Neonatal Resuscitation

Joseph Gilhooly, MD
Doernbecher Children’s
Hospital
NRP 2001
Resuscitation
Algorithm: 2001
Why we need to resuscitate:

pH 7.30 pH 7.00 pH 6.80

How often do we use our
resuscitation skills?
 Suction
Equipment

Warmer &
Blankets

Bag, Mask,
& Oxygen
Laryngoscope
and ETT Tube
Universal
Precautions
Assessment: Then

• Appearance
• Pulse
• Grimace
• Activity
• Respirations
 Assessment: Now
Physiologic
Parameters Questions to ask yourself
(Apgar’s best) • Clear of Meconium?
• Breathing • Breathing or Crying?
• Heart Rate • Good Muscle tone?
• Color • Color Pink?
• Term Gestation?
Initial Management: For all deliveries

• Provide warmth
• Position and Clear Airway
• Dry
• Give Oxygen (as necessary)
 Providing Warmth: The cycle of hypothermia
Acidosis
Pulmonary
Anaerobic
Vasoconstriction
metabolism

Pulmonary
Tissue Hypertension
hypoxia

Right to left
Hypoxemia shunting
Positioning: Sniffing
The “Trusty”
Bulb Syringe
Clear of
Meconium?
Color pink?
Pulse Oximetry: Resuscitation monitor

• Not affected by
acrocyanosis
• Be patient and get a
reading
• If baby in shock,
get central IV
access
 Breathing or Crying?

• Indications for PPV

– Apnea or gasping
– Heart rate <100 even if breathing
– Persistent central cyanosis (saturation
<90%) despite 100% free-flow oxygen
 Self-Inflating Bag
O2 Reservoir

Pressure manometer
attaches
PEEP valve port

200-750ml Bag size

Neopuff
• CPAP
• Pressure limited
ventilation with PEEP
• Blended oxygen
• Eliminates variability
associated with bag
ventilation
 Masks

Smallest sizes are for preterm infants

• Make sure the
airway is clear
• Lift the baby’s jaw
into the mask
• Keep the mouth
slightly open

Rate 40-60
 Indications for Intubation
• Meconium and baby is not vigorous
• PPV by bag-mask does not result in good
chest rise
• PPV needed beyond a few minutes
• Chest compressions necessary
• Route to administer epinephrine
• Special indications: Prematurity, CDH
Miller 0

Miller 1
 3.5 >2000 gm

3.0
1000-2000 gm

2.5
<1000 gm

Stylet
Intubation Technique
Lip reference mark: (6 + weight in kilos) cm

9-10 cm at the lip for

this term infant
 Indications for Compressions

• Heart rate <60 • Coordinate with

ventilation
bpm after 30sec
– 4 events in 2 seconds
of PPV – 90 compressions and
30 breaths per minute

One and Two and Three and Breathe

2 seconds
 Compressions

2 thumb technique preferred

 Medications: Epinephrine
• Indication: Heart rate <60 after 30 sec of
coordinated ventilation and compressions
• 1:10,000 (0.1mg/ml)
• Route: ETT or IV
• 0.1-0.3 ml/kg
– 1ml Term
– 0.5ml Preterm
– 0.25ml Extreme preterm
 Extended
Algorithm
• Endotracheal
Intubation if not
already accomplished
• Establish IV access
with UVC
• Stat CXR
• Discontinue efforts if
no heart rate after 15
minutes
IV Access: “Low” UVC
 Volume
• Indication: No response to resuscitation
and evidence of blood loss
• Normal Saline
– Ringers or Blood as alternatives
• 10 ml/kg, may repeat
• Route: IV (Umbilical vein)
 Sodium Bicarbonate
• Indication: Documented or assumed
metabolic acidosis
• Concentration: 4.2% NaHCO3
(0.5meq/ml)
• Dose: 2meq/kg
• Route: IV (Umbilical vein)
 Naloxone (Narcan)
• Indication: Severe respiratory depression
after PPV has restored a normal HR and
color and…
– History of maternal narcotic administration
within the past 4 hours
• Dose: 0.1mg/kg of 1mg/ml solution
• Route: ETT, IV, IM, SQ
 Hypoglycemia

• Blood Glucose <45-60

–5cc/k D10W
–Route IV