Update On Neonatal Resuscitation

Update on Neonatal Resuscitation
Rinawati Rohsiswatmo
INDONESIAN PICU NICU UPDATE – 2020/2021

Outline
1. Algorithm of neonatal resuscitation
2. Humidification
3. Oxygenation
4. Single versus binasal prong
5. Sustained inflation (SI)
6. Chest compression
7. Epinephrine (adrenaline) for neonatal resuscitation
8. Intraosseous versus umbilical vein for emergency access
9. Impact of duration of intensive resuscitation

Algorithm of Neonatal Resuscitation
Rohsiswatmo R, Rundjan L. Resusitasi Neonatus. Jakarta: UKK Neonatologi Ikatan Dokter Anak Indonesia; 2014

Humidification
• In the delivery room and during transportation,
interventions that can be practiced to prevent
hypothermia:
Plastic wrap or
bag, plastic caps, Radiant warmer Thermal mattress
cling wrap
Pre-warmed
Warm humidified Skin to skin
single/double
gases contact
walled incubators
Hosono S, et al. Summary of Japanese Neonatal Cardiopulmonary Resuscitation Guidelines 2015. Pediatrics International (2020) 62,128–139
Meyer MP, Owen LS, te Pas AB. Use of Heated Humidified Gases for Early Stabilization of Preterm Infants: A Meta-Analysis. Front Pediatr. 2018 Oct 25;6:319.

Humidification
Heating and humidification was achieved by
adding 30-50 ml of water and turning on the
device prior to expected delivery.The median
humidifier temperature was 36.5 oC
• Two studies (476 preterm infants <32 weeks gestation) were enrolled
• The number of infants with more severe hypothermia (<35.5◦C) was significantly reduced
• Preterm infants <28 weeks had significantly less admission hypothermia
• Mortality and measures of respiratory outcome were not significantly different, though there was a trend to
improvement in all respiratory measures assessed.
• There were no significant adverse events and no increase in admission hyperthermia (>37.5◦C)

Humidification
• Heating and humidification of inspired gases immediately after birth
and during transport → improves admission temperature in preterm
infants
• Consideration should be given to incorporating this technique into other strategies (e.g., use of
plastic wrap) designed to keep preterm infants warm on admission to the neonatal unit
With the used of heated humidified gases in delivery room, hypothermia was significantly
reduced, especially in ELBW infants

Humidification
• Short periods of exposure to cold dry respiratory gases → destructive effects
• ↓ lung compliance, ↑ work of breathing, release of proinflammatory cytokines
and damage to the mucociliary layer
• Humidity enhances mucociliary clearance
Bustamante-Marin XM, Ostrowski LE. Cilia and Mucociliary Clearance. Cold Spring Harb Perspect Biol. 2017;9(4).

History of Oxygen Use in Delivery Room
Initiating lower oxygen

concentration (21% to
Use of 21% was just as 30%) for preterm
effective as 100% oxygen newborn (< 35 weeks’
and lower mortality rate in gestation) and 21% for
term infants newborn ≥ 35 weeks’
ILCOR guidelines recommend gestation
starting term or near-term (ILCOR, 2020)
newborns needing ventilation
on air rather than pure
oxygen (ILCOR, 2010)
Oxygen was considered
“only to be good” and
clinicians were advised to
use it liberally (1960)
Kim E, Nguyen M. Oxygen Therapy for Neonatal Resuscitation in the Delivery Room. NeoReviews. 2019 Sep 1;20(9):e500-12.
Oei JL, Vento M. Is There a “Right” Amount of Oxygen for Preterm Infant Stabilization at Birth?. Frontiers in pediatrics. 2019;7.
Wyckoff Myra H., Wyllie Jonathan, Aziz Khalid, de Almeida Maria Fernanda, Fabres Jorge, Fawke Joe, et al. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020 Oct 20;142(16_suppl_1):S185–221.

