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Background Compared with those born at term gestation, infants with complex congenital heart defects (CCHD) who were delivered before 37 weeks of gestational age and received neonatal open cardiac surgery (OHS) have poorer neurodevelopmental outcomes in early childhood. Specific details related to the neurodevelopmental outcome of these infants remain unpublished. Objectives To describe the growth, disability, functional, and neurodevelopmental outcome in early childhood of preterm infants (born at Design/Methods We studied all infants with CCHD who received OHS within 6 weeks of corrected age between 1996 and 2016. In the Western Canadian Complex Pediatric Therapies Follow-up Program, comprehensive neurodevelopmental assessments at a corrected age of 18-24 months were done by multidisciplinary teams at the original referral sites. In addition to demographic and clinical data, standardized age-appropriate outcome measures included physical growth with calculated Z-scores, disabilities including cerebral palsy, visual impairment, sensorineural hearing loss; adaptive function (Adaptive Behavioural Assessment System-II); and cognitive, language, and motor skills (Bayley Scales of Infant and Toddler Development-III). Results From 1996 to 2016, 115 preterm infants (34±2 weeks gestation, 2339±637g, 64% males) with CCHD had OHS with 11(10%) deaths before first discharge and 21 (18%) by 2 years. Prior to the first surgery, 7 (6%) neonates had cerebral injuries. Overall, 7 had necrotizing enterocolitis; none had retinopathy of prematurity. All 94 surviving infants received comprehensive evaluation at 2 years corrected age; Eighteen (19%) had congenital syndromes who had worse functional and neurodevelopmental outcomes compared to those (n=76) without syndromal abnormalities (SA) (Table). Conclusion For preterm neonates with CCHD and early OHS, the mortality was significant, but the short-term neonatal morbidity was not increased. Compared with published preterm outcomes, the early outcome suggests more cerebral palsy but not sensorineural hearing loss, and greater neurodevelopmental delay. This information is important for management care of the infants, parental counselling and the decision-making process.

Background Current neonatal resuscitation guidelines recommend using 100% oxygen during chest compressions (CC), however the most effective oxygen concentration during cardiopulmonary resuscitation remains controversial. Aim In term newborn piglets with asphyxia-induced cardiac arrest does 21% oxygen compared to 100% oxygen during resuscitation using CC during sustained inflation (SI; CC + SI) will have a reduced time to return of spontaneous circulation (ROSC). Intervention and measurements Twenty-two mixed breed piglets (1–3 days old, 1.7–2.4 kg), were obtained on the day of the experiment and anesthetized, intubated, instrumented, and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were resuscitated using CC + SI and randomized to 21% oxygen (n = 8) or 100% oxygen (n = 8). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. Main results Baseline parameters were similar between 21% and 100% oxygen groups. There was no difference in asphyxiation (duration and degree) between groups. Time to ROSC was similar between 21% and 100% oxygen groups: median (interquartile range - IQR) 80 (70−190)sec vs. 90 (70−324)sec, (p = 0.56). There was no significant difference in the rate of ROSC between 21% and 100% oxygen groups: 7/8 (88%) vs. 5/8 (63%), (p = 0.569). All piglets that achieved ROSC survived to four hours post-resuscitation. Hemodynamics and regional perfusion were not significantly different between groups. Conclusions In term newborn piglets resuscitated by CC + SI, the use of 21% oxygen resulted in a similar time to ROSC, short-term survival, and hemodynamic recovery compared to 100% oxygen.

Background 6.5–9 million newborns worldwide require resuscitation at birth annually. During neonatal resuscitation, inaccurate or slow heart rate (HR) assessments may significantly increase risk of infant mortality or morbidity. Therefore fast, accurate, and effective HR assessment tools are critical for neonatal resuscitation. Objective To systematically review the literature about accuracy, latency, and efficacy of technologies for HR assessment during neonatal resuscitation. Methods Adhering to PRISMA guidelines, PubMed, EMBASE, and Google Scholar databases were systematically searched to identify studies related to technologies for HR assessment, which could be used to guide neonatal resuscitation. Results Forty-six studies evaluating HR assessment technologies for neonatal resuscitation were identified. In total, 16 studies (3/16 randomized trials and 13/16 observational studies) compared two or more HR assessment technologies to measure accuracy, latency, and efficacy. Of the trials, 1/3 had a low risk of bias while 2/3 had high risks. All observational studies had high risks of bias. Most studies considered infants not requiring resuscitation, constituting indirect evidence and lower certainty in the context of neonatal resuscitation. Two trials reported faster times to HR assessment using electrocardiogram with a mean(SD) 66(20) versus 114(39) s and a median(IQR) 24(19–39) versus 48(36–69) s (both p Conclusion While electrocardiography is faster to assess HR at birth and more reliable to detect HR changes compared to other recommended technologies, practice should not exclusively rely on ECG. While novel technologies could support HR assessment, no studies validate their clinical efficacy during neonatal resuscitation.

Background: Male and female newborns have differences in their fetal development, fetal-to-neonatal transition, and postnatal morbidity. However, the cardiovascular fetal-to-neonatal adaption is similar between sexes. No study has examined sex differences in newborns during hypoxia, asphyxia, cardio-pulmonary resuscitation, or post-resuscitation recovery. Methods: Secondary analysis (two previous publications and two studies currently under peer-review) of 110 term newborn mixed breed piglets (1-3 days of age, weighing 2.0 ± 0.2 kg), which were exposed to 30 min normocapnic hypoxia followed by asphyxia until asystole, which was achieved by disconnecting the ventilator and clamping the endotracheal tube. This was followed by cardio-pulmonary resuscitation. For the analysis piglets were divided into female and male groups. Cardiac function, carotid blood flow, and cerebral and renal oxygenation were continuously recorded throughout the experiment. Results: A total of 35/41 (85%) female and 54/69 (78%) male piglets resuscitated achieved ROSC (p = 0.881). The median (IQR) time to achieve return of spontaneous circulation in females and males was 111 (80-228) s and 106 (80-206) s (p = 0.875), respectively. The 4-h survival rate was similar between females and males with 28/35 (80%) and 49/54 (91%) piglets surviving (p = 0.241), respectively. Conclusions: No difference between female and male newborn piglets was observed during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery.

Central venous catheter (CVC) placement is common in the care of very low birthweight (VLBW) preterm neonates. Although it is generally considered to be safe, CVC placement is associated with complications, including extravasation that may lead to significant morbidity and mortality. We report the clinical course of an extremely preterm neonate born at 27 weeks gestation, and another 5 VLBW preterm neonates reported in the literature with hemidiaphragmatic paralysis related to extravasation of parenteral solution from CVC placement. In VLBW preterm neonates, spontaneous recovery of diaphragmatic paralysis related to extravasation of parenteral solution is possible.

