Neonatal Resuscitation

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Hubert Woods
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1 Neonatal Resuscitation High Risk Deliveries A person trained in neonatal resuscitation is usually called to be present for the following deliveries: 1. Antepartum factors Maternal diabetes Pregnancy induced hypertension Chronic hypertension Anaemia or Rhesus isoimmunisation Previous fetal or neonatal death Bleeding in second or third trimester Maternal infection Maternal cardiac, renal, pulmonary, thyroid or neurological disease Oligo/polyhydramnios Prolonged rupture of membranes Premature rupture of membranes Post-term gestation Multiple pregnancy Size-dates discrepancy Drug therapy Maternal substance abuse Fetal Malformation Diminished fetal activity No prenatal care Maternal age < 16 or > 35 years 2. Foetal factors Emergency Caesarean section Breech or other abnormal presentation Premature labour Precipitous labour PROM > 18 hrs. before delivery Prolonged labour (>24 hours) Prolonged second stage of labour (>2 hours) Fetal bradycardia Non-reassuring FHR patterns Use of general anaesthesia Uterine tetany Narcotics to mum within 4 hours of delivery Meconium-stained liquor Prolapsed cord Abruptio placentae Placenta praevia Apgar Score Apgar score Colour (Appearance) Blue or Pink centrally. Completely Pale Blue Pink extremities Heart Rate Absent < 100/min > 100/min Response to nasal stimuli (Grimace) No Grimace Cough or sneeze Tone (Activity) Limp Some flexion Active movement Breathing (Respiration) Absent Slow, irregular Cry Vigorous cry While the Apgar score at birth may not be useful for decision-making at the beginning of resuscitation, it is helpful for assessing the infant s condition and identifying the infant with a problem. Subsequent Apgar scores help in the assessment of the effectiveness of the resuscitative effort.

2 5 minutes Apgar score is useful to indicate response to resuscitation and is a rough prognostic indicator. If a baby scores <7 at 5 minutes the Apgar Score is repeated every 5 minutes up to 20 minutes to note the progress. Apgar score at 20 minutes is a good prognostic index for neurological outcome. Preparing for Resuscitation A staff should be assigned to check resuscitation equipment at every shift and replenish after every resuscitation. Equipment for Resuscitation 1. Resuscitation trolley 2. Stop clock (with second hand). In working order. 3. Overhead heater and light. Turn heater on well before delivery. Resuscitation area should not receive draughts from air conditioner or fan. 4. Resuscitation area which is padded shelf and covered with a clean dry cloth 5. 2 laryngoscopes with spare bulbs and batteries (size 0 and 1,straight blade laryngoscope and check lights) 6. Masks for preterm and term infants ml Self-inflating Bags with oxygen reservoir. Blow off valve working. 8. Wall or Oxygen cylinder with flow meter and connecting tubes. Ensure tank is full or nearly full. 9. Suction apparatus (Set at not > 100 mmhg) 10. Suction catheters (F5 - F12) 11. Stethoscope paediatric/ neonatal 12. Umbilical catheterization set with F3.5 and F5 catheters. 13. Endotracheal tubes, size 2.5, 3.0, 3.5, 4.0 mm internal diameter 14. Meconium aspirators 15. Sterile syringes and needles: 1, 2, 5, 10 mls, G21, G23, G25, G Drugs: Volume Expanders (Normal Saline or Ringer s lactate) Adrenaline 1:10000 ( dilute with distilled water 1ml of 1:1000 adrenaline to 10 ml) NaHCO 3 4.2% ( dilute 8.4% NaHCO 3 with equal volume of distilled water) Naloxone (0.4mg/ml preparation) 17. Prewarmed dry towels ( put under radiant warmer) 18. Sterile umbilical catheterisation tray Before each resuscitation, ensure the following (which would depend on the estimated size or gestation of the baby): Heater is switched on, Warm towels have been prepared. Oxygen tank is full or nearly full. Suction apparatus is working. Proper sized masks, ETT tubes, suction catheters are prepared Correct sized laryngoscope blade is chosen and the laryngoscope is working. Check that the resuscitation bag-valve mask device is functioning properly including the pop-off valve.

3 Drugs are available (and prepared if history suggestive of need). (See the preparations used in section of drugs) RESUSCITATION 1. Place infant on preheated radiant warmer 2. If thick or particulate meconium is in the amniotic fluid, perform a tracheal suctioning. (See notes on Meconium stained liquor). 3. Position the infant with neck slightly extended and suction the mouth first and then the nose. Suction should be gentle, brief and not too deep (may cause reflex bradycardia). 4. Dry amniotic fluid thoroughly from the baby and remove the wet linen from contact with infant. 5. Evaluate the respiration, heart rate and colour. 6. NG tube insertion after 2 minutes of Bag-valve-mask PPV. 7. Indications for Endotracheal Intubation: When prolonged PPV is required. When bag-and mask ventilation is ineffective When tracheal suctioning is required. When diaphragmatic hernia is suspected. 8. It is important to minimise hypoxia during intubation. Steps to do so include: Providing free-flow oxygen during intubation without interfering with the procedure. Limiting intubation attempts to 20 seconds. Providing appropriate ventilation with bag and mask using 100% O 2 before and between intubation attempts. 9. Vascular Access peripheral IV line; umbilical vein or intraosseous.

4 Can attempt tactile stimulation once only and briefly. Slap foot, flick heel, or rub back. 1. Evaluate Respiration * None or gasping Spontaneous Bag-mask-valve PPV with 100 % O 2 for 30 seconds. O 2 at 5 L/min. Rate of 40-60/min (10-15 in 15 sec). Infant's neck slightly extended to ensure open airway. Ensure gentle chest rise with bagging. If no chest rise: Reapply mask Reposition head Check for secretions, suction if present. Ventilate with mouth slightly open Increase pressure slightly After 30 secs of PPV with 100 % O 2 Evaluate Heart Rate Reevaluate every 30 secs < 100/min Pink or peripheral cyanosis 2. Evaluate Heart Rate (Count for 6 seconds,x10) Observe and monitor > 100/min 3. Evaluate Colour Blue Provide free flow O 2 by using oxygen tubing and cupped hand method with flow rate of at least 5 L/min until pink. Withdraw slowly. Below 60 Continue ventilation Chest Compressions Discontinue chest compressions Continue ventilation Above 100 Watch for spontaneous respiration (and do appropriate bagging if nil) Once spontaneous respiration is established discontinue ventilation. Initiate medications if HR below 60 after 30 secs of PPV with 100% oxygen and chest compressions. Notes on Chest Compressions: Provide firm surface or support for the back. Locate compression area. It is at the lower third of the sternum just below an imaginary line drawn between the nipples. Compress sternum at a rate of 3 compressions and 1 ventilation per 2 secs, giving 90 compressions and 30 ventilations in 1 minute. Compression depth is 1/3 of AP diameter. After 30 seconds, stop compressions and check HR for 6 seconds X10 Complications can occur if technique of chest compressions is poor e.g. broken ribs, lacerated liver and pneumothorax.

5 Meconium stained liquor: Meconium in amniotic fluid Suction the mouth, pharynx and nose at delivery of the head (before delivery of shoulders) using a 10F or larger suction catheter. Infant vigorous? - Good respiration - HR > 100/min - Good muscle tone YES Resuscitate as needed NO As soon as the infant is on radiant warmer and before drying: Residual meconium in the hypopharynx should be removed by suctioning under direct vision. The trachea must be intubated and meconium suctioned from the lower airway and repeated until clear. Tracheal suctioning can be done by a) Applying suction (100 mmhg) directly to the ET tube with a meconium aspirator adapter. Continuous suction is applied to the tube as it is withdrawn. Reintubation followed by suctioning should be repeated until returns are nearly free of meconium. DO NOT attempt to suction thick meconium with a suction catheter through an ET tube (catheter size too small). b) Alternatively use a large bore suction catheter (at least 12F) with an end hole and side hole inserted directly into the trachea. The catheter is rotated and continuous suction applied as it is being withdrawn. This is the recommended method in places with no meconium aspirator adapter. Continuous suction should not be applied for longer than 3 5 seconds. If baby is severely depressed with heart rate < 60/min., positive pressure ventilation may be needed even if some meconium remains in the airway. After tracheal suctioning, the stomach should be suctioned to prevent aspiration of meconium containing gastric contents. This should be done when the child is fully resuscitated and vital signs are stable.

