Songstad Nils T, Klingenberg Claus, McGillick Erin V, Polglase Graeme R, Zahra Valerie, Schmölzer Georg M, Davis Peter G, Hooper Stuart B, Crossley Kelly J
Department of Paediatric and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway.
Paediatric Research Group, UiT-The Arctic University of Norway, Tromsø, Norway.
Front Pediatr. 2020 Jun 2;8:262. doi: 10.3389/fped.2020.00262. eCollection 2020.
Neonatal resuscitation guidelines recommend administering intravenous (IV) adrenaline if bradycardia persists despite adequate ventilation and chest compressions (CC). Rapid IV access is challenging, but little evidence exists for other routes of administration. We compared IV, endotracheal (ET), and intranasal routes for adrenaline administration during resuscitation of asphyxiated newborn lambs. Near-term lambs ( = 22) were delivered by caesarean section. Severe asphyxia was induced by clamping the umbilical cord while delaying ET ventilation until blood flow in the carotid artery ceased. Following a 30 s sustained inflation and ventilation for 30 s, we commenced uncoordinated CC at 90/min. We randomized four groups receiving repeated treatment doses (Tds) every 3rd min of (i) IV-Adrenaline (50 μg), (ii) ET-Adrenaline (500 μg), (iii) Nasal-Adrenaline via an atomizer (500 μg), and (iv) IV-saline. If return of spontaneous circulation (ROSC) was not achieved after three Tds by the assigned route, up to two rescue doses (Rds) of IV adrenaline were administered. Main outcome measures were achievement of ROSC and time from start of CC to ROSC, defined as heart rate >100/min, and mean carotid arterial pressure >30 mmHg. In the IV-Adrenaline group, 5/6 lambs achieved ROSC after the first Td, whereas 1 lamb required two Tds before achieving ROSC. In the ET-Adrenaline group, 1/5 lambs required one Td, 1 lamb required three Tds, 2 lambs required 2 Rds, and 1 did not achieve ROSC. In the Nasal-Adrenaline group, 1/6 lambs required one Td, 2 required two Tds, whereas 3 lambs required either one (2 lambs) or two (1 lamb) Rds of adrenaline to achieve ROSC. In the IV-saline group, no lambs achieved ROSC until adrenaline Rds; 4/5 lambs required one Rd and 1 lamb required two Rds. Time to ROSC was shorter using IV-Adrenaline (2.4 ± 0.4 min) compared with ET-Adrenaline (10.3 ± 2.4 min), Nasal-Adrenaline (9.2 ± 2.2 min), and IV-saline (11.2 ± 1.2 min). IV adrenaline had superior efficacy compared with nasal or ET administration. Nasal administration had a similar effect as ET administration and is an easier route for early application. Nasal high-dose adrenaline administration for neonatal resuscitation merits further investigation.
新生儿复苏指南建议，如果尽管进行了充分通气和胸外按压（CC）但心动过缓仍持续存在，则应静脉注射（IV）肾上腺素。迅速建立静脉通路具有挑战性，但几乎没有其他给药途径的证据。我们比较了窒息新生羔羊复苏期间肾上腺素的静脉、气管内（ET）和鼻内给药途径。近足月羔羊（n = 22）通过剖宫产分娩。通过夹住脐带诱导严重窒息，同时延迟气管内通气直至颈动脉血流停止。在持续充气30秒并通气30秒后，我们以每分钟90次的频率开始不协调的胸外按压。我们将四组随机分组，每3分钟接受重复治疗剂量（Tds）：（i）静脉注射肾上腺素（50μg），（ii）气管内注射肾上腺素（500μg），（iii）通过雾化器鼻内注射肾上腺素（500μg），以及（iv）静脉注射生理盐水。如果按指定途径给予三个治疗剂量后未实现自主循环恢复（ROSC），则给予高达两个静脉注射肾上腺素的抢救剂量（Rds）。主要结局指标是实现ROSC以及从开始胸外按压到ROSC的时间，定义为心率>100次/分钟且平均颈动脉压>30 mmHg。在静脉注射肾上腺素组中，6只羔羊中有5只在第一个治疗剂量后实现了ROSC，而1只羔羊在实现ROSC之前需要两个治疗剂量。在气管内注射肾上腺素组中，5只羔羊中有1只需要一个治疗剂量，1只羔羊需要三个治疗剂量，2只羔羊需要两个抢救剂量，1只未实现ROSC。在鼻内注射肾上腺素组中，6只羔羊中有1只需要一个治疗剂量，2只需要两个治疗剂量，而3只羔羊需要一个（2只羔羊）或两个（1只羔羊）肾上腺素抢救剂量才能实现ROSC。在静脉注射生理盐水组中，直到给予肾上腺素抢救剂量之前没有羔羊实现ROSC；5只羔羊中有4只需要一个抢救剂量，1只羔羊需要两个抢救剂量。与气管内注射肾上腺素（10.3±2.4分钟）、鼻内注射肾上腺素（9.2±2.2分钟）和静脉注射生理盐水（11.2±1.2分钟）相比，静脉注射肾上腺素实现ROSC的时间更短（2.4±0.4分钟）。静脉注射肾上腺素的疗效优于鼻内或气管内给药。鼻内给药与气管内给药效果相似，且是早期应用更容易的途径。鼻内高剂量肾上腺素用于新生儿复苏值得进一步研究。