Respiratory failure is a common condition faced by critically ill neonates with respiratory distress syndrome (RDS). High frequency oscillatory ventilation (HFOV) is often used for neonates with refractory respiratory failure related to RDS. Volume guarantee (VG) mode has been added to some HFOV ventilators for providing consistent tidal volume. We sought to examine the impact of adding the VG mode during HFOV on systemic and cerebral hemodynamics, which has not been studied to date. A neonatal piglet model of moderate to severe RDS was induced by saline lavage. Piglets (full term, age 1–3 days, weight 1.5–2.4 kg) were randomized to have RDS induced and receive either HFOV or HFOV+VG (n = 8/group) or sham-operation (n = 6) without RDS. Cardiac function measured by a Millar® catheter placed in the left ventricle as well as systemic and carotid hemodynamic and oxygen tissue saturation parameters were collected over 240 min of ventilation. Mean airway pressure, alveolar-arterial oxygen difference and left ventricular cardiac index of piglets on HFOV vs. HFOV+VG were not significantly different during the experimental period. Right common carotid artery flow index by in-situ ultrasonic flow measurement and cerebral tissue oxygen saturation (near-infrared spectroscopy) significantly decreased in HFOV+VG at 240 min compared to HFOV (14 vs. 31 ml/kg/min, and 30% vs. 43%, respectively; p

Aim Despite the minimal evidence, neonatal resuscitation guidelines recommend using 100% oxygen when chest compressions (CC) are needed. Uninterrupted CC in adult cardiopulmonary resuscitation (CPR) may improve CPR hemodynamics. We aimed to examine 21% oxygen (air) vs. 100% oxygen in 3:1 CC:ventilation (C:V) CPR or continuous CC with asynchronous ventilation (CCaV) in asphyxiated newborn piglets following cardiac arrest. Methods Piglets (1–3 days old) were progressively asphyxiated until cardiac arrest and randomized to 4 experimental groups ( n =8 each): air and 3:1 C:V CPR, 100% oxygen and 3:1 C:V CPR, air and CCaV, or 100% oxygen and CCaV. Time to return of spontaneous circulation (ROSC), mortality, and clinical and biochemical parameters were compared between groups. We used echocardiography to measure left ventricular (LV) stroke volume at baseline, at 30min and 4h after ROSC. Left common carotid artery blood pressure was measured continuously. Results Time to ROSC (heart rate ≥100min −1 ) ranged from 75 to 592s and mortality 50–75%, with no differences between groups. Resuscitation with air was associated with higher LV stroke volume after ROSC and less myocardial oxidative stress compared to 100% oxygen groups. CCaV was associated with lower mean arterial blood pressure after ROSC and higher myocardial lactate than those of 3:1 C:V CPR. Conclusion In neonatal asphyxia-induced cardiac arrest, using air during CC may reduce myocardial oxidative stress and improve cardiac function compared to 100% oxygen. Although overall recovery may be similar, CCaV may impair tissue perfusion compared to 3:1 C:V CPR.

Doppler studies at rest suggest left ventricular (LV) diastolic function rapidly improves from the neonate to infant. Whether this translates to its response to hemodynamic challenges is uncertain. We sought to explore the impact of early LV maturation on its ability to tolerate atrial tachycardia. As tachycardia reduces filling time, we hypothesized that the neonatal LV would be less tolerant of atrial tachycardia. Landrace cross piglets of two age groups (1–3 days; NPs; 14–17 days, YPs; n = 7/group) were instrumented for an atrial pacing protocol (from 200 to 300 beats/min) and assessed by invasive monitoring and echocardiography. NPs maintained their LV output and blood pressure, whereas YPs did not. Although negative dP/d t in NPs at baseline was lower than that of YPs (−1,599 ± 83 vs. −2,470 ± 226 mmHg/s, respectively, P = 0.007), with increasing tachycardia negative dP/d t converged between groups and was not different. Both groups had similar preload reduction during tachycardia; however, NPs maintained shortening fraction while YPs decreased (NPs: 35.4 ± 1.4 vs. 31.8 ± 2.2%, P = 0.35; YPs: 31.4 ± 0.8 vs. 22.9 ± 0.8%, P < 0.001). Contractility measures did not differ between groups. Peak LV twist and untwisting rate also did not differ; however, NPs tended to augment LV twist through increased apical rotation and YPs through increasing basal rotation ( P = 0.009). The NPs appear more tolerant of atrial tachycardia than the YPs. They have at least similar diastolic performance, enhanced systolic performance, and different LV twist mechanics, which may contribute to improved tachycardia tolerance of NPs.

Background: Heart rate assessment immediately after birth in newborn infants is critical to the correct guidance of resuscitation efforts. There are disagreements as to the best method to measure heart rate. Objective: The aim of this study was to assess different methods of heart rate assessment in newborn infants at birth to determine the fastest and most accurate method. Methods: PubMed, EMBASE and Google Scholar were systematically searched using the following terms: ‘infant', ‘heart rate', ‘monitoring', ‘delivery room', ‘resuscitation', ‘stethoscope', ‘auscultation', ‘palpation', ‘pulse oximetry', ‘electrocardiogram', ‘Doppler ultrasound', ‘photoplethysmography' and ‘wearable sensors'. Results: Eighteen studies were identified that described various methods of heart rate assessment in newborn infants immediately after birth. Studies examining auscultation, palpation, pulse oximetry, electrocardiography and Doppler ultrasound as ways to measure heart rate were included. Heart rate measurements by pulse oximetry are superior to auscultation and palpation, but there is contradictory evidence about its accuracy depending on whether the sensor is connected to the infant or the oximeter first. Several studies indicate that electrocardiogram provides a reliable heart rate faster than pulse oximetry. Doppler ultrasound shows potential for clinical use, however future evidence is needed to support this conclusion. Conclusion: Heart rate assessment is important and there are many measurement methods. The accuracy of routinely applied methods varies, with palpation and auscultation being the least accurate and electrocardiogram being the most accurate. More research is needed on Doppler ultrasound before its clinical use.

BackgroundVisual attention (VA) is important for situation awareness and decision-making. Eye tracking can be used to analyse the VA of healthcare providers. No study has examined eye tracking during neonatal resuscitation.ObjectiveTo test the use of eye tracking to examine VA during neonatal resuscitation.MethodsSix video recordings were obtained using eye tracking glasses worn by resuscitators during the first 5 min of neonatal resuscitation. Videos were analysed to obtain (i) areas of interest (AOIs), (ii) time spent on each AOI and (iii) frequency of saccades between AOIs.ResultsFive videos were of acceptable quality and analysed. Only 35% of VA was directed at the infant, with 33% at patient monitors and gauges. There were frequent saccades (0.45/s) and most involved patient monitors.ConclusionDuring neonatal resuscitation, VA is often directed away from the infant towards patient monitors. Eye tracking can be used to analyse human performance during neonatal resuscitation.

BackgroundSustained inflation (SI) during chest compression (CC = CC+SI) has been recently shown as an alternative method during cardiopulmonary resuscitation in neonates. However, the optimal peak inflation pressure (PIP) of SI during CC+SI to improve ROSC and hemodynamic recovery is unknown.ObjectiveTo examine if different PIPs of SI during CC+SI will improve ROSC and hemodynamic recovery in severely asphyxiated piglets.MethodsTwenty-nine newborn piglets (1-3 days old) were anesthetized, intubated, instrumented and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were randomized into four groups: CC+SI with a PIP of 10 cmH2O (CC+SI_PIP_10, n = 8), a PIP of 20 cmH2O (CC+SI_PIP_20, n = 8), a PIP of 30 cmH2O (CC+SI_PIP_30, n = 8), and a sham-operated control group (n = 5). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.ResultsBaseline parameters were similar between all groups. There was no difference in asphyxiation (duration and degree) between intervention groups. PIP correlated positively with tidal volume (VT) and inversely with exhaled CO2 during cardiopulmonary resuscitation. Time to ROSC and rate of ROSC were similar between piglets resuscitated with CC+SI_PIP_10, CC+SI_PIP_20, and CC+SI_PIP_30 cmH2O: median (IQR) 75 (63-193) sec, 94 (78-210) sec, and 85 (70-90) sec; 5/8 (63%), 7/8 (88%), and 3/8 (38%) (p = 0.56 and p = 0.12, respectively). All piglets that achieved ROSC survived to four hours post-resuscitation. Piglets resuscitated with CC+SI_PIP_30 cmH2O exhibited increased concentrations of pro-inflammatory cytokines interleukin-1β and tumour necrosis factor-α in the frontoparietal cerebral cortex (both pConclusionIn asphyxiated term newborn piglets resuscitated by CC+SI, the use of different PIPs resulted in similar time to ROSC, but PIP at 30 cmH2O showed a larger VT delivery, lower exhaled CO2 and increased tissue inflammatory markers in the brain.

