Chest compressions superimposed with sustained inflation during neonatal cardiopulmonary resuscitation: are we ready for a clinical trial?

Neonates requiring cardiopulmonary resuscitation (CPR) are at risk of mortality and neurodevelopmental injury. Poor outcomes following the need for chest compressions (CCs) in the delivery room prompt the critical need for improvements in resuscitation strategies. This article explores a technique of CPR which involves CCs with sustained inflation (CC+SI). Unique features of CC+SI include (1) improved tidal volume delivery, (2) passive ventilation during compressions, (3) uninterrupted compressions and (4) improved stability of cerebral blood flow during resuscitation. CC+SI has been shown in animal studies to have improved time to return of spontaneous circulation and reduced mortality without significant increase in markers of inflammation and injury in the lung and brain, compared with standard CPR. The mechanics of CCs, rate of compressions, ventilation strategies and compression-to-ventilation ratios are detailed here. A large randomised controlled trial comparing CC+SI versus the current 3:1 compression-to-ventilation ratio is needed, given the growing evidence of its potential benefits.

Sustained inflation and chest compression versus 3:1 chest compression to ventilation ratio during cardiopulmonary resuscitation of asphyxiated newborns (SURV1VE): A cluster randomised controlled trial.

OBJECTIVE: In newborn infants requiring chest compression (CC) in the delivery room (DR) does continuous CC superimposed by a sustained inflation (CC+SI) compared with a 3:1 compression:ventilation (3:1 C:V) ratio decreases time to return of spontaneous circulation (ROSC). DESIGN: International, multicenter, prospective, cluster cross-over randomised trial. SETTING: DR in four hospitals in Canada and Austria, PARTICIPANTS: Newborn infants >28 weeks' gestation who required CC. INTERVENTIONS: Hospitals were randomised to CC+SI or 3:1 C:V then crossed over to the other intervention. MAIN OUTCOME MEASURE: The primary outcome was time to ROSC, defined as the duration of CC until an increase in heart rate >60/min determined by auscultation of the heart, which was maintained for 60 s. Sample size of 218 infants (109/group) was sufficient to detect a clinically important 33% reduction (282 vs 420 s of CC) in time to ROSC. Analysis was intention-to-treat. RESULTS: Patient recruitment occurred between 19 October 2017 and 22 September 2022 and randomised 27 infants (CC+SI (n=12), 3:1 C:V (n=15), two (one per group) declined consent). All 11 infants in the CC+SI group and 12/14 infants in the 3:1 C:V group achieved ROSC in the DR. The median (IQR) time to ROSC was 90 (60-270) s and 615 (174-780) s (p=0.0502 (log rank), p=0.16 (cox proportional hazards regression)) with CC+SI and 3:1 C:V, respectively. Mortality was 2/11 (18.2%) with CC+SI versus 8/14 (57.1%) with 3:1 C:V (p=0.10 (Fisher's exact test), OR (95% CI) 0.17; (0.03 to 1.07)). The trial was stopped due to issues with ethics approval and securing trial insurance as well as funding reasons. CONCLUSION: The time to ROSC and mortality was not statistical different between CC+SI and 3:1 C:V. TRIAL REGISTRATION: NCT02858583.

Correction: Nerdrum Aagaard et al. Significance of Neonatal Heart Rate in the Delivery Room-A Review. Children2023, 10, 1551.

In the original publication [...].

"I can't pose a whole heap of questions that I know I don't have time to follow up"-Exploring perceptions of an adolescent transition program.

BACKGROUND: Adolescent transition programs are patient education programs. They are geared towards enabling adolescents with chronic or long-term illnesses to become active partners in their health care and manage their own health. Although there is agreement about their importance, there is not an agreement on content or how they should be delivered. The study reported here was part of the first steps of an action research project. AIM: Our aim was to explore how health professionals understand the program at our hospital, and their opinions of its implementation. This would advance our knowledge of the practice of the program to support its development. METHODS: We conducted semi-structured individual interviews with 18 physicians and nurses. Data were analysed using qualitative content analysis. In our discussion of the generated data, we use the theory of practice architectures as a lens. RESULTS AND DISCUSSION: We generated four themes through the analysis, namely "We are (back) at scratch", "Time is always an issue", "Getting them ready for what is to come-transition as a synonym to transfer" and "Raising topics that go beyond medical issues". Changes to a practice requires changes to the practice architectures. Practice architectures can both enable and constrain a practice. Our analysis suggests a need for a more unified perception of the program goals, the cultural-discursive arrangements. Health professionals see time as a significant barrier to implementation and changes to the material-economic arrangements are particularly called for, i.e., more time, space and staff to practice the program. These also tie into the social-political arrangements of the program. CONCLUSION: There are arrangements in the practice architecture that currently seem to constrain the practice of the program. The practice is currently fragmented both within and across subspecialties. Efforts should be made to establish a more shared understanding of the program among health professionals. Furthermore, we should investigate how the practice of the program can be better supported.

