European Resuscitation Council Guidelines for Resuscitation ... - CPR

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18 de 0ctubre de 2010 www.elsuapdetodos.com1396 S. Richmond, J. Wyllie / Resuscitation 81 (2010) 1389–1399Table 7.1Oral tracheal tube lengths by gestation.Gestation (weeks)23–24 5.525–26 6.027–29 6.530–32 7.033–34 7.535–37 8.038–40 8.541–43 9.0Tracheal tube at lips (cm)in the delivery room, 76 and may help to identify airway obstruction.Neither additional benefit above clinical assessment alone, nor risksattributed to their use have been identified. The use of exhaled CO 2detectors with other interfaces (e.g. nasal airways, laryngeal masks)during PPV in the delivery room has not been reported.Confirming tracheal tube placementTracheal intubation may be considered at several points duringneonatal resuscitation:• When suctioning to remove meconium or other tracheal blockageis required.• If bag-mask ventilation is ineffective or prolonged.• When chest compressions are performed.• Special circumstances (e.g. congenital diaphragmatic hernia orbirth weight below 1000 g).The use and timing of tracheal intubation will depend on the skilland experience of the available resuscitators. Appropriate tubelengths based on gestation are shown in Table 7.1. 77Tracheal tube placement must be assessed visually during intubation,and positioning confirmed. Following tracheal intubationand intermittent positive-pressure, a prompt increase in heart rateis a good indication that the tube is in the tracheobronchial tree. 78Exhaled CO 2 detection is effective for confirmation of tracheal tubeplacement in infants, including VLBW infants 79–82 and neonatalstudies suggest that it confirms tracheal intubation in neonateswith a cardiac output more rapidly and more accurately than clinicalassessment alone. 81–83 Failure to detect exhaled CO 2 stronglysuggests oesophageal intubation 79,81 but false negative readingshave been reported during cardiac arrest 79 and in VLBW infantsdespite models suggesting efficacy. 84 However, neonatal studieshave excluded infants in need of extensive resuscitation. There isno comparative information to recommend any one method fordetection of exhaled carbon dioxide in the neonatal population.False positives may occur with colorimetric devices contaminatedwith adrenaline (epinephrine), surfactant and atropine. 75Poor or absent pulmonary blood flow or tracheal obstructionmay prevent detection of exhaled CO 2 despite correct tracheal tubeplacement. Tracheal tube placement is identified correctly in nearlyall patients who are not in cardiac arrest; 80 however, in criticallyill infants with poor cardiac output, inability to detect exhaledCO 2 despite correct placement may lead to unnecessary extubation.Other clinical indicators of correct tracheal tube placementinclude evaluation of condensed humidified gas during exhalationand presence or absence of chest movement, but these have notbeen evaluated systematically in newborn babies.Recommendation: Detection of exhaled carbon dioxide in additionto clinical assessment is recommended as the most reliablemethod to confirm tracheal placement in neonates with spontaneouscirculation.Route and dose of adrenaline (epinephrine)Despite the widespread use of adrenaline during resuscitation,no placebo controlled clinical trials have evaluated its effectiveness,nor has the ideal dose or route of administration been defined.Neonatal case series or case reports 85,86 indicate that adrenalineadministered by the tracheal route using a wide range of doses(3–250 gkg −1 ) may be associated with return of spontaneous circulation(ROSC) or an increase in heart rate. These case series arelimited by inconsistent standards for adrenaline administrationand are subject to both selection and reporting bias.One good quality case series indicates that tracheal adrenaline(10 gkg −1 ) is likely to be less effective than the same doseadministered intravenously. 87 This is consistent with evidenceextrapolated from neonatal animal models indicating that higherdoses (50–100 gkg −1 ) of adrenaline may be required when givenvia the tracheal route to achieve the same blood adrenaline concentrationsand haemodynamic response as achieved after intravenousadministration. 88,89 Adult animal models demonstrate that bloodconcentrations of adrenaline are significantly lower following trachealcompared with intravenous administration 90,91 and thattracheal doses ranging from 50 to 100 gkg −1 may be required toachieve ROSC. 92Although it has been widely assumed that adrenaline can begiven faster by the tracheal route than by the intravenous route,no clinical trials have evaluated this hypothesis. Two studies havereported cases of inappropriately early use of tracheal adrenalinebefore airway and breathing are established. 