In this review, we summarize the results of studies that investigated the effects of hypoxia and reoxygenation in cardiac arrest, including the use of different fractions of inspired oxygen, in neonatal animals. The studies were heterogenous in terms of anaesthetic regimens, and definitions of cardiac arrest and circulatory recovery. Cardiopulmonary resuscitation with 100% oxygen increased oxidative stress in maturing rats. Studies in fetal/neonatal lambs and post-transitional neonatal piglets indicate no consistent differences between ventilation with 21% vs. 100% oxygen with regards to recovery times, oxygen damage or adverse events. If 21% oxygen is as effective as 100% oxygen in newborn infants with cardiac arrest requiring chest compression, the use of 21% instead of 100% oxygen could reduce morbidity and mortality in asphyxiated infants. Unanswered questions include what is the most optimal cerebral oxygen delivery during reperfusion, as well as oxygenation targets after return of spontaneous circulation.

ObjectiveTo determine whether different chest compression (CC) rates during continuous CC with asynchronous ventilations (CCaV) reduce time to return of spontaneous circulation (ROSC) and improved haemodynamic recovery in piglets aged 24–72 hours with asphyxia-induced asystole.MethodsThirty piglets (aged 24–72 hours) were anaesthetised, intubated, instrumented and exposed to 30 min normocapnic hypoxia followed by asphyxia. Piglets were randomised into four groups: CCaV with CC rate of 90 (CCaV+90, n=8), 100 (CCaV+100, n=8) or 120 compressions per minute (CCaV+120, n=8), and a sham-operated group (n=6). Cardiac function, carotid blood flow, cerebral and renal oxygenation and respiratory parameters were continuously recorded. Cerebral cortical tissue was harvested and assayed for inflammatory and injury markers.ResultsAll three intervention groups had a similar number of piglets achieving ROSC (6/8, 5/8 and 5/8 for CCaV+120, CCaV+100 and CCaV+90, respectively) and mean ROSC time (120, 90 and 90 s for CCaV+120, CCaV+100 and CCaV+90, respectively). The haemodynamic recovery (indicated by carotid flow, cerebral and renal perfusion) was similar between CCaV+120 and sham by the end of experiment. In comparison, CCaV+90 and CCaV+100 had significantly reduced haemodynamic recovery compared with sham operated (p≤0.05). Inflammatory (interleukin [IL]-6 and IL-1β) and injury markers (lactate) were significantly higher in the frontoparietal cortex of CCaV+90 and CCaV+100 compared with sham, whereas brain injury markers were similar between CCaV+120 and sham.ConclusionsAlthough there was no difference between the groups in achieving ROSC, the haemodynamic recovery of CCaV+120 was significantly improved compared with CCaV+90 and CCaV+100, which were also associated with higher cerebral inflammatory and brain injury markers.

Objective We previously demonstrated that sustained inflation (SI) during chest compression (CC) significantly reduces time to return of spontaneous circulation (ROSC) when compared to 3:1 compression:ventilation (C:V) ratio during neonatal resuscitation. However, the optimal length of SI during CC to improve ROSC and hemodynamic recovery in severely asphyxiated piglets is unknown. Aim To examine if different lengths of SI will improve ROSC and hemodynamic recovery in severely asphyxiated piglets. Intervention and measurements Thirty newborn piglets (1–3 days) were anesthetized, intubated, instrumented and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were randomized into four groups: 3:1 C:V (n = 8), CC with an SI duration of either 20 s (CC+SI 20) (n = 8) or 60 s (CC+SI 60) (n = 8), and a sham group (n = 6). Cardiac function, carotid blood flow, cerebral and renal oxygenation as well as respiratory parameters were continuously recorded throughout the experiment. Main results When compared with 3:1 group, both CC+SI 20 and CC+SI 60 groups had significantly shorter ROSC time (p = 0.002). All three intervention groups had similar hemodynamic recovery by the end of 4 h observation period. There was no difference in lung injury markers among all experimental groups. However, when compared to the sham group, the concentrations of IL-6 (thalamus) and IL-6 + IL-8 (frontoparietal cortex) of the 3:1 C:V group were significantly higher, respectively. Conclusions Even though relatively less animals achieved ROSC, CC during SI significantly improved ROSC time compared to 3:1 C:V in asphyxiated newborn piglets. However, there was no difference in ROSC characteristics and hemodynamic recovery between two CC+SI groups.

BackgroundThe 2015 neonatal resuscitation guidelines added ECG as a recommended method of assessment of an infant’s heart rate (HR) when determining the need for resuscitation at birth. However, a recent case report raised concerns about this technique in the delivery room.ObjectivesTo compare accuracy of ECG with auscultation to assess asystole in asphyxiated piglets.MethodsNeonatal piglets had the right common carotid artery exposed and enclosed with a real-time ultrasonic flow probe and HR was continuously measured and recorded using ECG. This set-up allowed simultaneous monitoring of HR via ECG and carotid blood flow (CBF). The piglets were exposed to 30 min normocapnic alveolar hypoxia followed by asphyxia until asystole, achieved by disconnecting the ventilator and clamping the endotracheal tube. Asystole was defined as zero carotid blood flow and was compared with ECG traces and auscultation for heart sounds using a neonatal/infant stethoscope.ResultsOverall, 54 piglets were studied with a median (IQR) duration of asphyxia of 325 (200-491) s. In 14 (26%) piglets, CBF, ECG and auscultation identified asystole. In 23 (43%) piglets, we observed no CBF and no audible heart sounds, while ECG displayed an HR ranging from 15 to 80/min. Sixteen (30%) piglets remained bradycardic (defined as HR of ConclusionClinicians should be aware of the potential inaccuracy of ECG assessment during asphyxia in newborn infants and should rather rely on assessment using a combination of auscultation, palpation, pulse oximetry and ECG.

