neonatal resuscitation

see also:

• Neonates
• Resuscitation
• Dr Andrew Tagg's video on neonatal resuscitation
• Victorian Neonatal Resuscitation Project learning packages
  • Flowchart (pdf)
  • https://www.neoresus.org.au/learning-resources/key-concepts/
• Safer Care Vic - neonatal intubation

• not much help in resuscitation, however, an APGAR of 0 at 10 min has such a poor prognosis that further resuscitation attempts are generally considered futile and is an indication to cease these attempts, at least if return of circulation has not been achieved by 15 minutes.

• 7% of newborns will require assistance with breathing at birth with suctioning and positive pressure ventilation
• 0.8% require intubation
• 0.3% require chest compressions

• clear the mouth, followed by the nose, if the airway appears obstructed by meconium
• if baby is crying, do NOT attempt suctioning of trachea as this does not alter outcome and may cause harm
• if baby is not vigorous
  • suction oropharynx with a 10-12Fr catheter
  • consider tracheal suctioning BEFORE the newborn is stimulated to breathe, and BEFORE positive pressure ventilation is commenced
    • it should NOT be done if either:
      • operator does not have some airway expertise
      • infant has started crying
      • if it will significantly delay other resuscitation measures

• if baby is term, crying and has good tone, can stay with mother, wrapped with dry towel to keep warm
• OTHERWISE:
  • if preterm < 28wks or < 1500g:
    • try to ensure room temperature is > 26deg C
    • immediately place, while still wet and warm, into a polyethylene wrap or (food or medical grade, heat resistant), enclosed up to the neck with the head out
    • dry the newborn’s head and cover with a hat or a dry, warm towel or blanket
  • transfer baby to a neonatal resuscitation trolley if available and turn on the heater, oxygen and suction
  • call for assistance and continue as below

• start the clock or note the time
• assess colour, tone, breathing, heart rate

• routine care of the newborn

• check airway
• monitor SpO2 on right arm (pre-ductal) aiming for targets:
  • 60-70% at 1min
  • 65-85% at 2min
  • 70-90% at 3min
  • 75-90% at 4min
  • 80-90% at 5min
  • 85-90% at 10min
• consider starting CPAP

• improvement in heart rate is the primary measure of adequate ventilation
• control the airway
  • head in neutral position
  • suction out any meconium
• support the breathing
  • start positive pressure ventilation:
    • 5 inflation breaths (each 2-3 secs duration) via mouth-to-nose if neonatal equipment not at hand
    • neonatal bag and mask:
      • select a 240mL self-inflating neonatal bag
      • select correct size mask
        • should cover nose, mouth but not cover eyes nor extend below chin
      • assemble bag and mask, ensuring all valves are present and inserted correctly
        • on the oxygen end:
          • intake membrane with 2 flap valves
        • at the patient end:
          • pressure relief valve
          • patient lip valve
      • test bag and mask
        • without mask in situ, occlude patient port and squeeze bag, look and listen for function of the pressure relief valve
        • with mask in situ, occlude mask with palm of your hand and squeeze bag with other hand
          • should feel pressure on your palm and see the lip valve open and close - if these do not occur it is NOT safe to use
      • initially use just air and NO oxygen
        • if connect oxygen remember that at a flow rate of 5L/min will deliver 97-100% oxygen whether the reservoir bag is connected or not, such levels are only recommended if HR is persistently < 60
      • create a good seal with face using “two point top hold” technique
        • thumb and index on proximal part of mask, other fingers under chin applying jaw lift and also creating firmer fit of mask
    • CPAP via a T-piece device such as Neopuff Infant Resuscitator:
      • see http://www.neoresus.org.au/pages/documents/Operating_and_troubleshooting_T_Piece_Device_View_on_screen_February_2012.pdf
      • requires compressed gas source at 5-15Lpm
      • allows setting of PIP and PEEP
        • PEEP assists with lung expansion, helps establish functional residual capacity and improves oxygenation
        • initial settings:
          • gas source 10L/min (8L/min if using cylinder)
          • max. pressure relief valve to 50cm water (you need to manually test this!)
          • PIP 30cm water
            • may need higher PIP for initial inflations and if heart rate is not improving
              • increase by 5cm water increments (ie. 30 ⇒ 35 ⇒ 40 ⇒ 45 ⇒ 50 ⇒ 55 ⇒ 60) as needed to max. 60cm water
            • 20-25cm water for preterm < 32 weeks
            • NB. achieving the set PIP on the manometer is not a sign of effective ventilation - check the HR and oxygenation!!
          • PEEP 5-8cm water (via turning PEEP cap at the patient end, and manually test with the source flow rate you have chosen as this will change the PEEP!!!)
        • test by attaching the “test lung”
        • deliver CPAP by occluding PEEP valve with a finger for 0.5secs then release for 0.5secs for expiration
        • check adequate seal by checking PEEP is at desired value after each breath
      • operator controls inspiratory time by varying the duration of occlusion of the PEEP cap
      • can be used with a mask or with a ETT
    • continually reassess adequate technique and ventilation
      • if inadequate response, check technique, consider increasing PIP if using CPAP
    • tidal volume = 5-10mL/kg
    • breath rate 40-60 per minute (avoid excessive hyperventilation as may depress resp. centre and also reduce cerebral blood flow)
    • see http://www.neoresus.org.au/pages/documents/Operating_and_troubleshooting_a_self_inflating_bag_View_on_screen_February_2012.pdf
  • confirm a response - visible chest movement or increase in heart rate

