least 23-25°C (77°F)

Strategies to Provide Warmth

Environmental Temperature at least 23 25 C (77 F)– Warm Blankets for Drying– Hats

For newborns requiring resuscitation– Radiant Warmer

Monitor temperature in the delivery room and adjust as needed– Radiant Warmer

– Warm, humidified gases

F P i

and adjust as neededAvoid hyperthermia

For Preemies– Polyethylene Occlusive wrapping

– Heated (NaAcetate) Mattresses

2015: Monitor for Maintenance of Normal Temperature in the DRNormal Temperature in the DR

Monitor baby temperature– Rectal

– Axillary temperaturey p

– Utilize Servo Control on the Radiant Warmeron the Radiant Warmer

We Don’t Skimp on the Initial Steps!!

Provide warmth: Warm room, Radiant Warmer, Th l M tt Pl ti P h H tThermal Mattress, Plastic Poncho, Hat

Position in the open airway position, suction since the baby is not clearing her own airway, stimulate t e baby s ot c ea g e o a ay, st u ate

2015 Neonatal R it ti G id liResuscitation Guidelines

If baby is breathingand maintains heartrate…..

Role of CPAP in the Delivery Room

If heart rate and respiratory effort are adequate but there is increased work of breathing or athere is increased work of breathing or a perception of cyanosis then CPAP can be considered

CPAP may help establish functional residual capacityp y—CPAP can be delivered with a flow-inflating bag or a T-

piece resuscitator, but NOT a self-inflating bag (unless PEEP valve used)PEEP valve used).

CPAP vs Intubation for Preterm N b i h D li RNewborns in the Delivery Room

3 RCT ( 2358) 3 RCTs (n=2358) Potential benefit for reducing death or BPD (RR,

0.91; 95% CI, 0.83–1.00) No advantage for death alone, BPD alone, air leak,

severe IVH, NEC, ROP Tx Recommendation: For spontaneously breathing

preterm infants with respiratory distress requiring respiratory support in the delivery room, we suggest i iti l f CPAP th th i t b ti d PPVinitial use of CPAP rather than intubation and PPV

CPAP Started, Pulse Ox Placed on Right HandRight Hand

Respiratory Effort and Heart Rate?

HR=40HR=40Apneic

2015 Neonatal R it ti G id liResuscitation Guidelines

What Oxygen Concentration Should We Start PPV with for ELGAN Infant?Start PPV with for ELGAN Infant?

P: Among preterm newborns (< 37 wk GA) who receive PPV P: Among preterm newborns (< 37 wk GA) who receive PPVin the delivery room, does

I: low initial oxygen (21-30%) C: high initial high oxygen (50-100%) O: decrease mortality, BPD, ROP, intraventricular

h h l i d fi it ti t HR 100 bhemorrhage, neurologic deficit, time to HR > 100 bpm

Final AHA search strategy 1752 citations 46 potentially Final AHA search strategy 1752 citations, 46 potentially relevant studies 9 Studies included 8 RCTs, 1 Cohort

Washington DC 2014

Design/n GA (wk)

FiO2 %Low/Hi

Sat Targeting?

FiO2 masked?

/ /Dawson ’09 Cohort/125 <30 21 / 100 Y N

Rook ’14 RCT/123 <32 30 / 65 Y Y

Kapadia ’13 RCT/88 24 ‐ 34 21 / 100 Y N

Armanian ’12 RCT/32 29 ‐ 34 21 / 100 Y N

Rabi ’11 RCT/106 ≤ 32 21 / 100 Y* Y

Vento ’09 RCT/78 24 ‐ 28 30 / 90 Y NVento  09 RCT/78 24  28 30 / 90 Y N

Wang ’08 RCT/41 < 32 21 / 100 Y N

Saugstad ’98 RCT/138* < 37 21 / 100 N NSaugstad ’98 RCT/138* < 37 21 / 100 N N

Lundstrom ’95 RCT/69 < 33 21 / 100 N* N

Washington DC 2014Mortality before discharge: All RCT and quasi RCTRCT and quasi‐RCT

2015 Treatment Recommendation Among preterm2015 Treatment Recommendation: Among preterm newborns, we recommend that resuscitation be initiated with low oxygen (21-30%) and titrated to reach the saturation target.

Which Positive Pressure Ventilation Device to UseVentilation Device to Use

Self-inflating bag with Flow-inflating Bagpressure monometer

Flow inflating Bag

T-piece Resuscitator

Is One PPV Device Superior?

T-piece Resuscitators have replaced self-inflating bags and anesthesia bags in many hospitals due to difficulties in reliably maintaining PEEP with those other devicesother devices

2 RCTs available (n=533) Outcomes: mortality, air leak, BPD

Treatment Recommendation– There is insufficient evidence, so the

recommendation of one device over another would be purely speculative

Does Use of PEEP During DR V il i M f P ?DR Ventilation Matter for Preterms?