85,86 One case seriesdescribing in-hospital paediatric cardiac arrests suggested that survivalwas higher among infants who received their first dose ofadrenaline by the tracheal route; however, the time required forfirst dose administration using the tracheal and intravenous routeswere not provided. 93Paediatric 94,95 and newborn animal studies 96 showed no benefitand a trend toward reduced survival and worse neurologicalstatus after high-dose intravenous adrenaline (100 mcg kg −1 ) duringresuscitation. This is in contrast to a single paediatric caseseries using historic controls that indicated a marked improvementin ROSC using high-dose intravenous adrenaline (100 mcg kg −1 ).However, a meta-analysis of five adult clinical trials indicates thatwhilst high-dose intravenous adrenaline may increase ROSC, itoffers no benefit in survival to hospital discharge. 97Recommendation: If adrenaline is administered, give an intravenousdose 10–30 gkg −1 as soon as possible. Higher intravenousdoses should not be given and may be harmful. If intravenous accessis not available, then it may be reasonable to try tracheal adrenaline.If adrenaline is administered by the tracheal route, it is likely that alarger dose (50–100 gkg −1 ) will be required to achieve a similareffect to the 10 gkg −1 intravenous dose.www.elsuapdetodos.comPost-resuscitation careBabies who have required resuscitation may later deteriorate.Once adequate ventilation and circulation are established, theinfant should be maintained in or transferred to an environmentin which close monitoring and anticipatory care can be provided.GlucoseHypoglycaemia was associated with adverse neurological outcomein a neonatal animal model of asphyxia and resuscitation. 98Newborn animals that were hypoglycaemic at the time of an anoxicor hypoxic–ischemic insult had larger areas of cerebral infarctionand/or decreased survival compared to controls. 99,100 One clinicalstudy demonstrated an association between hypoglycaemia andpoor neurological outcome following perinatal asphyxia. 101 In
adults, children and extremely low-birth-weight infants receivingintensive care, hyperglycaemia has been associated with a worseoutcome. 102–104 However, in paediatric patients, hyperglycaemiaafter hypoxia–ischaemia does not appear to be harmful, 105 whichconfirms data from animal studies 106 some of which suggest itmay be protective. 107 However, the range of blood glucose concentrationthat is associated with the least brain injury followingasphyxia and resuscitation cannot be defined based on availableevidence. Infants who require significant resuscitation should bemonitored and treated to maintain glucose in the normal range.Induced hypothermiaSeveral randomised, controlled, multi-centre trials ofinduced hypothermia (33.5–34.5 ◦ C) of babies born at morethan 36 weeks gestational age, with moderate to severehypoxic–ischemic encephalopathy have shown that coolingsignificantly reduced death and neuro-developmental disability at18 months. 108–111 Systemic and selective head cooling producedsimilar results. 109–113 Modest hypothermia may be associatedwith bradycardia and elevated blood pressure that do not usuallyrequire treatment, but a rapid increase in body temperature maycause hypotension. 114 Profound hypothermia (core temperaturebelow 33 ◦ C) may cause arrhythmia, bleeding, thrombosis, andsepsis, but studies so far have not reported these complications ininfants treated with modest hypothermia. 109,115Newly born infants born at term or near-term with evolvingmoderate to severe hypoxic–ischemic encephalopathy should,where possible, be offered therapeutic hypothermia. Whole bodycooling and selective head cooling are both appropriate strategies.Cooling should be initiated and conducted under clearly definedprotocols with treatment in neonatal intensive care facilities andwith the capabilities for multidisciplinary care. Treatment shouldbe consistent with the protocols used in the randomised clinicaltrials (i.e. commence within 6 h of birth, continue for 72 h ofbirth and re-warm over at least 4 h). Animal data would stronglysuggest that the effectiveness of cooling is related to early intervention.There is no evidence in human newborns that coolingis effective if started more than 6 h after birth. Carefully monitorfor known adverse effects of cooling – thrombocytopeniaand hypotension. All treated infants should be followed longitudinally.Withholding or discontinuing resuscitationMortality and morbidity for newborns varies according to regionand to availability of resources. 116 Social science studies indicatethat parents desire a larger role in decisions to resuscitate and tocontinue life support in severely compromised babies. 117 Opinionsvary amongst providers, parents and societies about the balance ofbenefits and disadvantages of using aggressive therapies in suchbabies. 