Novel Insights from Clinical Practice Neonatology 2014;105:200–204 DOI: 10.1159/000357609
Received: September 19, 2013 Accepted after revision: November 28, 2013 Published online: January 24, 2014
Respiratory Function and Near Infrared Spectroscopy Recording during Cardiopulmonary Resuscitation in an Extremely Preterm Newborn Elliott S. Li a–c Po-Yin Cheung b, c Gerhard Pichler b–d Khalid Aziz b, c Georg M. Schmölzer b–d a
Faculty of Science, McGill University, Quebec, Que., b Neonatal Research Unit, Royal Alexandra Hospital, and Department of Pediatrics, University of Alberta, Edmonton, Alta., Canada; d Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
c
Established Facts • Current neonatal resuscitation guidelines recommend a coordinated 3:1 compression:ventilation ratio to deliver chest compressions to avoid interference of chest compressions and tidal volume delivery; however, the most effective ratio of delivering chest compressions remains controversial. • Mask ventilation studies in the delivery room have reported variable mask leak during positive pressure ventilation. • Current neonatal resuscitation guidelines recommend exhaled CO2 as a method to confirm endotracheal tube placement; however, poor or absent pulmonary blood flow may give false-negative results. • Exhaled CO2 values >14 mm Hg may correlate with return of spontaneous circulation.
Novel Insights • • • •
Continuous chest compressions with asynchronous ventilations may be effective in neonates. Chest compressions drastically increased mask leak. During bradycardia (heart rate ∼50/min) exhaled CO2 indicated correct tube placement. An increase in exhaled CO2 may precede and serve as a predictor for return of spontaneous circulation.
Key Words Infants · Newborn · Delivery room · Neonatal resuscitation · Chest compression
Abstract We describe a case highlighting several controversial and important topics regarding neonatal cardiopulmonary resuscitation (CPR). Current neonatal guidelines recommend a 3:1
© 2014 S. Karger AG, Basel 1661–7800/14/1053–0200$39.50/0 E-Mail [email protected] www.karger.com/neo
compression:ventilation ratio; however, the most effective ratio of delivering chest compressions (CC) remains controversial. We report a case of a male infant at 24 weeks’ postmenstrual age weighing 650 g on a background of preterm labor. At initial assessment the infant appeared floppy and apneic with a heart rate (HR) of 50–60 beats/min. Mask ventilation was ineffective, thus continuous CC (90/min) with asynchronous ventilations (60/min) was started. HR, blood pressure, oxygen saturation, cerebral oxygenation, respira-
Georg M. Schmölzer, MD, PhD Neonatal Research Unit, Royal Alexandra Hospital 10240 Kingsway Avenue NW Edmonton, AB T5H 3V9 (Canada) E-Mail georg.schmoelzer @ me.com
tory function, and exhaled carbon dioxide (ECO2) were continuously measured during CPR. Return of spontaneous circulation defined as HR >60/min was achieved after 90 s of CPR. Mask leak significantly increased during CC. During bradycardia (HR ∼50/min), ECO2 indicated correct tube placement and an increase of ECO2 >12 mm Hg was associated with rapid increase in HR >60/min. © 2014 S. Karger AG, Basel
Introduction
We report a case highlighting several controversial, yet important, topics relating to neonatal cardiopulmonary resuscitation (CPR) of newborn infants: (i) the effect of coordination of ventilation and chest compression (CC) versus continuous CC with asynchronous ventilation (CCaV); (ii) the impact of CC on mask leak; (iii) the effect of low cardiac output states on exhaled carbon dioxide (ECO2), and (iv) the estimation of return of spontaneous circulation (ROSC) defined as an heart rate (HR) >60 beats/min (bpm) using ECO2 [1]. This is the first case report where CCaV was delivered to an extremely preterm infant and physiological changes of HR, oxygen saturation, blood pressure, cerebral oxygenation, respiratory function, and ECO2 were continuously measured during CCaV (table 1; fig. 1).
