ABSTRACT
Even brief interruption of cardiac compressions significantly reduces critical coronary perfusion pressure during cardiopulmonary resuscitation (CPR). End-tidal CO2 (ETCO2) monitoring may provide a continuous noninvasive method of assessing return of spontaneous circulation (ROSC) without stopping to auscultate for heart rate (HR). However, the ETCO2 value that correlates with an audible HR is unknown. Our objective was to determine the threshold ETCO2 that is associated with ROSC after asphyxia-induced asystole. Neonatal swine (n = 46) were progressively asphyxiated until asystole occurred. Resuscitation followed current neonatal guidelines with initial ventilation with 100% O2 followed by cardiac compressions followed by epinephrine for continued asystole. HR was auscultated every 30 s, and ETCO2 was continuously recorded. A receiver operator curve was generated using the calculated sensitivity and specificity for various ETCO2 values, where a positive test was defined as the presence of HR >60 bpm by auscultation. An ETCO2 cut-off value of 14 mm Hg is the most sensitive ETCO2 value with the least false positives. When using ETCO2 to guide uninterrupted CPR in this model of asphyxia-induced asystole, auscultative confirmation of return of an adequate HR should be performed when ETCO2 ≥ 14 mm Hg is achieved. Correlation during human neonatal CPR needs further investigation.
Subject(s)
Asphyxia Neonatorum/complications , Breath Tests , Carbon Dioxide/metabolism , Cardiopulmonary Resuscitation , Exhalation , Heart Arrest/therapy , Heart Rate , Adrenergic Agonists/administration & dosage , Animals , Animals, Newborn , Asphyxia Neonatorum/metabolism , Asphyxia Neonatorum/physiopathology , Biomarkers/metabolism , Blood Pressure , Cardiopulmonary Resuscitation/methods , Disease Models, Animal , Epinephrine/administration & dosage , Heart Arrest/etiology , Heart Arrest/metabolism , Heart Arrest/physiopathology , Heart Auscultation , Heart Massage , Humans , Infant, Newborn , Positive-Pressure Respiration , Predictive Value of Tests , Sus scrofa , Time FactorsABSTRACT
The optimal mode of delivery for extremely low birth weight (ELBW) infants remains unknown. We reviewed the medical records of 374 ELBW infants (gestational age 23-34 weeks) delivered between 1998 and 2003 at UAMS. The cesarean section rate was 63.9%. The overall mortality rate was 16.0%. The mortality rate for vaginally delivered infants was 26.7% (36/135) vs. 10% (24/239) for cesarean section (P < .0001). Cesarean delivery was associated with higher odds of survival without severe brain injury (SBI) (OR = 2.33, 95% CI [1.36, 4.00]).
Subject(s)
Cerebral Hemorrhage/epidemiology , Delivery, Obstetric/methods , Infant Mortality , Infant, Extremely Low Birth Weight , Leukomalacia, Periventricular/epidemiology , Arkansas/epidemiology , Cerebral Ventricles , Cesarean Section , Female , Humans , Incidence , Infant, Newborn , Logistic Models , Male , Pregnancy , Retrospective Studies , Severity of Illness Index , VaginaABSTRACT
OBJECTIVE: Given the paucity of information regarding endotracheal epinephrine for newborn resuscitation, the objectives of this study were: (1) to determine the frequency of endotracheal epinephrine use in newborns in the delivery room, and (2) to determine whether the previously recommended dose of 0.01 to 0.03 mg/kg of endotracheal epinephrine is effective in establishing a return of spontaneous circulation. PATIENTS AND METHODS: A retrospective review was conducted for all neonates who received > or = 1 dose of epinephrine in the delivery room between January 1999 and December 2004. Infants who received > or = 1 dose of endotracheal epinephrine in the delivery room during resuscitation were included in the study population whether or not they survived to be admitted to the NICU. Exclusion criteria included lethal congenital anomalies, delivery outside the hospital, and missing medical charts. RESULTS: Of 93,656 infants, 52 neonates (0.06%) received epinephrine in the delivery room, 5 of whom met exclusion criteria. Of the remaining 47 infants, 44 (94%) received the first dose via the endotracheal tube. Only 14 (32%) of 44 achieved return of spontaneous circulation after endotracheal tube administration of epinephrine. Of the 30 remaining infants, 23 (77%) had return of spontaneous circulation with intravenous epinephrine after initially failing endotracheal tube epinephrine. There were no differences in clinical characteristics between newborns who responded to endotracheal tube versus intravenous epinephrine except for a lower blood glucose on NICU admission (52 vs 113 mg%). CONCLUSIONS: Endotracheal epinephrine is frequently used when intensive resuscitation is required in the delivery room. The previously recommended endotracheal epinephrine dose of 0.01 to 0.03 mg/kg is often ineffective. Higher endotracheal doses will likely be needed to improve efficacy. A prospective study is needed to determine the best endotracheal epinephrine dosing regimen. Until such information is available, intravenous administration should be the preferred route of delivery.