Significance of Neonatal Heart Rate in the Delivery Room-A Review.

BACKGROUND: Heart rate (HR) is considered the main vital sign in newborns during perinatal transition, with a threshold of 100 beats per minute (bpm), below which, intervention is recommended. However, recent changes in delivery room management, including delayed cord clamping, are likely to have influenced normal HR transition. OBJECTIVE: To summarize the updated knowledge about the factors, including measurement methods, that influence HR in newborn infants immediately after birth. Additionally, this paper provides an overview of delivery room HR as a prognostic indicator in different subgroups of newborns. METHODS: We searched PubMed, EMBASE, and Google Scholar with the terms infant, heart rate, delivery room, resuscitation, pulse oximetry, and electrocardiogram. RESULTS: Seven studies that described HR values in newborn infants immediately after birth were included. Pulse oximetry-derived HR percentiles after immediate cord clamping may not be applicable to the current practice of delayed cord clamping and the increasing use of delivery room electrocardiograms. Mask ventilation may adversely affect HR, particularly in premature and non-asphyxiated infants. Prolonged bradycardia is a negative prognostic factor, especially if combined with hypoxemia in infants <32 weeks of gestation. CONCLUSIONS: HR assessment in the delivery room remains important. However, the cardiopulmonary transition is affected by delayed cord clamping, gestational age, and underlying conditions.

Exhaled CO2 monitoring to guide non-invasive ventilation at birth: a systematic review.

OBJECTIVE: Measuring exhaled carbon dioxide (ECO2) during non-invasive ventilation at birth may provide information about lung aeration. However, the International Liaison Committee on Resuscitation (ILCOR) only recommends ECO2 detection for confirming endotracheal tube placement. ILCOR has therefore prioritised a research question that needs to be urgently evaluated: 'In newborn infants receiving intermittent positive pressure ventilation by any non-invasive interface at birth, does the use of an ECO2 monitor in addition to clinical assessment, pulse oximetry and/or ECG, compared with clinical assessment, pulse oximetry and/or ECG only, decrease endotracheal intubation in the delivery room, improve response to resuscitation, improve survival or reduce morbidity?'. DESIGN: Systematic review of randomised and non-randomised studies identified by Ovid MEDLINE, Embase and Cochrane CENTRAL search until 1 August 2022. SETTING: Delivery room. PATIENTS: Newborn infants receiving non-invasive ventilation at birth. INTERVENTION: ECO2 measurement plus routine assessment compared with routine assessment alone. MAIN OUTCOME MEASURES: Endotracheal intubation in the delivery room, response to resuscitation, survival and morbidity. RESULTS: Among 2370 articles, 23 were included; however, none had a relevant control group. Although studies indicated that the absence of ECO2 may signify airway obstruction and ECO2 detection may precede a heart rate increase in adequately ventilated infants, they did not directly address the research question. CONCLUSIONS: Evidence to support the use of an ECO2 monitor to guide non-invasive positive pressure ventilation at birth is lacking. More research on the effectiveness of ECO2 measurement in addition to routine assessment during non-invasive ventilation of newborn infants at birth is needed. PROSPERO REGISTRATION NUMBER: CRD42022344849.

The association between infant salivary cortisol and parental presence in the neonatal intensive care unit during and after COVID-19 visitation restrictions: A cross-sectional study.