Case Report At the Royal Alexandra Hospital site, a tertiary perinatal center, a dedicated resuscitation-stabilization-triage team (consisting of at least three members with registered nurse, respiratory therapist, and either neonatal nurse practitioner, neonatal fellow or neonatologist) attends deliveries of very preterm infants. During the resuscitation
and stabilization of high-risk newborns, HR by auscultation and using three chest electrodes, blood pressure by an appropriately sized cuff on the left arm, and oxygen saturation oximetry on the right wrist are routinely monitored (IntelliVue MP50 monitors; Philips Healthcare, Philips Electronics Ltd, Markham, Ont., Canada). This is augmented with gas flow and ECO2 monitoring (NM3; Philips Healthcare, Electronics Ltd), and cerebral near infrared spectrometry (Invos 5100; Somanetics Corp., Troy, Mich., USA). The University of Alberta Health Research Ethics Board approved these additional, non-invasive observations. Parental consent was obtained after the fact to utilize the data for research purposes. Maternal History and Delivery. A teenage primigravida delivered a male infant at 24 weeks’ postmenstrual age with a birth weight of 650 g on the background of preterm labor. Pregnancy was complicated by recreational drug use. Labor started 6 h prior to vaginal delivery with rupture of membranes for 20 min. Opiates were given for pain relief. The Apgar scores were 3, 2 and 7 at 1, 5, and 10 min, respectively. Resuscitation. Delayed cord clamping (DCC) was performed for 55 s and discontinued due to bradycardia. The infant was placed under a radiant heater and covered with a plastic wrap and appeared floppy, cyanotic, and apneic with a HR of 50–60 bpm. After the initial assessment, positive pressure ventilation (PPV) was started at ∼90 s after birth with a round silicone 28-mm facemask (Fisher & Paykel Healthcare, Auckland, New Zealand). The default settings are 30% oxygen in preterm infants 20 mm Hg after the second intubation, which was associated with HR increase to 145 bpm 45 s afterwards (fig. 1). The correct tube
References
Continuous Chest Compression in an Extremely Preterm Newborn
placement with the second intubation achieved HR and ECO2 improvement. An increase in cerebral oxygenation from 19 to 68% was observed approximately 120 s after a rapid increase in HR, despite normal oxygen saturation (fig. 1). Fuchs et al. [11] observed an increase in HR followed by an increase in cerebral tissue oxygen in very low birth weight infants receiving effective sustained inflation at birth. In addition, preterm infants requiring respiratory support in the delivery room have lower cerebral tissue oxygen values compared to normal transition [12]. This observation highlights that cerebral oxygenation depends on several factors including arterial oxygen saturation and cardiac output.
Conclusions
The presented case highlights several controversial topics during neonatal CPR: (i) CCaV may be effective in a newborn infant; (ii) mask leak may be large during CC, impeding ventilation; (iii) in a presumed very low cardiac output state ECO2 can be detected, and (iv) an increase in ECO2 may precede ROSC. Acknowledgement E.S.L. is supported in part by the Northern Alberta Clinical Trials and Research Centre, Faculty of Medicine and Dentistry, University of Alberta, and Neonatal Research Fund, Northern Alberta Neonatal Program, Alberta Health Services. G.M.S. is a recipient of a Banting Postdoctoral Fellowship, Canadian Institutes of Health Research and an Alberta Innovates – Health Solutions Clinical Fellowship.
Disclosure Statement The authors have no conflicts of interest to disclose.
1 Kattwinkel J, Perlman J, Aziz K, Colby C, Fairchild K, Gallagher J, Hazinski M, Halamek L, Kumar P, Little G, McGowan J, Nightengale B, Ramirez M, Ringer S, Simon W, Weiner G, Wyckoff M, Zaichkin J: Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S909–S919.
2 Berg RA, Hilwig RW, Kern KB, Ewy GA: ‘Bystander’ chest compressions and assisted ventilation independently improve outcome from piglet asphyxial pulseless ‘cardiac arrest’. Circulation 2000;101:1743–1748. 3 Schmölzer GM, O’Reilly M, LaBossiere J, Lee TF, Cowan S, Nicoll J, Bigam DL, Cheung PY: 3: 1 compression to ventilation ratio versus continuous chest compression with asynchronous ventilation in a porcine model of neonatal resuscitation. Resuscitation, Epub ahead of print.
