Advanced cardiopulmonary resuscitation in the newborn: Are there data to justify adopting different protocols for the extremely premature neonate
Reanimación cardiopulmonar avanzada neonatal: ¿hay datos para actuar de forma diferente frente al recién nacido extremadamente prematuro?
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Spain. Miembros del Grupo de Reanimación Cardiopulmonar Neonatal de la Sociedad Española de Neonatología." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Reanimación cardiopulmonar avanzada neonatal: ¿hay datos para actuar de forma diferente frente al recién nacido extremadamente prematuro?" ] ] "textoCompleto" => "<p class="elsevierStylePara">International guidelines on neonatal resuscitation recommend initiation of chest compression, and then adrenaline, in the event of severe bradycardia that does not respond to appropriate ventilation with positive pressure. No separate criteria are established for the resuscitation of extremely premature neonates (EPN) <span class="elsevierStyleSup">1</span>. Nonetheless, the fragility of these infants gives rise to the concern that the use of chest compression or adrenaline (advanced cardiopulmonary resuscitation, ACPR) might bring about an increase in the number of survivors with severe disabling neurological deficits.</p><p class="elsevierStylePara">Scarce data obtained at the end of the 1980s and in the early 1990s on the evolution of EPN who required ACPR in the delivery room drew a gloomy picture: among the 26 newborns weighing less than 751 g <span class="elsevierStyleSup">2-4</span> or with under 29 weeks gestation at birth <span class="elsevierStyleSup">5</span>, there were no survivors free of severe neurological sequelae. However, from the mid-1990s on some studies began to show a different scenario. Survival following ACPR among neonates under 1,000 g increased to 53-78 % <span class="elsevierStyleSup">6-9</span>, and neurological development was normal for more than half of those children who were followed up <span class="elsevierStyleSup">7-9</span>. This improvement in morbidity and mortality for EPNs following ACPR was paralleled by the general tendency observed in this group of patients during the 1990s, probably reflecting more appropriate obstetric and neonatal management, including the use of prenatal steroids, surfactant and other technological advances, such as new ventilation strategies <span class="elsevierStyleSup">10,11</span>.</p><p class="elsevierStylePara">After 1995 the trend towards improved evolution for EPNs appeared to come to a halt <span class="elsevierStyleSup"> 10</span>, in part owing to the more severe condition of the patients at birth <span class="elsevierStyleSup">12</span>. Has this also been the case among those requiring ACPR in the delivery room? In this issue of <span class="elsevierStyleItalic">Anales de Pediatría</span> two studies provide information gathered in the first years of the twenty-first century. Sánchez Torres <span class="elsevierStyleItalic">et al</span><span class="elsevierStyleSup">13</span> found no significant differences in survival at discharge between babies weighing less than 1,000 g requiring ACPR and those that did not (62.5 % <span class="elsevierStyleItalic">vs.</span> 76.3 %); only combined neurological morbidity analysis at discharge revealed significant differences between the groups (46.7 % <span class="elsevierStyleItalic">vs.</span> 21.6 %). In children weighing less than 1,251 g, Deulofeut <span class="elsevierStyleItalic">et al.</span><span class="elsevierStyleSup">14</span> found lower survival among those requiring ACPR (60 % <span class="elsevierStyleItalic">vs.</span> 85 %). However, among those weighing less than 1,001 g their results were comparable to the results of the Spanish study (59 % <span class="elsevierStyleItalic"> vs.</span> 77 %). In terms of short-term neurological morbidity, significant differences were found in the group weighing 751 to 1,000 g only for III/IV degree intraventricular hemorrhaging (37 % <span class="elsevierStyleItalic">vs.