A precipitous delivery has occurred in the ED and a term neonate has been delivered by vaginal delivery. Meconium-stained liquor was present. Currently the baby appears floppy and is not crying.
Which ONE of the following is TRUE?
Answer: D: When babies have meconium-stained amniotic fluid, they are at risk of developing meconium aspiration syndrome (MAS) – upon taking their first breath they inhale thick meconium that may cause a form of pneumonitis. In the past these babies would be suctioned intrapartum on the perineum – this is no longer recommended. Tracheal intubation and suctioning of meconium-stained but vigorous infants at birth does not reduce the incidence of MAS. Similarly, there are no systematic studies to address the benefit or complications of tracheal suctioning in meconium-stained, depressed infants. With meconium-stained depressed infants, ILCOR therefore still recommends the current traditional management of tracheal suctioning via an endotracheal tube, immediately after birth and before stimulation (to prevent meconium inhalation with the first breaths). If meconium is retrieved on this initial suctioning, further intubations and repeat suctioning is needed until the airway is clear of meconium. Review of the need for ventilation, compressions or adrenaline can then take place according to the standard neonatal resuscitation protocol. Positive pressure ventilation is inappropriate in this setting until it is certain that meconium has been cleared from the airway.Tracheal suctioning is not necessary for babies with meconium-stained fluid who are vigorous.
Air is the initial choice during newborn resuscitation. In full-term infants receiving resuscitation at birth with positive pressure ventilation, it is best to begin with air rather than 100% oxygen. If despite effective ventilation there is no increase in heart rate or if oxygenation (guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.
Reference:
Regarding ventilation strategies in newborn resuscitation, which ONE of the following is TRUE?
Answer: A: There is currently no evidence to support the use of inflation pressures higher than those that are necessary to achieve improvement in heart rate or chest expansion. This can usually be achieved in term infants with an inflation pressure of 30 cm H2O (LOE 4) and in preterm infants with pressures of 20–25 cm H2O (LOE 4). Occasionally, higher pressures are required (LOE 4). If positive-pressure ventilation is required, an initial inflation pressure of 20–25 cm H2O is adequate for most preterm infants. If prompt improvement in heart rate or chest movement is not obtained, then higher pressures to achieve effective ventilation may be needed. PEEP is likely to be beneficial during initial stabilization of apnoeic preterm infants who require positive-pressure ventilation and should be used if suitable equipment is available.
For spontaneously breathing preterm infants at ≥25 weeks’ gestation who have signs of respiratory distress, there is no significant difference between starting CPAP or intubation and mechanical ventilation in the delivery room when considering death or oxygen requirement at 36 weeks postmenstrual age. In spontaneously breathing infants at 25–28 weeks’ gestation, CPAP compared with intubation reduced the rates of mechanical ventilation from 100% to 46% and surfactant use from 77% to 38% (LOE 14).
Regarding ongoing monitoring during resuscitation of children, which ONE of the following is TRUE?
Answer: C: In the initial stages of cardiac arrest due to an asphyxial cause (which is most common in children), the ETCO2 is usually elevated. Level 4 evidence from adult and paediatric case series suggest that ETCO2 readings rise with interventions that increase cardiac output, and may be useful in assessing the quality of interventions such as good chest compression. As an estimate, if the ETCO2 is consistently <15 mmHg, it may indicate the quality of chest compressions is poor or excessive ventilation is decreasing the CO2 level. The ETCO2 must be interpreted with caution for 1–2 minutes after administration of adrenaline or other vasoconstrictive medications because these medications may decrease the ETCO2 .
In one LOE 4 and two LOE 5 adult case series an abrupt and sustained rise in ETCO2 often preceded identification of ROSC. Two LOE 4 paediatric cases series showed that a low ETCO2 (10–15 mmHg) despite 15–20 minutes of advanced life support is strongly associated with failure to achieve ROSC. The data is insufficient to recommend this as a threshold for terminating resuscitation measures.
There is insufficient evidence (small case series, level 4 or 5 evidence) to recommend for or against the routine use of echocardiography during paediatric cardiac arrest. Clearly, however, in the hands of trained personnel, echo may be useful in identifying a case for arrest such as tamponade. The use of echo must be weighed against the obvious deleterious effect of delayed or interrupted CPR.
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