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Abstract
Background Heart rate (HR) is used to guide interventions during delivery room (DR) neonatal resuscitation. Dry electrode ECG (NeoBeat) may detect HR more rapidly than pulse oximetry (PO) and portable ECG, but real-time comparisons of these devices are lacking.
Design/methods PO, ECG and NeoBeat were placed sequentially on newborns in the DR. Time for device placement and time to accurate HR acquisition were noted.
Results DR resuscitations of 28 preterm/term infants were observed. The NeoBeat was placed faster (ie, 3 s) than PO (20 s, p=<0.0001) and ECG (16 s, p=<0.0001). Total time from initiation of device placement to HR acquisition was fastest with NeoBeat (13 s) versus ECG (42 s, p<0.0001) and PO (105 s, p<0.0001) (duration values=median).
Conclusions These observations in a small cohort of relatively well neonates demonstrate that the NeoBeat is significantly faster to place and consistently acquires HR faster than PO and ECG.
- resuscitation
- neonatology
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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What is known on this topic?
Wet electrode ECG is superior to pulse oximetry for newborn heart rate detection in the first minutes after delivery.
Dry electrode ECG has become available for newborn heart rate detection and can rapidly detect a heart rate in full-term babies shortly after delivery.
What this study adds?
Dry electrode ECG detects an accurate heart rate significantly sooner than both wet electrode ECG and pulse oximetry in both term and preterm infants.
Both wet and dry electrode ECG detect an accurate heart rate significantly faster than pulse oximetry.
Dry electrode ECG has the potential to be a superior modality for heart rate detection in more complicated deliveries.
Introduction
Heart rate (HR) is the most important indicator of newborn transition at birth and serves as an essential guide in determining the effectiveness of delivery room (DR) resuscitation.1 Currently, pulse oximetry (PO) and wet electrode ECG are the preferred modes of acquiring HR at birth.1 However, there are limitations to the usability of either modality.2 Comparative studies have shown that ECG provides a reliable HR earlier than PO during DR resuscitations.2–4 However, electrodes are difficult to attach on damp newborn skin and require appropriate skin preparation to ensure adequate HR detection.2
Dry electrode ECG technology has emerged as a potentially superior method of assessing neonatal HR in the DR. When placed around the infant torso, it has been shown to rapidly and accurately detect HR in the healthy, term newborn, acquiring a heart rate in about 10 s.5 This non-invasive device, the NeoBeat Newborn Heart Rate Meter (figure 1), is used extensively throughout Europe, Africa and Asia. The NeoBeat can be placed on damp newborn skin, obviating the need for specific skin preparation, which reduces the ‘operator-dependent’ variability seen with placement of ECG or PO.
NeoBeat Newborn Heart Rate Meter; Laerdal Medical, LGH-532–00033.
Given these characteristics, the NeoBeat may provide an accurate, more rapid HR compared with ECG and PO in complicated, DR resuscitations. The objective of this study was to compare the time to accurate HR acquisition between PO, ECG and the NeoBeat in newborns that may require DR resuscitation.
Methods
This pilot study was conducted at New York-Presbyterian HospitalWeill Cornell Medicinefrom April 2019 until August 2020. Current practice is to use portable PO (Masimo RD SET Neo) and ECG (Phillips IntelliVue X2) to assess newborn HR during DR resuscitations. A previously developed practice plan standardised placement of these devices. For this study, dry electrode ECG (NeoBeat Newborn Heart Rate Meter; Laerdal Medical, LGH-532–00033) was used as an additional modality for HR detection. Neonatal intensive care unit nurses were trained on placement of the NeoBeat prior to use.
During resuscitation, the pulse oximeter and the ECG leads were placed on the newborn in sequential order. The NeoBeat was placed after affixing the other devices. Each delivery was attended by a member of the study team who directly observed and recorded the time required for device placement and the time to accurate HR acquisition after placement. Inclusion criteria were any newborns with estimated fetal weight (EFW) ≥1500 gm (weight limit for NeoBeat) in whom PO and ECG would be routinely applied. This included preterm infants approximately 30–35 weeks gestational age (when EFW on day of delivery was unavailable) and term infants at risk for DR resuscitation. Newborns with skin or thoracic anomalies were excluded.
For PO, device placement time was measured from initiation of drying the wrist to plugging it into the monitor. ECG device placement time started with the initial wiping of the chest to affixing all three leads. NeoBeat placement time was determined from picking up the device to its placement on the torso.