</span> 12 %), and no differences in mortality or neuro-imaging were found in those weighing less than 751 g. Unfortunately, a high number of children were lost for follow-up, which questions the validity of extrapolating the findings to the population studied.</p><p class="elsevierStylePara">What results are to be expected for other age-groups of neonates who had ACPR? In a cohort of 26 full-term neonates, 69 % survived, of whom 67 % were normal at follow-up <span class="elsevierStyleSup">9</span>. Following pediatric ACPR, survival at discharge hovered at around 50 %, and more than 80 % of babies suffered no worsening of their prior neurological state <span class="elsevierStyleSup"> 15,16</span>. Among adults only 20-30 % survive, of whom around 25 % will suffer serious neurological sequelae <span class="elsevierStyleSup">17,18</span>. Thus, the best results for survival are to be expected during the neonatal period --including EPN. Of all those patients resuscitated, symptom-free survival is expected by around 45 % of full-term newborns, 40 % of children, 30-45 % of EPNs, and somewhat less than 20 % of adults.</p><p class="elsevierStylePara">There are certain limitations that must be borne in mind when interpreting the available data. First, all the studies are retrospective. Partly for this reason we know very little about the characteristics of the event. We lack information about what caused the cardiopulmonary arrest, the reasons for undertaking ACPR or its duration, the means used for resuscitation (adrenaline dose, use of other drugs, volume expansion, etc.) or the monitoring of the event. All of these factors may have a significant effect on the results of resuscitation.</p><p class="elsevierStylePara">In older children and adults the cause that precipitates the arrest is an important prognostic factor <span class="elsevierStyleSup">15,16</span>; it is probable that different etiologies might also affect EPNs in different ways <span class="elsevierStyleSup">19</span>. Furthermore, animal experimental models show that the success of ACPR depends in part on the duration of the arrest prior to the beginning of CPR, its duration and the ability to establish a sufficient flow. The prognosis is better for children with severe bradycardia at the beginning of resuscitation than it is for those who are asystolic <span class="elsevierStyleSup">15</span>. Among infants born at term, persistent asystolia lasting more than 10 minutes in spite of appropriate ACPR is associated with very poor prognosis <span class="elsevierStyleSup"> 2,14</span>. Although it is likely that EPNs behave in a similar fashion, the particular physiological characteristics of this group may imply differences in times, drug doses and sequences that will have to be evaluated in animal models and prospective clinical studies.</p><p class="elsevierStylePara">Again, we lack knowledge concerning the attitudes and guidelines in the various centers. It has been noted that an active approach with respect to perinatal management of EPNs increases the survival rate without increasing morbidity at one year of age, while a restrictive attitude leads to greater mortality without reducing the morbidity of the survivors <span class="elsevierStyleSup">20</span>. Differences in the management of these neonates during ACPR may have an influence on the results. Thus, strategies such as control of oxygenation (FiO<span class="elsevierStyleInf">2</span>), ventilation (CO<span class="elsevierStyleInf">2</span>), inspiratory (PIP) and expiratory (PEEP) pressures, and the monitoring of their effects (pulsoxymetry, capnography, arterial pressure) might help bring about a more favorable evolution. Finally, one of the greatest limitations is the scarcity of follow-up data, which, when available, often cover short time periods and show elevated losses.