BACKGROUND The Neonatal Resuscitation Program (NRP) states that if positive pressure ventilation (PPV) was started because a baby had a low heart rate (HR), the baby’s HR should begin to increase within the first 15sec of PPV. However, this recommendation has not been examined in either an animal models nor in the delivery room. OBJECTIVES To assess changes in HR in piglets with asphyxia induced bradycardia. DESIGN/METHODS Term newborn piglets (n=30) were anesthetized, intubated, instrumented, and exposed to 40min normocapnic hypoxia followed by asphyxia. Asphyxia was achieved by clamping the endotracheal tube until the piglet had bradycardia (defined as HR 25% of baseline); at that time CPR was initiated. As per NRP protocol PPV was immediately started for 30sec followed by chest compression. HR was continuously recorded using an ECG during the whole duration of the experiment. Changes in HR during PPV were assessed and divided into four epochs (0-10sec, 5-15sec, 10-20sec and 20-30sec, respectively) after start of PPV. RESULTS The median (IQR) duration of asphyxia was similar between the groups with 189 (128–291)sec, 126 (70–197)sec, 118 (66–250)sec for 3:1C:V, SI+90 and SI+120 respectively (p=0.37; oneway ANOVA with Bonferroni). At time of start of PPV the mean (SD) HR was 35 (13)/min. An increase in HR >100/min was observed in 6/30 (5%) at 30 seconds of PPV. None achieved changes in HR at the epochs 0-10sec, 5-15sec, or 10-20sec. After 15sec of PPV 13/30 (43%) had a decrease in HR and 11/ 30 (36%) had no change in HR. CONCLUSION Adequate PPV does not increase HR in piglets with asphyxia induced bradycardia. This is contrary to the current NRP, which recommends that after 15 sec of PPV HR should be assessed.

BACKGROUND The current Pediatric Advanced Life Support guidelines recommends that newborns who require cardiopulmonary resuscitation (CPR) in settings (e.g., prehospital, Emergency department, or paediatric intensive care unit, etc.) should receive continuous chest compressions with asynchronous ventilations (CCaV) if an advanced airway is in place. However, this has never been examined in a newborn model of neonatal asphyxia. OBJECTIVES To determine if CCaV at rates of 90/min or 120/min compared to current standard of 100/min will reduce the time to return of spontaneous circulation (ROSC) in a porcine model of neonatal resuscitation. DESIGN/METHODS Term newborn piglets were anesthetized, intubated, instrumented, and exposed to 40-min normocapnic hypoxia followed by asphyxia, which was achieved by clamping the endotracheal tube until asystole. Piglets were randomized into 3 CCaV groups: chest compression (CC) at a rate of 90/min (CCaV 90,n=7), of 100/min (CCaV 100,n=7), of 120/min (CCaV 120,n=7), or sham-operated group. A two-step randomization process with sequentially numbered, sealed brown envelope was used to reduce selection bias. After surgical instrumentation and stabilization an envelope containing the allocation “sham” or “intervention” was opened (step one). The sham-operated group had the same surgical protocol, stabilization, and equivalent experimental periods without hypoxia and asphyxia. Only piglets randomized to “intervention” underwent hypoxia and asphyxia. Once the criteria for CPR were met, a second envelope containing the group allocations was opened (step two). Cardiac function, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. RESULTS The mean (±SD) duration of asphyxia was similar between the groups with 260 (±133)sec, 336 (±217)sec, and 231 (±174)sec for CCav 90, CCaV 100, and CCaV 120, respectively (p=1.000; oneway ANOVA with Bonferroni post-test). The mean (SD) time to ROSC was also similar between groups 342 (±345)sec, 312 (±316)sec, and 309 (±287)sec for CCav 90, CCaV 100, and CCaV 120, respectively (p=1.000; oneway ANOVA with Bonferroni post-test). Overall, 5/7 in the CCaV 90, 5/7 in CCaV 100, and 5/7 in the CCaV 120 survived. CONCLUSION There was no significant difference in time to ROSC for either chest compression technique during cardiopulmonary resuscitation in a porcine model of neonatal asphyxia.

BACKGROUND: Improved obstetrical and neonatal care has increased the survival of very preterm neonates, who may have oxygen free radical diseases of neonatology including Retinopathy of Prematurity (ROP). Multiple risk factors have been identified for developing ROP such as gestation, hypoxemia and hypercapnia. However, there is little information regarding the predictive factors for ROP at the early hours after birth. OBJECTIVES: We aimed to investigate the incidence and risk factors ROP in the very preterm neonates. We also examined if the hemodynamic parameters and urine output during the first day of life would be associated with the development of ROP later. DESIGN/METHODS: Using a prospective database supplemented with retrospective chart review, we identified very preterm neonates born at gestation 80 mmHg) and hypoxia (PaO2

Background: High-quality chest compression is essential during neonatal cardiopulmonary resuscitation (CPR). However, the optimal compression to ventilation ratio (C:V) that should be used during neonatal CPR to optimize coronary and cerebral perfusion while providing adequate ventilation remains unknown. Objective: We hypothesized that different C:V ratios (e.g., 2: 1 or 4: 1) will reduce the time to return of spontaneous circulation (ROSC) in severely asphyxiated piglets. Methods: Thirty-one newborn piglets (1–4 days old) were anesthetized, intubated, instrumented, and exposed to 50-min normocapnic hypoxia followed by asphyxia. Piglets were randomized into 4 groups: 2: 1 (n = 8), 3: 1 (n = 8), 4: 1 (n = 8) C:V ratio, or a sham group (n = 7). Cardiac function, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. Results: Thirty-one piglets were included in the study, and there was no difference in the duration of asphyxia or the degree of asphyxiation (as indicated by pH, PaCO2, and lactate) among the different groups. The median (IQR) time to ROSC was similar between the groups with 127 (82–210), 96 (88–126), and 119 (83–256) s in the 2: 1, 3: 1, and 4: 1 C:V ratio groups, respectively (p = 0.67 between groups). Similarly, there was no difference in 100% oxygen requirement or epinephrine administration between the experimental groups. Conclusions: Different C:V ratios resulted in similar ROSC, mortality, oxygen, and epinephrine administration during resuscitation in a porcine model of neonatal asphyxia.

Introduction The purpose of inflations during cardiopulmonary resuscitation (CPR) is to deliver an adequate tidal volume (V T ) to facilitate gas exchange. However, no study has examined V T delivery during chest compression (CC) in detail to understand the effect of CC on lung aeration. The aim of the study was to examine V T changes during CC and their effect on lung aeration. Methods Piglets were anaesthetised, instrumented and intubated with zero leak. They were then randomly assigned to CPR using either 3:1 compression:ventilation ratio (C:V) (n=6), continuous CC with asynchronous ventilations (CCaV) (90 CC/min with 30/min asynchronous ventilations) (n=6) or continuous CC superimposed with 30 s sustained inflations (CC+SI) with a CC rate of 120/min (n=5). A respiratory function monitor (NM3, Respironics, Philips, Andover, Massachusetts, USA) was used to continuously measure inspiration tidal volume (V Ti ) and expirational tidal volume (V Te ). ANOVA with Bonferroni post-test were used to compare variables of all three groups. Results During the inflation in the 3:1 C:V group, the mean (SD) V Ti and V Te was 23.5 (5.3) mL/kg and 19.4 (2.7) mL/kg (p=0.16), respectively. During the CC, we observed a significant V T loss in the 3:1 group with V Ti and V Te being 4.1 (1.2) mL/kg and 11.1 (3.3) mL/kg (p=0.007), respectively. In the CCaV group, V Te was higher compared with V Ti , but this was not significant. In the CC+SI group, a V T gain during each CC with V Ti and V Te of 16.3 (3.2) mL/kg and 14 (3) mL/kg (p=0.21), respectively, was observed. Conclusions V T delivery is improved using CC+SI compared with 3:1 C:V. This improvement in V T delivery may lead to better alveolar oxygen delivery and lung aeration.

