Neonatal Resuscitation Joseph Gilhooly, MD Doernbecher Children’s Hospital

NRP 2001

Resuscitation Algorithm: 2001

Why we need to resuscitate: pH 7.30 pH 7.00 pH 6.80

How often do we use our resuscitation skills?

Suction Equipment Warmer & Blankets Bag, Mask, & Oxygen Laryngoscope and ETT Tube

Universal Precautions

Assessment: Then Appearance Pulse Grimace Activity Respirations

Assessment: Now Clear of Meconium? Breathing or Crying? Breathing Physiologic Parameters (Apgar’s best) Questions to ask yourself Clear of Meconium? Breathing or Crying? Good Muscle tone? Color Pink? Term Gestation? Breathing Heart Rate Color

Initial Management: For all deliveries Provide warmth Position and Clear Airway Dry Give Oxygen (as necessary)

Providing Warmth: The cycle of hypothermia Acidosis Pulmonary Vasoconstriction Anaerobic metabolism Pulmonary Hypertension Tissue hypoxia Right to left shunting Hypoxemia

Positioning: Sniffing

The “Trusty” Bulb Syringe

Clear of Meconium?

Color pink?

Pulse Oximetry: Resuscitation monitor Not affected by acrocyanosis Be patient and get a reading If baby in shock, get central IV access

Breathing or Crying? Indications for PPV Apnea or gasping Heart rate <100 even if breathing Persistent central cyanosis (saturation <90%) despite 100% free-flow oxygen

Self-Inflating Bag Pressure manometer attaches O2 Reservoir PEEP valve port 200-750ml Bag size

Neopuff CPAP Pressure limited ventilation with PEEP Blended oxygen Eliminates variability associated with bag ventilation

Masks Smallest sizes are for preterm infants

Make sure the airway is clear Lift the baby’s jaw into the mask Keep the mouth slightly open Rate 40-60

Indications for Intubation Meconium and baby is not vigorous PPV by bag-mask does not result in good chest rise PPV needed beyond a few minutes Chest compressions necessary Route to administer epinephrine Special indications: Prematurity, CDH

Miller 0 Miller 1

>2000 gm 3.5 3.0 1000-2000 gm 2.5 <1000 gm Stylet

Intubation Technique

Lip reference mark: (6 + weight in kilos) cm 9-10 cm at the lip for this term infant

Indications for Compressions Heart rate <60 bpm after 30sec of PPV Coordinate with ventilation 4 events in 2 seconds 90 compressions and 30 breaths per minute One and Two and Three and Breathe 2 seconds

2 thumb technique preferred Compressions 2 thumb technique preferred

Medications: Epinephrine Indication: Heart rate <60 after 30 sec of coordinated ventilation and compressions 1:10,000 (0.1mg/ml) Route: ETT or IV 0.1-0.3 ml/kg 1ml Term 0.5ml Preterm 0.25ml Extreme preterm

Extended Algorithm Endotracheal Intubation if not already accomplished Establish IV access with UVC Stat CXR Discontinue efforts if no heart rate after 15 minutes

IV Access: “Low” UVC

Volume Indication: No response to resuscitation and evidence of blood loss Normal Saline Ringers or Blood as alternatives 10 ml/kg, may repeat Route: IV (Umbilical vein)

Sodium Bicarbonate Indication: Documented or assumed metabolic acidosis Concentration: 4.2% NaHCO3 (0.5meq/ml) Dose: 2meq/kg Route: IV (Umbilical vein)

Naloxone (Narcan) Indication: Severe respiratory depression after PPV has restored a normal HR and color and… History of maternal narcotic administration within the past 4 hours Dose: 0.1mg/kg of 1mg/ml solution Route: ETT, IV, IM, SQ

Hypoglycemia Blood Glucose <45-60 5cc/k D10W Route IV