OBJECTIVES: Parent-infant interaction in the neonatal intensive care unit (NICU) promotes health and reduces infant stress. During the COVID-19 pandemic, however, NICUs restricted parent-infant interaction to reduce viral transmission. This study examined the potential relationship between pandemic visitation restrictions, parental presence and infant stress as measured by salivary cortisol. METHODS: A two-NICU cross-sectional study of infants with gestational age (GA) 23-41 weeks, both during (n = 34) and after (n = 38) visitation restrictions. We analysed parental presence with and without visitation restrictions. The relationship between infant salivary cortisol and self-reported parental NICU presence in hours per day was analysed using Pearson's r. A linear regression analysis included potential confounders, including GA and proxies for infant morbidity. The unstandardised B coefficient described the expected change in log-transformed salivary cortisol per unit change in each predictor variable. RESULTS: Included infants had a mean (standard deviation) GA of 31(5) weeks. Both maternal and paternal NICU presence was lower with versus without visitation restrictions (both p ≤0.05). Log-transformed infant salivary cortisol correlated negatively with hours of parental presence (r = -0.40, p = .01). In the linear regression, GA (B = -0.03, p = .02) and central venous lines (B = 0.23, p = .04) contributed to the variance in salivary cortisol in addition to parental presence (B = -0.04 p = .04). CONCLUSION: COVID-19-related visitation restrictions reduced NICU parent-infant interaction and may have increased infant stress. Low GA and central venous lines were associated with higher salivary cortisol. The interaction between immaturity, morbidity and parental presence was not within the scope of this study and merits further investigation.

A Piglet Perinatal Asphyxia Model to Study Cardiac Injury and Hemodynamics after Cardiac Arrest, Resuscitation, and the Return of Spontaneous Circulation.

Neonatal piglets have been extensively used as translational models for perinatal asphyxia. In 2007, we adapted a well-established piglet asphyxia model by introducing cardiac arrest. This enabled us to study the impact of severe asphyxia on key outcomes, including the time taken for the return of spontaneous circulation (ROSC), as well as the effect of chest compressions according to alternative protocols for cardiopulmonary resuscitation. Due to the anatomical and physiological similarities between piglets and human neonates, piglets serve as good models in studies of cardiopulmonary resuscitation and hemodynamic monitoring. In fact, this cardiac arrest model has provided evidence for guideline development through research on resuscitation protocols, pathophysiology, biomarkers, and novel methods for hemodynamic monitoring. Notably, the incidental finding that a substantial fraction of piglets have pulseless electrical activity (PEA) during cardiac arrest may increase the applicability of the model (i.e., it may be used to study pathophysiology extending beyond the perinatal period). However, the model generation is technically challenging and requires various skill sets, dedicated personnel, and a fine balance of the measures, including the surgical protocols and the use of sedatives/analgesics, to ensure a reasonable rate of survival. In this paper, the protocol is described in detail, as well as experiences with adaptations to the protocol over the years.

Biochemical surveillance versus clinical observation of term infants born after prolonged rupture of membranes - A quality assurance initiative.

AIM: To examine whether biochemical surveillance vs clinical observation of term infants with prolonged rupture of membranes as a risk factor for early-onset sepsis is associated with differences in patient trajectories in maternity and neonatal intensive care units. METHODS: A retrospective study of live-born infants with gestational age ≥ 37 + 0 weeks born after prolonged rupture of membranes (≥24 h) in four Norwegian hospitals 2017-2019. Two hospitals used biochemical surveillance, and two used predominantly clinical observation to identify early-onset sepsis cases. RESULTS: The biochemical surveillance hospitals had more C-reactive protein measurements (p < 0.001), neonatal intensive care unit admissions (p < 0.001) and antibiotic treatment (p < 0.001). Hospitals using predominantly clinical observation initiated antibiotic treatment earlier in infants with suspected early-onset sepsis (p = 0.04) but not in infants fulfilling early-onset sepsis diagnostic criteria (p = 0.09). There was no difference in antibiotic treatment duration (p = 0.59), fraction of infants fulfilling early-onset sepsis diagnostic criteria (p = 0.49) or length of hospitalisation (p = 0.30), and no early-onset sepsis-related adverse outcomes. CONCLUSION: The biochemical surveillance hospitals had more C-reactive protein measurements, but there was no difference in antibiotic treatment duration, early-onset sepsis cases, length of hospitalisation or adverse outcomes. Personnel resources needed for clinical surveillance should be weighed against the limitation of potentially painful procedures.

Video-Recorded Airway Suctioning of Clear and Meconium-Stained Amniotic Fluid and Associated Short-Term Outcomes in Moderately and Severely Depressed Preterm and Term Infants.