Preeclampsia is a disorder of pregnancy with a significant impact on maternal and fetal health. The complexity of this multifactorial condition has precluded development of effective therapies and, although many potential pathways have been investigated, the etiology still requires clarification. Our group has investigated the scavenger lectin-like oxidized LDL (LOX-1) receptor, which may respond to factors released from the distressed placenta that contribute to the vascular pathologies observed in preeclampsia. Given the known beneficial effects of sodium tanshinone IIA sulfonate (STS; a component of Salvia miltiorrhiza) on vasodilation, reduction of oxidative stress, and lipid profiles, we have investigated its role as a potential treatment strategy. We hypothesized that STS would improve vascular endothelial function and, combined with a reduction in oxidative stress, would improve pregnancy outcomes in a rat model of preeclampsia (reduced uteroplacental perfusion pressure, RUPP). We further hypothesized this may occur via the action of STS on the LOX-1 and/or platelet-activating factor (PAF) receptor axes. The RUPP model increased maternal blood pressure, vascular oxidative stress, and involvement of the vascular PAF receptor. Treatment with STS during pregnancy decreased both oxidative stress and involvement of the PAF receptor; however, it also increased involvement of the LOX-1 receptor, which is in line with the concept that scavenger receptors, such as LOX-1 and PAF, are upregulated in response to ligand binding and/or under pathological conditions. In this model of preeclampsia, however, the vascular actions of STS did not lead to improvements in pregnancy outcome such as fetal biometrics or maternal blood pressure.

Objective To determine the distending pressure needed to achieve sufficient tidal volume (V T ) delivery during continuous chest compressions (CC) superimposed by sustained inflation (SI) (CC+SI). Design Randomised animal/manikin trial. Setting University laboratory. Subjects Cadaver piglets/manikin. Interventions SI distending pressures of 5, 10, 15, 20, 25 and 30 cm H 2 O were delivered in random order during CC+SI for 2 min each. Main outcome measures V T , gas flow and airway pressure. Spearman9s r for distending pressure and V T . Results Distending pressure and V T correlated in cadaver piglets (r=0.83, p T was delivered during chest recoil during CC in both models. In cadaver piglets, a distending pressure ∼25 cm H 2 O was needed to achieve an adequate V T . Conclusions Chest recoil generates V T depending on an adequate distending pressure. This has previously been demonstrated in adult animals. A pressure of ∼25 cm H 2 O is needed to achieve an adequate V T delivery.

BackgroundAsphyxia is the most common reason for newborns to fail to make a successful fetal-to-neonatal transition. There is currently a lack of data evaluating hemodynamic effects of epinephrine during neonatal cardiopulmonary resuscitation.MethodsTwenty-four newborn piglets were exposed to asphyxia. Thereafter, positive pressure ventilation was commenced for 30 s, followed by chest compressions (CC). Piglets were randomized into three experimental groups: 3:1 compression:ventilation ratio; CC during sustained inflation (SI) at a rate of 90 CC per minute, or CC during SI at a rate of 120 CC per minute. Epinephrine (0.01 mg/kg per dose) was administered to a maximum of four doses. Hemodynamic parameters were measured throughout the experiment.ResultsAnimals were divided into survivors and nonsurvivors. End-diastolic and developed pressures declined after epinephrine administration in the survivor group. dp/dt min was significantly higher in the survivor group whereas dp/dt max showed no significant differences. Epinephrine had no effect on either heart rate or cardiac output in both groups. Ejection fraction increased after epinephrine with no significant difference between groups.ConclusionEpinephrine did not affect survival rates or return of spontaneous circulation in our postnatal porcine model of neonatal asphyxia.

Approximately 10% of infants will need resuscitation at birth. Resuscitations are performed by nurses, physicians, and other health care providers (HCPs) following international guidelines such as the Neonatal Resuscitation Program (NRP). Often, basic neonatal resuscitation equipment (e.g. monitoring and airway supplies) is not organized to facilitate equipment identification and retrieval, hindering HCP performance. In this study, we developed an equipment box with input from NRP-trained providers, reorganizing neonatal resuscitation equipment to improve ordering, grouping, and labeling. In a crossover simulation study, we tested HCP performance with this box against performance using a standard equipment bag. HCPs were faster in completing a simulated resuscitation scenario when using the equipment box (mean completion time 176 ± 21.6 s) compared with the standard equipment bag (192.6 ± 20.2 s) (p < 0.0001). Despite familiarity with the standard equipment bag, all HCPs preferred the equipment box. Reorganizing basic neonatal resuscitation to improve ordering, grouping, and labeling may improve HCP performance.

Background Early studies suggest an association of abnormal carbon dioxide (PCO2) or oxygen (PO2) levels with adverse inpatient outcomes in very preterm babies. Recent resuscitation practice changes, such as targeted oxygen therapy, end-expiratory pressure, and rescue surfactant may influence these associations. Objective The aim of this study is to assess the range of the initial partial pressures of PCO2 and PO2 in preterm neonates 55 mmHg). Seventeen of the infants with arterial blood gases (22%) had hypoxia (80 mmHg). In infants with venous blood samples, none had venous PCO2 60 mmHg. Multivariable logistic regression analysis showed no association of low or high PCO2 or PO2 with death or major inpatient morbidities. Conclusion With current resuscitation and stabilization practices, hyperoxia and hypocarbia was uncommon, and hypercarbia occurred frequently. None of these findings correlate with adverse inpatient outcomes or death. Our findings are in direct contrast to published observations using historical practices.

Background: Despite being an experimental therapy in preterm neonates, inhaled nitric oxide (iNO) is used as a rescue therapy when high-frequency oscillatory ventilation (HFOV) and other conventional therapies fail. Objective: We aimed to determine the outcomes of very-low-birth-weight (VLBW) neonates with hypoxemic respiratory failure (HRF) who had received iNO after maximal conventional therapies. Methods: We retrospectively reviewed preterm neonates (Results: During the study period, 1,168 eligible preterm neonates were admitted; 155 (13%) had HRF treated with HFOV, of whom 47 (30%) received iNO. The baseline characteristics between the 24 survivors and 23 nonsurvivors were not different. Survivors had a greater decrease in oxygenation index than nonsurvivors (61 vs. 33%) after 6 h of iNO (p = 0.003). The causes of death were refractory hypoxemia (8), multi-organ failure (7), treatment withdrawal (6), and others (2). During the NICU stay, 23 survivors (96%) developed complications. At 18-24 months, 7 (29%) had significant disabilities. Conclusions: Of the VLBW neonates with severe HRF rescued by HFOV and iNO, many survived without neurodevelopmental disability at early childhood, despite multiple short-term complications. Further research is necessary to understand the clinical course and risk factors of adverse outcomes and to improve the management care of these critically ill neonates.

To assess development of fatigue during chest compressions (CCs) in simulated neonatal cardiopulmonary resuscitation (CPR). Prospective randomized manikin crossover study. Thirty neonatal healthcare professionals who successfully completed the Neonatal Resuscitation Program performed CPR using (i) 3:1 compression:ventilation (C:V) ratio, (ii) continuous CC with asynchronous ventilation (CCaV) at a rate of 90 CC per min and (iii) CCaV at 120 CC per min for a duration of 10 min on a neonatal manikin. Changes in peak pressure (a surrogate of fatigue) and CC rate were continuously recorded and fatigue among groups was compared. Participants were blinded to pressure tracings and asked to rate their level of comfort and fatigue for each CPR trial. Compared with baseline, a significant decrease in peak pressure was observed after 72, 96 and 156 s in group CCaV-120, CCaV-90 and 3:1 C:V, respectively. CC depth decreased by 50% within the first 3 min during CCaV-120, 30% during CCaV-90 and 20% during 3:1 C:V. Moreover, 3:1 C:V and CCaV were similarly preferred by healthcare professionals. Similarly, 3:1 C:V and CCaV CPR were also fatiguing. We recommend that rescuers should switch after every second cycle of heart rate assessment during neonatal CPR.

