NEONATAL RESUSCITATION

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

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

13. Evaluating the Need for Resuscitation NRP 2006

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: 597-602

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: 1393-98

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

21. T-piece resuscitator • 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): 642-5. • Paterson et al, Anesthesiology 1994; 80(6):1248-53

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 • 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 • 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

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

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.”

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)

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 20-25 cm H2O adequate • Consider giving prophylactic surfactant

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

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”