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Neonatal Resuscitation
Jess Paul
UBC RCPC-EM Residency Program
RCH Grand Rounds April 23, 2014
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NRP: Who cares?
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Who cares?
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4.2% participation in a NNR
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38.7% previous NNR training
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75-85% rated comfort, knowledge, and preparedness for
caring for sick neonates as poor or very poor
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Who cares?
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90% make intrauterine to extrauterine transition without aide
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10% require basic resuscitation
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1% require advanced resuscitation
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NRP
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Stop, breathe
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WARM, DRY, STIMULATE!!!
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Ventilation
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NRP
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Lesson 1: Overview and Principles of Resuscitation
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Lesson 2: Initial Steps of Resuscitation
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Lesson 3: Use of Resuscitation Devices for Positive-Pressure Ventilation
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Lesson 4: Chest Compressions
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Lesson 5: Endotracheal Intubation and LMA Insertion
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Lesson 6: Medications
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Lesson 7: Special Considerations
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Lesson 8: Resuscitation of Babies Born Preterm
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Lesson 9: Ethics and Care at the End of Life
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Lesson 1: Overview and Principles
of Resuscitation
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Transition Trouble
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Persistent pulmonary Hypertension
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Failure of pulmonary arterioles to relax
Systemic hypotension
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Poor cardiac contractility
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Bradycardia
Lungs not filling with air
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Fluid remaining despite initial breaths
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Meconium blockage
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Equipment
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No longer “optional” in the birth setting, and should be
available for every birth:
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a. Compressed air source
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b. Oxygen blender to mix oxygen and compressed air with
flowmeter
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c. Pulse oximeter for neonatal use and oximeter probe
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d. Laryngeal mask airway (size 1)
Suction, warmer, intubation kit, umbilical catheter set
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Quiz
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What % of newborns need extensive resuscitation?
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Quiz
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A baby doesn’t begin breathing in response to stimulation,
you assume she is in ________ apnea and should provide
______.
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The Bottom Line
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Only 10% require some assistance. Only 1% need major
resuscitation measures.
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Ventilation!!! (most often fixes HR)
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Teamwork!
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Flow:
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A: Initial Steps
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B: Adequate Ventilation
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C: Chest Compressions
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D: Epinephrine
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Lesson 2: Initial Steps of
Resuscitation
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3 Essential Questions
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CPAP/blended O2/sup O2
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If HR >100 but not at target sats or if irregular resps
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Start at 21% O2 then blend up to target sat
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CPAP: 5-6 mm H20 pressure
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Meconium!!!
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Suction to 80-100mm H2O
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Quiz
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3 questions you ask at every delivery?
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Term infant, mec delievery, good tone and crying.
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Resuscitation?
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The Bottom Line
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Sniffing position
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Tackle stimulation
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Fetus has O2 sat of 60%, can take 10 mins to reach >90%
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If persistent apnea despite stimulation: PPV!
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Oximeter guided O2 targets
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Vigorous:
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Good tone
Strong resp efforts
HR <100
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Lesson 3: Positive Pressure
Ventilation
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OG: 8 F feeding tube
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Quiz
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Begin resuscitation of term newborns with ___ %O2?
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Indications for PPV? (3)
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PPV PIP and PEEP pressures?
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The Bottom Line
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No blow-by or CPAP with self inflating bags
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PPV can be discontinued:
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Effective ventilation:
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HR >100
Appropriate O2 sats
Onset of spontaneous resps
Bilateral breath sounds
Chest movement
PPV:
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Apnea/gasping
HR <100
Persistent cyanosis and low O2 if supp O2 at 100%
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Lesson 4: Chest Compressions
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HR <60 despite 30 seconds of adequate ventilation
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100% O2
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45-60 sec before pulse check
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If still HR <60; intubate and epi
Rate:
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Chest compressions 90/min
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Breathes 30/min
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3:1 ratio
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Quiz
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A baby has required 60secs of chest compressions and is
ventilated with a BMV. The chest is not moving well. The
heart rate is 4 in 6 seconds. Now what?
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Quiz
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Chest compressions are indicated after ___ seconds of
adequate ventilation for a heart rate below ____?
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O2 concentration during CPR?
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Phrase used to time and coordinate CPR to ventilation?
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Time before HR check?
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Rate of CPR, rate of ventilation?
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The Bottom Line
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If HR <60 despite 30 secs of adequate ventilation, start chest
compressions
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Once chest compressions; 100% O2 until oximeter working
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Two thumb technique preferred
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“1 and 2 and 3 and breathe” cadence
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CPR 90/min and RR 30/min (3:1 ratio)
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HR check at 45-60 sec, if HR < 60: intubate and epi
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Lesson 5: Endotracheal Intubation
and LMA Insertion
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Intubation
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No RSI drugs needed
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No atropine pre treatment
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Miller blade
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00 extreme preterm
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0 preterm
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1 term
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LMA
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Size 1
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Contraindicated in:
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Meconium
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Preterm infants (<32 wks) or <2000g
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Quiz
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Blade size for term infant?
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ETT size for 2000g infant?
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The Bottom Line
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ETT sized by weight
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Blade by GA
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Depth: wt in kg +6
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No LMA
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<32 wks
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mec
Indications:
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Non-vigorous mec suctioning
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If BMV not effective or prolonged
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During chest compressions
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Special circumstances:
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Extreme prematurity
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Surfactant administration
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Diaphragmatic hernia
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Lesson 6: Medications
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Epi only if HR<60 after 30 sec adequate ventilation
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ETT epi only while IV being established only
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IO?