2 randomized trials of 596 preterm newborns2 randomized trials of 596 preterm newborns

No advantage for Mortality, CLD, time to Heart Rate > 100 bpm need for CPR O saturations airRate > 100 bpm, need for CPR, O2 saturations, air leak

Use of PEEP reduced the maximum O Use of PEEP reduced the maximum O2concentration needed during resuscitation

T t t R d ti Treatment Recommendation– We suggest using PEEP of 5 cm H2O during

d li it ti f t i f tdelivery room resuscitation for preterm infants

Which Positive Pressure Ventilation Device to UseVentilation Device to Use

Self-inflating bag with Flow-inflating Bagpressure monometer

Flow inflating Bag

T-piece Resuscitator

2015 Neonatal R it ti G id liResuscitation Guidelines

PPV started with T-pieceset at 25/5 cm H2O

FiO2 21 3 FiO2 .21-.3 Heart rate still 40 bpm Could place ECG leads

Stay Focused on Achieving Effective PPVEffective PPV

25/5 cm H2O noted on T-piece resuscitator (therefore no mask leak)

Sniffing position Mouth is open PIP increased to 30 Slight chest rise is noted Equal breath sounds Heart rate remains 40 No CO2 detection during

mask ventilation

Advanced AirwayAdvanced Airway No LMA for thisNo LMA for this

small of an infant

I f t i i t b t d Infant is intubated

New table for e tab e odepth of insertion for ELBW infants o a sbased on gestational age g g

Initial Depth of Insertion for E d h l T b f ELBW I fEndotracheal Tube for ELBW Infants

Increasing evidence that 6 + weight in kgIncreasing evidence that 6 + weight in kg at the lip results in frequent malposition of the tube for infants <28 weeks EGAthe tube for infants <28 weeks EGA

Nasal-Tragus Length

Estimate tip-to-lip distance with nasal-tragus length (NTL) + 1 cm

Confirm Advanced Airway Placement

RT puts the colorimetric ETCO2detector on and reports…

Slight Color change!

Nurse reports heartNurse reports heart rate is steadily rising to above 100 bpm

CPR was avoided by focusing on effective ventilation

Get to the NICUNICU

Debrief as soon as possible

What if…despite PPV via the ETT the heart rate remained low andthe heart rate remained low and

you had to start CPR??

Is CPR used for ELBW infants?ELBW infants?

Is CPR effective for Is CPR effective for ELBW infant?

DR-CPR for ELBW Infants

It is not uncommon for ELBW infants to receiveIt is not uncommon for ELBW infants to receive delivery room CPR (DR-CPR) defined as compressions ± medications– Significant variation from center to center (6-28%)– Little detail regarding the quality of the resuscitation

ff tefforts

Most reports are case series or case/control l d i l d i f t t 1500 (VLBW)analyses and include infants up to 1500g (VLBW).

Very limited data on long-term outcome of ELBW i f t h d DR CPR ( f ll tinfants who undergo DR-CPR (poor follow-up rates introduce significant bias).

2010

Methods Study design: cohort analysis for the period of

January 1996 to December 2002 (19 centersJanuary 1996 to December 2002 (19 centers included)

St d l ti Study population: – Inclusion criteria: inborn, birth weight 401-1000 g and

EGA 23-30 weeks

– Exclusion criteria: Syndromes or major malformations and infants in extremis who were not offered resuscitation or intensive care

Predictor variable: DR-CPR defined as cardiac compressions with or without drugs in the delivery room

Flow Diagram of Patient Selection

BW 401-1000g and 23 wks EGAborn Jan 1, 1996 and Dec 31,2002:

N=10476Outborn infants: N=1209

Infants Inborn: N=9267 Major Anomalies: N=242

Non viable infants: N=331Major Anomalies absent: N=9025

Non-viable infants: N=331

CPR data points missing: N = 9Study Cohort: N = 8685

DR CPR h tN DR CPR h t DR-CPR cohort:N=1333 (15%)

No DR-CPR cohort: N=7352 (85%)

Proportion of DR-CPR in ELBW Infants by CenterInfants by Center

0 0001p=0.0001

3 4 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Neonatal Research Network Centers

Proportion of ELBW Infants Receiving DR CPR by Gestational AgeDR-CPR by Gestational Age

om C

PR

30

eliv

ery

Ro

20

25211/873

314/1567

290/1791

ceiv

ing

De

10

15238/1716

151/124184/793

fant

s R

ec

5

10 29/447 16/257

Obstetrical Gestational Age (wks)% o

f In

023 24 25 26 27 28 29 30

Prognostic Implications of DR-CPR on Long Term Neurodevelopmental Outcomes usingTerm Neurodevelopmental Outcomes using

Logistic Modeling

Odds Ratio 95% CIOdds Ratio 95% CIDeath by follow-up 2.06 1.79 – 2.37NDI 1.23 1.02 - 1.49NDI 1.23 1.02 1.49NDI or Death 1.70 1.46– 1.99MDI < 70 1.19 0.98 - 1.45PDI < 70 1.59 1.29 – 1.96Moderate or severe CP 1.64 1.22 – 2.20Hearing aid in both ears 1.92 1.12 – 3.27

Conclusions DR-CPR is a prognostic marker for adverse

neurodevelopmental outcomes in ELBW infants.neurodevelopmental outcomes in ELBW infants.

ELBW infants who undergo delivery room CPR and have a 5 min Apgar score < 2 have only a 14%have a 5 min Apgar score < 2 have only a 14% chance of disability free survival.

Prolonged CPR in such infants should be viewed with caution.

The occurrence of DR-CPR should prompt appropriate parental counseling and neurodevelopmental follow-up.

Conclusions The significant mortality and morbidity rates

in ELBW DR CPR recipients suggest that wein ELBW DR-CPR recipients suggest that we need improved DR-CPR techniques tailored for this vulnerable populationfor this vulnerable population.

– Enhanced resuscitation education

– High-fidelity ELBW simulators

I d i i– Improved post-resuscitation care Cardiovascular support strategies

Neuro-protective strategies

But Most ImportantlyBut Most Importantly….

We need to maintain intense initial focusWe need to maintain intense initial focus on Effective PPV so that CPR can be avoided in the ELBW infantavoided in the ELBW infant