Neonatal Resuscitation Review

1
Neonatal Resuscitation Review

• March 2006
• Disclaimer
• Palliser Health Region disclaims all liability
  for loss or damage of any kind to any person,
  howsoever arising, in relation to use of or
  reliance on any material contained within this
  presentation.

2
Assess and Support

• Vast majority of newborns require minimal
  resuscitation.
• Temperature (warm and dry)
• AIRWAY (position and suction)
• BREATHING (stimulate to cry)
• CIRCULATION (heart rate and color)

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First 30 Seconds Initial Steps

• Airway clear of meconium?
• Breathing or crying?
• Good muscle tone?
• Color pink?
• Term gestation?
• If Yes
• Provide warmth, clear airway, dry

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If No

• Provide warmth
• Position, clear airway as necessary (may indicate
  need for endotracheal intubation)
• Dry, stimulate, reposition
• Provide oxygen as necessary
• Now
• Evaluate respirations, heart rate, and color

5
If Apnea or HR lt 100

• Provide positive-pressure ventilation
• Provide PPV with bag and mask for approximately
  30 seconds
• After 30 seconds, evaluate NB again

6
HR gt 60 or HR lt 60?

• If HR gt 60 provide PPV until HR gt 100
• If HR lt 60 support circulation by starting chest
  compressions
• After about 30 seconds of chest compressions and
  PPV evaluate NB again
• If HR still below 60 administer epinephrine as
  you continue PPV and chest compressions
• If HR remains lt 60, continue and repeat actions,
  providing PPV, chest compressions and repeat
  epinephrine

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Meconium-Stained Amniotic Fluid

• Differentiate between vigorous and depressed
  infant
• 1) Vigorous
• Strong respiratory effort, good muscle tone
• HR gt 100 bpm
• 2) Depressed
• Weak/absent respiratory effort, poor muscle
  tone/limp
• HR lt 100 bpm
• NOTE If NB is depressed meconium-stained,
  delay drying stimulation and suction the
  trachea before taking any further resuscitative
  steps

8
Temperature

• Depressed infants are at higher risk for cold
  stress and recovery from acidosis can be delayed.
• Prevent heat loss by
• Quickly drying off the amniotic fluid
• Place the infant under a preheated warmer
• Remove the wet linens from direct contact with
  the baby

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Airway Positioning/Suctioning

• Place the infant on his/her back or side in a
  neutral position
• Do not hyperextend or flex the neck
• If meconium staining is observed the trachea
  should be suctioned BEFORE other resuscitative
  efforts.
• Suction the MOUTH and then the NOSE with a bulb
  suction or 8 or 10F suction catheter
• Suction gently for 3 5 seconds per attempt
• Provide time for spontaneous ventilation or
  assisted ventilation with 100 oxygen

10
Stimulation

• Most newborns will begin to breathe effectively
  in response to mild stimulation (drying, warming,
  and suctioning).
• Additional tactile stimulation may be used
• Slapping or clicking the soles of the feet
• Rubbing the infants back

11
Heart Rate

• Evaluate immediately after respirations have been
  assessed
• Palpate pulse 1) apical or 2) umbilical
• Continue assessment if HR is gt100 bpm and
  spontaneous respirations are present
• If HR lt100 bpm begin PPV with 100 O2
• If HR is lt60 continue PPV with 100 O2 and begin
  chest compressions

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Ventilation

• Adequate ventilation is the key to neonatal
  resuscitation. Indications for PPV are
• Gasping respirations/apnea
• Central cyanosis despite 100 oxygen
• HR lt 100 bpm
• Administer an assisted rate of 40 60 breaths
  per minute (breathe two three)
• If chest expansion inadequate
• 1) Reapply the mask
• 2) Reposition/suction/ventilate with mouth
  slightly open
• 3) Increase inflation pressures

13
Intubation

• Tracheal intubation is indicated if
• 1) BM ventilation is ineffective
• 2) tracheal suctioning is required for
  meconium-stained amniotic fluid
• 3) prolonged PPV ventilation is necessary
• 4) tracheal administration of medications is
  required

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Chest Compressions

• If the HR lt 60 bpm after providing PPV with 100
  O2 for at least 30 seconds, initiate chest
  compressions
• Compress chest approximately 1/3 of the AP
  diameter of the chest
• 31 compression-ventilation ratio at 120X per
  minute (actual delivery will be 90 compressions
  and 30 breaths per minute)
• D/C compressions when HR reaches 60 or more

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Epinephrine

• Asystole or HR lt 60 bpm despite ventilation and
  O2
• 0.01 0.03 mg/kg (0.1 to 0.3 ml/kg of
• 110,000 solution) IV, IO, ET
• 0.1 mg/kg (0.1 ml/kg) of 11000 solution may be
  considered ET
• Dose may be repeated every 3 5 minutes if
  required (higher doses may be required if the NB
  does not respond to standard doses)

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Volume expanders

• Volume expanders may be indicated if there is
  evidence of acute bleeding from the
  fetal/maternal unit
• Pallor persists despite oxygenation
• HR is gt 100 but pulses are faint
• Response to resuscitation is poor
• Administer N/S or R/L 10 ml/kg bolus over 5-10
  minutes

17
Glucose

• Used for treatment of hypoglycemia, documented or
  strongly suspected.
• If indicated during acute resuscitation,
  administer
• 2 ml/kg (200 mg) of 10 glucose slow IV push (10
  0.10 g/ml)
• Maximum concentration for newborn administration
  is 12.5 (0.125 g/ml)

18
Naloxone

• Indicated when prolonged apnea (without
  bradycardia) or cyanosis may be due to
  respiratory depression caused by narcotics
• Dose 0.1 mg/kg (supplied 0.4 mg/ml)
• IV, ET, SC, IM
• Administration after birth to infants of addicted
  mothers may precipitate seizures or other
  withdrawal symptoms.
• Assist ventilation before naloxone administration
  to avoid sympathetic stimulation.