118,119Withholding resuscitationIt is possible to identify conditions associated with high mortalityand poor outcome, where withholding resuscitation may beconsidered reasonable, particularly when there has been the opportunityfor discussion with parents. 24,120,121A consistent and coordinated approach to individual cases bythe obstetric and neonatal teams and the parents is an importantgoal. 23 Withholding resuscitation and discontinuation oflife-sustaining treatment during or following resuscitation areconsidered by many to be ethically equivalent and cliniciansshould not be hesitant to withdraw support when the possibilityof functional survival is highly unlikely. The following18 de 0ctubre de 2010 www.elsuapdetodos.comS. Richmond, J. Wyllie / Resuscitation 81 (2010) 1389–1399 1397guidelines must be interpreted according to current regional outcomes.• Where gestation, birth weight, and/or congenital anomalies areassociated with almost certain early death, and unacceptablyhigh morbidity is likely among the rare survivors, resuscitation isnot indicated. 122 Examples from the published literature include:extreme prematurity (gestational age less than 23 weeks and/orbirthweight less than 400 g), and anomalies such as anencephalyand confirmed Trisomy 13 or 18.• Resuscitation is nearly always indicated in conditions associatedwith a high survival rate and acceptable morbidity. This will generallyinclude babies with gestational age of 25 weeks or above(unless there is evidence of fetal compromise such as intrauterineinfection or hypoxia–ischaemia) and those with most congenitalmalformations.• In conditions associated with uncertain prognosis, where thereis borderline survival and a relatively high rate of morbidity, andwhere the anticipated burden to the child is high, parental desiresregarding resuscitation should be supported.Withdrawing resuscitation effortsData from infants without signs of life from birth, lasting atleast 10 min or longer, show either high mortality or severe neurodevelopmentaldisability. 123,124 If faced with a newly born babywith no detectable heart rate which remains undetectable for10 min, it is appropriate to then consider stopping resuscitation.The decision to continue resuscitation efforts when the infant hasno detectable heart rate for longer than 10 min is often complexand may be influenced by issues such as the presumed aetiologyof the arrest, the gestation of the baby, the potential reversibilityof the situation, and the parents’ previous expressed feelings aboutacceptable risk of morbidity.If the heart rate is less than 60 min −1 at birth and persisting after10 or 15 min the situation is even less clear and a firm recommendationcannot be made.References1. Wyllie J, Perlman JM, Kattwinkel J, et al. 2010 International Consensus on CardiopulmonaryResuscitation and Emergency Cardiovascular Care Science withTreatment Recommendations. Part 11. Neonatal resuscitation. Resuscitation;doi:10.1016/j.resuscitation.2010.08.029, in press.2. Perlman JM, Wyllie J, Kattwinkel J, et al. 2010 International Consensus on CardiopulmonaryResuscitation and Emergency Cardiovascular Care Science withTreatment Recommendations. Part 11. Neonatal resuscitation. Circulation; inpress.3. Biarent D, Bingham R, Richmond S, et al. European Resuscitation Council Guidelinesfor Resuscitation 2005. Section 6. Paediatric life support. Resuscitation2005;67(Suppl. 1):S97–133.4. Palme-Kilander C. Methods of resuscitation in low-Apgar-score newborninfants—a national survey. Acta Paediatr 1992;81:739–44.5. Dahm LS, James LS. Newborn temperature and calculated heat loss in the deliveryroom. Pediatrics 1972;49:504–13.6. Stephenson J, Du JTKO. The effect if cooling on blood gas tensions in newborninfants. J Pediatr 1970;76:848–52.7. Gandy GM, Adamsons Jr K, Cunningham N, Silverman WA, James LS. Thermalenvironment and acid-base homeostasis in human infants during the first fewhours of life. J Clin Invest 1964;43:751–8.8. Kent AL, Williams J. Increasing ambient operating theatre temperature andwrapping in polyethylene improves admission temperature in prematureinfants. J Paediatr Child Health 2008;44:325–31.9. Knobel RB, Wimmer Jr JE, Holbert D. Heat loss prevention for preterm infantsin the delivery room. J Perinatol 2005;25:304–8.10. Apgar V. A proposal for a new method of evaluation of the newborn infant. CurrRes Anesth Analg 1953;32.11. Chamberlain G, Banks J. Assessment of the Apgar score. Lancet 1974;2:1225–8.12. Owen CJ, Wyllie JP. Determination of heart rate in the baby at birth. Resuscitation2004;60:213–7.13. Kamlin CO, Dawson JA, O’Donnell CP, et al. Accuracy of pulse oximetry measurementof heart rate of newborn infants in the delivery room. J Pediatr2008;152:756–60.www.elsuapdetodos.com
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