Neonatal Resuscitation

Neonatal resuscitation skills are important because of the potential for serious disability or death in high-risk infants and in a few unpredicted full term low-risk deliveries. Careful review of resuscitative procedures is important before problem deliveries arise. Preparation A. Advanced preparation requires acquisition and maintenance of proper equipment and supplies. Neonatal Resuscitation Equipment and Supplies Suction Equipment Bulb syringe Suction catheters,5 (or 6), 8, 10 Fr Meconium aspirator Bag-and-Mask Equipment Oral airways, newborn and premature sizes Infant resuscitation bag with a pressurerelease valve/pressure gauge to give 90100% O2 Intubation Equipment Laryngoscope with straight blades, No.O (preterm) and No.1(term newborn). Extra bulbs and batteries for laryngoscope Endotracheal tubes, Size 2.5, 3.0, 3.5, 4.0 mm Medications Epinephrine 1:10,000, 3 cc or 10 cc ampules Naloxone 0.4 mg/mL,1 mL ampules Dextrose 10% in water, 250 cc Sterile water, 30 cc Miscellaneous D:\FILES\A_BOOKS\Pediatrics 5 Minute Review\New Editing\Neonatal Resuscitation.wpd Volume expanders-one or more of these: Albumin 5% solution Normal Saline Ringer’s Lactate solution Stylet Scissors Gloves Oxygen with flow meter and tubing Cushion rim face masks in newborn and premature sizes Mechanical Suction 8 Fr feeding tube and 20 cc syringe



Radiant warmer and towels or blankets Stethoscope Adhesive tape, ½ or 3/4 inch width Syringes, 1 cc, 3 cc, 5 cc, 10 cc, 20 cc, 50 cc Umbilical artery catheterization tray Cardiotachometer and ECG oscilloscope B. Immediate Preparation 1.

Alcohol sponges 3-way stopcocks 3 Fr feeding tube Umbilical tape Needles, 25, 21, 18 gauge Umbilical catheters 3 1/2 and 5 Fr

Suction, oxygen, proper-sized face mask and the resuscitation bag should be checked.

2. 3.

Appropriately sized ET tubes, cut to 13 cm, should be laid out. Medications should be prepared and an umbilical catheter and tray should be prepared.

II. Neonatal Resuscitation Procedures A. Immediate evaluation includes assessment of muscle tone, color, and respiratory effort during the delivery. B. After delivery, the infant should be placed on a preheated radiant warmer after the cord is clamped. The infant should be quickly dried with warm towels. The infant should be placed supine with its neck in a neutral position. A towel neck roll under the shoulders may help prevent neck flexion and airway occlusion. C. The upper airway is cleared by suctioning; the mouth first, and then the nose, using a bulb syringe or a mechanical suction device, with an 8 or 10 Fr catheter. Suctioning should be limited to 5 seconds at a time. D. Determine whether breathing is effective and pulse is >100 beats/min. If so, positive pressure ventilation (PPV) is not needed. If cyanosis is present, oxygen should be administered. E. Free flowing oxygen may be given at a rate of 5 L/min by holding the tubing ½ inch in front of the infant’s nose. Alternatively, an oxygen mask and resuscitation bag may be used. When the infant’s color is pink, the oxygen should be gradually discontinued while observing the skin color for recurrence of cyanosis. F. Positive pressure ventilation should be initiated if the infant is not breathing effectively after the initial steps. Response to brief tactile stimulation should be assessed by gently slapping the soles of the feet or rubbing the back. If the infant is apneic or gasping, begin PPV with 100% O2, immediately. If the heart rate is <100 beats/min, give PPV immediately by bag-mask.

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Bag-Mask ventilation. The infant should be in the supine position with head slightly extended or neutral. The first ventilations should be given at a rate of 40-60/min. Visible chest wall movement indicates adequate ventilation. Endotracheal intubation is initiated if the infant is nonresponsive to bag-mask PPV.When effective ventilation is in place, the first cycle of evaluation and care is complete.


