PEDIATRICS Vol. 115 No. 4 April 2005, pp. 1072-1073 (doi:10.1542/peds.2004-2870)
COMMENTARY |
Neonatal Resuscitation: What Role for Volume Expansion?
Department of Pediatrics
St Louis University
St Louis, MO 63119
The article by Wyckoff et al1 in this issue of Pediatrics is an interesting review of intravenous volume expansion for neonatal resuscitation in a single tertiary care center. The authors conclude that volume expansion is used infrequently at their medical center, that the use is most often contrary to a widely used set of recommendations,2 and that the utility is uncertain.
Recommendations for intravenous volume expansion during neonatal resuscitation were not included in older textbooks and discussions of resuscitation in the delivery room.3 The sixth edition of Standards and Recommendations of Hospital Care of Newborn Infants4 did include a statement on resuscitation, citing the administration of blood or plasma expanders if the infant is in hypovolemic shock. The successor publication, Guidelines for Perinatal Care, included a detailed recommendation for the use of volume expansion during resuscitation "[i]f significant hypovolemia is suspected."5 This statement has been carried over, more or less intact, into the 4 editions of the Textbook of Neonatal Resuscitation.2
Neonatal cardiorespiratory depression requiring resuscitation is most often the result of hypoxemia but could be complicated by or the result of significant fetal/neonatal hypovolemia. Clinical experiences and limited published data indicate that events such as fetomaternal hemorrhage,6 vasa previa, placenta previa, incision of the placenta at Cesarean section, and tight nucal cord7 may result in significant hypovolemia at birth. At least on occasion the clinical condition of the resuscitated child in these circumstances will improve dramatically after intravenous volume infusion.
One who is thoughtfully reluctant to use volume expansion for difficult resuscitations not accompanied by strong clinical suspicions of hypovolemia considers the absence of proven efficacy, the potential of already enhanced blood volume as a response to asphyxia,8 that an increased preload is unlikely to assist neonatal stroke volume when the circulating volume is normal or already expanded, the potential adverse effects of volume loading during cardiopulmonary resuscitation,9 and the possibility that the vulnerable microcirculation of the asphyxiated neonatal brain may incur additional injury with rapid volume expansion.10–12
Wyckoff et al1 document that volume expansion was used in 13 of 23 infants who received intensive cardiopulmonary resuscitation. Hypovolemia was suspected in only 3 of the 13. Ten of the 13 received volume because of an inadequate response in heart rate despite epinephrine and continued cardiopulmonary resuscitation. A previous report from the same institution concluded that the major reason for a poor response to resuscitation was inadequate ventilation.13 The adequacy or inadequacy of the ventilatory support for each of the infants in this report who received volume expansion because of poor response to resuscitation would be of major interest in judging both the necessity and efficacy of volume expansion. On the other hand we have no evidence that newly born infants who respond poorly to resuscitation would not benefit from volume expansion,14 and some evidence documents that preterm infants respond to volume expansion with an increase in cardiac output.15
So what should be next? We are indebted to Wyckoff et al for the documentation of what I think is a common practice, but their data lend little clinical insight. We now have the occasion to examine the variance in our practice and attempt to derive more systematic and data-based approaches. In the circumstance of a poor response to resuscitative efforts without a strong suspicion of hypovolemia, I believe we could maintain equipoise to the study question of using or not using volume expansion. Applying the experience reported here, a delivery base of 
380000 will be required to generate 100 potential study patients for a randomized study. Such a study seems worthwhile, but the investigational logistics seem daunting. This study would require a multicentered approach and a facilitated presumptive consent process.
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FOOTNOTES |
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Accepted Jan 3, 2005.
Address correspondence to William J. Keenan, MD, Department of Pediatrics, St Louis University, 1465 S Grand, St Louis, MO 63119. E-mail: keenanwj{at}slu.edu
No conflict of interest declared.
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REFERENCES |
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- Wyckoff MH, Perlman JM, Laptook AR. Use of volume expansion during delivery room resuscitation in near-term and term infants.
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[Abstract/Free Full Text] - Kattwinkel J. Textbook of Neonatal Resuscitation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2000
- Abramson H. Resuscitation of the Newborn Infant. 2nd Ed. St Louis, MO: Mosby; 1966
- American Academy of Pediatrics. Standards and Recommendations for Hospital Care of Newborn Infants. 6th ed. Evanston, IL: American Academy of Pediatrics; 1977
- Brann A, Cefalo R, eds. Guidelines for Perinatal Care. Evanston, IL: American Academy of Pediatrics and American College of Obstetricians and Gynecologists; 1983
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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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