Neonatal Resuscitation, Dr. Wylie 7/17/14

Neonatal Resuscitation

Todd Wylie, M.D.

Department of Emergency Medicine

University of Florida College of Medicine

Jacksonville

Physiology

• Fetal Circulation– Placenta

• Low vascular resistance

– Fetal lungs• High vascular

resistance

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Physiology

• Fetal Circulation– Right-to-left

shunts• Foramen ovale• Ductus

arteriosus

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Physiology

• Fetal Circulation– From the

placenta…• Oxygenated

blood…• Ductus

venosus into IVC…

• Right atrium…• Shunted thru

foramen ovale…

• Into left atrium

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Physiology

• Fetal Circulation– From the SVC

and IVC…• Minimal mixing

with oxygenated blood…

• Right atrium to right ventricle…

• Shunted through ductus arteriosus…

• Into distal aorta

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Physiology

• Fetal Oxygenation– Adequate tissue

oxygenation secondary to:

• Fetal hemoglobin• Decreased fetal

oxygen consumption

• Differential blood flow

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Physiology

• Changes at Delivery

– Alveolar fluid clearance

– Lung expansion

– Circulatory changes

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Physiology

• Difficulties Transitioning– Risk factors

• Maternal conditions (advanced age, diabetes, hypertension, substance abuse)

• Fetal conditions (prematurity, postmaturity, multiple gestation, anomalies)

• Antepartum problems (oligohydramnios, polyhydramnios, placental anomalies)

• Delivery (breech, transverse, meconium, maternal narcotics, difficult delivery)

Physiology

• Difficulties Transitioning– Lack of respiratory effort– Blockage of the airways– Impaired lung function– Persistent pulmonary hypertension– Cardiac anomalies


Introduction – Multiparous female to ED with severe contractions; is preterm (28 weeks); precipitous delivery of pre-term neonate as put into resuscitation bay.

PMH for mother –G6P6, Normal prenatal visits, estimate gestational age 28 weeks currently, no other issues.

Exam for mother – Awake, alert, stable, can provide appropriate history as needed

CASE 1


Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; note clear amniotic fluid.

Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’sAPGAR = 1

CASE 1

Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27

http://en.wikipedia.org/wiki/Midwifery

http://en.wikipedia.org/wiki/user:bcatt



• APGAR Score– Performed at 1 and 5 minutes– Evaluate condition after delivery and need for intervention

Component 0 1 2Appearance Whole body

cyanoticCyanotic extremities

Good color

Pulse No heart rate < 100 BPM > 100 BPM

Grimace No response to stimulation

Grimace Grimace, vigorous cry

Activity Limp, no movement

Some muscle tone

Active motion

Respiration Not breathing Slow, irregular Cries well

Quick Tangential Point


APGAR Score

“These scores should not be used to dictate appropriate resuscitative actions, nor should interventions for

depressed newborns be delayed until the 1-minute assessment.”

Textbook of Neonatal Resuscitation, 6th Edition; Page 35.




Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’s APGAR = 1

CASE 1






• What is the next step?– “ABCDs”

• Initial steps – provide warmth, suction Airway as necessary, dry, stimulate

• Reassess• Positive pressure ventilation (Breathing)• Reassess• Ventilation corrective steps (Breathing)• Reassess• Chest compressions• Reassess• Give Drugs


• Initial steps– Provide warmth

• Warm towels• Radiant warmer

– Clear airway as necessary

– Dry and stimulate

– Reassess

Term Gestation?Breathing or crying?

Good tone?Routine

Care

WarmClear airway if needed

DryStimulate

HR less than 100?Gasping or

Apnea?

No

Yes

30 sec


Reassessment

Patient remains: CyanoticApneicPulse is in the 50s

CASE 1






• Subsequent steps– Positive-pressure

ventilation (PPV)• Self-inflating bag• Position neck in

neutral position• Suction mouth and

nose• Ventilate at 40-60

bpm

– SpO2 monitoring• Right hand or wrist

– Reassess


Apnea?

LaboredBreathingCyanosis

Positive-PressureVentilation

SpO2 monitoring

HR below 100?

Yes

5-10 breaths

No

Clear airwaySpO2 monitor

CPAP?

