Journal of Neonatal Biology

LMA^® Supreme™ Airway for Prolonged Resuscitation of a Severely Asphyxiated Newborn

Arturo Giustardi¹, Marco Benigni¹, Matteo Parotto² and Vincenzo Zanardo^{3* 1}Department of Pediatrics, Cavalese Hospital, Cavalese, Italy
²Department of Anesthesiolology, Toronto University, Canada
³Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy
^*Correspondence: Vincenzo Zanardo, Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy, Tel: + 0497290027, Email:

Received: 27-Dec-2019 Published: 30-Jul-2020, DOI: 10.35248/2167-0897.20.9.276

Introduction

The American Academy of Pediatrics AAP has included the LMA in their recent 2015 neonatal resuscitation guidelines because effective ventilation can be achieved quickly during an airway emergency [1]. However, to date, there are limited studies that have evaluated LMA efficacy during the resuscitation of severely depressed newborns. [2]. In this case report, we present a successful prolonged resuscitation performed with LMA^® Supreme™ Airway (Medical Europe Ltd., Dublin Road, Athlone, Co Westmeath, Ireland) in a severely acidotic vacuum extracted neonate. LMA^® Supreme™ is a single use, second generation, gastric access device which forms an effective first seal with the oropharynx (oropharyngeal seal) and an innovative second seal™ with the upper esophageal sphincter (the esophageal seal), which can minimize gastric insufflation and reduce the risk of aspiration

Key Points

• AAP has included the LMA in their 2015 neonatal resuscitation Guidelines.

• Limited studies have evaluated LMA efficacy in severely depressed newborns.

• We present the successful resuscitation of a severely asphyxiated neonate via a Supreme Laryngeal Mask Airway™.

Case Report

A 3.4 kg male born after normal gestation at 39 weeks, via instrumental (kiwi) vaginal delivery for worsening abnormal cardiotocography (CTG). At birth, the infant was apneic, hyporeactive and cyanotic with a heart rate >100 bpm. He was dried, stimulated, the airway was cleared and, due to lack of improvement, positive pressure ventilation was started with LMA Supreme and bag, following the AHA and AAP Guidelines for Neonatal Resuscitation. 1 Apgar score was 2 (heart rate >100 bpm) at 1st minute. Arterial cord blood gas analysis at birth revealed severe acidosis: pH-6.91, PaO₂-22.7, PaCO₂-78.9, HCO₃-13.4, ABE-15.3.

Nevertheless, at the 5^th and 10^th minute the neonate persisted apneic and hyporeactive with Apgar score 3 (heart rate >100 and acrocyanotic) and 4 (heart rate >100 and completely pink), respectively.

After the 10^th minute of life the patient started to present active motion and week hypoventilation.

At the 15^th minute the spontaneous respiration was effectively recovered and concurrently, arterial blood gas analysis improved: pH-7.23, PaO₂-62.7, PaCO₂-28.9, HCO₃-15.4, ABE-13.3. The neonate was then transitioned from spontaneous ventilation via LMA to CPAP (FiO₂ 25%). Simultaneously, passive cooling to initiate hypothermia was initiated, and systemic cooling maintained for 72 hours after transfer to a level III NICU.

Subsequently, there was tolerance of enteral feeding after 72 hours of life, with the suspension of nasal CPAP and of oxygen on the 2^nd day of life and cooling procedure on the 3^th day.

The following exams showed no alterations: CFM (1^st to 3^rd day of life), echocardiogram (1^st day of life), transfontanellar ultrasound (1^st, 3^rd and 5^th, days of life) and otoacoustic emission test (7^th day of life). A brain magnetic resonance (5^th day of life) was normal. The newborn was discharged with the breastfeeding mother on the 7^th day of life.

Neurodevelopmental follow up (3^rd, 6^th, 12^th, and 24^th month of life) was normal.

Discussion

We report a severe neonatal asphyxia case resolved without sequel at two years neurodevelopmental follow up, effectively treated with prolonged LMA ventilation and therapeutic systemic hypothermia. At birth the neonate’s pH was 6.91, with a significant respiratory component (PaCO₂ 79.8 mmHg), but conversely his heart rate was >100 bpm.

In this case-report, some clinical circumstances contributed to a favorable outcome with exclusive use of a LMA Supreme. All phases of the procedure were well tolerated by the neonate (perhaps in part as a result of the advantages provided by a second generation supraglottic device) [3,4]. In addition, intratracheal cardiokinetic drugs were not indicated with reassuring heart rate >100 bpm. Finally, systemic therapeutic hypothermia, currently the only recognized beneficial therapy for children with neonatal HIE, has the potential to improve development at 18 to 24 months for term and late preterm newborn babies at risk of brain damage [5].

Conclusion

In conclusion, in the current case, characterized by severe cord blood acidosis but sustained neonate’s heart rate at birth, a neonatal LMA Supreme use proved to have an effective seal, allowing prolonged ventilation and ultimately stabilization that contributed to prevent the neonate’s brain damage and unfavorable developmental outcome together with systemic therapeutic hypothermia.

Disclosure

The authors report no conflict of interest.

Ethical Approval

The study was approved by the institutional review board of Cavalese Hospital.

Acknowledgments

No disclosures or acknowledgments.

REFERENCES

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