Oxygen for Resuscitation Preductal saturation target during
resuscitation
AHA 2020: Age Target saturation

• Newborn < 35 weeks’ gestation → start with a lower oxygen 1 min 60-70%
concentration (21% to 30%) 2 min 65-85%
• Newborn ≥ 35 weeks’ gestation → start with 21% oxygen (air) 3 min 70-90%
• Start with 100% oxygen is NOT recommended 4 min 75-90%
5 min 80-90%
10 min 85-90%
Subsequent titration of oxygen concentration using

pulse oximetry is advised
Wyckoff Myra H., Wyllie Jonathan, Aziz Khalid, de Almeida Maria Fernanda, Fabres Jorge, Fawke Joe, et al. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Circulation. 2020 Oct 20;142(16_suppl_1):S185–221.

Oxygen for Resuscitation
• Oxygen should be introduced in any of the following circumstances:
• SpO2 does not reach target SpO2 values at any time
• The heart rate does not increase >100 times/minutes
• Chest compression is started
• During oxygen use, if SpO2 reaches 95% or more at any time or
exceeds target values at this time, the FiO2 must be reduced or
oxygen use must be suspended
Hosono S, et al. Summary of Japanese Neonatal Cardiopulmonary Resuscitation Guidelines 2015. Pediatrics International (2020) 62,128–139

Optimizing Oxygenation of the Extremely Premature Infant during the
First Few Minutes of Life: Start Low or High?
Graphic abstract of the study by Dekker et al on the effect of initial high vs low FiO2 on breathing effort in preterm infants at birth. Copyright Satyan Lakshminrusimha
Saugstad OD, Lakshminrusimha S, Vento M. Optimizing Oxygenation of the Extremely Premature Infant during the First Few Minutes of Life: Start Low or High? The Journal of Pediatrics. 2020 Jul 11;0(0).

Consequences of 100% Oxygen Resuscitation in Term
Neonates
The blue lines represent fetal PaO2 levels; the red line and pink line represent postnatal PaO2 levels with 100 and 21% oxygen resuscitation
The shaded red and pink areas represent the degree of free radical injury following 100% and 21% oxygen resuscitation
Lakshminrusimha S, Saugstad OD. The fetal circulation, pathophysiology of hypoxemic respiratory failure and pulmonary hypertension in neonates, and the role of oxygen therapy. J Perinatol. 2016 Jun;S3-S11.

Oxygen in Extremely Preterm Infant
• No significant differences were seen in a meta analysis of RCTs comparing lower
(≤30%) with higher (≥60%) oxygen for infants born <29 weeks’ gestation
• Guidelines currently recommend the usage of 21-30% oxygen for extremely
preterm infants to minimize exposure to supplemental oxygen in the absence of
convincing evidence of benefit from higher concentrations
Titrating supplemental oxygen against peripheral oxygen saturations is recommended,

although data on the optimal targets are limited in this population
Louise S. Owen, Brett J. Manley and Peter G. Davis, Seminars in Fetal and Neonatal Medicine, 2019

Study in Cipto Mangunkusumo Hospital
ANALYSIS ON THE IMPACT OF THE DIFFERENCE OF EXPOSURE TO INITIAL OXYGEN CONCENTRATION IN
RESUSCITATION OF PREMATURE INFANTS AGAINST BRONCHOPULMONAL DYSPLASIA, MUCOSAL INTEGRITY AND
INTESTINAL MICROBIOTA
Risma Kerina Kaban, Agus Firmansyah, Asril Aminullah, Suhendro, Rianto Setiabudy, Abdurahman Sukadi, Sri Widia A. Jusman M. S., Badriul Hegar Syarif, Rinawati Rohsiswatmo, Budiman Bela
• In premature infants between 25–32 weeks of gestational age

who were resuscitated using 30% vs. 50% initial FiO2 level, we
found no significant differences in rates of BPD, oxidative
stress markers, intestinal mucosa disintegrity and intestinal micro
biota
• Suggestion: administration of 30% or 50% initial FiO2 may be

equally safe for premature infants, start the resuscitation
of preterm infants with initial FiO2 30% and adjust
according to recent SpO2 guidelines

Is There a “Right” Amount of Oxygen for Preterm
Infant Stabilization at Birth?
Even though great importance is placed on

initial FiO2 and the need to avoid hyperoxia,
further evaluation of other aspects of oxygen
handling, e.g., SpO2 targeting is needed
Oei JL, Vento M. Is There a "Right" Amount of Oxygen for Preterm Infant Stabilization at Birth?. Front Pediatr. 2019;7:354