BACKGROUND: The aim of this study was to investigate delivery room airway suctioning and associated short-term outcomes in depressed infants. METHODS: This is a single-centre prospective observational study of transcribed video recordings of preterm (gestational age, GA < 37 weeks) and term (GA ≥ 37 weeks) infants with a 5 min Apgar score ≤ 7. We analysed the association between airway suctioning, breathing, bradycardia and prolonged resuscitation (≥10 min). For comparison, non-suctioned infants with a 5 min Apgar score ≤ 7 were included. RESULTS: Two hundred suction episodes were performed in 19 premature and 56 term infants. Breathing improved in 1.9% of premature and 72.1% of term infants, and remained unchanged in 84.9% of premature and 27.9% of term infants after suctioning. In our study, 61 (81.3%) preterm and term infants who were admitted to the neonatal intensive care unit experienced bradycardia after airway suctioning. However, the majority of the preterm and more than half of the term infants were bradycardic before the suction procedure was attempted. Among the non-airway suctioned infants (n = 26), 73.1% experienced bradycardia, with 17 non-airway suctioned infants being admitted to the neonatal intensive care unit. There was a need for resuscitation ≥ 10 min in 8 (42.1%) preterm and 32 (57.1%) term infants who underwent airway suctioning, compared to 2 (33.3%) preterm and 19 (95.0%) term infants who did not receive airway suctioning. CONCLUSIONS: In the infants that underwent suctioning, breathing improved in most term, but not preterm infants. More non-suctioned term infants needed prolonged resuscitation. Airway suctioning was not directly associated with worsening of breathing, bradycardia, or extended resuscitation needs.

But what do we mean by "health"? A critical perspective on the concept of health in the adolescent transition program of a Norwegian university hospital.

BACKGROUND: To understand better what influences the practice of our transition program, we wanted to explore the underlying theory of health. METHODS: We performed a qualitative content analysis of the written material that guides the program, comprising a quality system guideline, two checklists, a guide to health professionals and managers, and three patient brochures. RESULTS: The analysis resulted in the formulation of three themes; "Being on top of medical management", "Ability to promote own health" and "Awareness of own goals and expectations". CONCLUSION: Our analysis indicates that the program content revolves mainly around medical management and that other dimensions of health are not emphasised. We question what the goals of the program are and if these goals are explicit and shared among the program stakeholders. An explicit program theory is vital and needs to be evident in material supporting transition programs.

A cross-sectional study of neonatal intensive care unit overcrowding and understaffing associated with bacterial outbreaks.

AIM: To study whether overcrowding and/or nurse understaffing preceded four bacterial outbreaks during a 5-year period in a Norwegian university hospital neonatal intensive care unit (NICU). METHODS: A repeated cross-sectional study based on prospectively collected data from the Norwegian neonatal network's (NNN) web-based electronic database, digital work schedules and information about the outbreaks from logs, reports and publications. Number of admitted patients, category 4-5 patients (i.e., with the highest nurse to patient ratio), rostered nursing staff and nurse specialists were analysed in relation to periods (1) >28 days before individual outbreaks, (2) ≤28 days before, (3) during and (4) after outbreaks. Overcrowding and understaffing were compared between the four periods with Chi-square test and post hoc analysis with Bonferroni correction. RESULTS: When all outbreaks were analysed together, overcrowding was more frequent in the periods within 28 days of outbreaks compared to the other periods (p < 0.001). For understaffing, the periods within 28 days of outbreaks were only different from the periods >28 days before outbreaks (p < 0.001). The trends regarding individual outbreaks were less consistent, but there were more category 4-5 patients before and during the outbreaks. CONCLUSION: Bacterial outbreaks in a 5-year period were weakly associated with overcrowding and understaffing.

Advanced Clinical Neonatal Nursing Students' Transfer of Performance: From Skills Training With Real-Time Feedback on Ventilation to a Simulated Neonatal Resuscitation Scenario.