• double check head position
• apply jaw thrust
• 5 inflation breaths
• confirm a response - visible chest movement or increase in heart rate

• use a 2nd person to help airway control and repeat inflation breaths
• inspect oropharynx under direct vision and repeat inflation breaths
• insert an oropharynx and repeat inflation breaths
• confirm a response - visible chest movement or increase in heart rate

• continue with ventilation breaths if no spontaneous breathing

• if HR is not detectable or slow (< 60bpm) and NOT getting faster
  • 100% oxygen
  • start chest compressions at 120 bpm
    • first confirm chest movement - if not moving - return to airway
    • cycles of 3 chest compressions to 1 breath for 30sec
    • thumbs on sternum is usually better than the 2 finger approach
  • consider intubation or LMA
    • infant epiglottis is curved and floppy
    • narrowest airway is at the cricoid not the cords
    • use a 2.5 to 3.5 uncuffed ETT depending on prematurity of infant
      • < 1kg = 2.5; 1-2kg = 3.0; 2-3kg = 3.5; >3kg = 3.5/4.0; or gestation in weeks/10
    • tracheal intubation is likely if:
      • ETT is visualized passing through the vocal cords
      • heart rate rises above 100 bpm soon after intubation & commencing positive pressure ventilation
      • breath sounds are auscultated in both axillae
      • condensation is seen on the inside of the endotracheal tube during expiration
      • chest rises and falls with each inflation
    • use a Pedi-Cap ETCO2 detector which connects onto ETT
      • can be used for up to 2 hours and on any weight newborn (even though states only for > 1kg)
      • color should change from purple during inspiration to yellow in expiration if there is ventilation and adequate circulation (if poor circulation then it will change to tan instead of yellow in expiration)
        • NB. this does NOT exclude intubation of R main bronchus!
      • if color remains purple during ventilation cycle, either:
        • inadequate tidal volume delivered, perhaps due to a large air leak if ETT too small or PIP is too low
        • oesophageal intubation ⇒ re-check ETT position
        • no perfusion ⇒ see below
        • cardiac arrest ⇒ see below
      • if color remains yellow during ventilation cycle, device is damaged ⇒ replace with new one
  • reassess heart rate
    • if improving, stop compressions, if not breathing, continue ventilation
    • if heart rate still < 60 , continue ventilation and compressions
      • venous access via IO needle and give adrenaline:
        • adrenaline 0.1-0.3mL/kg of 1:10,000 iv or 0.5-1mL/kg via ETT
        • iv NSaline 10ml/kg may be of benefit
        • dextrose to Rx hypoglycaemia 5ml/kg of 10% dextrose
          • nb. dextrose sticks are not reliable for hypoglycaemia in neonates
        • naloxone 200mcg im in term baby if suspect resp. depression
        • NB. rapid or excessive infusions of hypertonic solutions (eg. bicarb, dextrose, colloid) may cause intracranial haemorrhage, particularly in premature infants

• tension pneumothorax - transilluminate thorax
• narcotic-induced resp. depression
  • consider narcane if maternal narcotics a possible factor
• sepsis
• anaemia