Yes


Reassessment

Somewhat improved heart rate and color

Heart rate increases to 90’s with continued PPV

Oxygen saturation in the 80’s

CASE 1






• Pulse oximetry– Attached to preductal location on right upper extremity– Saturation may normally remain low for several minutes after

deliveryTargeted preductal SpO2 after

delivery

1 min 60-65 percent

2 min 65-70 percent

3 min 70-75 percent

4 min 75-80 percent

5 min 80-85 percent

10 min 85-95 percent



Reassessment

Somewhat improved heart rate and color

Heart rate increases to 90’s with continued PPV

Oxygen saturation in the 80’s

CASE 1






• Subsequent steps– Heart rate less

than100 BPM• Ventilation

corrective steps• Continue BMV

ventilation

HR below 100? Postresus.care

Ventilation correctivesteps

Yes

No

HR < 60?

No

Continueventilation

YesHR < 100 but > 60?


• Ventilation Corrective Steps – 3 possible reasons for ineffective ventilation– Inadequate mask seal– Airway is blocked– Not enough pressure used

Measures to improve positive-pressure ventilation

M Mask adjustment

R Reposition airway

S Suction mouth and nose

O Open mouth

P Pressure increase

A Airway alternative



Reassessment

Heart rate increases to > 100 with continued PPV

Attempts to provide supplemental oxygen result in decreasing oxygen saturation and decreasing heart rate

Obvious inadequate respiratory effort

CASE 1






Your kind of stuck here aren’t you…



Yes

No

HR < 60?

No

Continueventilation

YesHR < 100 but > 60?


• Consider placing an orogastric tube to…– Suction gastric contents– Serve as vent for air in

stomach

• Consider endotracheal intubation for…– PPV beyond a few minutes– Meconium and floppy– Chest compressions– PPV with inadequate

improvement– Special circumstances

What to do if positive-pressure ventilation is to be continued…


Reassessment

Heart rate with PPV remains above 100

Color improved

Continue to provide respiratory support (oxygen saturation in low 90’s)

NICU team present with warmer

CASE 1






Introduction – Multiparous female to ED in labor; precipitous delivery as put into resuscitation bay of term neonate. Meconium stained amniotic fluid.

PMH for mother –G6P6, Normal prenatal visits, due date 2 days from now, no other issues.

Exam for mother – Awake, alert, stable, can provide appropriate history as needed

CASE 2


Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; meconium stained.

Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’s (< 60)APGAR = 1

CASE 2










– Reassess


Good tone?Routine

Care


DryStimulate


Apnea?

No

Yes

30 sec

Hold On!!!


• Meconium is present and baby is NOT vigorous– Provide warmth


– Before drying (!!!)• Oropharynx and

hypopharynx suctioned • Trachea suctioned under

direct visualization


– Reassess


Good tone?Routine

Care

WarmDirect suctioning of trachea

DryStimulate


Apnea?

No

Yes

30 sec


• To suction the trachea– Insert a laryngoscope– Suction mouth and

posterior pharynx– Insert endotracheal

tube– Attach to meconium

aspirator– Suction


Neonatal ResuscitationQuick Tangential Point


Reassessment

No improvement in respirations (apneic), heart rate (50’s), or color (cyanotic)

CASE 2








neutral position• Suction mouth and

nose• Ventilate at 40-60

bpm

– Reassess


Apnea?



SpO2 monitoring

HR below 100?

Yes

5-10 breaths

No


CPAP?

Yes


Reassessment

Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone)

CASE 2









ventilation



Yes

No

HR < 60?

No

Continueventilation

YesHR < 100 but > 60?


Reassessment

Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone)

CASE 2






• Subsequent steps– Heart rate < 60

BPM• Chest

compressions (90/min)

• Continue ventilation at 30 BPM

– Reassess


Chest compressionsConsider intubation

Coordinate with PPV

Yes

HR < 60?

No

Continueventilation

Yes

HR < 60?

HR < 100 but > 60?


• Indications for endotracheal intubation– PPV beyond a few minutes– Meconium and floppy– Chest compressions– PPV with inadequate

improvement– Special circumstances


Sondeintubation new.jpg; Author – bigomar2


How do you select the endotracheal tube size?

