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Neonatal Resuscitation

Objectives

• Perform rapid evaluation of newborn • Select and use equipment correctly• Demonstrate effective resuscitation techniques• Describe the management of meconium at birth• Discuss ARC guidelines (2010)

Reference: ARC website: http://www.resus.org.au

Neonatal Apnoea

Hypoxaemic stress

(rapid breathing)

Primary apnoea

(deep irregular gasping)

Secondary apnoea

•May be in utero

•Heart rate, tone ↓

•Responds to stimulation and air/O2

•HR, BP, PaO2 ↓

•Will not respond to stimulation → PPV

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300

150

0

Hypoxaemia - Apnoea

40

0

(Rapid Breathing)

PrimaryApnoea

(Irregular gasping)

SecondaryApnoea

Heart Rate

Blood PressureTime

Time

Primary and secondary apnoea are clinically indistinguishable

Hypoxaemia –Alveoli and Pulmonary Arterioles

First

Breaths

Arterioles Dilate and Blood Flow Increases

Third

Second

Fetal lungfluid

Air

Air Air

Resuscitation Equipment

• Overhead radiant warmer, adequate lighting• Infant stethoscope• T-piece device or self-inflating ventilation bag &

mask (with variety of mask sizes)

• O2 saturation monitor• Laryngoscope with infant-sized blades • Laryngeal mask airway – size 1• Suction apparatus with catheters

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Initial Assessment• Rapid evaluation of newborn

• Tone, breathing, heart rate

• Stimulate – dry with warm towel (discard wet towel) Preterm infants (< 28/40) → polyethylene bag up to neck without drying to prevent heat loss)

• Start clock• Ensure airway open• Keep warm, place under radiant warmer if required• Consider the need for help

Apgar score not useful initial indicator

Incorrect: Neck Over Extended

Incorrect: Neck Under Extended

Correct: Neck Slightly Extended

Neonatal position for opening the airway

appropriate suction only if needed5 cm/few secs

Evaluate RespirationsBreathing Not

BreathingGood tone

IPPV x 30secs Evaluate HR HR < 100

considerSpO2 monitoring

HR > 100

Routine care Re-evaluate HR

Evaluation and Action I

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Evaluation and Action II

Ventilation x 30 seconds

Evaluate HR

HR > 100 HR < 60

Effective respirations

Continue ventilation

Gradually reduce, Begin cardiac compressions

discontinue PPV ↑ O2 to 100%

SpO2 monitoring

Pulse oximeter levels

Targeted pre‐ductal SpO2 after birth (using pulse oximeter on right wrist)

1 min 60‐70% 2 min 65‐85% 3 min 70‐90% 4 min 75‐90% 5 min 80‐90% 10 min 85‐90%

Bag and Mask Ventilation

• Mainstay of ventilatory support• Advantages over intubation

• Immediately available

• Requires little skill

• Low potential for injury

• May continue for a prolonged time

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Selection of Mask

• Correct:• Covers mouth and nose,

• but not eyes

• Incorrect:• Too large -• covers eyes

• Incorrect:• Too small -

• does not cover• mouth and nose

Bag and Mask Use• Air initially; if no rapid improvement:

• supplement with oxygen at 10 litres/min (titrated to SpO2) – especially after 60 secs IPPV

• Control pressure• Pop-off valve

• Pressure gauge

• 40-60 breaths/min @ 20-30 mL/breath

• Effective IPPV means bilateral slight rise of chest and abdomen and HR increases

Meconium• Suctioning mouth, nose, hypo-pharynx before the

shoulders are born is not recommended• Vigorous infant

• Tracheal suction not indicated

• Infant with absent or depressed respirations, HR < 100, or poor tone• Do not stimulate infant• Prompt intubation to clear meconium below cords• Do not delay resuscitation

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Indications for Intubation

• Tracheal suction for meconium• If absent or depressed respirations, heart rate <

100, or poor muscle tone

• Prolonged ventilation• Inability to ventilate with bag & mask• Suspected diaphragmatic hernia (concave

abdomen)

Cardiac Compressions

• Indicated when HR < 60 after 30 seconds of effective ventilation

• 3 compressions : 1 breathfor desired heart rate of 90/min (120 episodes/min)

• Increase O2 to 100% • Re-evaluate HR every 30 seconds

• pulse oximetry enables assessment without interruption

Cardiac Compressions

Two-thumbs technique preferred

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Drug Therapy Considerations

• Drugs rarely needed, only in critically depressed infants

• Consider anomaly incompatible with life• Consider severe hypoxia beyond salvage• Estimate weight for correct drug dose• IV access by umbilical vein catheter

Drugs• Adrenaline (1:10,000)

• Use if HR < 60 after 30-60 sec cardiac compression and ventilation

• IV dose 0.1 to 0.3 mL/kg/dose (preferred route)• ETT dose 0.5 to 1.0 mL/kg/dose (if no IV access)

• Repeat every few minutes as needed (HR remains <60 despite effective ventilations and cardiac compressions)

• Naloxone• Not a resuscitation drug• Observe baby for secondary apnoea

Fluids

• Normal Salineo When suspected blood loss

o When there is poor response to adequate resuscitation

o 10 ml/kg iv push over a few minutes o may be repeated depending on response

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Summary

• Initial resuscitation includes evaluation for tone, respirations, heart rate and avoidance of thermal stress

• Skills needed for basic neonatal resuscitation include

• Airway management, appropriate suctioning, ventilation and cardiac compressions

• Drug cards helpful

• Intubation of vigorous babies with meconium does not improve outcomes