Background: Advanced clinical neonatal nurses are expected to have technical skills including bag-mask ventilation. Previous studies on neonatal bag-mask ventilation skills training focus largely on medical students and/or physicians. The aim of this study was to investigate whether advanced clinical neonatal nursing students' bag-mask ventilation training with real-time feedback resulted in transfer of bag-mask ventilation performance to a simulated setting without feedback on ventilation. Materials and Methods: Students in advanced clinical neonatal nursing practiced bag-mask ventilation on a premature manikin (Premature Anne, Laerdal Medical, Stavanger, Norway) during skills training. A flow sensor (Neo Training, Monivent AB, Gothenburg, Sweden) was placed between the facemask and the self-inflating bag (Laerdal Medical), and visual feedback on mask leak (%), expiratory tidal volume (VT e in ml/kg), ventilation rate and inflation pressure was provided. Two months later, the students participated in a simulated neonatal resuscitation scenario. The same variables were recorded, but not fed back to the students. We compared ventilation data from skills- and simulation training. A structured questionnaire was used to investigate the students' self-perceived neonatal ventilation competence before and after the skills- and simulation training. Results: Mask leakage and ventilation rate was higher, and VT e lower and highly variable in the simulated scenario compared with skills training (all p < 0.001). There was no statistically significant difference in inflation pressure (p = 0.92). The fraction of ventilations with VT e within the target range was lower during simulation (21%) compared to skills training (30%) (p < 0.001). There was no difference in the students' self-perceived competence in bag-mask ventilation before vs. after skills- and simulation training. Conclusion: Skills training with real-time feedback on mask leak, ventilation rate, tidal volume, and inflation pressure did not result in objective or subjective improvements in bag-mask ventilation in a simulated neonatal resuscitation situation. Incorrect VT e delivery was common even when feedback was provided. It would be of interest to study whether more frequent training, and training both with and without feedback, could improve transfer of performance to a simulated resuscitation setting.

Neonatal Impedance Cardiography in Asphyxiated Piglets-A Feasibility Study.

Objectives: Impedance cardiography (ICG) is a non-invasive method for continuous cardiac output measurement and has the potential to improve monitoring and treatment of sick neonates. PhysioFlow® is a signal-morphology ICG-system showing promising results in adults with low and high cardiac output, but no data from neonates or neonatal models exist. The aim of this study was to investigate PhysioFlow® feasibility in asphyxiated newborn piglets. Methods: Fifteen piglets, under continuous arterial heart rate (HR) and blood pressure (BP) monitoring, were asphyxiated until asystole. Cardiopulmonary resuscitation was performed and the piglets monitored after return of spontaneous circulation (ROSC). Arterial lactate was measured at baseline, every 5 min throughout asphyxiation, at asystole, and at 10 min and later every 30 min after ROSC. PhysioFlow® measured cardiac stroke volume (SV) and HR, and calculated cardiac index (CI) (L/m2/min). Registrations with a signal quality < 75% were excluded, and registrations recorded for 30 min from start of asphyxia analyzed. Pearson correlations were calculated for CI; and HR, mean BP and blood lactate. Results: The piglets were asphyxiated for median (interquartile range) 30 (20-35) min and had a lactate at asystole of 15.0 (9.1-17.0) mmol/L. Out of a total of 20.991 registrations in all animals combined, there were 10.148 (48.3%) registrations with a signal quality ≥ 75%. Signal quality ≥ 75% varied in individual piglets from 7 to 82% of registrations. We analyzed 1.254 registrations recorded 30 min from initiation of asphyxia, i.e., in piglets with brief asphyxia times, this included cardiopulmonary resuscitation and post-ROSC observation. There was a positive correlation between CI and SVI (r = 0.90, p < 0.001), and between CI and HR (r = 0.446, p < 0.001). There was no correlation between CI, or mean BP or lactate (p = 0.98 and 0.51, respectively). Conclusion: About half of ICG-registrations in asphyxiated piglets were of good quality. However, signal quality was highly variable between piglets. In total, there was a higher proportion of reliable ICG-registrations than reported from clinical delivery room studies using electrical velocimetry. Our data are physiologically plausible and supports further research evaluating PhysioFlow® for cardiac output monitoring in perinatal asphyxia. In particular, factors influencing inter-individual variations in signal quality should be explored.

Delivery Room ST Segment Analysis to Predict Short Term Outcomes in Near-Term and Term Newborns.

