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Randomized trial of oxygen weaning strategies following chest compressions during neonatal resuscitation

Abstract

Background

The Neonatal Resuscitation Program (NRP) recommends using 100% O2 during chest compressions and adjusting FiO2 based on SpO2 after return of spontaneous circulation (ROSC). The optimal strategy for adjusting FiO2 is not known.

Methods

Twenty-five near-term lambs asphyxiated by umbilical cord occlusion to cardiac arrest were resuscitated per NRP. Following ROSC, lambs were randomized to gradual decrease versus abrupt wean to 21% O2 followed by FiO2 titration to achieve NRP SpO2 targets. Carotid blood flow and blood gases were monitored.

Results

Three minutes after ROSC, PaO2 was 229 ± 32 mmHg in gradual wean group compared to 57 ± 13 following abrupt wean to 21% O2 (p < 0.001). PaO2 remained high in the gradual wean group at 10 min after ROSC (110 ± 10 vs. 67 ± 12, p < 0.01) despite similar FiO2 (~0.3) in both groups. Cerebral O2 delivery (C-DO2) was higher above physiological range following ROSC with gradual wean (p < 0.05). Lower blood oxidized/reduced glutathione ratio (suggesting less oxidative stress) was observed with abrupt wean.

Conclusion

Weaning FiO2 abruptly to 0.21 with adjustment based on SpO2 prevents surge in PaO2 and C-DO2 and minimizes oxidative stress compared to gradual weaning from 100% O2 following ROSC. Clinical trials with neurodevelopmental outcomes comparing post-ROSC FiO2 weaning strategies are warranted.

Impact

  • In a lamb model of perinatal asphyxial cardiac arrest, abrupt weaning of inspired oxygen to 21% prevents excessive oxygen delivery to the brain and oxidative stress compared to gradual weaning from 100% oxygen following return of spontaneous circulation.

  • Clinical studies assessing neurodevelopmental outcomes comparing abrupt and gradual weaning of inspired oxygen after recovery from neonatal asphyxial arrest are warranted.

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Fig. 1: Inspired O2 concentration and weaning strategy in gradual wean and abrupt wean groups after ROSC.
Fig. 2: The left carotid arterial blood flow during fetal baseline, asphyxia, resuscitation, and ROSC.
Fig. 3: Comparison of PaO2 and SaO2.
Fig. 4: Comparison of PvO2 and SvO2.
Fig. 5: Comparison of PaCO2.
Fig. 6: Comparison of C-DO2.

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Acknowledgements

The work has been supported by NIH grants HD096299 (to P.V.), HD072929 (to S.L.), American Academy of Pediatrics- Neonatal Resuscitation Program Research Grant (to S.L.), UC Davis Child Health Research Grant and First Tech Federal Credit Union (to D.S.), Children’s Miracle Network at UC Davis Children’s Hospital Research Grant (to D.S.), and NRP Research Grant from Canadian Pediatric Society. Presented in an abstract form at the American Academy of Pediatrics, National Conference and Exhibition (AAP-NCE) 2020 and received the Young Investigator Award (D.S.).

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D.S. and S.L. made substantial contributions to conception and design, acquisition, extraction, analysis and interpretation of data and drafting the manuscript. P.V., P.C., A.L.L., M.E.H., Z.A., M.H.W., and S.W. made substantial contributions to data acquisition and extraction. All authors critically revised and approved the final version for publication.

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Correspondence to Deepika Sankaran.

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Sankaran, D., Vali, P., Chen, P. et al. Randomized trial of oxygen weaning strategies following chest compressions during neonatal resuscitation. Pediatr Res 90, 540–548 (2021). https://doi.org/10.1038/s41390-021-01551-1

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