1. NEONATAL RESUSCITATION

8. “The most important and effective action in neonatal resuscitation is to ventilate the baby’s lungs”

9. Obstetrician and Neonatologist Pediatrician Collaboration
It is very important for disciplines to communicate before deliveries occur
Need to know maternal risk factors -may influence personnel attending delivery, equipment available and set-up at delivery
Allows for adequate counseling of parents in high-risk situations
Allows for discussions about viability and outcomes

10. Preparation for Resuscitation- Personnel and Equipment
Every delivery should be attended by at least 1 person whose only responsibility is the baby, and who is capable of initiating resuscitation.
When resuscitation is anticipated, additional personnel should be present in the delivery room before the delivery occurs
Prepare necessary equipment
Turn on radiant warmer
Check resuscitation equipment
Every birth should be attended by at least 1 person whose only responsibility is the baby and who is capable of initiating resuscitation. Either that person or someone else who is immediately available should be able to perform a complete resuscitation. It is not sufficient to have someone “on call” (either at home or in a remote area of the hospital) for neonatal resuscitation in the delivery room. If the delivery is anticipated to be high risk and thus may require more advanced neonatal resuscitation, or if the resuscitation will be of a baby less than approximately 32 weeks’ gestation, additional equipment and personnel are necessary in the delivery room. (See Lesson 8.) All personnel should observe appropriate body fluid precautions during resuscitation as defined by hospital policy.
Instructor Tip: You should ask yourself these questions: Is every birth in this setting attended by a person who can initiate resuscitation? What is the protocol for assembling team members for an anticipated high-risk birth? Is equipment set up the same in every room so that no one has to search for items?

11. Preparation for Resuscitation – Risk Factors
The majority, but not all, of neonatal resuscitations can be anticipated by identifying the presence of antepartum and intrapartum risk factors associated with the need for neonatal resuscitation
In many cases, delivery of a depressed newborn can be anticipated on the basis of the antepartum and intrapartum history.

13. Evaluating the Need for Resuscitation
NRP 2006
If the answer to all of the initial questions is “Yes,” and the newborn is term, the newborn may receive routine care to continue transition. If the answer to any one of these questions is “No,” the newborn will require some form of resuscitation.
Instructor Tip: Assess these criteria simultaneously. The decision to provide routine care or proceed with initial steps takes only a few seconds.

14. Why color not included in initial risk assessment
In utero, fetal oxygenation saturation approximately 60%
Full-term babies may take >10 minutes for saturation >90%
Majority reach >90% by 5-8 minutes
Preductal pulse oximetry values rise quicker than postductal
Slower rise after c-section compared to vaginal delivery
Preterm neonates rise slower than term and don’t reach as high values

15. Meconium
Intrapartum oro- and naso-pharyngeal suctioning no longer recommended upon delivery of head
Based on the following study which randomized to no intrapartum suctioning of oro- and naso-pharynx vs. standard of suctioning upon delivery of head
No difference in meconium aspiration syndrome, need for mechanical ventilation or death
No difference in other respiratory disorders, pneumothoraces, need for positive pressure ventilation in the delivery room or Apgar scores
No complications noted from intrapartum suctioning
Vain et al, Lancet 2004; 364:

16. Oxygen Concentration During Positive-Pressure Ventilation
“The Neonatal Resuscitation Program (NRP) recommends use of 100% oxygen when positive-pressure ventilation is required during neonatal resuscitation. However, research suggests that resuscitation with something less than 100% may be just as successful.”
Free flow 100% oxygen should be used in the cyanotic but spontaneously breathing neonate
“If resuscitation is started with less than 100% oxygen, supplemental oxygen up to 100% should be administered if there is no appreciable improvement within 90 seconds following birth.”
“If oxygen is unavailable, use room air to deliver positive-pressure ventilation.”