Neonatology 2014;105:200–204 DOI: 10.1159/000357609
203
4 Schmölzer GM, Kamlin OC, O’Donnell CP, Dawson JA, Morley CJ, Davis PG: Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 2010; 95:F393–F397. 5 Schmölzer GM, Morley CJ, Wong C, Dawson JA, Kamlin COF, Donath SM, Hooper S, Davis PG: Respiratory function monitor guidance of mask ventilation in the delivery room: a feasibility study. J Pediatr 2012;160:377–381.e2. 6 Solevåg AL, Madland JM, Gjærum E, Nakstad B: Minute ventilation at different compression to ventilation ratios, different ventilation rates; and continuous chest compressions with asynchronous ventilation in a newborn manikin. Scand J Trauma Resusc Emerg Med 2012;20:73.
204
7 Nicoll J, O’Reilly M, LaBossiere J, Lee TF, Cowan S, Bigam DL, Cheung PY, Schmölzer GM: Effect of cardiac output changes on exhaled carbon dioxide in newborn piglets. Resuscitation, Epub ahead of print. 8 Chalak LF, Barber CA, Hynan L, Garcia D, Christie L, Wyckoff MH: End-tidal CO2 detection of an audible heart rate during neonatal cardiopulmonary resuscitation after asystole in asphyxiated piglets. Pediatr Res 2011; 69:401–405.
Neonatology 2014;105:200–204 DOI: 10.1159/000357609
9 Kamlin C, O’Donnell CPF, Everest NJ, Davis PG, Morley CJ: Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation 2006;71:319–321. 10 Hooper SB, Fouras A, Siew ML, Wallace MJ, Kitchen MJ, Pas AB, Klingenberg C, Lewis RA, Davis PG, Morley CJ, Schmölzer GM: Expired CO2 levels indicate degree of lung aeration at birth. PLoS One 2013;8:e70895. 11 Fuchs H, Lindner W, Uschko A, Trischberger T, Schmid M, Hummler HD: Cerebral oxygenation in very low birth weight infants supported with sustained lung inflations after birth. Pediatr Res 2011;70:176–180. 12 Binder C, Urlesberger B, Avian A, Pocivalnik M, Müller W, Pichler G: Cerebral and peripheral regional oxygen saturation during postnatal transition in preterm neonates. J Pediatr 2013;63:394–399.
Li /Cheung /Pichler /Aziz /Schmölzer
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Received: September 19, 2013 Accepted after revision: November 28, 2013 Published online: January 24, 2014
Respiratory Function and Near Infrared Spectroscopy Recording during Cardiopulmonary Resuscitation in an Extremely Preterm Newborn Elliott S. Li a–c Po-Yin Cheung b, c Gerhard Pichler b–d Khalid Aziz b, c Georg M. Schmölzer b–d a
Faculty of Science, McGill University, Quebec, Que., b Neonatal Research Unit, Royal Alexandra Hospital, and Department of Pediatrics, University of Alberta, Edmonton, Alta., Canada; d Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
c
Established Facts • Current neonatal resuscitation guidelines recommend a coordinated 3:1 compression:ventilation ratio to deliver chest compressions to avoid interference of chest compressions and tidal volume delivery; however, the most effective ratio of delivering chest compressions remains controversial. • Mask ventilation studies in the delivery room have reported variable mask leak during positive pressure ventilation. • Current neonatal resuscitation guidelines recommend exhaled CO2 as a method to confirm endotracheal tube placement; however, poor or absent pulmonary blood flow may give false-negative results. • Exhaled CO2 values >14 mm Hg may correlate with return of spontaneous circulation.
Novel Insights • • • •
Continuous chest compressions with asynchronous ventilations may be effective in neonates. Chest compressions drastically increased mask leak. During bradycardia (heart rate ∼50/min) exhaled CO2 indicated correct tube placement. An increase in exhaled CO2 may precede and serve as a predictor for return of spontaneous circulation.
