What is the prognosis for survival after 10 minutes of asphyxia?

From the Guidelines

The prognosis for survival after 10 minutes of asphyxia is extremely poor, with death being the most likely outcome, but recent evidence suggests that some individuals may survive with minimal neurological damage if they receive immediate and optimal resuscitation efforts, including therapeutic hypothermia. After 10 minutes without oxygen, those who do survive typically experience severe and permanent brain damage, as brain cells begin to die after 4-6 minutes without oxygen, and by 10 minutes, widespread and irreversible brain damage has usually occurred 1. However, a recent study published in 2020 found that among 105 newborn infants with Apgar scores of 0 or 1 at 10 minutes who were successfully resuscitated and received therapeutic hypothermia, 20% survived without moderate-to-severe neurodevelopmental impairment, and 37% of the survivors did not have moderate or severe impairment 1.

The poor prognosis results from the brain's high oxygen requirements and limited energy reserves, and without oxygen, the brain quickly depletes its glucose and ATP stores, leading to cell membrane breakdown, toxic calcium influx, and ultimately neuronal death. Even with immediate and optimal resuscitation efforts after 10 minutes of asphyxia, the likelihood of meaningful neurological recovery is extremely low, but the use of therapeutic hypothermia may improve outcomes in some cases 1. The evidence supporting this recommendation is of very low certainty, but the possibility of survival and intact survival after ongoing resuscitation is valued, and the task force agreed that in addition to considering duration of resuscitation, it was important to consider whether all recommended resuscitation interventions were provided 1.

Some key points to consider in the management of asphyxia include:

• The importance of immediate and optimal resuscitation efforts, including therapeutic hypothermia
• The need to balance the risk of ceasing resuscitation too early, when return of spontaneous circulation (ROSC) and long-term survival may still be achievable, and continuing resuscitation for too long, when ROSC may occur but survival is associated with a high risk of severe neurological injury
• The use of a single time interval after birth to discontinue intensive resuscitation for all newborns may not be appropriate, as the time taken to accomplish steps of a resuscitation up to the point of administration of 1 or more doses of epinephrine varies widely across studies, and may depend on the characteristics and time to attendance of the resuscitation team 1.

In terms of specific management, the American Heart Association guidelines recommend continuing CPR with as few interruptions in chest compressions as possible, and administering epinephrine at a dose of 0.01 mg/kg (0.1 mL/kg of 1:10 000 solution) every 3 to 5 minutes, while CPR is continued 1. However, the most recent and highest quality evidence suggests that the use of therapeutic hypothermia may be the most important factor in improving outcomes in cases of asphyxia, and that this should be considered in addition to standard resuscitation efforts 1.

From the Research

Prognosis for Survival after Asphyxia

The prognosis for survival after 10 minutes of asphyxia is a complex topic that has been studied in various research papers.

• The chance of survival after asphyxia depends on several factors, including the duration of asphyxia, the effectiveness of cardiopulmonary resuscitation (CPR), and the use of therapeutic hypothermia 2.
• A study published in 2019 found that the survival benefit of end-tidal CO2-guided chest compression delivery was limited by severe asphyxia duration, with poor survival rates after 23 minutes of asphyxia 3.
• Another study published in 2011 found that therapeutic hypothermia increased intact survival and improved neurodevelopmental outcome in survivors of perinatal asphyxial encephalopathy 4.
• A review published in 2016 discussed the short and long-term prognosis in perinatal asphyxia, highlighting the importance of early intervention and the potential of emerging biological and physiological markers to improve outcome prediction 2.
• Other studies have investigated the effects of epinephrine and vasopressin on cerebrovascular and systemic hemodynamics during CPR, with mixed results 5, 6.

Factors Affecting Survival

Several factors can affect the chance of survival after asphyxia, including:

• Duration of asphyxia: Longer durations of asphyxia are associated with poorer survival rates 3.
• Effectiveness of CPR: High-quality CPR can improve survival rates 3, 5.
• Use of therapeutic hypothermia: Therapeutic hypothermia has been shown to improve survival and neurodevelopmental outcomes in survivors of perinatal asphyxial encephalopathy 4, 2.
• Use of medications: Epinephrine and vasopressin have been studied as potential treatments for asphyxia, with mixed results 5, 6.