Weight (grams) Gestational age (wks) Tube size (mm)

< 1,000 < 28 2.5

1,000 – 2,000 28 – 34 3.0

2,000 – 3,000 34 – 38 3.5

> 3,000 > 38 3.5 – 4.0



Reassessment

Neonate with improved heart rate (is now up to 80’s)

Need to continue PPV

CASE 2




than100 BPM• Continue positive

pressure ventilation



Yes

No

HR < 60?

No

Continueventilation

YesHR < 100 but > 60?


Reassessment

Heart rate improves with PPV to 100’s

NICU team present with warmer

CASE 2



Introduction – Young female with history of drug abuse (prescription pain medications) to ED in labor; precipitous delivery as put into resuscitation bay of near-term neonate.

PMH for mother – G2P1, drug abuse (prescription pain medications – is currently abusing), 1 prenatal visit, thinks due date is “a couple weeks from now.”

Exam for mother – post-partum, speech somewhat slurred

CASE 3



Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’sAPGAR = 1

CASE 3







– Reassess


Good tone?Routine

Care


DryStimulate


Apnea?

No

Yes

30 sec


Reassessment

Remains cyanoticApneic Pulse is 50 BPM

CASE 3





neutral position• Suction nose and

mouth• Ventilate at 40-60

bpm

– Reassess


Apnea?



SpO2 monitoring

HR below 100?

Yes

5-10 breaths

No


CPAP?

Yes


Reassessment

Patient remains cyanoticApneicPulse is < 60 BPM

CASE 3






ventilation



Yes

No

HR < 60?

No

Continueventilation

YesHR < 100 but > 60?


Reassessment


CASE 3



• Subsequent steps– Heart rate < 60

BPM• Chest

compressions (90/min)

• Continue ventilation at 30 BPM

– Reassess


Chest compressionsConsider intubation

Coordinate with PPV

Yes

HR < 60?

No

Continueventilation

Yes

HR < 60?

HR < 100 but > 60?


Reassessment


CASE 3



• Subsequent steps– Vascular access– Drugs

• Epinephrine • Volume expansion

– Reassess

HR < 60?According to

condition

Vascular accessIV Epinephrine

(0.01 mg/kg of 1:10,000)

HR < 60

Continue PPV and Chest compressions

Yes

Every 3-5 min

No

Yes


• Vascular access– Umbilical vein catheter

• Aseptic technique• Depth of 2-4 cm



• Epinephrine– Action – increases heart

rate and myocardial contractility, causes peripheral vasoconstriction

– Indication – heart rate < 60 despite adequate ventilation and chest compressions

– Dose – 0.01 mg/kg of 1:10,000 solution IV

• Isotonic saline– Action – increases

intravascular volume– Indication – hypovolemia– Dose – 10 ml/kg of 0.9 NS

over 5-10 minutes


Drugs


Reassessment

Heart rate now > 100

Cyanosis resolving

NICU team present

CASE 3



• Summary of resuscitation steps– Initially provide warmth, clear airway, dry and stimulate infant– If meconium staining and non-vigorous infant, suction before

stimulation– If infant continues with poor respiratory effort or HR < 100, start

PPV with BMV, initiate pulse oximetry– If not improving take ventilation corrective steps– Intubate if BMV is ineffective or prolonged, or chest

compressions are being performed– If HR < 60 despite adequate ventilation, start chest

compressions at 90 per minute– If HR rate < 60 despite adequate ventilation and chest

compressions, administer IV epinephrine


• Suction equipment – Bulb syringe – Mechanical suction– Meconium aspirator – 8F feeding tube

• Vascular access– Umbilical vessel

catheterizations supplies

• Intubation equipment – Laryngoscope with straight

blades– Face masks (preterm and

term infant sizes) – Oxygen source

• Medications – D10 solution – Epinephrine– Isotonic solution (0.9 NS) – Naloxone

• Miscellaneous – Radiant warmer – Warm towels – Cardiac monitor – Pulse oximeter – Oropharyngeal airways

Equipment



• Epinephrine • Volume expansion• Sodium

bicarbonate

– Reassess


condition


(0.01 mg/kg of 1:10,000)

HR < 60


Yes

Every 3-5 min

No

Yes



• Epinephrine • Volume expansion• Sodium

bicarbonate

– Reassess


condition


(0.01 mg/kg of 1:10,000)

HR < 60


Yes

Every 3-5 min

No

Yes

Healthcare

Neonatal Resuscitation, Dr. Wylie 7/17/14