Key Words Infants · Newborn · Delivery room · Neonatal resuscitation · Chest compression
Abstract We describe a case highlighting several controversial and important topics regarding neonatal cardiopulmonary resuscitation (CPR). Current neonatal guidelines recommend a 3:1
© 2014 S. Karger AG, Basel 1661–7800/14/1053–0200$39.50/0 E-Mail [email protected] www.karger.com/neo
compression:ventilation ratio; however, the most effective ratio of delivering chest compressions (CC) remains controversial. We report a case of a male infant at 24 weeks’ postmenstrual age weighing 650 g on a background of preterm labor. At initial assessment the infant appeared floppy and apneic with a heart rate (HR) of 50–60 beats/min. Mask ventilation was ineffective, thus continuous CC (90/min) with asynchronous ventilations (60/min) was started. HR, blood pressure, oxygen saturation, cerebral oxygenation, respira-
Georg M. Schmölzer, MD, PhD Neonatal Research Unit, Royal Alexandra Hospital 10240 Kingsway Avenue NW Edmonton, AB T5H 3V9 (Canada) E-Mail georg.schmoelzer @ me.com
tory function, and exhaled carbon dioxide (ECO2) were continuously measured during CPR. Return of spontaneous circulation defined as HR >60/min was achieved after 90 s of CPR. Mask leak significantly increased during CC. During bradycardia (HR ∼50/min), ECO2 indicated correct tube placement and an increase of ECO2 >12 mm Hg was associated with rapid increase in HR >60/min. © 2014 S. Karger AG, Basel
Introduction
We report a case highlighting several controversial, yet important, topics relating to neonatal cardiopulmonary resuscitation (CPR) of newborn infants: (i) the effect of coordination of ventilation and chest compression (CC) versus continuous CC with asynchronous ventilation (CCaV); (ii) the impact of CC on mask leak; (iii) the effect of low cardiac output states on exhaled carbon dioxide (ECO2), and (iv) the estimation of return of spontaneous circulation (ROSC) defined as an heart rate (HR) >60 beats/min (bpm) using ECO2 [1]. This is the first case report where CCaV was delivered to an extremely preterm infant and physiological changes of HR, oxygen saturation, blood pressure, cerebral oxygenation, respiratory function, and ECO2 were continuously measured during CCaV (table 1; fig. 1).
Case Report At the Royal Alexandra Hospital site, a tertiary perinatal center, a dedicated resuscitation-stabilization-triage team (consisting of at least three members with registered nurse, respiratory therapist, and either neonatal nurse practitioner, neonatal fellow or neonatologist) attends deliveries of very preterm infants. During the resuscitation
and stabilization of high-risk newborns, HR by auscultation and using three chest electrodes, blood pressure by an appropriately sized cuff on the left arm, and oxygen saturation oximetry on the right wrist are routinely monitored (IntelliVue MP50 monitors; Philips Healthcare, Philips Electronics Ltd, Markham, Ont., Canada). This is augmented with gas flow and ECO2 monitoring (NM3; Philips Healthcare, Electronics Ltd), and cerebral near infrared spectrometry (Invos 5100; Somanetics Corp., Troy, Mich., USA). The University of Alberta Health Research Ethics Board approved these additional, non-invasive observations. Parental consent was obtained after the fact to utilize the data for research purposes. Maternal History and Delivery. A teenage primigravida delivered a male infant at 24 weeks’ postmenstrual age with a birth weight of 650 g on the background of preterm labor. Pregnancy was complicated by recreational drug use. Labor started 6 h prior to vaginal delivery with rupture of membranes for 20 min. Opiates were given for pain relief. The Apgar scores were 3, 2 and 7 at 1, 5, and 10 min, respectively. Resuscitation. Delayed cord clamping (DCC) was performed for 55 s and discontinued due to bradycardia. The infant was placed under a radiant heater and covered with a plastic wrap and appeared floppy, cyanotic, and apneic with a HR of 50–60 bpm. After the initial assessment, positive pressure ventilation (PPV) was started at ∼90 s after birth with a round silicone 28-mm facemask (Fisher & Paykel Healthcare, Auckland, New Zealand). The default settings are 30% oxygen in preterm infants 20 mm Hg after the second intubation, which was associated with HR increase to 145 bpm 45 s afterwards (fig. 1). The correct tube
References
Continuous Chest Compression in an Extremely Preterm Newborn
placement with the second intubation achieved HR and ECO2 improvement. An increase in cerebral oxygenation from 19 to 68% was observed approximately 120 s after a rapid increase in HR, despite normal oxygen saturation (fig. 1). Fuchs et al. [11] observed an increase in HR followed by an increase in cerebral tissue oxygen in very low birth weight infants receiving effective sustained inflation at birth. In addition, preterm infants requiring respiratory support in the delivery room have lower cerebral tissue oxygen values compared to normal transition [12]. This observation highlights that cerebral oxygenation depends on several factors including arterial oxygen saturation and cardiac output.