Oxygen Saturation Target
• Divided into 2 groups:

those with a 5-min SpO2 ≥ 80% VS those with a 5-min SpO2 <80%
• Preterm infants needing respiratory support:

• do not reach the SpO2 target of 80% at 5 min after birth → diminished regional
cerebral tissue oxygen saturation values → cerebral hypoxia
• Heart rate was significantly lower at minute 3 and 4 in the <80% group
Binder-Heschl C, Pichler G, Avian A, Schwaberger B, Baik-Schneditz N, Mileder L, Heschl S, Urlesberger B. Oxygen saturation targeting during delivery room stabilization: what does this mean for regional cerebral oxygenation?. Frontiers in pediatrics. 2019;7:274.

Single Versus Binasal Prong
• Infants of birth weight <1000 g, ventilated, requiring < 50% oxygen and ventilator rate ≤20/minute, and
considered by the clinical management team to be ready for extubation
• They were randomly allocated to receive nasal CPAP delivered through binasal (Hudson) prongs or a single nasal
prong
• For extremely low birthweight infants ventilated using an endotracheal tube, nasal CPAP delivered through binasal
(Hudson) prongs is more effective in preventing failure of extubation than that delivered through a single nasal
prong
Davis P, Davies M, Faber B. A randomised controlled trial of two methods of delivering nasal continuous positive airway pressure after extubation to infants weighing less than 1000 g: binasal (Hudson) versus single nasal prongs. Arch Dis Child Fetal Neonatal Ed. 2001 Sep;85(2):F82-5.

Binasal Prong for Transport

Sustained Inflation (SI)
• For preterm newborn infants who receive PPV for bradycardia or ineffective
respirations at birth → AHA 2020 suggest against the routine use of initial
sustained inflation(s) greater than 5 seconds
• A sustained inflation may be considered in research settings
• For term or late preterm infants who receive PPV for bradycardia or ineffective
respirations at birth → it is not possible to recommend any specific duration for
initial inflations due to the very low confidence in effect estimates
Sustained inflation has not been recommended

Sustained Inflation (SI)
• Ten trials enrolling 1467 infants met author’s inclusion criteria

• Preterm newborn (23-36 weeks of gestational age)
• The sustained inflation lasted between 15 and 20 seconds at pressure between 20 and 30 cmH2O
• Use of sustained inflation had no impact on the primary outcomes of this review: mortality in the
delivery room and mortality during hospitalisation
• Among secondary outcomes, duration of mechanical ventilation was shorter in the sustained lung
inflation group
• Conclusion: sustained lung inflation was not better than intermittent ventilation for reducing
mortality
Bruschettini M, O'Donnell CPF, Davis PG, Morley CJ, Moja L, Calevo MG. Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes. Cochrane Database of Systematic Reviews 2020, Issue 3.

Chest Compression
• In the past, providers used a variety of techniques to
perform chest compressions during resuscitation of
newborn infants
• The most common techniques used 2 thumbs with the
remaining fingers surrounding the lateral and posterior
chest, or 2 fingers placed vertically on the lower
sternum
Chest compressions in the newborn infant should be delivered by the 2-thumb,

hands encircling-the-chest method as the preferred option

Chest Compression
• Six studies that had reported data concerning both chest compression depth and chest compression
rate were included
• The two-thumb-encircling hands technique was associated with deeper chest compressions compared
with two-finger technique for mean chest compression depth, but no significant difference in the mean
chest compression rate was noted
• The two-thumb-encircling hands technique is a more appropriate technique for a single rescuer to
perform high-quality chest compression in consideration of chest compression depth than the two-
finger technique in infant manikin studies
Lee JE, Lee J, Oh J, Park CH, Kang H, Lim TH, et al. Comparison of two-thumb encircling and two-finger technique during infant cardiopulmonary resuscitation with single rescuer in simulation studies. Medicine (Baltimore).2019 Nov ;98(45).
Textbook of Neonatal Resuscitation (NRP), 7th Ed. American Academy of Pediatrics; 2016.

