Neonatal Life Support VIII
Octubre - 2020
VIII.- POSTRESUSCITATION CARE
1.-
Rewarming of Hypothermic Newborns (NLS 858: EvUp)
The most recent review of this topic was published in the 2015 CoSTR for
NLS.1,9,10 In 2020, the NLS Task Force undertook an EvUp to determine if
any additional
evidence was published after 2015 that would necessitate consideration
of a new SysRev. An EvUp (see Supplement Appendix C-10) identified 133
studies; of these, 2 were considered eligible for inclusion. Although
the EvUp identified no new prospective trials of rates of rewarming, the
2 new retrospective studies124,125 increased the number of infants in
observational trials nearly 4-fold to 379 infants. Both studies found
that the rate of rewarming (after adjustment for confounders) was
not associated with the critical outcomes identified in each study.
However, 1 study125 suggested that rapid rewarming reduces the risk for
respiratory distress syndrome.
The NLS Task Force agreed that a SysRev that includes the new studies
analyzed by using GRADE criteria will likely allow the development of a
weak recommendation in relation to the rate of rewarming of hypothermic
infants, as opposed to the “no recommendation” that was made in 2015. As
a result, the task force will consider prioritization of a SysRev in the
near future. Until the completion of a new SysRev, the 2015
recommendation remains in effect.1,9,10
Population, Intervention, Comparator, Outcome, Study Design, and Time Frame
Population: Newborn infants who are hypothermic (less than 36.0°C) on admission
Intervention: Rapid rewarming
Comparator: Slow rewarming
Outcome21:
Survival (to hospital discharge or as defined by authors) (critical)
Convulsions/seizures (critical)
Hemorrhage/pulmonary hemorrhage (critical)
Need for respiratory support (important)
Hypoglycemia (important)
Episodes of apnea (important)
Treatment Recommendation
This treatment recommendation (below) is unchanged from 2015.1,9,10
The confidence in effect estimates is so low that a recommendation for
either rapid rewarming (0.5°C/h or greater) or slow rewarming (0.5°C/h
or less) of unintentionally hypothermic newborn infants (temperature
less than 36°C) at hospital admission would be speculative.
2.- Induced Hypothermia in Settings With Limited Resources (NLS 734: EvUp)
This topic was most recently
reviewed in 2015.1,9,10 In 2020, the NLS Task Force undertook an EvUp to
identify any studies published after 2015.
Population, Intervention, Comparator, Outcome, Study Design, and Time Frame
Population: Newborn infants with HIE managed in limited-resource settings
Intervention: Therapeutic hypothermia delivered by passive hypothermia and/or ice packs
Comparator: Standard care
Outcome21 :
Survival (critical)
Neurodevelopmental impairment (any) (important)
The EvUp (see Supplement Appendix C-11) identified 142 studies; 13 of these were thought worthy of inclusion. 126–138 The NLS Task Force agreed that these 13 studies did not identify sufficient new evidence to consider a new SysRev and, even if added to previous studies, would not likely add to the level of certainty of the evidence summarized in 2015.1,9,10 It is becoming increasingly difficult (as a result of clinician and parent preferences) to perform large, multicenter randomized trials with a “no-therapeutic hypothermia” control group. However, a protocol was published for 1 such study in hospitals in India, Bangladesh, or Sri Lanka; a multicenter RCT of therapeutic hypothermia using a servo-controlled cooling device compared with standard care without therapeutic hypothermia has a planned enrollment of 418 infants.139 When completed, such a study (NCT02387385) could provide valuable additional information.
Accumulation of data from such a study or from a group of smaller studies might warrant an updated SysRev. Future studies of this subject should ideally try to examine the contributions of population characteristics, cooling method, and availability of concomitant intensive care to outcomes. Interestingly, a survey of hospitals in California identified a range of practices and opinions about the additional services (specialized nurses, video electroencephalogram monitoring, pediatric neurology and neuroradiology services, developmental follow-up services, etc) that should be required of centers providing neonatal therapeutic hypothermia.140 In addition to wide variation in opinions about necessary resources such as electroencephalogram monitoring, only 92% of centers reported using an evidence-based protocol, and there was a lack of universal agreement that therapeutic hypothermia centers should treat a minimum volume of patients annually. Considering this variation across high-resource locations, it is not surprising that there is lack of certainty supporting recommendations for when and how to provide therapeutic hypothermia for low- and middle-income countries.