</p><p class="elsevierStylePara">The first minutes following delivery are probably not the best moment for deciding on the life or death of an EPN, due to the scarce information on each individual child. Occasionally the clinical data will show no real possibility of the patient responding to treatment (for example, persistent asystolia lasting at least ten minutes in spite of correct ACPR); in such cases discontinuation of CPR is justified. Nevertheless, in most instances it is only possible to establish a general prognosis in the form of percentages that make no provision for the individual characteristics of the resuscitated patient. In this situation of uncertainty, the sick child has the right to be treated if there exists a real hope of life without severe neurodevelopmental disability. Throughout the first days of life, the analysis of the clinical situation and neuroimaging studies will provide relevant information. Although establishing a neurological prognosis for an EPN who survives ACPR may be particularly difficult, in the event of extremely severe brain damage, a multidisciplinary approach in close relationship with the family of the newborn may counsel against maintaining extraordinary therapeutic measures.</p><p class="elsevierStylePara">Sánchez Torres <span class="elsevierStyleItalic">et al</span>. concluded that the increased level of mortality and the risk of severe brain damage traditionally associated with the use of ACPR in EPNs do not appear to be confirmed <span class="elsevierStyleSup">13</span>. These data justify not using different criteria with ENPs when chest compression or the administration of adrenaline is indicated. In addition, they underline the need for (and difficulty of) clinical care that encompasses all the multiple factors at play: the very real presence of the neonate, his or her gestational age, the clinical evolution, the hopes of the parents and our capacity to establish a long-term prognosis. The exclusive use of risk percentages separated from this multivariate picture can become a form of prejudice, which, instead of offering the real infant a balanced treatment, fails to avoid extreme attitudes such as therapeutic overzealousness, or the discontinuation of life-sustaining treatments dictated by times decided by professionals, and not by the evolution of the pathology. More still, given the difficulties and the risk of long-term handicaps that the extremely premature neonate faces, it seems reductive to affirm as the only answer his or her death. It is incumbent upon the attending team and society as a whole to offer the best possible treatment, as well as to assist and support the newborn infant and his/her family.</p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleBold"> Correspondence:</span></p><p class="elsevierStylePara">A. Martín-Ancel MD.<br></br> Servicio de Neonatología. Hospital Universitario San Juan de Dios.<br></br> P.º Sant Joan de Déu, 2. 08950 Esplugues de Llobregat. Barcelona. Spain.<br></br> E-mail: <a href="mailto:amartina@hsjdbcn.org" class="elsevierStyleCrossRefs"> amartina@hsjdbcn.org</a></p>" "pdfFichero" => "37v66n01a13097350pdf001.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "European Resuscitation Council guidelines for resuscitation 2005. Section 6. Paediatric life support." 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 14 | 11 | 25 |
| 2024 Octubre | 84 | 68 | 152 |
| 2024 Septiembre | 108 | 35 | 143 |
| 2024 Agosto | 103 | 74 | 177 |
| 2024 Julio | 67 | 36 | 103 |
| 2024 Junio | 82 | 37 | 119 |
| 2024 Mayo | 84 | 35 | 119 |
| 2024 Abril | 82 | 43 | 125 |
| 2024 Marzo | 50 | 39 | 89 |
| 2024 Febrero | 54 | 44 | 98 |
| 2024 Enero | 45 | 29 | 74 |
| 2023 Diciembre | 68 | 18 | 86 |
| 2023 Noviembre | 55 | 27 | 82 |
| 2023 Octubre | 63 | 22 | 85 |
| 2023 Septiembre | 55 | 26 | 81 |
| 2023 Agosto | 75 | 27 | 102 |
| 2023 Julio | 53 | 31 | 84 |
| 2023 Junio | 50 | 34 | 84 |
| 2023 Mayo | 61 | 27 | 88 |
| 2023 Abril | 41 | 20 | 61 |
| 2023 Marzo | 52 | 34 | 86 |