Epinephrine (Adrenaline) for Neonatal Resuscitation
• Administration of intravascular epinephrine if HR < 60 bpm after
ventilation and chest compression (0.01–0.03 mg/kg)
• Endotracheal epinephrine at a larger dose (0.05–0.1 mg/kg) if intravascular access
not available
• Administration of further doses of epinephrine every 3 to 5 minutes

• If the heart rate remains < 60 bpm (preferably intravascularly)
• The administration of endotracheal epinephrine should not delay attempts

to establish vascular access
If the response to endotracheal epinephrine is inadequate → intravascular dose be given

as soon as vascular access is obtained

Endotracheal Versus Intravenous Routes of Epinephrine
• Systematic review comparing doses, routes, and intervals of epinephrine

(0.01 to 0.03 mg/kg) in neonatal resuscitation given intravenously (IV)
every 3 to 5 minutes
• There were no differences between IV and endotracheal epinephrine for
the primary outcome of death at hospital discharge or for failure to
achieve ROSC, time to ROSC or proportion receiving additional
epinephrine
• Conclusion: administration of epinephrine by endotracheal

versus IV routes resulted in similar survival and other
outcomes
Isayama T, Mildenhall L, Schmölzer GM, Kim H-S, Rabi Y, Ziegler C, et al. The Route, Dose, and Interval of Epinephrine for Neonatal Resuscitation: A Systematic Review. Pediatrics. 2020.

Epinephrine (Adrenaline) for Neonatal Resuscitation
• Transitioning newborn lamb model (n=44)

• Groups: RA (Right Atrial) epinephrine (0.03 mg/kg), low UVC (Umbilical Vein Catheter)
epinephrine (0.03 mg/kg), post compression ETT epinephrine (0.1 mg/kg), and pre compression
ETT epinephrine (0.1 mg/kg)
• Asystole was induced by umbilical cord occlusion, resuscitation was initiated following 5 minutes
of asystole
• The absorption of ETT epinephrine is low and delayed at birth
• RA and low UVC epinephrine rapidly achieve high plasma concentrations resulting in ROSC
Vali P, Chandrasekharan P, Rawat M, Gugino S, Koenigsknecht C, Helman J, et al. Evaluation of Timing and Route of Epinephrine in a Neonatal Model of Asphyxial Arrest. JAHA 2017;6(2).

Intraosseous Versus Umbilical Vein for Emergency
Access
• Umbilical venous catheterization as the primary method of vascular access during
newborn infant resuscitation in the delivery room
If umbilical venous access is not feasible → the intraosseous route is a reasonable

alternative for vascular access during newborn resuscitation

Procedure of Intraosseous Access in Neonate
1. Identify the insertion site

2. Clean the insertion site with 3. Hold the intraosseous needle
• For term newborns, the perpendicular to the skin and
preferred site is the flat surface
antiseptic solution
advance the needle through the
of the lower leg, approximately 2
cm below and 1 to 2 cm medial skin to the surface of the bone
to the tibial tuberosity (the bony (periosteum)
bulge below the knee cap)

4. Direct the needle perpendicular to the
bone and advance the needle through the
bone cortex into the marrow space
When the needle enters the marrow

space, a distinct change in resistance
(“pop”) is noticeable
5. Follow the manufacturer’s instructions for

removing the stylet and securing the needle

6. Connect an infusion set to the needle’s hub, open the stopcock toward the needle, flush the
needle, and administer the medication or fluid
7. Monitor the insertion site for evidence of swelling or fluid extravasation

Impact of Duration of Intensive Resuscitation
• Failure to achieve return of spontaneous circulation in newborn
infants despite 10 to 20 minutes of intensive resuscitation is
associated with a high risk of mortality and a high risk of moderate-
to-severe neurodevelopmental impairment among survivors
Discussion of discontinuing resuscitative efforts with the clinical team and

family if not ROSC around 20 minutes after birth

Reminding of Hypoxic Ischemic Encephalopathy (HIE)
• One of the most serious birth complications affecting full term infants
• Brain injury that prevents adequate blood flow to the infant’s brain occurring as a result of a
hypoxic-ischemic event during the prenatal, intrapartum or postnatal period
• The manifestations of perinatal HIE in early postnatal life
Poor umbilical cord

Abnormal fetal gases (pH < 7.0 or
Low Apgar scores
heart rate tracings base deficit ≥ 12
mmol/L)
The need for

Presence of respiratory support
meconium stained within the first
fluid several minutes of
postnatal life
Allen KA, Brandon DH. Hypoxic Ischemic Encephalopathy: Pathophysiology and Experimental Treatments. Newborn Infant Nurs Rev. 2011;11(3):125-133