Endotracheal Tube Size and Depth of Insertion From Upper Lip Weight <1000 g 1000-2000 g 2000-3000 g 3000 g or more Gestational Age <28 weeks 28-34 weeks 34-38 weeks 39->40 weeks Size 2.5 mm 3.0 mm 3.5 mm 4.0 mm Depth 7 cm 8 cm 9 cm 10 cm

G. Evaluation of Heart Rate 1. If the heart rate is >100 beats/min, PPV can be discontinued after the infant is breathing effectively. Support should be gradually withdrawn while observing for adequacy of spontaneous breathing and heart rate. 2. Chest compressions should be started if the heart rate is <80 beats/min, after 1530 seconds of adequate ventilation. PPV should also be continued. a. Compressions are applied to the lower sternum just below the nipple line, but above the xiphoid process. The resuscitator’s thumbs are used to compress the sternum while the fingers surround the chest, or the middle and index fingers of one hand may be used to compress while the other hand supports the infant’s back. The sternum is compressed ½ to 3/4 inch. b. Chest compressions are alternated with ventilations at a ratio of 3:1. The combined rate should be 120/min (ie, 80 compressions and 30 ventilations). After 30 sec, evaluate the response. If the pulse is >80 beats/min, chest compressions can be stopped and PPV continued until the heart rate is 100 beats/min and effective breathing is maintained. 3. Epinephrine should be given if the heart rate remains below 80/minute after 30 seconds of PPV and chest compressions.

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Neonatal Resuscitation Medications Medication Concentration Preparation Dosage Rate/Precautio ns Epinephrine 1:10,000 1 mL 0.1-0.3 mL/kg IV or ET May repeat in 3-5 min if HR is <80/min Volume expanders Whole blood Albumin 5% Normal saline Ringer lactate Naloxone 0.4 mg/mL 1 mL 0.1 mg/kg (0.25 mL/kg) IV, ET, IM, SQ Naloxone 1.0 mg/mL 1 mL 1 mg/kg (0.1 mL/kg) IV, ET, IM, SQ Sodium bicarbonate 0.5 mEq/mL (4.2% solution) Diluted with sterile water to make 0.5 mEq/mL 20 mL or two 10-mL prefilled syringes 2 mEq/kg IV IV, ET preferred IM, SQ acceptable Give slowly, over at least 2 min. Give rapidly 40 mL 10 mL/kg IV Give rapidly. May dilute 1:1 with normal saline if given via ET Give over 5-10 min by syringe or IV drip


Other Medications a. Volume Expanders. Hypovolemia may be caused by either occult blood loss (eg, fetal-maternal transfusion) or by obvious hemorrhage. Volume expansion is indicated for patients who have known or suspected blood loss and poor response to other resuscitative measures. Albumin 5%, normal saline, or Ringer lactate can be given in boluses of 10 mL/kg over 5 to 10 minutes. If

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acute blood loss sufficient to cause shock and neonatal depression, much larger volumes will be necessary and O-negative blood may be justified. b. Sodium bicarbonate is recommended for infants during prolonged resuscitation for infants refractory to other measures. c. Naloxone hydrochloride is given to infants with prolonged respiratory depression following narcotic anesthesia given to the mother within 4 hrs before delivery. Naloxone is contraindicated in infants of mothers who are addicted to narcotics. 5. Umbilical vessel catheterization is recommended when vascular access is required during resuscitation. The large, centrally located, thin-walled and flat vein is used, and a 3.5 or 5.0 Fr radiopaque catheter is inserted into the vein until a free flow of blood can be aspirated. III. Special Cases A. Meconium Staining 1. Meconium staining occurs in 12% of deliveries. A few of these infants develop meconium aspiration syndrome (MAS), which consists of small airway obstruction, air-trapping, and inflammatory pneumonitis. Complications include pneumothorax and persistent pulmonary hypertension. MAS is seen most often in infants with asphyxia and thick “pea soup” meconium staining at birth. 2. If meconium staining is detected, the infant’s mouth, nose, and posterior pharynx should be suctioned thoroughly before the delivery of the shoulders and thorax. Meconium should be removed before the first breath occurs. 3. When meconium is thick and particulate and/or the infant is apneic or depressed, the infant should be quickly intubated and suctioned endotracheally. The ET tube is withdrawn slowly while continuing suction. Reintubation and suctioning should continue until no more meconium is produced. B. Preterm Infant Resuscitation. Infants weighing <1500 g are more likely to need resuscitation. PPV and early intubation are usually required. ET tube placement is necessary for all infants <1250 g. IV. Post-resuscitation Management A. Vital signs should be monitored and infant’s feedings withheld. Ten percent glucose is often given IV. B. The circulation, perfusion, neurologic status, and urine output should be monitored. Moderate fluid restriction is usually instituted. A physical exam and lab studies, such as blood gases, glucose, and hematocrit, should be completed. § D:\FILES\A_BOOKS\Pediatrics 5 Minute Review\New Editing\Neonatal Resuscitation.wpd


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