BACKGROUND: ST-segment changes to the fetal electrocardiogram (ECG) may indicate fetal acidosis. No large-scale characterization of ECG morphology immediately after birth has been performed, but ECG is used for heart rate (HR) assessment. We aimed to investigate ECG morphology immediately after birth in asphyxiated infants, using one-lead dry-electrode ECG developed for HR measurement. METHODS: Observational study in Tanzania, between 2013-2018. Near-term and term infants that received bag-mask ventilation (BMV), and healthy controls, were monitored with one-lead dry-electrode ECG with a non-diagnostic bandwidth. ECGs were classified as normal, with ST-elevations or other ST-segment abnormalities including a biphasic ST-segment. We analyzed ECG morphology in relation to perinatal variables or short-term outcomes. RESULTS: A total of 494 resuscitated and 25 healthy infants were included. ST-elevations were commonly seen both in healthy infants (7/25; 28%) and resuscitated (320/494; 65%) infants. The apparent ST-elevations were not associated with perinatal variables or short-term outcomes. Among the 32 (6.4%) resuscitated infants with "other ST-segment abnormalities", duration of BMV was longer, 1-min Apgar score lower and normal outcomes less frequent than in the resuscitated infants with normal ECG or ST-elevations. CONCLUSIONS: ST-segment elevation was commonly seen and not associated with negative outcomes when using one-lead dry-electrode ECG. Other ST-segment abnormalities were associated with prolonged BMV and worse outcome. ECG with appropriate bandwidth and automated analysis may potentially in the future aid in the identification of severely asphyxiated infants.

Sepsis treatment options identified by 10-year study of microbial isolates and antibiotic susceptibility in a level-four neonatal intensive care unit.

AIM: This observational study investigated the microbiology of blood culture-positive sepsis episodes and susceptibility to empiric antibiotics in early-onset sepsis (EOS) and late-onset sepsis (LOS) in a level-four neonatal intensive care unit (NICU) from 2010 to 2019. METHODS: It was based on patient records and data that Oslo University Hospital, Norway, routinely submitted to the Norwegian Neonatal Network database. Clinical data were merged with blood culture results, including antibiotic susceptibility. RESULTS: We studied 5249 infants admitted to the NICU 6321 times and identified 324 positive blood cultures from 287 infants, with 30 EOS and 305 LOS episodes. Frequent causative agents for EOS were group B streptococci (33.3%), Escherichia coli (20.0%) and Staphylococcus aureus (16.7%). All were susceptible to empiric ampicillin and gentamicin. LOS was most frequently caused by coagulase-negative staphylococci (CONS) (73.8%), Staphylococcus aureus (15.7%) and Enterococci (6.9%). CONS, Staphylococcus aureus, Enterococci, Escherichia coli, Klebsiella and Enterobacter represented 91.9% of LOS episodes and were susceptible to vancomycin and cefotaxime (96.1%), vancomycin and gentamicin (97.0%) and cloxacillin and gentamicin (38.1%). CONCLUSION: Empiric treatment with ampicillin and gentamicin was adequate for EOS. Combining vancomycin and gentamicin may be a safer alternative to cefotaxime for LOS, as this reduces exposure to broad-spectrum antibiotics.

Corrigendum: Management of the unexpected difficult airway in neonatal resuscitation.

[This corrects the article DOI: 10.3389/fped.2021.699159.].

A critical appraisal of tools for delivery room assessment of the newborn infant.

Assessment of an infant's condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed. IMPACT: This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn's postnatal condition. A revised neonatal scoring system should account for infant maturity and the interventions administered. Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.

Management of the Unexpected Difficult Airway in Neonatal Resuscitation.

A "difficult airway situation" arises whenever face mask ventilation, laryngoscopy, endotracheal intubation, or use of supraglottic device fail to secure ventilation. As bradycardia and cardiac arrest in the neonate are usually of respiratory origin, neonatal airway management remains a critical factor. Despite this, a well-defined in-house approach to the neonatal difficult airway is often lacking. While a recent guideline from the British Pediatric Society exists, and the Scottish NHS and Advanced Resuscitation of the Newborn Infant (ARNI) airway management algorithm was recently revised, there is no Norwegian national guideline for managing the unanticipated difficult airway in the delivery room (DR) and neonatal intensive care unit (NICU). Experience from anesthesiology is that a "difficult airway algorithm," advance planning and routine practicing, prepares the resuscitation team to respond adequately to the technical and non-technical stress of a difficult airway situation. We learned from observing current approaches to advanced airway management in DR resuscitations in a university hospital and make recommendations on how the neonatal difficult airway may be managed through technical and non-technical approaches. Our recommendations mainly pertain to DR resuscitations but may be transferred to the NICU environment.