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Epi 1:10,000
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1m1/kg by ET (max 3ml dose)
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0.1m1/kg by IV Q3-5min
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Umbilical Vein Catheter Steps
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“sterile field”: antiseptic, gloves, PPE
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Loose tie at base
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3.5F (<3.5 kg); 5 F (>3.5kg)
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3 way stopcock and 3ml syringe
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Cut perpendicular at 1-2cm above skin
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Depth 2-4cm
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Withdrawal blood
Epi, NS flush, and secure with tape
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NEJM UVC Video
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Emergent UVC
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http://www.nejm.org.ezproxy.library.ubc.ca/doi/full/10.1056/NE
JMvcm0800666
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Fluid Replacement
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Fetal/maternal hemorrhage or fetal shock
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NS/Ringers/Whole blood
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10ml/kg IV over 5-10mins
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Quiz
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What is the potential problem with ETT epi?
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Pulse check how often?
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If HR <60, how often for epi?
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Epi concentration?
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Epi by umbilical vein should be followed by what?
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Fluid resuscitation dose?
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The Bottom Line
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Epi only if HR<60 after 30 sec adequate ventilation
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ETT epi only while IV being established only
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Fluid
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Fetal/maternal hemorrhage or shock despite resuscitation
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NS/Ringers/whole blood
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10ml/kg IV over 5-10 mins
Epi 1:10,000
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1m1/kg by ET x 1(max 3ml dose)
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0.1m1/kg by IV Q
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Lesson 7: Special Considerations
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Choanal Atresia
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Pierre Robin Syndrome
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Congenital Diaphragmatic Hernia
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Pneumothorax (transillumination)
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Pleural effusions
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Hypoglycemia
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IV glucose:
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<4 and symptomatic
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<2.5 and asymptomatic for 0-4 hrs of age
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<3.5 and asymptomatic for 4-24 hrs of age
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D10W 2ml/kg then D10W infusion 80-100ml/kg/day
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Repeat Q10-20mins
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Avoid D25W as hyperosmolar
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Maternal Opioid Use
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Naloxone 0.1mg/kg
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Only after initial resuscitation
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Not for chronic/methadone maternal use
Pulmonary hypertension
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Supp O2 or PPV
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Congenital Heart Disease
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Metabolic Acidosis
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No bicarb unless adequate ventilation
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Therapeutic Hypothermia
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>36 wks and perinatal asphyxia
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Seizures
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Altered LOC
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Hypotonia
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Hyporeflexia
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Can improve outcomes of severe hypoxic-ischemic
encephalopathy
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Initiated within 6 hrs
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33.5-34.5C for 72 hrs
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Quiz
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Baby with choanal atreasia. What do you do?
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A mec baby has been resuscitated and then develops acute
respiratory deterioration. A ____?___ should be expected.
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The Bottom Line
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Diaphragmatic hernia: intubate and OG
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Choanal atresia: oral airway
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Pierre Robin: prone and NP airway
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Congenital cardiac disease rarely causes acute issues
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Naloxone only after resus in recent maternal opioid use
babies
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Ongoing monitoring of temp, BG, O2 sat
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Lesson 8: Preterm Resuscitation
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Increased heat loss
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Weak chest muscles
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Immature immune systems
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Fragile intracranial capillaries
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Small blood volume
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Limited surfactant
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<29 wk: polyethylene bag wrap and warmer
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Monitor O2 sat from beginning; avoid hyperoxia
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Giving PEEP
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Don’t give surfactant until fully resuscitated
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Handle baby gently
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No trendelenburg
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Quiz
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In addition to a warmer, what else can you use to keep a 27
week baby warm?
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A baby at 30 wk GA, required PPV for an initial HR of 80. She
responds quickly with rising HR and spontaneous
respirations. At 2 mins of age, she is breathing, has a HR of
140 and CPAP at 50% O2. Her sats are 95%. What should you
do:
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Increase the O2 concentration?
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Decrease the O2 concentration?
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Leave the O2 concentration the same?
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The Bottom Line
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Increased risk of resuscitation in preemies
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More vulnerable to hyperoxia: target 85-95%
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Increased heat loss Æ bag wrap <29 weeks
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PEEP if intubated
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Decrease risk of brain injury
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Continuous monitoring
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Lesson 9: Ethics and Care at the
End of Life
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Discontinuation of resuscitation:
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10 mins of no HR
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Practicality
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The Very Bottom Line
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Vigorous: stay with mom (even if meconium)
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Warm, dry, stimulate
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Ventilation!!!
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No chest compressions until ventilation until adequate for 30
sec and HR <60
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Umbilical vein catheter is not that hard
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Acknowledgements
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Kristyn Chatwin: RCH NRP Coordinator
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References:
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AHA. Textbook of Neonatal Resuscitation. 6 edition. Elk Grove Village, Dallas,
Tex: American Academy of Pediatrics; 2011.
Anon. Addendum to the NRP Provider Textbook 6th Edition; Recommendations
for specific modifications in the Canadian context. 2011.
Lo MD, Mazor SS. Chapter 11 Neonatl Resuscitation. In: Rosen’s Emergency
Medicine-Concepts and Clinical Practice.Vol 1. 8th ed.
Anon. CPS Medications for Neonatal Rsuscitation Program 2011 Canadian
Adaptation.
Kester-Greene N, Lee JS. Preparedness of urban, general emergency
department staff for neonatal resuscitation in a Canadian setting. CJEM.
2013;15(0):1–7.
Anderson J, Leonard D, Braner DAV, Lai S, Tegtmeyer K. Umbilical Vascular
catheterization. New England Journal of Medicine. 2008.