17. Evidence Against Resuscitation with 100% Oxygen
Moderately asphyxiated term neonates resuscitated with room air had
Quicker return of regular respiratory pattern
Lower markers of oxidative stress at 28 days of life
Vento et al, Pediatrics 2001; 107: 642-7
Asphyxiated term neonates resuscitated with room air had
Quicker time to first cry
Shorter length of resuscitation
Lower markers of oxidative stress at 48 hours of life
Lower markers of heart and kidney injury at 48 hours of life
Vento et al, Am J Respir Crit Care Med 2005; 172:

18. Evidence of Safety of Room Air Resuscitation
Neonates (>1000 g) resuscitated with room air had
No difference in
mortality
hypoxic ischemic encephalopathy
length of resuscitation
“treatment failure”
No difference at 18 or 24 months of age in
growth
attainment of developmental milestones
hearing status
cerebral palsy or mental retardation

19. Positive-pressure Ventilation
Call for help when starting positive-pressure ventilation
Signs of effective ventilation
Increasing heart rate
Breath sounds or chest movement

20. T-piece Resuscitator
The T-piece resuscitator has 2 controls to adjust the inspiratory pressure. The inspiratory pressure control sets the amount of pressure desired during a normal assisted breath. The maximum pressure relief control is a safety feature that prevents the pressure from exceeding a preset value (usually 40 cm H2O, but adjustable). Excessive pressure can also be avoided by watching the circuit pressure gauge.

21. T-piece resuscitator Downside of T-piece
T-piece resuscitator better at maintaining and delivering desired pressures
Self-inflating or flow-inflating bags easier to overshoot and less consistent peak inflating pressures
T-piece resuscitator better to deliver sustained i-time
Downside of T-piece
Takes longer to adjust peak inspired pressures

22. Gastric decompression
Bridge of nose to earlobe to point halfway between xyphoid process and umbilicus

23. Confirmation of correct ETT position
Primary Methods
Increasing heart rate
Carbon dioxide production
If cardiac output remains poor insufficient CO2 may be exhaled to be detected by above means
Secondary Methods
Bilateral breath sounds best over lungs
Symmetric chest rise

24. Laryngeal Mask Airway (LMA)

25. LMA Use in DR Resuscitation
Two studies demonstrated effective use of the laryngeal mask airway for delivery of positive-pressure ventilation in the delivery room.
Quick to insert
Easy to insert i.e. all successfully placed on 1st attempt
However, these studies excluded patients needing chest compressions and suctioning for meconium was not done through the LMA
Gandini et al, Anesthesia and Analgesia 1999; 89(3):
Paterson et al, Anesthesiology 1994; 80(6):

26. Potential Advantages of LMA
Avoids issues with seal for BMV
Head position does not need to be manipulated for placement
Avoids compression of facial nerves/vessels
Can be placed and maintained in stable position in most patients with craniofacial malformations
Less skill needed to give PPV with LMA compared to face mask
Avoids vagal response with laryngoscopy
Avoids edema/trauma with repeated ETT placement attempts
Easy to place
Fast to place

27. LMA and NRP
“There is insufficient evidence to support the routine use of the LMA as the primary airway device during neonatal resuscitation, in the setting of meconium stained amniotic fluid, when chest compressions are required, in very low birth weight babies or for delivery of emergency intratracheal medications.”
However, consider use when both mask ventilation and endotracheal intubation have failed

28. LMA Placement Technique
Lubricate- especially surface that will slide against palate/pharynx
Inflate slightly with 2-3 ml of air
Hold like a pencil
Insert as should lie
Insert until feel resistance
Inflate another 2-3 ml (max 6ml)
Should see slight rise in LMA w/second inflation of cuff

30. Epinephrine

31. Evidence for Changes in Epinephrine Dosing
Adult and animal data provide evidence that intratracheal delivery of epinephrine is less efficacious
Evidence that more than 10 times dose may be needed intratracheally for optimal effect
Physiologically this increased dose may be needed in the newborn due to:
Decreased pulmonary blood flow
During CPR
Pulmonary vasoconstriction
Presence of persistent alveolar fluid
Shunts bypassing lung circulation
Patent ductus arteriosus
Patent foramen ovale

32. Special Considerations- Narcan
Not recommended as part of initial resuscitation
Should be reserved for neonates with known short time administration of narcotic to mother (<4 hours before delivery) who have been resuscitated and have a restored circulation but remain apneic
Concern of use if any concern of maternal addiction due to potential precipitation of acute withdrawal syndrome in neonate
Dosing
0.1 mg/kg IV or IM
IV preferred due to longer onset of action with IM
Endotracheal dosing not recommended

33. Special Considerations: Sodium Bicarbonate
Included as part of post-resuscitation care for correction of metabolic acidosis
Administration recommendations
Use only after establishment of adequate ventilation and circulation
Dose 2 meq/kg IV
Administer no faster than 1 meq/kg/min