The purpose of chest compressions (CCs) is to generate blood flow to vital organs in a state in which the myocardium is unable to produce forward blood flow by internal pump mechanisms. In newborn infants requiring CCs in the delivery room, the most frequent cause of myocardial compromise is energy depletion due to hypoxia. Hypoxemia and the accompanying hypercarbia and metabolic acidosis (ie, asphyxia) causes systemic vasodilation, further compromising perfusion pressure. Hence, in neonatal cardiopulmonary resuscitation (CPR), the focus is on both reversing hypoxia and enhancing coronary and systemic perfusion pressure. There are limited clinical data to support a recommendation for how CC and ventilation should be optimized for this purpose in the newborn. However, studies in animal models and manikins suggest that using a compression-to-ventilation ratio (C:V) of 3:1 and delivering compressions during a pause in ventilation results in improved ventilation and reversal of hypoxia. Use of the 3:1 ratio, compared with higher C:V ratios, also results in more effective CC during prolonged CPR. A C:V ratio of 3:1 is perceived as more exhausting to perform than higher ratios, and a high CC rate, which may be beneficial, cannot be achieved with pauses in CCs for the delivery of ventilation. Continuous CCs and asynchronous ventilation have been shown to have improved outcomes in adults and older children after cardiac arrest, and current evidence suggests that it is as good as a 3:1 C:V ratio in neonatal resuscitation. Further studies are needed and should focus on the optimal resuscitative approach in neonatal CPR.

Objective In contrast to the resuscitation guidelines of children and adults, guidelines on neonatal resuscitation recommend synchronized 90 chest compressions with 30 manual inflations (3:1) per minute in newborn infants. The study aimed to determine if chest compression with asynchronous ventilation improves the recovery of bradycardic asphyxiated newborn piglets compared to 3:1 Compression:Ventilation cardiopulmonary resuscitation (CPR). Intervention and measurements Term newborn piglets ( n =8/group) were anesthetized, intubated, instrumented and exposed to 45-min normocapnic hypoxia followed by asphyxia. Protocolized resuscitation was initiated when heart rate decreased to 25% of baseline. Piglets were randomized to receive resuscitation with either 3:1 compressions to ventilations (3:1C:V CPR group) or chest compressions with asynchronous ventilations (CCaV) or sham. Continuous respiratory parameters (Respironics NM3 ® ), cardiac output, mean systemic and pulmonary artery pressures, and regional blood flows were measured. Main results Piglets in 3:1C:V CPR and CCaV CPR groups had similar time to return of spontaneous circulation, survival rates, hemodynamic and respiratory parameters during CPR. The systemic and regional hemodynamic recovery in the subsequent 4h was similar in both groups and significantly lower compared to sham-operated piglets. Conclusion Newborn piglets resuscitated by CCaV had similar return of spontaneous circulation, survival, and hemodynamic recovery compared to those piglets resuscitated by 3:1 Compression:Ventilation ratio.

Background: The brain is vulnerable to injury and dysfunction during transition after birth in neonates. Clinical assessment of the neurological status immediately following birth is difficult, especially during resuscitation. Objective: Our aim was to review physiological monitoring of the brain during immediate postnatal transition - the first 15 min after birth. Methods: A systematic search of PubMed and EMBASE was performed using the following terms: newborn, neonate, neonates, transition, after-birth, delivery room, cerebral, brain, monitoring, neurology, oxygenation, saturation, activity, imaging, perfusion, Doppler, and blood flow. Additional articles were identified by manual search of cited references. Only human studies describing cerebral changes during the first 15 min after birth were included. Results: Six studies were identified, which described sequential measurements of cerebral perfusion using Doppler sonography, one of these in combination with continuous monitoring of cerebral tissue oxygenation with near-infrared spectroscopy (NIRS). A further 15 studies were identified that used NIRS to continuously monitor cerebral tissue oxygenation. In one study, cerebral activity was continuously monitored with an additional amplitude-integrated encephalogram. Conclusion: Monitoring the brain provides additional information during immediate transition and may help to guide resuscitation. Doppler sonography is technically challenging during resuscitation and is therefore of limited value. NIRS provides continuous monitoring and is feasible even in very-low-birth-weight infants. In the future, an amplitude-integrated encephalogram might give further information on the status of the brain, but before any of these modalities can routinely be recommended during neonatal resuscitation, clinical trials targeting stable brain function parameters are needed.

In adult humans and pig models, strain rate (SR) correlates strongly with invasive measures of contractility but does not demonstrate a force-frequency relationship, which is a fundamental behavior of myocardial contraction. Given the considerable maturational changes of the myocardium from fetal stages to adulthood, extrapolation of adult findings to the young heart may not be appropriate. We sought to evaluate the SR response of the immature heart to increased heart rate (HR) and inotropic stimulation.The study consisted of two parts. In part 1, children without obvious structural or functional cardiac abnormalities were evaluated following successful radiofrequency ablation. Echocardiography was performed at baseline HR and then with atrial pacing and isoprenaline infusion titrated to achieve 130% of baseline HR. Left ventricular (LV) speckle tracking-derived SR and tissue Doppler isovolumic acceleration (IVA, a load-independent marker of contractility) were measured. In part 2, young piglets were submitted to atrial pacing at 200, 230, and 260 bpm. Invasive LV dP/dt was assessed, and speckle tracking-derived SR was measured at all stages. Repeated measures analysis of variance was used for comparison with baseline values.In part 1, the LV SR and IVA (septal and lateral) in 23 children (ages 7.8-17.5 years) increased significantly with pacing and isoprenaline infusion (P .001). In part 2, SR and invasive dP/dt increased significantly with increasing HR in young piglets (1-17 days; P .01 and P .001, respectively). Both LV SR and dP/dt plateaued at highest HRs concurrent with the decrease in LV end-diastolic dimension from baseline (73.0% ± 9.9% of the baseline value at 260 bpm; P .001).SR in children is augmented with chronotropic and inotropic stimulation and in young infant piglets with chronotropic stimulation; in both children and piglets it has a force-frequency relationship, a behavior that is consistent with a measure of contractility.