| 2023 Febrero | 34 | 18 | 52 |
| 2023 Enero | 36 | 22 | 58 |
| 2022 Diciembre | 33 | 24 | 57 |
| 2022 Noviembre | 71 | 60 | 131 |
| 2022 Octubre | 44 | 39 | 83 |
| 2022 Septiembre | 39 | 41 | 80 |
| 2022 Agosto | 48 | 56 | 104 |
| 2022 Julio | 40 | 52 | 92 |
| 2022 Junio | 34 | 36 | 70 |
| 2022 Mayo | 44 | 44 | 88 |
| 2022 Abril | 53 | 54 | 107 |
| 2022 Marzo | 43 | 50 | 93 |
| 2022 Febrero | 42 | 35 | 77 |
| 2022 Enero | 33 | 42 | 75 |
| 2021 Diciembre | 42 | 57 | 99 |
| 2021 Noviembre | 34 | 49 | 83 |
| 2021 Octubre | 48 | 51 | 99 |
| 2021 Septiembre | 41 | 61 | 102 |
| 2021 Agosto | 37 | 28 | 65 |
| 2021 Julio | 29 | 46 | 75 |
| 2021 Junio | 51 | 47 | 98 |
| 2021 Mayo | 44 | 29 | 73 |
| 2021 Abril | 121 | 39 | 160 |
| 2021 Marzo | 92 | 31 | 123 |
| 2021 Febrero | 78 | 12 | 90 |
| 2021 Enero | 46 | 19 | 65 |
| 2020 Diciembre | 49 | 23 | 72 |
| 2020 Noviembre | 34 | 18 | 52 |
| 2020 Octubre | 21 | 13 | 34 |
| 2020 Septiembre | 20 | 15 | 35 |
| 2020 Agosto | 20 | 13 | 33 |
| 2020 Julio | 27 | 12 | 39 |
| 2020 Junio | 26 | 16 | 42 |
| 2020 Mayo | 29 | 22 | 51 |
| 2020 Abril | 29 | 15 | 44 |
| 2020 Marzo | 26 | 14 | 40 |
| 2020 Febrero | 23 | 15 | 38 |
| 2020 Enero | 22 | 5 | 27 |
| 2019 Diciembre | 34 | 14 | 48 |
| 2019 Noviembre | 10 | 12 | 22 |
| 2019 Octubre | 21 | 11 | 32 |
| 2019 Septiembre | 24 | 6 | 30 |
| 2019 Agosto | 15 | 17 | 32 |
| 2019 Julio | 26 | 14 | 40 |
| 2019 Junio | 39 | 18 | 57 |
| 2019 Mayo | 45 | 17 | 62 |
| 2019 Abril | 66 | 18 | 84 |
| 2019 Marzo | 20 | 18 | 38 |
| 2019 Febrero | 36 | 21 | 57 |
| 2019 Enero | 37 | 19 | 56 |
| 2018 Diciembre | 27 | 27 | 54 |
| 2018 Noviembre | 44 | 29 | 73 |
| 2018 Octubre | 43 | 19 | 62 |
| 2018 Septiembre | 18 | 15 | 33 |
| 2018 Agosto | 3 | 0 | 3 |
| 2018 Julio | 4 | 0 | 4 |
| 2018 Junio | 2 | 0 | 2 |
| 2018 Mayo | 13 | 0 | 13 |
| 2018 Abril | 22 | 0 | 22 |
| 2018 Marzo | 23 | 0 | 23 |
| 2018 Febrero | 11 | 0 | 11 |
| 2018 Enero | 25 | 0 | 25 |
| 2017 Diciembre | 9 | 0 | 9 |
| 2017 Noviembre | 21 | 0 | 21 |
| 2017 Octubre | 16 | 0 | 16 |
| 2017 Septiembre | 13 | 0 | 13 |
| 2017 Agosto | 15 | 0 | 15 |
| 2017 Julio | 14 | 0 | 14 |
| 2017 Junio | 28 | 11 | 39 |
| 2017 Mayo | 19 | 15 | 34 |
| 2017 Abril | 15 | 2 | 17 |
| 2017 Marzo | 14 | 3 | 17 |
| 2017 Febrero | 10 | 13 | 23 |
| 2017 Enero | 4 | 5 | 9 |
| 2016 Diciembre | 21 | 16 | 37 |
| 2016 Noviembre | 46 | 11 | 57 |
| 2016 Octubre | 40 | 10 | 50 |
| 2016 Septiembre | 41 | 7 | 48 |
| 2016 Agosto | 16 | 5 | 21 |
| 2016 Julio | 10 | 6 | 16 |
| 2016 Junio | 2 | 0 | 2 |
| 2016 Mayo | 2 | 0 | 2 |
| 2016 Abril | 1 | 0 | 1 |
| 2016 Marzo | 1 | 0 | 1 |
| 2016 Febrero | 4 | 0 | 4 |
| 2015 Diciembre | 5 | 0 | 5 |
| 2015 Noviembre | 4 | 0 | 4 |
| 2015 Octubre | 1 | 11 | 12 |
| 2015 Septiembre | 4 | 0 | 4 |
| 2015 Agosto | 0 | 8 | 8 |
| 2015 Julio | 12 | 0 | 12 |
| 2015 Junio | 22 | 0 | 22 |
| 2015 Mayo | 29 | 0 | 29 |
| 2015 Abril | 30 | 0 | 30 |
| 2015 Marzo | 18 | 4 | 22 |
| 2015 Febrero | 11 | 0 | 11 |
| 2015 Enero | 31 | 0 | 31 |
| 2014 Diciembre | 45 | 2 | 47 |
| 2014 Noviembre | 28 | 1 | 29 |
| 2014 Octubre | 37 | 2 | 39 |
| 2014 Septiembre | 30 | 3 | 33 |
| 2014 Agosto | 44 | 2 | 46 |
| 2014 Julio | 37 | 3 | 40 |
| 2014 Junio | 72 | 2 | 74 |
| 2014 Mayo | 73 | 5 | 78 |
| 2014 Abril | 59 | 2 | 61 |
| 2014 Marzo | 73 | 16 | 89 |
| 2014 Febrero | 68 | 10 | 78 |
| 2014 Enero | 65 | 10 | 75 |
| 2013 Diciembre | 83 | 29 | 112 |
| 2013 Noviembre | 62 | 16 | 78 |
| 2013 Octubre | 117 | 16 | 133 |
| 2013 Septiembre | 77 | 18 | 95 |
| 2013 Agosto | 85 | 19 | 104 |
| 2013 Julio | 59 | 11 | 70 |
| 2013 Junio | 14 | 5 | 19 |
| 2013 Mayo | 8 | 4 | 12 |
| 2013 Abril | 6 | 1 | 7 |
| 2013 Marzo | 20 | 6 | 26 |
| 2013 Febrero | 21 | 2 | 23 |
| 2013 Enero | 3 | 0 | 3 |
| 2012 Diciembre | 3 | 2 | 5 |
| 2012 Noviembre | 6 | 0 | 6 |
| 2012 Octubre | 1 | 2 | 3 |
| 2012 Septiembre | 4 | 0 | 4 |
| 2012 Agosto | 4 | 2 | 6 |
| 2012 Julio | 0 | 2 | 2 |
| 2007 Enero | 9055 | 0 | 9055 |
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