OB--Fetal Viability
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þ Fetal Viability Summary:
 - current gestational age at which to attempt resuscitation:  24 weeks
   (as of 1996)
 - at gestations under 24 weeks, call it a miscarriage and don't even try to
   resuscitate:  the fetus is nonviable.
 - this may be different at institutions with very sophisticated NICUs.
 - if unsure of age, try intubating with a 2.5 mm ET tube; if it won't go in,
   the neonate isn't viable.

þ "With regard to survival outcome and the limits of viability of the preterm
  neonate, a recent retrospective study from Johns Hopkins published in the
  NEJM (Nov 25, 1993) is instructive:
 - 142 infants born at 22 to 25 weeks gestation were studiedretrospectively;
 - a total of 39% survived for at least six months;
 - none of the 29 infants born at 22 weeks survived;
 - 15% of those born at 23 weeks survived;
 - 56% of those born at 24 weeks survived;
 - 79% of those born at 25 weeks survived.
 Of those who did survive:
 - only 2% of those born at 23 weeks survived without severe intracranial
   abnormalities;
 - 21% of those at 24 weeks had no severe abnormalities;
 - 69% of those at 25 weeks had no severe abnormalities.
   The authors concluded that aggressive resuscitation should be pursued
for premature infants at 25 weeks gestation, and should not be pursued for
those at 22 weeks or less.  Those at 23 or 24 weeks - not sure.
   Aggressive resuscitation of the preterm infant is a complex issue, made
even more difficult by the Baby Doe laws governing care of the handicapped,
and by interwoven and often incompatible considerations of the family and
society.
   Should parents have the right to allow their premature infant to die,
if it will probably, but not necessarily, have severe disabilities
throughout its entire life?  Should they be forced to assume care for a
child that will demand exacting, continuous attention for the rest of its
life, when they might already have other small children at home?
   Conversely, if a parent demands aggressive treatment of a seriously
premature infant with little chance for a good outcome, should society be
forced to pay the astronomical sums of money which will be required for the
complex medical care the severely deformed or disabled infant will require
for the rest of its life, when this money could be used more effectively
elsewhere, for instance, in vaccinating the entire pediatric population?
   The more I got into these sorts of questions, the more I considered it
an intractable, insoluble issue.  At 19.5 weeks, however, I submit that
attempts at resuscitation could only be considered grotesque
experimentation."
 -- Charles Steinbruegge, MD, Chicago

þ In a prospective study (1) of 316 children born 24-26 weeks gestation, only
  95 or 30.1% surived at 5 years (corrected for prematurity).  Of these only
  57 or 18% were "normal" i.e. no sensorineural disability. 1.  Doyle WD.
  Outcome to five years of age of children born at 24-26 weeks' gestational
  age in Victoria.  Med. J Aus.  1995; 163:  11 - 14.

þ There are several things to address. 1)your certainty of gestational age--if
  you don't know by a good ultrasound go to step #2. 2)Go ahead and attempt
  intubation, don't use anything smaller than a 2.5 ETT, if you can get that
  in there is a small chance of viability. 3) While 24 weeks is still the
  "official" cut-off,  some institutions are getting rare survivals in 23 and
  x/7 weeks age group, but only at the most advanced Neonatal units.  There is
  someone at LeBonheur that is saying he can save 22 weekers by putting them
  immediately on a high frequency oscillatory vent, rubbing their rabbit's
  foot, and performing a little voodoo--who knows where it could go?! 4)Take a
  visit up to the unit if you haven't been in one for a while, talk to the
  peds folks and let them tell you a couple horror stories, it will help you
  justify those tough "no rususcitations".  Remember that this is the ethical
  thing to do, and some folks have been successfully sued for 'wrongful
  life'--wonderful world ain't it!

  My wife is a pediatrician and I frequently here the stories of how so-and-so
  intubated with a 2.0 tube somewhere and the child went on to suffer
  horribly, parents were given false hope, and enourmus expense was incurred
  by many--both financial and emotional.

  Evan E. Fusco, MD
  LSU EM Residency Prog.