Critical Concepts
NICU
Brian M. Barkemeyer, MD
LSUHSC Division of Neonatology
2011-12
At birth
• 100% of infants need someone present
dedicated to the infant and capable of initial
steps in neonatal resuscitation
• 10% of infants require some level of
resuscitation at birth
• 1% of infants require major resuscitation
“Golden hour”
• At no other time in one’s life will necessary
critical concepts in resuscitation have a
potential lifelong impact
– Appropriate interventions (or the lack thereof) can
make the difference between life or death, or
normal life vs. life of disability
Preparation
• NRP - Neonatal Resuscitation Program
– Evidence-based, standardized program jointly
sponsored by American Academy of Pediatrics and
American Heart Association
• Proper equipment
• Knowledge
– In most cases, the need for neonatal
resuscitation is predictable
– But not always!
Risk Factors Predictive of
Need for Neonatal Resuscitation
• Maternal illness
– Hypertension
– Diabetes
– Infection
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Prematurity
Post-maturity
Multiple gestation
Maternal bleeding
Maternal drug abuse
No prenatal care
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Fetal distress
Abnormal fetal position
Abnormal labor
Fetal anomalies
Macrosomia
IUGR
Placental abnormalities
Meconium-stained
amniotic fluid
Transition to
Extrauterine Life
• Fluid-filled alveoli to air-filled alveoli
• Circulatory changes
– Decreased pulmonary vascular resistance resulting
in increased pulmonary blood flow and cessation
of flow through foramen ovale and ductus
arteriosus
– Cessation of flow to placenta resulting in
increased systemic vascular resistance
Lack of Appropriate Resuscitation
• Interrupts normal transition to extrauterine
life
• Hypoxia
• Respiratory and metabolic acidosis
• Ischemia
• Potential for death or long term adverse
outcome
Three Basic Questions
• Term infant?
• Breathing/crying at birth?
• Normal tone at birth?
• If the answer to these three questions is yes,
infant doesn’t need resuscitation, but does
deserve initial steps
Initial Steps
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Drying
Warming
Stimulation
Positioning
Clear airway
• Necessary for all newborns!
Warming
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Appropriate room temperature
Rapid drying to avoid evaporative heat loss
Remove wet towels
Mother – skin to skin
Radiant heat warmer
Blankets, cap
• Premature infants and IUGR infants at highest
risk for hypothermia
Establishment of the Airway
• Suction mouth then nose (“M before N”)
• Shoulder roll to aid in positioning
• Head positioned in slight extension, or
“sniffing position”
– Not too extended
– Not too flexed
ABC’s
• Airway
– Suction secretions, assess for anomalies
• Breathing
– Stimulate respiratory effort
• Tactile
• Bag-mask positive pressure ventilation (PPV)
• Circulation
– Assess heart rate
• Chest compressions if PPV ineffective at restoring heart rate
Skills to Learn
• Neonatal assessment
• Use of bulb suction
• Administration of positive pressure ventilation
by bag-mask
• Intubation and assistance with intubation
• Chest compressions
Assessment/Reassessment:
Sequential steps in resuscitation
• Initial steps
[30 seconds]
• PPV
[30 seconds]
• Chest compressions
[30 seconds]
• Medications
[30 seconds]
Neonatal Assessment
• Respirations
– Normal rate and depth, good chest movement
• Heart rate
– Normal > 100
– Count for 6 seconds, multiply x 10
• Color
– Pink lips and trunk
– Acrocyanosis vs. central cyanosis
Indications for PPV
• If after initial steps in resuscitation [30 sec],
assessment reveals
– Apnea
– Gasping respirations
– Heart rate < 100
Indications for Chest Compressions
• If after initial steps in resuscitation [30 sec]
and effective PPV [30 sec], assessment reveals
– Heart rate < 60
Indications for Epinephrine
• Heart rate persists < 60 after
– Initial steps
– PPV
– Chest compressions
[30 seconds]
[30 seconds]
[30 seconds]
• Dosage given IV (UVC preferred), or
endotracheal (higher dose given)
Indications for Volume Administration
• History of blood loss at delivery suggesting
hypovolemia
AND
• Infant appears to be in shock (pallor, poor perfusion,
failure to respond appropriately to resuscitation
efforts)
• IV, 10-20 mL/kg, Normal saline, Ringer’s lactate, or Oblood
Meconium-stained Amniotic Fluid
• 15% of deliveries; at risk for meconium
aspiration syndrome
• Suctioning of upper airway and trachea in
infants who are not vigorous may help
prevent meconium aspiration syndrome
– Vigorous defined by
• Heart rate > 100
• Normal respiratory effort
• Normal tone
Positive Pressure Ventilation
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Appropriate size mask and bag
Self-inflating vs. flow-inflating bag
Forming a good seal with mask
Achieve adequate chest rise
40-60 breaths per minute
• When done appropriately, PPV should result
in improvement in heart rate and color
Ineffective PPV
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Reposition mask on face
Reposition head
Suction upper airway
Ventilate with mouth open
Increase ventilatory pressure
Replace bag
Endotracheal intubation
Self-inflating bag
Flow-inflating bag
Chest Compressions
• Should be coordinated with PPV
• 2 thumb method preferred
• Compression of sternum 1/3 depth of AP
diameter of chest
• 120 events per minute (compressions and
respirations combined)
• “One and two and three and breathe”
Chest Compressions
Endotracheal Intubation
• ET tube size similar to size of patient’s little
finger
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< 28 wks, < 1000 g
28-34 wks, 1000-2000 g
34-38 wks, 2000-3000 g
38-42 wks, > 3000 g
= 2.5 ETT
= 3.0 ETT
= 3.5 ETT
= 4.0 ETT
• Insertion depth
– “Tip to lip” measurement = weight in kg plus 6
• 2 kg patient should have ETT secure at 8 cm mark at lip
Endotracheal Intubation
Unique Aspects of Endotracheal
Intubation in Infants
• Narrowest part of airway is subglottic area
• Uncuffed ET tubes typically utilized
• Increased airway resistance associated with
more narrow airway diameter
• Relative lack of structural support for neonatal
airway
Unique Anatomic Challenges
• Choanal atresia
– Endotracheal intubation may be required
• Pierre-Robin sequence
– Prone positioning
– NG tube into posterior pharynx
• Congenital diaphragmatic hernia
– Endotracheal intubation
– Gastric decompression
Key Points
• Appropriate resuscitation requires a rapid
series of assessments, interventions, and
reassessments
• All infants deserve basic steps of resuscitation
– Drying, warming, positioning, clear airway
• Prompt initiation of respiratory support with
positive pressure ventilation by bag-mask is
the key to successful resuscitation of most
infants