Neonatal assessment in the delivery room--Trial to Evaluate a Specified Type of Apgar (TEST-Apgar)

Mario Rüdiger, Nicole Braun, Jacob Aranda, Marta Aguar, Renate Bergert, Alica Bystricka, Gabriel Dimitriou, Khaled El-Atawi, Sascha Ifflaender, Philipp Jung, Katarina Matasova, Violeta Ojinaga, Zita Petruskeviciene, Claudia Roll, Jens Schwindt, Burkhard Simma, Nanette Staal, Gloria Valencia, Maria Gabriela Vasconcellos, Maie Veinla, Máximo Vento, Benedikt Weber, Anke Wendt, Sule Yigit, Heinz Zotter, Helmut Küster, TEST-Apgar Study-Group, Mario Rüdiger, Nicole Braun, Jacob Aranda, Marta Aguar, Renate Bergert, Alica Bystricka, Gabriel Dimitriou, Khaled El-Atawi, Sascha Ifflaender, Philipp Jung, Katarina Matasova, Violeta Ojinaga, Zita Petruskeviciene, Claudia Roll, Jens Schwindt, Burkhard Simma, Nanette Staal, Gloria Valencia, Maria Gabriela Vasconcellos, Maie Veinla, Máximo Vento, Benedikt Weber, Anke Wendt, Sule Yigit, Heinz Zotter, Helmut Küster, TEST-Apgar Study-Group

Abstract

Background: Since an objective description is essential to determine infant's postnatal condition and efficacy of interventions, two scores were suggested in the past but weren't tested yet: The Specified-Apgar uses the 5 items of the conventional Apgar score; however describes the condition regardless of gestational age (GA) or resuscitative interventions. The Expanded-Apgar measures interventions needed to achieve this condition. We hypothesized that the combination of both (Combined-Apgar) describes postnatal condition of preterm infants better than either of the scores alone.

Methods: Scores were assessed in preterm infants below 32 completed weeks of gestation. Data were prospectively collected in 20 NICU in 12 countries. Prediction of poor outcome (death, severe/moderate BPD, IVH, CPL and ROP) was used as a surrogate parameter to compare the scores. To compare predictive value the AUC for the ROC was calculated.

Results: Of 2150 eligible newborns, data on 1855 infants with a mean GA of 28(6/7) ± 2(3/7) weeks were analyzed. At 1 minute, the Combined-Apgar was significantly better in predicting poor outcome than the Specified- or Expanded-Apgar alone. Of infants with a very low score at 5 or 10 minutes 81% or 100% had a poor outcome, respectively. In these infants the relative risk (RR) for perinatal mortality was 24.93 (13.16-47.20) and 31.34 (15.91-61.71), respectively.

Conclusion: The Combined-Apgar allows a more appropriate description of infant's condition under conditions of modern neonatal care. It should be used as a tool for better comparison of group of infants and postnatal interventions.

Trial registration: clinicaltrials.gov Protocol Registration System (NCT00623038). Registered 14 February 2008.

Figures

Figure 1
Figure 1
Distribution-pattern of the Specified-Apgar (A, B) and Expanded-Apgar (C, D) at 1 and 10 minutes. In the boxplot, the central box represents the values from the lower to upper quartile (25 to 75 percentile). The middle line represents the median. The vertical line extends from the minimum to the maximum value. Outlier values are displayed as black dots, extreme values are displayed as an asterix.
Figure 2
Figure 2
Combined-Apgar: Relative risk for perinatal mortality.