Conclusions
The presented case highlights several controversial topics during neonatal CPR: (i) CCaV may be effective in a newborn infant; (ii) mask leak may be large during CC, impeding ventilation; (iii) in a presumed very low cardiac output state ECO2 can be detected, and (iv) an increase in ECO2 may precede ROSC. Acknowledgement E.S.L. is supported in part by the Northern Alberta Clinical Trials and Research Centre, Faculty of Medicine and Dentistry, University of Alberta, and Neonatal Research Fund, Northern Alberta Neonatal Program, Alberta Health Services. G.M.S. is a recipient of a Banting Postdoctoral Fellowship, Canadian Institutes of Health Research and an Alberta Innovates – Health Solutions Clinical Fellowship.
Disclosure Statement The authors have no conflicts of interest to disclose.
1 Kattwinkel J, Perlman J, Aziz K, Colby C, Fairchild K, Gallagher J, Hazinski M, Halamek L, Kumar P, Little G, McGowan J, Nightengale B, Ramirez M, Ringer S, Simon W, Weiner G, Wyckoff M, Zaichkin J: Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S909–S919.
2 Berg RA, Hilwig RW, Kern KB, Ewy GA: ‘Bystander’ chest compressions and assisted ventilation independently improve outcome from piglet asphyxial pulseless ‘cardiac arrest’. Circulation 2000;101:1743–1748. 3 Schmölzer GM, O’Reilly M, LaBossiere J, Lee TF, Cowan S, Nicoll J, Bigam DL, Cheung PY: 3: 1 compression to ventilation ratio versus continuous chest compression with asynchronous ventilation in a porcine model of neonatal resuscitation. Resuscitation, Epub ahead of print.
Neonatology 2014;105:200–204 DOI: 10.1159/000357609
203
4 Schmölzer GM, Kamlin OC, O’Donnell CP, Dawson JA, Morley CJ, Davis PG: Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 2010; 95:F393–F397. 5 Schmölzer GM, Morley CJ, Wong C, Dawson JA, Kamlin COF, Donath SM, Hooper S, Davis PG: Respiratory function monitor guidance of mask ventilation in the delivery room: a feasibility study. J Pediatr 2012;160:377–381.e2. 6 Solevåg AL, Madland JM, Gjærum E, Nakstad B: Minute ventilation at different compression to ventilation ratios, different ventilation rates; and continuous chest compressions with asynchronous ventilation in a newborn manikin. Scand J Trauma Resusc Emerg Med 2012;20:73.
204
7 Nicoll J, O’Reilly M, LaBossiere J, Lee TF, Cowan S, Bigam DL, Cheung PY, Schmölzer GM: Effect of cardiac output changes on exhaled carbon dioxide in newborn piglets. Resuscitation, Epub ahead of print. 8 Chalak LF, Barber CA, Hynan L, Garcia D, Christie L, Wyckoff MH: End-tidal CO2 detection of an audible heart rate during neonatal cardiopulmonary resuscitation after asystole in asphyxiated piglets. Pediatr Res 2011; 69:401–405.
Neonatology 2014;105:200–204 DOI: 10.1159/000357609
9 Kamlin C, O’Donnell CPF, Everest NJ, Davis PG, Morley CJ: Accuracy of clinical assessment of infant heart rate in the delivery room. Resuscitation 2006;71:319–321. 10 Hooper SB, Fouras A, Siew ML, Wallace MJ, Kitchen MJ, Pas AB, Klingenberg C, Lewis RA, Davis PG, Morley CJ, Schmölzer GM: Expired CO2 levels indicate degree of lung aeration at birth. PLoS One 2013;8:e70895. 11 Fuchs H, Lindner W, Uschko A, Trischberger T, Schmid M, Hummler HD: Cerebral oxygenation in very low birth weight infants supported with sustained lung inflations after birth. Pediatr Res 2011;70:176–180. 12 Binder C, Urlesberger B, Avian A, Pocivalnik M, Müller W, Pichler G: Cerebral and peripheral regional oxygen saturation during postnatal transition in preterm neonates. J Pediatr 2013;63:394–399.
Li /Cheung /Pichler /Aziz /Schmölzer
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
