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Duration of resuscitation in neonates with Apgar scores at 10min of less than 3 in the hypothermia era
Duración de la reanimación en neonatos con Apgar a los 10min menor de 3 en la era de la hipotermia
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Martín-Ancel, A. Balaguer, A. García-Alix" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Martín-Ancel" "email" => array:1 [ 0 => "amartina@hsjdbcn.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Balaguer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "García-Alix" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neonatología, Agrupación Sanitaria Hospital Sant Joan de Déu-Hospital Clínic-Maternitat, Esplugues de Llobregat, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Pediatría, Hospital General de Catalunya, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Duración de la reanimación en neonatos con Apgar a los 10<span class="elsevierStyleHsp" style=""></span>min menor de 3 en la era de la hipotermia" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Deciding when to discontinue cardiopulmonary resuscitation procedures (CPR) in asphyctic newborns (NBs) is complex. For some time it has been judged that children with an Apgar score of 0 at 10 min will very probably die or have severe neurological sequelae. The current international consensus on neonatal CPR (ILCOR 2010)<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> therefore recommends considering the cessation of CPR at 10<span class="elsevierStyleHsp" style=""></span>min postpartum when no heart beat has been detected up to that point (the Apgar score at 10<span class="elsevierStyleHsp" style=""></span>min remains 0), whereas it takes the view that there are insufficient data to establish recommendations when severe bradycardia (HR<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60) persists at 10–15<span class="elsevierStyleHsp" style=""></span>min after birth. However, the results of followup of NBs with hypoxic–ischaemic encephalopathy at the age of 6–7, published recently, suggest that the time may have come to reconsider this recommendation.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We do not yet have a marker that allows us to establish a firm prognosis of death or severe neurological sequelae in patients with perinatal asphyxia during the first 10<span class="elsevierStyleHsp" style=""></span>min of life, but certain data may serve as a guide in making decisions. A systematic review published in 2007<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> assessed the seven observational cohort studies that had tried to answer this question, together with data of its own, identifying a total of 94 patients: of these, 94% died or were handicapped severely, 2% were handicapped moderately, 1% were handicapped mildly and 3% lacked follow-up data. However, important methodological problems make it difficult to draw firm conclusions from these studies: some did not take account of the presence of congenital malformations or of gestational age, the data on followup was sparse in respect of duration and mode of assessment, and most of them were published over a decade ago. Finally, their results are difficult to transfer to the medical care we now offer, since none of these NBs had received hypothermia treatment. More recently, in 2009, Laptook et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> showed the outcome at 18–22 months of asphyctic NBs admitted to the neonatal unit according to their Apgar scores at 10<span class="elsevierStyleHsp" style=""></span>min. This is a secondary observational study in neonates of over 35 weeks’ gestational age who had been included in a randomised clinical trial to assess hypothermia treatment for hypoxic–ischaemic encephalopathy. The follow-up results at age 6 to 7 that this group has published recently<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> confirm the findings observed at 18 to 22 months of age: of the 24 children without a heart beat at 10<span class="elsevierStyleHsp" style=""></span>min (Apgar 10<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0), 5 (20.8%) survived free of moderate or severe handicap. Although the small number of patients does not allow conclusions to be drawn on the impact of hypothermia treatment on NBs with Apgar 0 at 10<span class="elsevierStyleHsp" style=""></span>min, in the study group as a whole cooling significantly reduced the risk of death or moderate/severe handicap associated with Apgar score at 10<span class="elsevierStyleHsp" style=""></span>min (OR, 0.44; 95% CI, 0.23–0.83).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This study also revealed that in the hypothermia era, survival at age 6 to 7 years free of moderate or severe handicap for an Apgar score at 10<span class="elsevierStyleHsp" style=""></span>min of 0, 1, 2 was not very different (20.8%, 9% and 14.3%, respectively), whereas children with scores of 3 and 4 showed a rate of survival free of moderate or severe handicap of 36.1% and 55.3%, respectively. In the two studies included in the review carried out in the pre-hypothermia era a similar outcome was also observed between the children who had had Apgar scores of 0 at 10<span class="elsevierStyleHsp" style=""></span>min and those who had scores of 1 or 2.