1. Critical Concepts NICU
Brian M. Barkemeyer, MD
LSUHSC Division of Neonatology

2. At birth
100% of infants need someone present dedicated to the infant and capable of initial steps in neonatal resuscitation
10% of infants require some level of resuscitation at birth
1% of infants require major resuscitation

3. “Golden hour”
At no other time in one’s life will necessary critical concepts in resuscitation have a potential lifelong impact
Appropriate interventions (or the lack thereof) can make the difference between life or death, or normal life vs. life of disability

4. Preparation NRP - Neonatal Resuscitation Program Proper equipment
Evidence-based, standardized program jointly sponsored by American Academy of Pediatrics and American Heart Association
Proper equipment
Knowledge
In most cases, the need for neonatal resuscitation is predictable
But not always!

5. Risk Factors Predictive of Need for Neonatal Resuscitation
Maternal illness
Hypertension
Diabetes
Infection
Prematurity
Post-maturity
Multiple gestation
Maternal bleeding
Maternal drug abuse
No prenatal care
Fetal distress
Abnormal fetal position
Abnormal labor
Fetal anomalies
Macrosomia
IUGR
Placental abnormalities
Meconium-stained amniotic fluid

6. Transition to Extrauterine Life
Fluid-filled alveoli to air-filled alveoli
Circulatory changes
Decreased pulmonary vascular resistance resulting in increased pulmonary blood flow and cessation of flow through foramen ovale and ductus arteriosus
Cessation of flow to placenta resulting in increased systemic vascular resistance

7. Lack of Appropriate Resuscitation
Interrupts normal transition to extrauterine life
Hypoxia
Respiratory and metabolic acidosis
Ischemia
Potential for death or long term adverse outcome

8. Three Basic Questions Term infant? Breathing/crying at birth?
Normal tone at birth?
If the answer to these three questions is yes, infant doesn’t need resuscitation, but does deserve initial steps

9. Initial Steps Drying Warming Stimulation Positioning Clear airway
Necessary for all newborns!

10. Warming Appropriate room temperature
Rapid drying to avoid evaporative heat loss
Remove wet towels
Mother – skin to skin
Radiant heat warmer
Blankets, cap
Premature infants and IUGR infants at highest risk for hypothermia

11. Establishment of the Airway
Suction mouth then nose (“M before N”)
Shoulder roll to aid in positioning
Head positioned in slight extension, or “sniffing position”
Not too extended
Not too flexed

12. ABC’s Airway Breathing Circulation
Suction secretions, assess for anomalies
Breathing
Stimulate respiratory effort
Tactile
Bag-mask positive pressure ventilation (PPV)
Circulation
Assess heart rate
Chest compressions if PPV ineffective at restoring heart rate

13. Skills to Learn Neonatal assessment Use of bulb suction
Administration of positive pressure ventilation by bag-mask
Intubation and assistance with intubation
Chest compressions

14. Assessment/Reassessment: Sequential steps in resuscitation
Initial steps [30 seconds]
PPV [30 seconds]
Chest compressions [30 seconds]
Medications [30 seconds]

15. Neonatal Assessment Respirations Heart rate Color
Normal rate and depth, good chest movement
Heart rate
Normal > 100
Count for 6 seconds, multiply x 10
Color
Pink lips and trunk
Acrocyanosis vs. central cyanosis

17. Indications for PPV
If after initial steps in resuscitation [30 sec], assessment reveals
Apnea
Gasping respirations
Heart rate < 100

18. Indications for Chest Compressions
If after initial steps in resuscitation [30 sec] and effective PPV [30 sec], assessment reveals
Heart rate < 60

19. Indications for Epinephrine
Heart rate persists < 60 after
Initial steps [30 seconds]
PPV [30 seconds]
Chest compressions [30 seconds]
Dosage given IV (UVC preferred), or endotracheal (higher dose given)

20. Indications for Volume Administration
History of blood loss at delivery suggesting
hypovolemia
AND
Infant appears to be in shock (pallor, poor perfusion, failure to respond appropriately to resuscitation efforts)
IV, mL/kg, Normal saline, Ringer’s lactate, or O- blood

21. Meconium-stained Amniotic Fluid
15% of deliveries; at risk for meconium aspiration syndrome
Suctioning of upper airway and trachea in infants who are not vigorous may help prevent meconium aspiration syndrome
Vigorous defined by
Heart rate > 100
Normal respiratory effort
Normal tone

22. Positive Pressure Ventilation
Appropriate size mask and bag
Self-inflating vs. flow-inflating bag
Forming a good seal with mask
Achieve adequate chest rise
40-60 breaths per minute
When done appropriately, PPV should result in improvement in heart rate and color

23. Ineffective PPV Reposition mask on face Reposition head
Suction upper airway
Ventilate with mouth open
Increase ventilatory pressure
Replace bag
Endotracheal intubation

24. Self-inflating bag

25. Flow-inflating bag

26. Chest Compressions Should be coordinated with PPV
2 thumb method preferred
Compression of sternum 1/3 depth of AP diameter of chest
120 events per minute (compressions and respirations combined)
“One and two and three and breathe”

27. Chest Compressions

28. Endotracheal Intubation
ET tube size similar to size of patient’s little finger
< 28 wks, < 1000 g = 2.5 ETT
28-34 wks, g = 3.0 ETT
34-38 wks, g = 3.5 ETT
38-42 wks, > 3000 g = 4.0 ETT
Insertion depth
“Tip to lip” measurement = weight in kg plus 6
2 kg patient should have ETT secure at 8 cm mark at lip

29. Endotracheal Intubation

30. Unique Aspects of Endotracheal Intubation in Infants
Narrowest part of airway is subglottic area
Uncuffed ET tubes typically utilized
Increased airway resistance associated with more narrow airway diameter
Relative lack of structural support for neonatal airway

31. Unique Anatomic Challenges
Choanal atresia
Endotracheal intubation may be required
Pierre-Robin sequence
Prone positioning
NG tube into posterior pharynx
Congenital diaphragmatic hernia
Endotracheal intubation
Gastric decompression

32. Key Points
Appropriate resuscitation requires a rapid series of assessments, interventions, and reassessments
All infants deserve basic steps of resuscitation
Drying, warming, positioning, clear airway
Prompt initiation of respiratory support with positive pressure ventilation by bag-mask is the key to successful resuscitation of most infants