An accurate HR was defined as the initial appearance of a reliable waveform tracing on PO, QRS complexes on ECG and clear digital read on the NeoBeat. Any variations or challenges in device placement, resuscitation measures, as well as correlation of the device HRs were noted. Continuous positive airway pressure (CPAP) and positive pressure ventilation (PPV) were provided using a flow-inflating bag. Management of newborns was based on HR ascertained by PO and ECG only. The HR data obtained from the NeoBeat were not used for clinical decision making.
After each resuscitation, charts were reviewed for mode of delivery, Apgar scores, gestational age, birth weight, gender and indication for resuscitation team presence at delivery. The Friedman test along with post hoc pairwise Wilcoxon signed-rank tests (and Holm correction for multiple comparisons) were used to test the difference in median time to device placement, HR acquisition, and total time to HR acquisition between PO, ECG and NeoBeat. To address missing data in the PO group, imputation via mean time was used. Statistical significance was evaluated at the 0.05 alpha level. All analyses were performed in R (V.3.5.3) for Windows.
Results
Twenty-eight DR resuscitations in which PO, portable ECG and the NeoBeat were used for HR detection were obtained. The indications for continuous HR monitoring included prematurity (n=18), fetal bradycardia/non-reassuring tracing (n=7), shoulder dystocia (n=1), concern for fetal anomalies/fetal hydrops (n=2) and fetal supraventricular tachycardia (n=1). The majority of these infants received only routine resuscitation (n=14) with the remaining receiving a combination of CPAP (n=12), PPV (n=9) or intubation (n=5) (table 1). No infants required chest compressions.
Patient demographics
The NeoBeat was placed faster (ie, 3 s (IQR 2–6 s)) than both PO (ie, 20 s (IQR 15–26 s), p=<0.0001) and ECG (ie, 16 s (IQR 10–23 s), p=<0.0001). ECG was placed faster than PO (p=0.017) (figure 2). Once placed, the NeoBeat acquired a HR within a median time of 10 s (IQR 6–14 s), compared with 27 s for ECG (IQR 18–36 s) and 83 s for PO (IQR 59–88 s). Overall, the total time from initiation of device placement to HR acquisition was 13 s for the NeoBeat (median, IQR 10–18 s), compared with 42 s for ECG (IQR 31–63 s, p<0.0001) and 105 s for PO (IQR 75–110 s, p<0.0001). The total time to HR acquisition was faster with ECG compared with PO (p<0.001). Finally, data acquisition was very tight with NeoBeat, with a narrow IQR, compared to PO or ECG (figure 2) (all duration values=median)
Comparison of times to place device and times to heart rate (HR) acquisition between pulse oximetry (PO), ECG and the NeoBeat.
In all 28 neonates, the NeoBeat and ECG ascertained a correlating HR during resuscitation (once the ECG detected a HR). PO did not provide an accurate HR in 6 of the 28 deliveries during 5 min of continuous monitoring. No adverse effects, including skin irritation, were noted from NeoBeat placement in any patients.
Discussion
This pilot cohort of preterm/term neonates requiring minimal resuscitation, consistently demonstrated that the NeoBeat was faster to place and acquired HR more rapidly than both standard ECG and PO (~13 s compared with 42 s and 105 s, respectively). Use of these three modalities in tandem and demonstration of correlating HRs (once established on ECG and PO) further validates the accuracy of the NeoBeat in the neonatal population and its potential use for continuous neonatal HR measurement immediately after birth.
Limitations of this study include both the small sample size and overall well status of these newborns. This makes it difficult to determine whether dry electrode ECG would continue to acquire HR faster in those newborns requiring more intensive resuscitation, such as chest compressions.
An important advantage of the NeoBeat is its ease of application, not requiring skin preparation or adjustment of cables and leads. This mitigates user variability in device application and ensures consistently rapid HR detection. The ability to place the NeoBeat on the upper abdomen also offers the important advantage of continued access to the newborn chest during resuscitation. This minimises interference with critical manoeuvres such as heart and lung auscultation, assessment of chest rise during ventilation and optimal performance of chest compressions. These features make the NeoBeat a unique and potentially superior modality for use in more complicated DR resuscitations. Future studies are needed to determine the effectiveness of the NeoBeat during deliveries requiring intensive resuscitation.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
The institutional review board of Weill Cornell Medicine approved this study.
Footnotes
Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.
Contributors JBB: conception of the work, acquisition and interpretation of data. CC and JP: conception of the work and interpretation of data. VC: analysis of the data.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests JP has previously received travel grants from Laerdal Global health to oversee Research in Tanzania.
Provenance and peer review Not commissioned; externally peer reviewed.