Neonatal Resuscitation

An outline review

Anticipation and Recognition of the Neonate in Distress

A. Recognition and treatment of Primary and Secondary apnea

                1. Primary Apnea: When asphyxiated, the infant responds with a increased respiratory
                                                   rate. If the episode continues, the infant becomes apnic, followed by a drop in heart rate
                                                   and a slight increase in blood pressure. The infant will respond to stimulation and 02 therapy with
                                                   spontaneous respirations.

               2. Secondary apnea: When asphyxia is allowed to continue after primary
                                                      apnea, the infant responds with a period a gasping respirations, falling heart rate, and
                                                      falling blood pressure. The infant takes a last breath
                                                      and then enters the secondary apnea period. The infant will not respond
                                                      to stimulation and death will occur unless resuscitation begins immediately.

* Because after delivery of an infant it is impossible to differentiate between
primary apnea and secondary apnea, assume the infant is in secondary apnea and begin resuscitation immediately.

B. High risk deliveries: Infants are at greater risk for distress

                       1. Thick meconium after maternal membranes ruptured
                       2. Fetal distress
                       3. "Crash" C-section
                       4. Premature birth

C. Gather and test appropriate equipment:

                      1. Flow dependent or self inflating bag attached to 100% source gas
                      2. Appropriate size mask
                      3. Bulb syringe
                      4. Wall suction
                      5. Warmer bed and blankets
                      6. Intubation equipment
                      7. Blow by 02 capabilities

D. Appropriate personnel present for delivery:

1. Physician, Nurse, Respiratory therapist

Initial Steps for Neonatal Resuscitation in Delivery Room

A. Warm & Dry infant

1. Place infant under radiant heat warmer bed and dry infant (tactile stimuli)
This helps prevent cold stress.

B. Initiate ABCís

1. A= Establish airway: position head in neutral position and bulb sx mouth
and nose.

                         2. B= Breathing : Bag & Mask Ventilation or Bag & Et tube always with
                                                       100% FI02.
                         3. C= Circulation: Assess heart rate by listening to Apical pulse with
                                                          stethoscope, pulse in umbilicus, or brachial pulse.

C. Evaluate infant for:

1. Color: central vs. acrocyanosis. If centrally cyanotic give infant blow by
oxygen.

2. Signs of Respiratory distress:

                                 a. Increased WOB
                                 b. Nasal flaring
                                 c. Tachypnea
                                 d. Grunting

Bag and Mask Ventilation in the Newborn

1. Indications for bag mask ventilation

a. Apnea
b. Heart rate less than 100 bpm

2. Self inflating vs. flow dependent bag

3. Rate = 40-60 bpm

4. Pressure used =

                              a. Initial breath after delivery = 30-40 cm H20
                              b. Normal delivery = 15-20 cm H20
                              c. Diseased Lungs = 20-40 cm H20

5. Technique/Trouble shooting problems of Bag mask ventilation

                              a. Check for a good seal
                              b. Check for a patent airway
                              c. Are you using enough pressure ?

Intubation of the Neonate:

1. Indications for intubation:

                   a. Prolonged bag and mask ventilation
                   b. Bag and mask is ineffective
                   c. Tracheal suctioning

2. Et tube sizes and correct suction catheter sizes:

Weight of Infant Et tube Size Suction catheter size

< 1000 gms	2.5 Et tube	5-6 french suction catheter
1000-2000 gms	3.0 Et tube	6 french suction catheter
2000-3000 gms	3.5 Et tube	8 french suction catheter
>3000 gms	4.0 Et tube	8 french suction catheter

Chest Compressions

1. Indications: If after 15-30 seconds of positive pressure ventilation with 100% FI02 the heart rate is

a. below 60 bpm
b. between 60-80 bpm and not increasing

              2. Technique:
                                      a. 1 fingers breadth below nipple line, using 2 fingers
                                      b. 1/2 to 3/4 compression depth
                                      c. accompanied by ventilations, ratio is 3:1 or 90 compressions to
                                          ventilations in 1 minute.

Medications:

            1. Indications for Medications: If infants heart rate remains below 80 beats per minute despite adequate
                                                                       ventilation ( with 100%), and chest compressions for a minimum of 30 seconds or
                                                                        Heart rate = 0 .

Epinephrine: Increases the rate and strength of cardiac contractions and causes peripheral vasoconstriction.
Indications are same as above

              Volume expanders are for hypovolemic states:
                                                     signs of hypovolemia include pallor despite oxygenation, weak pulses with
                                                     a good heart rate, poor response to resuscitative efforts, decreased blood
                                                     pressure ( may not be available).

Naloxone Hydochloride (Narcan): given if there is severe respiratory depression and a history of maternal
narcotic administration within the past 4 hours.

             Sodium Bicarbonate: helps correct metabolic acidosis, indicated when there
                                                        Is a prolonged arrest that does no respond to other therapy. NaHC03 should only be used if
                                                        adequate ventilation is provided. Because it is a hyperosmotic solution, give slowly in order
                                                        to minimize the risk of intraventricular hemorrhage.

Dosage Chart

Drug name	Dose	Concentration
Epinephrine	0.01-0.03 mg/kg or 0.1-0.3 ml/kg	*1:10,000
Volume Expander	10 ml/kg	Whole blood, 5% Albumin, Normal saline, Ringerís Lactate
Sodium Bicarbonate	2 mEq/kg	0.5 mEq/ml (4.2% solution)
Naloxone Hydrochloride	0.1 mg/kg	1.0 mg/ml or 0.4 mg/ml

Special Resuscitative Efforts:

1. Meconium Present at delivery

                  a. Thick vs. Thin: It is generally agreed upon that if thick meconium is present, the baby should be intubated
                                                 and suctioned immediately after delivery. For thin meconium, intubation is optional.
                  b. Doctor should suction oral and nasopharnyx when head is delivered
                  c. After delivery, infant is placed under radiant heat warmer and intubated in
                      order to clear meconium from airway.

2. Diaphragmatic hernia:

a. Do not bag mask, intubate as soon as possible.
b. Insert oral gastric tube to decompress GI tract.

Prepared by: Kay Givens, RRT, Med. Pediatric Educational Coordinator for the Medical Center of Louisiana
References: Neonatal Resuscitation, 1994 American Heart Association/Academy of Pediatrics, Rev 9/96.

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