34. Sodium Bicarbonate Rationale for use Rationale against use
Severe acidosis can cause myocardial dysfunction, pulmonary vasoconstriction and may decrease benefits of catecholamine therapy
Rationale against use
Can increase intracellular acidosis by increasing CO2
May decrease cerebral blood flow
Associated with intraventricular hemorrhage in preterm neonates

35. Post Resuscitation Care: Induced Hypothermia
Hypothermia protective against brain injury after asphyxial injury in animal models
Two neonatal outcome studies
One selective head cooling
Other whole body cooling
Both enrolled only term infants >1800/2000 g
Both started w/in 6 hours of birth
Both found decrease in death or severe disability in subgroup with moderate hypoxic-ischemic encephalopathy

36. Post Resuscitation Care: Induced Hypothermia
NRP statements
“There is insufficient data to recommend routine use of modest systemic or selective cerebral hypothermia after resuscitation of infants with suspected asphyxia”
“Avoidance of hyperthermia is particularly important in babies who may have had a hypoxic-ischemic event.”

37. Post-Resuscitation Care
Routine Care
For neonates who needed no resuscitation and have no risk factors
Stay with moms
Thermoregulation-dry and place on mom’s chest
Warmth-skin-to-skin
Airway-wipe mouth and nose if needed
Ongoing observation of breathing, activity and color

38. Post-Resuscitation Care
Observational Care (was called supportive care in 2006 NRP)
For neonates at risk
Maternal or fetal risk factors
Meconium stained amniotic fluid
Depressed breathing, activity and/or cyanosis
Management
Placed under radiant warmer initially and resuscitated as needed
Evaluated frequently during immediate neonatal period
admission to transitional area of nursery

39. Post-Resuscitation Care
Post-resuscitation Care (was called on-going care in 2006 NRP)
For neonates who require positive pressure ventilation or more extensive resuscitation
Management
Ongoing monitoring and evaluation
Intensive care nursery

40. Premature Babies Additional Risk due to: Excessive heat loss
Vulnerability to hyperoxic injury
Immature lungs and diminished respiratory drive
Vulnerability to infection
Immature brains that are prone to hemorrhage
Small blood volume, increasing the implications of blood loss
Babies who are born preterm are at risk for a variety of complications.
Their thin skin, large surface area, and decreased fat allow them to lose heat easier.
Their immature organs may be more easily damaged by excessive oxygen.
Their weak muscles may make it difficult for them to breathe.
Their drive to breathe may be decreased due to immaturity of the nervous system.
Their lungs may be immature and deficient in surfactant.
Their immune systems are immature, making infection more likely.
Fragile capillaries within their developing brains may rupture.
Small blood volume makes them more susceptible to hypovolemic effects of blood loss.

41. Temperature “The initial steps of resuscitation are to provide warmth…
Adverse effects of hypothermia
Admission temperature to NICU is independent risk factor of death
Bradycardia
Metabolic acidosis
Mechanisms to prevent hypothermia in the DR
Bags
Hats
Radiant warmers
Ambient room temperature
Warmer packs
Need to monitor closely to avoid risk of hyperthermia!!!

42. Keeping Premature Babies Warm
Increase delivery room temperature
Preheat radiant warmer
Use warming pad
Consider polyethylene bag for babies <28 weeks’ gestation
Do not need to dry before placing in bag or wrapping
Premature babies are particularly vulnerable to cold stress. Steps to reduce heat loss include
Increase the temperature of the delivery room or resuscitation area.
Preheat the radiant warmer by turning it on well before the birth.
Place a portable warming pad under layers of towels on the resuscitation table. Follow the manufacturer’s recommendation for activation and place the correct side next to the baby.
If the baby is born at less than 28 weeks’ gestation, consider placing him or her, below the neck, in a reclosable polyethylene bag. This is done without first drying the skin, and the bag can be a standard 1-gallon, food-grade polyethylene bag purchased in a grocery store.
Use a pre-warmed transport incubator to maintain temperature while the baby is being transported from the delivery room to the nursery.

43. Oxygen Administration
Hyperoxic/reperfusion injury may be more significant in preterm babies
Oxygen blender, air source, and pulse oximeter recommended for babies born at <32 weeks’ gestation.
“It is recommended that you start somewhere between room air and 100% oxygen so that you can either increase of decrease the concentration as the baby’s condition indicates.”
Hyperoxic reperfusion injury may be a more significant factor for the baby born preterm, because the mechanisms that protect the body from oxygen injury may have not yet fully developed. In resuscitating preterm newborns, you should be vigilant about avoiding excessive oxygen. This additional equipment is especially recommended in preterm babies born at less than approximately 32 weeks’ gestation who are electively delivered at your facility. If your facility does not have these resources and there is insufficient time to transfer the mother to another facility, the resources in oxygen management described for a term baby can be used.