Scoring for HIE
Thompson Score
< 10 = mild HIE

11-14 = moderate HIE
≥ 15 = severe HIE
Sarnat Staging
Thompson CM, Puterman AS, Linley LL, Hann FM, van der Elst CW, Molteno CD, Malan AF. Acta Paediatr. 1997 Jul; 86(7):757-61
Sheikh M. Comparison of the Four Proposed Apgar Scoring Systems in the Assessment of Birth Asphyxia and Adverse Early Neurologic Outcomes. PLoS ONE. 2015 Mar 26;10:e0122116.

Cooling Therapy
Criteria for cooling therapy:
1. Gestational age ≥ 36 weeks or birth weight ≥ 1800 g
2. Evidence of fetal distress, e.g. a history of acute perinatal
(sentinel) event, cord blood pH ≤ 7.0, or base deficit ≤ -
16 mEq/L
Selective head cooling with cool cap
3. Evidence of neonatal distress, e.g APGAR score ≤ 5 at
10 minutes, postnatal (within first hour of life) blood gas
pH ≤ 7.0 or base deficit ≤ -16 mEq/L, or a continous
need for ventilation at birth at least 10 minutes
** Extended criteria → pH ≤ 7.1 and or base excess < -12

mEq/L from cord blood gas or blood gas within the first
hour after birth
Shankaran S, Laptook A, Pappas A, Das A, Tyson J, Ehrenkranz R, et al. Optimizing Cooling for HIE. :35
Whole body cooling with Blanketrol
Keputusan Menteri Kesehatan Republik Indonesia Nomor Hk.01.07/Menkes/214/2019 Tentang Pedoman Nasional Pelayanan Kedokteran Tata Laksana Asfiksia

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Update on Neonatal Resuscitation

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

Initiating lower oxygen

INDONESIAN PICU NICU UPDATE – 2020/2021

AHA 2020: Age Target saturation

Subsequent titration of oxygen concentration using

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

Titrating supplemental oxygen against peripheral oxygen saturations is recommended,

INDONESIAN PICU NICU UPDATE – 2020/2021

• In premature infants between 25–32 weeks of gestational age

• Suggestion: administration of 30% or 50% initial FiO2 may be

INDONESIAN PICU NICU UPDATE – 2020/2021

Even though great importance is placed on

INDONESIAN PICU NICU UPDATE – 2020/2021

• Divided into 2 groups:

• Preterm infants needing respiratory support:

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

Sustained inflation has not been recommended

INDONESIAN PICU NICU UPDATE – 2020/2021

• Ten trials enrolling 1467 infants met author’s inclusion criteria

INDONESIAN PICU NICU UPDATE – 2020/2021

Chest compressions in the newborn infant should be delivered by the 2-thumb,

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

• Administration of further doses of epinephrine every 3 to 5 minutes

• The administration of endotracheal epinephrine should not delay attempts

If the response to endotracheal epinephrine is inadequate → intravascular dose be given

INDONESIAN PICU NICU UPDATE – 2020/2021

• Systematic review comparing doses, routes, and intervals of epinephrine

• Conclusion: administration of epinephrine by endotracheal

INDONESIAN PICU NICU UPDATE – 2020/2021

• Transitioning newborn lamb model (n=44)

INDONESIAN PICU NICU UPDATE – 2020/2021

If umbilical venous access is not feasible → the intraosseous route is a reasonable

INDONESIAN PICU NICU UPDATE – 2020/2021

1. Identify the insertion site

INDONESIAN PICU NICU UPDATE – 2020/2021

When the needle enters the marrow

5. Follow the manufacturer’s instructions for

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

Discussion of discontinuing resuscitative efforts with the clinical team and

INDONESIAN PICU NICU UPDATE – 2020/2021

Poor umbilical cord

The need for

INDONESIAN PICU NICU UPDATE – 2020/2021

< 10 = mild HIE

INDONESIAN PICU NICU UPDATE – 2020/2021

** Extended criteria → pH ≤ 7.1 and or base excess < -12

INDONESIAN PICU NICU UPDATE – 2020/2021

INDONESIAN PICU NICU UPDATE – 2020/2021

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