BACKGROUND Decision-making in neonatal resuscitation depends on clinical evaluation, oxygen saturation and heart-rate. However, the position of vital signs monitors varies between institutions and might lead to obstructed or difficult to see displays, which might affect Health Care Provider (HCP) performance. OBJECTIVES To compare Situation Awareness (SA), Neonatal Resuscitation (NRP) checklist score, Visual Attention (VA) and participant satisfaction during simulated neonatal resuscitations using two vital signs monitors locations. DESIGN/METHODS NRP-trained HCPs were recruited from a tertiary Neonatal Intensive Care Unit and randomized to either central (eye-level on the radiant warmer) or peripheral (left of the warmer) monitor placement. Following an orientation scenario, each HCP lead a resuscitation requiring intubation and chest compressions with a high-fidelity manikin (Newborn HAL, Gaumard Scientific, Miami, FL) and a standardized assistant. Each scenario was paused at 3 predetermined points and the HCP was asked 5 SA questions at each pause, per the Situation Awareness Global Assessment Tool (SAGAT) format. Simulations were video-recorded to analyze SAGAT responses and performance rating using a modified NRP checklist. VA was recorded using eye-tracking glasses (Tobii Pro, Tobii Technology Inc., Falls Church, VA) worn by participants. Statistical analysis was performed using Mann-Whitney U test. A post-simulation survey examined user preference. RESULTS We randomized 30 HCPs; all were analyzed for SA and NRP checklist scores. Twenty-two eye-tracking recordings were of sufficient quality and analyzed. SAGAT scores (median 11/15 vs. 12/15, p=0.52) and NRP Checklist Scores (median 46/50, p=0.75) were similar between groups. Distribution of VA was also similar in both groups. In the post-simulation survey, all HCPs found central monitor placement convenient, compared with only 8/15 in peripheral placement. CONCLUSION During simulated neonatal resuscitation, HCPs found central monitor placement more convenient. However, no differences in accuracy of situation awareness responses, NRP checklist scores, or visual attention were found. Hi-fidelity simulation, SAGAT, and eye-tracking can be used to evaluate physical ergonomics of neonatal resuscitation.

BACKGROUND Current resuscitation guidelines recommend 3:1 C:V ratio, however the most effective C:V ratio in newborns remains controversial. We recently demonstrate that combining chest compressions (CC) with a sustained inflation (SI) (=CC+SI) significantly improves return of spontaneous circulation (ROSC) in asphyxiated newborn piglets compared to 3:1 C:V resuscitation. However, the optimal length of SI during CC+SI is unknown. OBJECTIVES To examine if a 60sec SI compared to a 20sec SI or 3:1 C:V will reduce will reduces ROSC during resuscitation in asphyxiated newborn piglets. DESIGN/METHODS Cardiac arrest with achieved was induced in newborn piglets and then randomized to receive either “3:1 C:V ratio, SI+CC-20sec” or “SS+CC-60sec”. Piglets randomized to “SI+CC+20sec” or “SI+CC+60sec” received 90/min CC during a SI of 20sec or 60sec. Piglets randomized to 3:1 C:V received 90/min CC and 30 inflations/min. The default settings for airway pressures were peak inflation pressure of 30 cm H2O and a positive end expiratory pressure of 6 cm H2O. The primary outcome was duration of CC to achieve ROSC. RESULTS Eight piglets were randomized to each group; the mean (SD) age and weight was similar between groups. Median (IQR) ROSC was significantly shorter in the SI+CC-20sec and SI+CC-60sec group with 96 (68–168) sec and 78 (60–91) sec compared to the 3:1 C:V group with 235 (182–347)sec (p=0.002). 5/8 in the SI+CC-60sec group, 7/8 in the SI+CC-20sec and 8/8 in the 3:1 C:V group received epinephrine (p=0.82). CONCLUSION Lengths of SI during CC+SI does not affect ROSC, however CC+SI compared to 3:1 C:V does improve ROSC in newborn piglets.

Background— Guidelines on neonatal resuscitation recommend 90 chest compressions (CCs) and 30 manual inflations (3:1) per minute in newborns. The study aimed to determine whether CC s during sustained inflations (SIs) improves the recovery of asphyxiated newborn piglets in comparison with coordinated 3:1 resuscitation. Methods and Results— Term newborn piglets (n=8/group) were anesthetized, intubated, instrumented, and exposed to 45-minute normocapnic hypoxia followed by asphyxia. Piglets were randomly assigned to receive either 3:1 resuscitation (3:1 group) or CCs during SIs (SI group) when the heart rate decreased to 25% of baseline. Piglets randomly assigned to the SI group received SIs with a pressure of 30 cm H 2 O for 30 s. During the SI, CCs at a rate of 120/min were provided. SI was interrupted after 30 s for 1 s before a further 30-s SI was provided. CCs were continued throughout SIs. CCs and SI were continued until the return of spontaneous circulation. Continuous respiratory parameters, cardiac output, mean systemic and pulmonary artery pressures, and regional blood flows were measured. Mean (standard deviation) time for return of spontaneous circulation was significantly reduced in SI group versus 3:1 group (32 [11] s versus 205 [113] s, respectively). In the SI group, administration of oxygen and epinephrine was significantly lower, whereas minute ventilation and exhaled CO 2 were significantly increased. The SI group had significantly higher mean systemic and pulmonary arterial pressures during resuscitation in comparison with the 3:1 group (51 [10] versus 31 [5] mm Hg; 41[7] versus 31 [7] mm Hg, respectively; all P Conclusions— Combining CCs and SIs significantly improved the return of spontaneous circulation with better hemodynamic recovery in asphyxiated newborn piglets in comparison with standard coordinated 3:1 resuscitation.

Objective: To analyse impact of delayed cord clamping (DCC60sec) on cerebral regional tissue oxygenation (crSO2) and fractional tissue oxygen extraction (cFTOE) in spontaneously breathing preterm neonates during the first 15 min after birth.Methods: Two-centre observational study, crSO2 and cFTOE was monitored in neonates with DCC60sec or early cord clamping (ECC

The kidney is an organ highly susceptible to injury by regional tissue oxygen desaturation during hypoxic episodes. Transcutaneous monitoring of renal tissue oxygen saturation is therefore of increasing interest. The aim of the present study was to compare renal tissue oxygen saturation measured by near-infrared spectroscopy (NIRS) during acute hypoxia in neonates directly on the kidney and transcutaneously. We hypothesized that transcutaneous renal tissue oxygen saturation measurements would be influenced by superficial tissue. Five term newborn piglets were anesthetized, instrumented and exposed to normocapnic hypoxia at an inspired oxygen concentration of 0.14. Regional tissue oxygen saturation (rSO₂) was simultaneously measured for comparison with the sensor of NIRS (Invos 5100, Somanetics Corp., Troy, MI, USA) applied directly on the left kidney (renaldirect rSO₂) and on the skin of right flank above the right kidney (renalskin rSO₂). Cerebral regional tissue oxygenation (cerebralskin rSO₂), arterial oxygen saturation, heart rate (HR) and mean arterial pressure (MAP) were also monitored. NIRS parameters were analyzed in 5 s intervals during first 2 min of hypoxia. Hypoxia was achieved with an arterial oxygen desaturation from median (range) 95.3% (86.8-98.0) to 23.5% (13.0-41.0) after 2 min. HR and MAP did not change significantly during hypoxia. There were pronounced and lower renaldirect rSO₂ readings when compared with those of renalskin rSO₂ with significant differences from 25 to 55 s after initiation of hypoxia. Changes of cerebralskin rSO₂ and renalskin rSO₂ were similar. Transcutaneous monitoring of renal tissue oxygen saturation may underestimate acute oxygen desaturation of the kidney during hypoxia in neonates.

