Discontinuation of resuscitation

1.10. Discontinuation and/or withdrawal of resuscitation efforts

The Australian Resuscitation Council Guidelines suggest:

“If, despite provision of all the recommended steps of resuscitation and excluding reversible causes, a newborn requires ongoing cardiopulmonary resuscitation (CPR) after birth, we suggest discussion of discontinuing resuscitative efforts with the clinical team and family. ANZCOR suggests that a reasonable time frame to consider this change in goals of care is around 20 minutes after birth.” (ANZCOR, 2021, Guideline 13.10).

Prolonged effective resuscitation attempts beyond 20 minutes in a newly born infant without signs of life may result in a return of spontaneous circulation, but the risk of death or severe disability is extremely high.  Systematic reviews and case reports (LOE 4) of infants who were successfully resuscitated after an Apgar score of 0 at 10 minutes of age reported:

 

The International Liaison Committee on Resuscitation state:

“Failure to achieve return of spontaneous circulation in newborn infants despite 10 to 20 minutes of intensive resuscitation is associated with a high risk of mortality and a high risk of moderate-to-severe neurodevelopmental impairment among survivors. However, there is no evidence that any specific duration of resuscitation consistently predicts mortality or moderate-to-severe neurodevelopmental impairment. If, despite provision of all the recommended steps of resuscitation and excluding reversible causes, a newborn infant requires ongoing cardiopulmonary resuscitation (CPR) after birth, we suggest discussion of discontinuing resuscitative efforts with the clinical team and family. A reasonable time frame to consider this change in goals of care is around 20 minutes after birth.”
(Wyckoff, M.H., & Weiner, G.M. on behalf of the Neonatal Life Support Collaborators. (2020). Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation; 142 (Supp 1); S185-S221 ).

 

Before resuscitation is discontinued, also consider:

  • The quality of the resuscitation efforts during the first ten to twenty minutes after birth.
  • Have resuscitation efforts been continuous?

 

Ethical considerations:

  • Ethically there is no difference between non-initiation of resuscitation and stopping or withdrawing resuscitation efforts after they have been initiated.
  • There is no ethical or legal requirement to provide ongoing support just because resuscitation attempts have been initiated.
  • The decision not to initiate resuscitation at birth should be made in consultation with the parents.
  • The ILCOR Consensus statement (2010) states:
    “ In conditions associated with uncertain prognosis, when there is borderline survival and a relatively high rate of morbidity and when the burden to the child is high, the parents views on resuscitation should be supported. When gestation, birth weight, or congenital anomalies are associated with almost certain early death and an unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated”. 

 

Circumstances when non-initiation of resuscitation is appropriate

  • Antenatal diagnosis of a lethal fetal anomaly.
  • Extreme prematurity (Less than 23 completed weeks’ gestation).

In these circumstances, if the infant is liveborn, it is appropriate that no other interventions other than comfort care are provided.

 

Circumstances when the decision to discontinue resuscitation is more challenging

  • When it is not clear when the fetal heart was last heard before the infant’s birth.
  • When a severely depressed infant is born with a detectable heart rate but then becomes asystolic during ongoing resuscitation efforts.
  • If endotracheal tube placement in the trachea cannot be confirmed or oesophageal intubation is discovered.
  • When a tension pneumothorax is suspected.
  • Until volume expanders or O Negative red blood cells can be administered to rule out severe hypovolaemia secondary to fetal blood loss as a contributing factor.
  • If a structural anomaly is suspected (e.g diaphragmatic hernia or congenital heart disease)

 

In paramedic practice: (Birth in the pre-hospital environment)

  • Birth may have occurred prior to the ambulance crew arriving. Unless the paramedic crew is present at  the birth, they will not know how long the infant has been asystolic or whether the infant had a heart rate at birth.
  • The mother may be found unconscious and collapsed in the home following an eclamptic seizure or be involved in motor vehicle accident. Assessment of the fetal heart rate cannot be made until the mother arrives at a hospital.
  • Paramedics cannot rule out a tension pneumothorax or other structural anomalies (e.g. diaphragmatic hernia, congenital heart disease) in the pre-hospital environment.
  • Paramedics are strongly advised to consult with the local neonatal retrieval team. In Victoria, call PIPER on 1300 137 650.

 

Clinical challenges:

  • How long to continue resuscitation efforts in a newly born infant with a heart rate greater than 0, but less than 60 bpm after 10 or 15 minutes of continuous and effective resuscitation efforts.
  • The ILCOR guidelines (2010) state that there is insufficient evidence to support or refute the time frame that should be allowed to lapse before discontinuing resuscitation efforts in a newborn infant with a heart rate less than 60 bpm but greater than zero.
  • Consult with the local neonatal retrieval team or a consultant neonatologist from a  tertiary centre for advice as soon as possible after birth. In Victoria, call PIPER on 1300 137 650.
  • The maximum doses of Adrenaline that should be administered.
    • No randomised controlled trial has ever evaluated the ideal dose of Adrenaline for newborn infants with a heart rate <60 bpm.
    • Evidence extrapolated from paediatric and animal studies suggests that the use of doses of intravenous Adrenaline greater than 0.1mg/kg:
      • Increased the risk of mortality
      • Increased the risk of intracranial pressure
      • Interfered with cerebral cortical blood flow and cardiac output
    • High dose Adrenaline is not recommended for newly born infants.
  • What to do if a heart rate is detected after the decision to stop resuscitation has been made?
    • Consult with the local neonatal retrieval team or a neonatologist from a tertiary centre as soon as possible for ongoing management advice.
    • Transfer the infant to the neonatal or special care nursery.
    • Refer to Learning Module 4:  Post-resuscitation Care for more information about stabilisation, monitoring and care of the infant who has experienced a significant peripartum hypoxic insult.

 

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