References

    1. Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anaesth Anal. 1953;32:260–7.
    1. Rüdiger M, Küster H, Herting E, Berger A, Müller C, Urlesberger B, et al. Variations of Apgar Score of very low birth weight infants in different neonatal intensive care units. Acta Paediatr. 2009;98(8):1433–6. doi: 10.1111/j.1651-2227.2009.01347.x.
    1. Lopriore E, von Burk F, Walther FJ, de Beaufort AJ. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. Br Med J. 2004;329(143):144.
    1. O’Donnell CPF, Kamlin COF, Davis PG, Carlin JB, Morley CJ. Interobserver variability of the 5 minute apgar score. J Pediatr. 2006;149:486–9. doi: 10.1016/j.jpeds.2006.05.040.
    1. Rüdiger M, Wauer RR, Schmidt K, Küster H. The Apgar Score [Letter to the Editor] Pediatrics. 2006;118(3):1314–5. doi: 10.1542/peds.2006-1254.
    1. American Academy of Pediatrics Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists, Committee on Obstetric Practice: The Apgar Score. Pediatrics. 2006;117:1444–7. doi: 10.1542/peds.2006-0325.
    1. Jobe A, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med. 2001;163:1723–9. doi: 10.1164/ajrccm.163.7.2011060.
    1. DeLong R, DeLong D, Clarke-Pearson D. Comparing the areas under two or more correlated receiver operating characteristics curves: A nonparametric approach. Biometrics. 1988;44:837–45. doi: 10.2307/2531595.
    1. Apgar V, James LS. Further observations on the newborn scoring system. Am J Dis Child. 1962;104:419–28.
    1. Dunn PM. Soranus of Ephesus (circa AD 98–138) and perinatal care in Roman times. Arch Dis Child Fetal Neonatal Ed. 1995;73(1):F51–2. doi: 10.1136/fn.73.1.F51.
    1. Runge M. Die Krankheiten der ersten Lebenstage. zweite, umgearbeitete und vermehrte Auflage. 1893. Suttgart, Verlag von Ferdinand Enke.
    1. Soranus E. Gynecology. Translated by O. Temkin. Baltimore: The John Hopkins Press; 1956.
    1. Bharti B, Bharti S. A review of the Apgar score indicated that contextualization was required within the contemporary perinatal and neonatal care framework in different settings. J Clin Epidemiol. 2005;58:121–9. doi: 10.1016/j.jclinepi.2004.04.012.
    1. American Academy of Pediatrics Use and abuse of the Apgar Score. Pediatrics. 1986;78(6):1148–9.
    1. Pinheiro JMB. The Apgar cycle: a new view of a familiar scoring system. Arch Dis Child Fetal Neonatal Ed. 2009;94:F70–2. doi: 10.1136/adc.2008.145037.
    1. Crawford JS, Davies P, Pearson JF. Significance of the individual components of the Apgar score. Br J Anaesth. 1973;45:148–58. doi: 10.1093/bja/45.2.148.
    1. O’Donnell CPF, Kamlin COF, Davis PG, Carlin JB, Morley CJ. Clinical assessment of infant colour at delivery. Arch Dis Child Fetal Neonatal Ed. 2007;92:465–7. doi: 10.1136/adc.2007.120634.
    1. Casey BM, McIntire DD, Leveno KJ. The continuing value of the apgar score for the assessment of newborn infants. N Engl J Med. 2001;344(7):467–71. doi: 10.1056/NEJM200102153440701.
    1. Schmidt B, Kirpalani H, Rosenbaum P, Cadman D. Strength and limitations of the Apgar score: A critical appraisal. J Clin Epidemiol. 1988;41(9):843–50. doi: 10.1016/0895-4356(88)90100-X.
    1. McIntire DD, Bloom SL, Casey BM, Leveno KJ. Birth weight in relation to morbidity and mortality among newborn infants. N Engl J Med. 1999;340:1234–8. doi: 10.1056/NEJM199904223401603.
    1. Saria S, Rajani AK, Gould J, Koller D, Penn AA. Integration of early physiological responses predicts later illness severity in preterm infants. Sci Transl Med. 2010;2(48):48ra65. doi: 10.1126/scitranslmed.3001304.
    1. Apgar V. The newborn (apgar) scoring system. Pediatr Clin North Am. 1966;13(3):645–50.
    1. Gluckman PD, Wyatt JS, Azzopardi D, Ballard R, Edwards AD, Ferriero DM, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet. 2005;365:663–70. doi: 10.1016/S0140-6736(05)17946-X.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren