+

Neonatal Resuscitation
Jess Paul
UBC RCPC-EM Residency Program
RCH Grand Rounds April 23, 2014
+
NRP: Who cares?
+
Who cares?

„ 4.2% participation in a NNR

„ 38.7% previous NNR training

„ 75-85% rated comfort, knowledge, and preparedness for

caring for sick neonates as poor or very poor
+
Who cares?

„ 90% make intrauterine to extrauterine transition without aide

„ 10% require basic resuscitation
„ 1% require advanced resuscitation
+
NRP

„ Stop, breathe

„ WARM, DRY, STIMULATE!!!

„ Ventilation
+
NRP

„ Lesson 1: Overview and Principles of Resuscitation

„ Lesson 2: Initial Steps of Resuscitation

„ Lesson 3: Use of Resuscitation Devices for Positive-Pressure Ventilation

„ Lesson 4: Chest Compressions

„ Lesson 5: Endotracheal Intubation and LMA Insertion

„ Lesson 6: Medications

„ Lesson 7: Special Considerations

„ Lesson 8: Resuscitation of Babies Born Preterm

„ Lesson 9: Ethics and Care at the End of Life

+
Lesson 1: Overview and Principles
of Resuscitation
+
+
+
+
+
Transition Trouble

„ Persistent pulmonary Hypertension

„ Failure of pulmonary arterioles to relax

„ Systemic hypotension
„ Poor cardiac contractility
„ Bradycardia

„ Lungs not filling with air

„ Fluid remaining despite initial breaths
„ Meconium blockage
+
+
+
+
Equipment

„ No longer “optional” in the birth setting, and should be

available for every birth:
„ a. Compressed air source
„ b. Oxygen blender to mix oxygen and compressed air with
flowmeter
„ c. Pulse oximeter for neonatal use and oximeter probe
„ d. Laryngeal mask airway (size 1)

„ Suction, warmer, intubation kit, umbilical catheter set

+
Quiz

• What % of newborns need extensive resuscitation?

+
Quiz

„ A baby doesn’t begin breathing in response to stimulation,

you assume she is in ________ apnea and should provide
______.
+
The Bottom Line

„ Only 10% require some assistance. Only 1% need major

resuscitation measures.

„ Ventilation!!! (most often fixes HR)

„ Teamwork!

„ Flow:
„ A: Initial Steps
„ B: Adequate Ventilation
„ C: Chest Compressions
„ D: Epinephrine
+
Lesson 2: Initial Steps of
Resuscitation
+
3 Essential Questions
+
+
+
+
+
+
+
+
+
+
+
CPAP/blended O2/sup O2

„ If HR >100 but not at target sats or if irregular resps

„ Start at 21% O2 then blend up to target sat

„ CPAP: 5-6 mm H20 pressure

+
+
Meconium!!!
+
Suction to 80-100mm H2O
+
Quiz

„ 3 questions you ask at every delivery?

+

„ Term infant, mec delievery, good tone and crying.

„ Resuscitation?
+
The Bottom Line

„ Sniffing position

„ Tackle stimulation

„ Fetus has O2 sat of 60%, can take 10 mins to reach >90%

„ If persistent apnea despite stimulation: PPV!

„ Oximeter guided O2 targets

„ Vigorous:
„ Good tone
„ Strong resp efforts
„ HR <100
+
Lesson 3: Positive Pressure
Ventilation
+
+
+
+
OG: 8 F feeding tube
+
Quiz

„ Begin resuscitation of term newborns with ___ %O2?

„ Indications for PPV? (3)

„ PPV PIP and PEEP pressures?

+
The Bottom Line

„ No blow-by or CPAP with self inflating bags

„ PPV can be discontinued:

„ HR >100
„ Appropriate O2 sats
„ Onset of spontaneous resps

„ Effective ventilation:
„ Bilateral breath sounds
„ Chest movement

„ PPV:
„ Apnea/gasping
„ HR <100
„ Persistent cyanosis and low O2 if supp O2 at 100%
+
Lesson 4: Chest Compressions

„ HR <60 despite 30 seconds of adequate ventilation

„ 100% O2

„ 45-60 sec before pulse check

„ If still HR <60; intubate and epi

„ Rate:
„ Chest compressions 90/min
„ Breathes 30/min
„ 3:1 ratio
+
+
+
+
Quiz

„ A baby has required 60secs of chest compressions and is

ventilated with a BMV. The chest is not moving well. The
heart rate is 4 in 6 seconds. Now what?
+
Quiz

„ Chest compressions are indicated after ___ seconds of

adequate ventilation for a heart rate below ____?

„ O2 concentration during CPR?

„ Phrase used to time and coordinate CPR to ventilation?

„ Time before HR check?

„ Rate of CPR, rate of ventilation?

+
The Bottom Line

„ If HR <60 despite 30 secs of adequate ventilation, start chest

compressions

„ Once chest compressions; 100% O2 until oximeter working

„ Two thumb technique preferred

„ “1 and 2 and 3 and breathe” cadence

„ CPR 90/min and RR 30/min (3:1 ratio)

„ HR check at 45-60 sec, if HR < 60: intubate and epi

+
Lesson 5: Endotracheal Intubation
and LMA Insertion
+
Intubation

„ No RSI drugs needed

„ No atropine pre treatment

„ Miller blade
„ 00 extreme preterm
„ 0 preterm
„ 1 term
+
+
LMA

„ Size 1

„ Contraindicated in:
„ Meconium
„ Preterm infants (<32 wks) or <2000g
+
Quiz

„ Blade size for term infant?

„ ETT size for 2000g infant?

+
The Bottom Line

„ ETT sized by weight

„ Blade by GA

„ Depth: wt in kg +6

„ No LMA
„ <32 wks
„ mec

„ Indications:
„ Non-vigorous mec suctioning
„ If BMV not effective or prolonged
„ During chest compressions
„ Special circumstances:
„ Extreme prematurity
„ Surfactant administration
„ Diaphragmatic hernia
+
Lesson 6: Medications

„ Epi only if HR<60 after 30 sec adequate ventilation

„ ETT epi only while IV being established only

„ IO?

„ Epi 1:10,000
„ 1m1/kg by ET (max 3ml dose)
„ 0.1m1/kg by IV Q3-5min
+
+
Umbilical Vein Catheter Steps

„ “sterile field”: antiseptic, gloves, PPE

„ Loose tie at base

„ 3.5F (<3.5 kg); 5 F (>3.5kg)

„ 3 way stopcock and 3ml syringe

„ Cut perpendicular at 1-2cm above skin

„ Depth 2-4cm
„ Withdrawal blood

„ Epi, NS flush, and secure with tape

+
+
+
NEJM UVC Video

„ Emergent UVC
„ http://www.nejm.org.ezproxy.library.ubc.ca/doi/full/10.1056/NE
JMvcm0800666
+
Fluid Replacement

„ Fetal/maternal hemorrhage or fetal shock

„ NS/Ringers/Whole blood

„ 10ml/kg IV over 5-10mins

+
Quiz

„ What is the potential problem with ETT epi?

„ Pulse check how often?
„ If HR <60, how often for epi?
„ Epi concentration?
„ Epi by umbilical vein should be followed by what?
„ Fluid resuscitation dose?
+
The Bottom Line

„ Epi only if HR<60 after 30 sec adequate ventilation

„ ETT epi only while IV being established only

„ Fluid
„ Fetal/maternal hemorrhage or shock despite resuscitation
„ NS/Ringers/whole blood
„ 10ml/kg IV over 5-10 mins

„ Epi 1:10,000
„ 1m1/kg by ET x 1(max 3ml dose)
„ 0.1m1/kg by IV Q
+
Lesson 7: Special Considerations
+
Choanal Atresia
+
Pierre Robin Syndrome
+
Congenital Diaphragmatic Hernia
+
Pneumothorax (transillumination)
+
Pleural effusions
+
Hypoglycemia

„ IV glucose:
„ <4 and symptomatic
„ <2.5 and asymptomatic for 0-4 hrs of age
„ <3.5 and asymptomatic for 4-24 hrs of age