6 Medications used in Neonatal Resuscitation: Type Indications Concentration to Administer Adrenaline 1) HR < 60/min 1: despite a minimum of 30 (The only seconds of preparation adequate available is ventilation with 1:1000. Dilute 100 % O 2 and 1ml of chest Adrenaline compressions. 1:1000 with 2) Heart rate is distilled water zero. to 10ml) Preparation Route Dosage/ 1 ml mg/kg ml/kg. IV or ET Rate/ Precautions Give rapidly. May dilute with normal saline to 1-2 ml if giving via ET. Volume Expanders 1) Prolonged arrest not responding to resuscitation 2)Evidence or suspicion of acute blood loss with signs of hypovolaemia Normal Saline Ringer's lactate 40 ml 10 ml/kg IV Give over 5 10 minutes. Give by syringe or IV drip. Sodium Bicarb. Naloxone HCl 1)Severe metabolic acidosis is suspected or proven by blood analysis; 2)Prolonged arrest not responding to resuscitation Severe respiratory depression and a history of maternal narcotics administered within the past 4 hours. 0.5 meq/ml (4.2% solution) 0.4 mg/ml (dilution that is usually available) 1.0 mg/ml 20 ml or two 10- ml prefilled syringes 1 ml 2 meg/kg IV only. (4 ml/kg) 0.1 mg/kg (0.25 ml/kg) IV ET IM SC 0.1 mg/kg (0.1 ml/kg) IV ET IM SC Give slowly, over at least 2 minutes. Give only if infant is being effectively ventilated. Give rapidly. IV, ET preferred. IM, SC acceptable.

7 Summary: Use of medications during neonatal resuscitation: Begin: HR zero OR HR < 60/min after 30 secs. PPV and chest compressions. Give adrenaline May be repeated every 3-5 minutes if required HR above 100? No Yes Discontinue medications Prolonged arrest that does not respond to other therapy? Give sodium bicarbonate Evidence or suspicion of acute blood loss with signs of hypovolaemia Give volume expander May be repeated if signs of hypovolaemia persist Evidence of continuing depression? Yes 1. Consider other causes, e.g. Pneumothorax Diaphragmatic hernia Persistent pulmonary hypertension (PPHN) 2. Consider starting dopamine 3. Obtain consultation. Severe respiratory depression and a history of maternal narcotics administered within the past 4 hours Give Naloxone hydrochloride. Post Resuscitation Care CXR ABG Correct metabolic acidosis BP monitoring Volume replacement if BP low Correct Hypocalcaemia & Hypoglycaemia Treat seizures Document the resuscitation.

8 Special Circumstances in Resuscitation of the Newly Born Infant Condition History/Clinical Signs Actions Mechanical blockage of the airway Meconium or mucus blockage Choanal Atresia Pharyngeal airway malformation Pneumothorax Pleural effusion / ascites Congenital diaphragmatic hernia Pneumonia/sepsis Meconium-stained amniotic fluid. Poor chest wall movement. Pink when crying, cyanotic when quiet Persistent retractions, poor air entry Impaired lung function Asymmetrical breath sounds. Persistent cyanosis / bradycardia Diminished air movement. Persistent cyanosis / bradycardia Asymmetrical breath sounds. Persistent cyanosis/bradycardia. Scaphoid abdomen Diminished air movement. Persistent cyanosis / bradycardia Impaired cardiac function Congenital heart disease Persistent cyanosis / bradycardia Foetal / maternal haemorrhage Pallor; poor response to resuscitation Intubation for suctioning / ventilation Oral airway. Endotracheal intubation Prone positioning, posterior nasopharyngeal tube Needle thoracentesis Immediate intubation. Needle thoracentesis, paracenteris. Possible volume expansion. Endotracheal intubation. Placement of orogastric catheter Endotracheal intubation. Possible volume expansion Diagnostic evaluation Volume expansion, possibly including red blood cells. Reference: 1. Textbook of Neonatal Resuscitation from the American Academy of Paediatrics and AHA International Guideline for Neonatal Resuscitation Consensus (PEDIATRICS Vol. 106 No. 3 September 2000).

5 Million neonatal deaths each year worldwide. 20% caused by neonatal asphyxia. Improvement of the outcome of 1 million newborns every year

1 5 Million neonatal deaths each year worldwide 20% caused by neonatal asphyxia Improvement of the outcome of 1 million newborns every year International Liaison Committee on Resuscitation (ILCOR) American