44. Adjusting Oxygen
Optimum saturation for preterm babies in first minutes of life unknown
“During the first few minutes, saturations of 70%-80% are acceptable, as long as the heart rate is increasing, the baby is being ventilated and the oxygen saturations are increasing.”
95% oxygen saturation is too high for preterm babies
Adjust oxygen concentration to achieve desired saturations (89%-94% range)
Studies conducted with full-term babies following birth have shown that it may normally take more than 10 minutes for oxyhemoglobin saturations to rise to 90%. Studies have not been conducted to define the optimal saturation for premature babies following birth. However, oxygen saturations of greater than 95% may be too high if a preterm baby is receiving supplemental oxygen. Several steps are recommended to reduce excessive tissue oxygenation if a very preterm baby is electively delivered at your facility. These steps become more important as gestational age decreases.

45. Assisting Ventilation in Premature Newborns
Follow same criteria for initiating positive-pressure ventilation with term babies
Consider using CPAP if the baby is breathing spontaneously and has a heart rate above 100 bpm, but is having difficulty such as labored respirations, persistent cyanosis, or low oxygen saturation
Use the lowest inflation pressure to achieve an adequate response
Usually cm H2O adequate
Consider giving prophylactic surfactant
Babies born significantly preterm have immature lungs and may be difficult to ventilate, but also are more easily injured with positive-pressure ventilation. Use the same criteria for assisting ventilation with a preterm baby that you have learned for assisting ventilation with a term baby.
Administration of continuous positive airway pressure (CPAP) may be helpful in babies who are breathing spontaneously and have a heart rate greater than 100 bpm, but appear to have labored respirations or are cyanotic. Continuous positive airway pressure may be administered with a flow-inflating bag or with a T-piece resuscitator, but not with a self-inflating bag.
If positive-pressure ventilation is required due to apnea, a heart rate less than 100 bpm, or persistent cyanosis, an initial inflation pressure of 20 to 25 cm H2O is adequate for most preterm babies. Use the lowest inflation pressure necessary to achieve an adequate response.
Studies have shown that babies born at less than 30 weeks’ gestation may benefit from being given surfactant after resuscitation while still in the delivery room. Prophylactic administration of surfactant will be determined by local care practices. Babies should be fully resuscitated before surfactant is given.

46. Decreasing Brain Injury
Handle the baby gently
Avoid the Trendelenburg (head down) position
Avoid high airway pressures when possible
Risk of restricting venous return from head
Risk of producing pneumothorax
Adjust ventilation gradually based on physical examination, oximetry, blood gases
Avoid rapid intravenous fluid boluses and hypertonic solutions
Sodium Bicarbonate
Greater than 10% dextrose
The brains of babies born before 32 weeks’ gestation have a network of capillaries that are prone to rupture leading to brain hemorrhage. The following precautions may help avoid intraventricular bleeding:
Handle the baby gently, even during the stress of the resuscitation.
Avoid placing the baby in a head-down position.
Only enough positive pressure to achieve a rise in heart rate and adequate ventilation should be provided.
Use an oximeter and blood gas analysis to adjust ventilation gradually, avoiding rapid changes in CO2 content of the blood.
If volume expansion is necessary, avoid giving the infusion too rapidly or using hypertonic solutions intravenously.

47. No response to Resuscitation
“Discontinuation of resuscitation efforts may be appropriate after 10 minutes of absent heart rate following complete and adequate resuscitation efforts”
If there is no heart rate after 10 minutes of complete and adequate resuscitation efforts and there is no evidence of other causes of newborn compromise, discontinuation of resuscitation efforts may be appropriate. Current data indicate that, after 10 minutes of asystole, newborns are very unlikely to survive, or likely to survive with severe disability. However, more than 10 minutes after birth may have been required to assess the baby and optimize the resuscitation efforts.
There is no obligation to continue life support if it is the judgment of experienced clinicians that such support would not be in the best interest of the baby or would serve no useful purpose (ie, would be futile). In the case of withdrawal of critical care interventions and institution of comfort care support after successful initial resuscitation, the parents should be in agreement with this judgment.