„ D10W 2ml/kg then D10W infusion 80-100ml/kg/day

„ Repeat Q10-20mins

„ Avoid D25W as hyperosmolar

+

„ Maternal Opioid Use

„ Naloxone 0.1mg/kg
„ Only after initial resuscitation
„ Not for chronic/methadone maternal use

„ Pulmonary hypertension
„ Supp O2 or PPV

„ Congenital Heart Disease

„ Metabolic Acidosis
„ No bicarb unless adequate ventilation
+
Therapeutic Hypothermia

„ >36 wks and perinatal asphyxia

„ Seizures
„ Altered LOC
„ Hypotonia
„ Hyporeflexia

„ Can improve outcomes of severe hypoxic-ischemic

encephalopathy

„ Initiated within 6 hrs

„ 33.5-34.5C for 72 hrs

+
Quiz

„ Baby with choanal atreasia. What do you do?

„ A mec baby has been resuscitated and then develops acute

respiratory deterioration. A ____?___ should be expected.
+
The Bottom Line

„ Diaphragmatic hernia: intubate and OG

„ Choanal atresia: oral airway

„ Pierre Robin: prone and NP airway

„ Congenital cardiac disease rarely causes acute issues

„ Naloxone only after resus in recent maternal opioid use

babies

„ Ongoing monitoring of temp, BG, O2 sat

+
Lesson 8: Preterm Resuscitation

„ Increased heat loss

„ Weak chest muscles

„ Immature immune systems

„ Fragile intracranial capillaries

„ Small blood volume

„ Limited surfactant
+

„ <29 wk: polyethylene bag wrap and warmer

„ Monitor O2 sat from beginning; avoid hyperoxia

„ Giving PEEP

„ Don’t give surfactant until fully resuscitated

„ Handle baby gently

„ No trendelenburg
+
Quiz

„ In addition to a warmer, what else can you use to keep a 27

week baby warm?

„ A baby at 30 wk GA, required PPV for an initial HR of 80. She

responds quickly with rising HR and spontaneous
respirations. At 2 mins of age, she is breathing, has a HR of
140 and CPAP at 50% O2. Her sats are 95%. What should you
do:
„ Increase the O2 concentration?
„ Decrease the O2 concentration?
„ Leave the O2 concentration the same?
+
The Bottom Line

„ Increased risk of resuscitation in preemies

„ More vulnerable to hyperoxia: target 85-95%

„ Increased heat loss Æ bag wrap <29 weeks

„ PEEP if intubated

„ Decrease risk of brain injury

„ Continuous monitoring
+
Lesson 9: Ethics and Care at the
End of Life
„ Discontinuation of resuscitation:
„ 10 mins of no HR
+
Practicality
+
The Very Bottom Line

„ Vigorous: stay with mom (even if meconium)

„ Warm, dry, stimulate

„ Ventilation!!!

„ No chest compressions until ventilation until adequate for 30

sec and HR <60

„ Umbilical vein catheter is not that hard

+
Acknowledgements

„ Kristyn Chatwin: RCH NRP Coordinator

„ References:
„ AHA. Textbook of Neonatal Resuscitation. 6 edition. Elk Grove Village, Dallas,
Tex: American Academy of Pediatrics; 2011.
„ Anon. Addendum to the NRP Provider Textbook 6th Edition; Recommendations
for specific modifications in the Canadian context. 2011.
„ Lo MD, Mazor SS. Chapter 11 Neonatl Resuscitation. In: Rosen’s Emergency
Medicine-Concepts and Clinical Practice.Vol 1. 8th ed.
„ Anon. CPS Medications for Neonatal Rsuscitation Program 2011 Canadian
Adaptation.
„ Kester-Greene N, Lee JS. Preparedness of urban, general emergency
department staff for neonatal resuscitation in a Canadian setting. CJEM.
2013;15(0):1–7.
„ Anderson J, Leonard D, Braner DAV, Lai S, Tegtmeyer K. Umbilical Vascular
catheterization. New England Journal of Medicine. 2008.