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The set of data obtained in the era of therapeutic hypothermia, from hospitals where high quality can be expected in resuscitation technique and subsequent medical care, indicate that one must be cautious in establishing the duration of resuscitation. Factors such as the aetiology of the asphyctic event, the time without a detectable heart rate, the gestational age, the preconditioning or sensitisation of the patient, the quality of resuscitation procedures and of subsequent treatment potentially influence the response time and the outcome in a way that is difficult to assess at the time of resuscitation. The risk of continuing resuscitation in neonates with Apgar 0 at 10<span class="elsevierStyleHsp" style=""></span>min would lie in increasing the survival of patients with severe neurological sequelae, whereas stopping it would prevent the survival of NBs who would be free of moderate or severe sequelae at school age. Nowadays we have diagnostic tools of a clinical nature, neuroimaging, neurophysiological and neurobiochemical tools, which make it possible to assess the severity and extent of brain damage during the first 72<span class="elsevierStyleHsp" style=""></span>h of life much more precisely than Apgar score at 10<span class="elsevierStyleHsp" style=""></span>min.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Furthermore, even in those cases in which the decision is made to withdraw life support on account of the severity and extent of brain damage, the parents will have had time to get to know and be with their child and say goodbye. Although it is difficult to assess the impact of these measures, most parents value having seen and embraced their child while he or she was alive, and this probably facilitates the grieving process.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The available data are still insufficient, but they do make it necessary to think anew about what the best moment is to decide whether to maintain or withdraw life support in NBs with the lowest Apgar 10 scores. Delaying this decision from 10<span class="elsevierStyleHsp" style=""></span>min until the first hours of life in those NBs who are slow to respond to CPR would make it easier to achieve greater certainty about the prognosis and would give time to ascertain the parents’ opinion, which is very rarely available during initial resuscitation in the delivery room.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín-Ancel A, Balaguer A, García-Alix A. Duración de la reanimación en neonatos con Apgar a los 10<span class="elsevierStyleHsp" style=""></span>min menor de 3 en la era de la hipotermia. An Pediatr (Barc). 2015;82:129–130.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Neonatal Resuscitation Chapter Collaborators" "etal" => true "autores" => array:6 [ 0 => "J.M. Perlman" 1 => "J. Wyllie" 2 => "J. Kattwinkel" 3 => "D.L. Atkins" 4 => "L. Chameides" 5 => "J.P. 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Herranz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2015" "editorial" => "Ministerio de Sanidad, Servicios Sociales e Igualdad" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008200000003/v2_201504151313/S2341287915000368/v2_201504151313/en/main.assets" "Apartado" => array:4 [ "identificador" => "26006" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008200000003/v2_201504151313/S2341287915000368/v2_201504151313/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287915000368?idApp=UINPBA00005H" ]
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| 2021 October | 42 | 76 | 118 |
| 2021 September | 26 | 48 | 74 |
| 2021 August | 32 | 49 | 81 |
| 2021 July | 29 | 35 | 64 |
| 2021 June | 41 | 33 | 74 |
| 2021 May | 29 | 32 | 61 |
| 2021 April | 133 | 91 | 224 |
| 2021 March | 66 | 25 | 91 |
| 2021 February | 33 | 11 | 44 |
| 2021 January | 24 | 23 | 47 |
| 2020 December | 31 | 18 | 49 |
| 2020 November | 33 | 11 | 44 |
| 2020 October | 28 | 23 | 51 |
| 2020 September | 41 | 13 | 54 |
| 2020 August | 41 | 9 | 50 |
| 2020 July | 43 | 24 | 67 |
| 2020 June | 59 | 11 | 70 |
| 2020 May | 56 | 27 | 83 |
| 2020 April | 53 | 14 | 67 |
| 2020 March | 45 | 20 | 65 |
| 2020 February | 47 | 19 | 66 |
| 2020 January | 36 | 16 | 52 |
| 2019 December | 73 | 21 | 94 |
| 2019 November | 37 | 19 | 56 |
| 2019 October | 35 | 11 | 46 |
| 2019 September | 40 | 18 | 58 |
| 2019 August | 54 | 35 | 89 |
| 2019 July | 34 | 23 | 57 |
| 2019 June | 36 | 26 | 62 |
| 2019 May | 39 | 13 | 52 |
| 2019 April | 61 | 43 | 104 |
| 2019 March | 33 | 15 | 48 |
| 2019 February | 33 | 24 | 57 |
| 2019 January | 32 | 20 | 52 |
| 2018 December | 27 | 29 | 56 |
| 2018 November | 66 | 26 | 92 |
| 2018 October | 63 | 16 | 79 |
| 2018 September | 24 | 12 | 36 |
| 2018 August | 3 | 0 | 3 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 7 | 0 | 7 |
| 2018 April | 26 | 0 | 26 |
| 2018 March | 31 | 0 | 31 |
| 2018 February | 10 | 0 | 10 |
| 2018 January | 16 | 0 | 16 |
| 2017 December | 15 | 0 | 15 |
| 2017 November | 22 | 0 | 22 |
| 2017 October | 17 | 0 | 17 |
| 2017 September | 16 | 0 | 16 |
| 2017 August | 18 | 0 | 18 |
| 2017 July | 24 | 3 | 27 |
| 2017 June | 28 | 11 | 39 |
| 2017 May | 26 | 14 | 40 |
| 2017 April | 32 | 27 | 59 |
| 2017 March | 14 | 34 | 48 |
| 2017 February | 12 | 5 | 17 |
| 2017 January | 18 | 3 | 21 |
| 2016 December | 23 | 11 | 34 |
| 2016 November | 36 | 9 | 45 |
| 2016 October | 43 | 10 | 53 |
| 2016 September | 40 | 6 | 46 |
| 2016 August | 29 | 4 | 33 |
| 2016 July | 13 | 4 | 17 |
Show all