Hydrogen sulfide may protect multiple organ systems against ischemic-reperfusion injuries. It is unknown if treatment with sodium hydrosulfide (NaHS, a hydrogen sulfide donor) will improve myocardial function and minimize oxidative stress in hypoxic-reoxygenated newborn piglets. Mixed breed piglets (1-5 day, 1.5-2.5 kg) were anesthetized and acutely instrumented for the measurement of systemic, pulmonary and regional (carotid, superior mesenteric and renal) hemodynamics and blood gas parameters. The piglets were induced with normocapnic alveolar hypoxia (10-15% oxygen, 2h) followed by reoxygenation with 100% (1h) then 21% oxygen (3h). At 10 min of reoxygenation, either NaHS (10mg/kg, 5 ml) or saline (5 ml) was administered intravenously for 30 min (5 min bolus followed by 25 min of continuous infusion) in a blinded, block-randomized fashion (n = 7/group). Plasma lactate and troponin I levels and tissue markers of myocardial oxidative stress were also determined. Two hours hypoxia caused cardiogenic shock (45 ± 3% of respective normoxic baseline), reduced regional perfusion with metabolic acidosis (pH 6.94 ± 0.02). NaHS infusion significantly improved recovery of cardiac index (84 ± 3% vs. 72 ± 5% in controls), systemic oxygen delivery (84 ± 3% vs. 72 ± 5% in controls) and systemic oxygen consumption (102 ± 5% vs. 84 ± 6% in controls) at 4h of reoxygenation. NaHS had no significant effect on systemic and pulmonary blood pressures, regional blood flows, plasma lactate and troponin I levels. The myocardial glutathionine ratio was reduced in piglets treated with NaHS (vs. controls, P0.05). Post-resuscitation administration of NaHS improves cardiac function and systemic perfusion and attenuates myocardial oxidative stress in newborn piglets following hypoxia-reoxygenation.

Introduction International neonatal resuscitation guidelines recommend that correct tube placement should be confirmed by clinical assessment and exhaled CO 2 detection. Absence of exhaled CO 2 after intubation suggests oesophageal intubation, non-aerated lungs, low tidal volume delivery, or low cardiac output. The relationship between changes in cardiac output and exhaled CO 2 in neonates is unknown. The aim of the study was to determine if changes in cardiac output affect exhaled carbon dioxide in a porcine model of neonatal resuscitation. Method Term piglets ( n =5) aged 3–4 days were anesthetised, intubated, instrumented and exposed to normocapnic hypoxia. Exhaled CO 2 was continuously measured using a flow sensor (Respironics NM3 ® ). Pulmonary artery blood flow, a surrogate for cardiac output was measured using an ultrasonic flow probe (Transonic ® ). A semi-quantitative CO 2 -detector (Pedi-Cap ® ) was placed between the tracheal tube and flow sensor to assess colour change at changing levels of cardiac output. Results Median (IQR) pulmonary artery blood flow significantly decreased from 177 (147–177)mL/kg/min at baseline to 4 (3–26)mL/kg/min during hypoxia ( p =0.02). Exhaled CO 2 remained similar throughout the experiment, 47 (41–47)mmHg at baseline vs. 40 (38–41)mmHg at the end of the hypoxia ( p =1.00). Additionally, at each time point, colour change at the Pedi-Cap ® was observed. Conclusion A significant decrease in cardiac output was not associated with changes in exhaled CO 2 or failure to achieve a Pedi-Cap ® colour change.

Tracheal intubation remains a common procedure during neonatal intensive care. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes. The current gold standard test to confirm tube position is a chest radiograph, however this is often delayed until after ventilation has commenced. Hence, point of care methods to confirm correct tube placement have been developed. The aim of this article is to review the available literature on tube placement in newborn infants. We reviewed books, resuscitation manuals and articles from 1830 to the present with the search terms "Infant, Newborn", "Endotracheal intubation", "Resuscitation", "Clinical signs", "Radiography", "Respiratory Function Tests", "Laryngoscopy", "Ultrasonography", and "Bronchoscopy". Various techniques have been studied to help clinicians assess tube placement. However, despite 85 years of clinical practice, the search for higher success rates and quicker intubation continues. Currently, chest radiography remains the gold standard test to confirm tube position. However, rigorous evaluation of new techniques is required to ensure the safety of newborn infants.

OBJECTIVES Cardiovascular dysfunction occurs in the majority of asphyxiated neonates and has been suggested to be a major cause of neonatal morbidity and mortality. We previously demonstrated that cyclosporine A treatment during resuscitation can significantly improve cardiovascular performance in asphyxiated newborn piglets. However, the mechanisms through which cyclosporine elicits its protective effect in neonates have not yet been fully characterized. We hypothesized that cyclosporine A treatment would attenuate myocardial and cardiac mitochondrial injury during the resuscitation of asphyxiated newborn piglets. DESIGN After acute instrumentation, piglets received normocapnic alveolar hypoxia (10% to 15% oxygen) for 2 hours followed by reoxygenation with 100% oxygen (0.5 hr) and then 21% oxygen (3.5 hr). At 4 hours of reoxygenation, plasma troponin level, left ventricle myocardial levels of lipid hydroperoxides, cytochrome-c, and mitochondrial aconitase activity were determined. SETTING Neonatal asphyxia and reoxygenation. SUBJECTS Twenty-four newborn (1-4 days old) piglets. INTERVENTIONS Piglets were randomized to receive an IV bolus of cyclosporine A (10 mg/kg) or normal saline (placebo, control) at 5 minutes of reoxygenation (n=8/group). Sham-operated piglets (n=8) underwent no asphyxia-reoxygenation. MEASUREMENTS AND MAIN RESULTS Asphyxiated piglets treated with cyclosporine had lower plasma troponin and myocardial lipid hydroperoxides levels (vs. controls, both p

When asphyxiated neonates require additional cardiovascular support to moderate doses of dopamine infusion, controversy exists on the differential hemodynamic effects of two approaches (adding a second inotrope vs. increasing dopamine dosage). We hypothesized that high-dose dopamine (HD) would be detrimental to systemic and regional perfusion as compared with dopamine and epinephrine (D + E) combination therapy using a swine model of neonatal hypoxia-reoxygenation (H-R).Twenty-seven piglets (1-4 d, 1.5-2.5 kg) were used for continuous monitoring of systemic arterial pressure (mean arterial pressure, MAP) and pulmonary arterial pressure (PAP), cardiac output (cardiac index, CI), and carotid (carotid artery flow index, CAFI), superior mesenteric (superior mesenteric artery flow index), and renal arterial flows. H-R piglets underwent 2 h of hypoxia followed by 2 h of reoxygenation before drug infusion (2 h).The hemodynamics of H-R piglets deteriorated gradually after reoxygenation. HD and D + E infusions improved CI similarly (both groups vs. control; P0.05). Both regimens increased MAP (P0.05) but not PAP, with decreased PAP/MAP ratio in D + E piglets. Both regimens improved CAFI and superior mesenteric artery flow index, with decreased mesenteric vascular resistance in HD-treated piglets. No significant effect on renal perfusion was observed.In H-R newborn piglets treated with a moderate dose of dopamine, adding epinephrine or further increasing dopamine improved systemic hemodynamics similarly; these treatments have differential effects on the pulmonary and mesenteric circulations.

Although recent advances in neonatal care have improved survival rates, rates of bronchopulmonary dysplasia remain unchanged. Although neonatologists are increasingly applying gentle ventilation strategies in the neonatal intensive care unit, the same emphasis has not been applied immediately after birth. A lung-protective strategy should start with the first breath to help in the establishment of functional residual capacity, facilitate gas exchange, and reduce volutrauma and atelectotrauma. This paper will discuss techniques and equipment during breathing assistance in the delivery room.