Treatment Recommendation
This recommendation (below) is unchanged from 2015.1,9,10
We suggest that newborn infants at term or near-term with evolving
moderate-to-severe hypoxic-ischemic encephalopathy in low-income
countries and/or other settings with limited resources may be treated
with therapeutic hypothermia (weak recommendation, low-quality evidence).
Cooling should only be considered, initiated, and conducted under
clearly defined protocols with treatment in neonatal care facilities
with the capabilities for multidisciplinary care and availability of
adequate resources to offer intravenous therapy, respiratory support,
pulse oximetry, antibiotics, anticonvulsants, and pathology testing.
Treatment should be consistent with the protocols used in the randomized
clinical trials in developed countries, ie, cooling to commence within 6
hours, strict temperature control at 33° to 34°C for 72 hours and
rewarming over at least 4 hours.
3.- Postresuscitation Glucose Management (NLS 607: EvUp)
The most recent review of this topic was published in the 2010 CoSTR.12–14
In 2020, the NLS Task Force undertook an EvUp to determine if any
additional studies
were published after 2015 that would necessitate an update to the prior
SysRev. The EvUp (see Supplement Appendix C-12) identified 648 studies;
52 were reviewed and, of those, 13 were worthy of inclusion. Overall,
this EvUp suggests the need to maintain vigilance for neonatal
hypoglycemia and hyperglycemia in the aftermath of resuscitation, that
the use of protocols for blood glucose management may avoid both
hypoglycemia and hyperglycemia, and that these protocols may also avoid
large swings in blood glucose concentration that have also been
associated with harm. The NLS Task Force agreed that the EvUp highlights
the fact that research is needed to determine the optimal protocols for
glycemic management for preterm and term infants in the aftermath of
resuscitation, and identifying the optimal target glucose range should
be a high priority. Because the most recent review of the topic was
published in 2010, the NLS Task Force agreed that there has been
sufficient new evidence published about glucose management after newborn
resuscitation to consider prioritizing a SysRev on the topic of blood
glucose management.
Population, Intervention,
Comparator, Outcome, Study Design, and Time Frame
Population: Newborn infants who have received drugs for resuscitation
Intervention: Glucose infusion
Comparator: No glucose infusion
Outcome21:
Survival (to hospital discharge or as defined by authors) (critical)
Convulsions/seizures (critical)
Hemorrhage/pulmonary hemorrhage (critical)
Need for respiratory support (important)
Hypoglycemia (important)
Episodes of apnea (important)
Treatment Recommendation
This treatment recommendation (below) is unchanged from 2010.12–14
Intravenous glucose infusion should be considered as soon as practical
after resuscitation, with the goal of avoiding hypoglycemia.
IX.- TOPICS NOT REVIEWED IN 2020
Term umbilical cord management (NLS 1551-SysRev in process)
Preterm umbilical cord management (NLS 787-SysRev in process)
Babies born to mothers who are hypothermic or hyperthermic (NLS 804)
Stimulation for apneic newborns (NLS 1558)
Respiratory function monitoring in the delivery room (NLS 806)
Laryngeal mask for neonatal resuscitation (NLS 618)
Less-invasive surfactant administration (New)
CPAP versus increased oxygen for term infants in the delivery room (NLS 1579)
Optimal peak inspiratory pressure (NLS New)
Oxygen saturation target percentiles (NLS 1580)
Use of feedback CPR devices for neonatal cardiac arrest (NLS 862)
Oxygen use post-ROSC for newborns (NLS 1569)
Oxygen delivery during CPR (Neonatal) (NLS 738)
Hypovolemia (risk factors for newborns) (NLS 1555)
Effect of monitoring technology on team function (NLS 1559)
ARTICLE INFORMATION
The American Heart Association requests that this document be cited as
follows: Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J,
Guinsburg R, Hosono S, Isayama T, Kapadia VS, Kim H-S, Liley HG,
McKinlay CJD, Mildenhall L, Perlman JM, Rabi Y, Roehr CC, Schmölzer GM,
Szyld E, Trevisanuto D,
Velaphi S, Weiner GM; on behalf of the Neonatal Life Support
Collaborators. Neonatal life support: 2020 International Consensus on
Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science With Treatment
Recommendations. Circulation. 2020;142(suppl 1):S185–S221. doi: 10.1161/
CIR.0000000000000895 Supplemental materials are available with this
article at https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000000895
This article has been copublished in Resuscitation. Published by
Elsevier Ireland Ltd. All rights reserved. This article has been
copublished in Pediatrics.