Neonatal Resuscitation

FOOTNOTES:

  (1) Guidelines apply to neonates at birth and first few months.
CPR Indications:
  All conditions assoc. with high rate of survival and acceptable morbidity (includes ≥ 25 wk gestation
[unless fetal compromise] and most congenital malformations).
CPR Not Indicated:
  Almost certain death and high morbidity expected (includes < 23 wk or < 400 g, anencephaly, and
chromosomal abnormalities).
CPR Questionable:
  Uncertain prognosis, survival borderline, and high morbidity and burden – support parental desires
Note: The majority of newborns who will need resuscitation can be identified before birth. At least one
person who can perform a complete resuscitation should be at every delivery. Additional skilled personnel
should be recruited if resuscitation is anticipated. Special preparations are required for preterm deliver
(<37 wk). Further info available at www.aap.org/NRP.

(2) Routine Care: Do not separate baby from mother

(3) AIRWAY 

Initial steps of resuscitation:
Place baby under radiant heat
LBW (< 1500 g) – use additional warming techniques (e.g., plastic wrapping).
Monitor temperature closely; avoid hyperthermia
Position head in “sniffing” position to open airway
Only perform suctioning (including with a bulb syringe), if baby has obvious obstruction to spontaneous breathing or requires PPV.

Dry baby and stimulate breathing
Meconium staining:
  Routine intrapartum suctioning no longer advised
Vigorous infant (HR > 100, strong respiratory effort, good muscle tone) – do not perform ET suctioning
Not vigorous – perform ET suctioning immediately after birth

(4) Evaluate

  Simultaneous assessment of all 3 (HR, RR, SpO2) (in < 30 sec)
HR is a good indicator of improvement or deterioration
Reassess all 3 (RR, HR, oxygenation) every 30 sec

(5) Oxygen
  Indications:

    Pulse oximetry (with probe attached to right upper extremity; usually wrist or arm), should be used to assess any need for supplementary oxygen.

  Dosage:

Term babies: Begin resuscitation with air

O2 administration should be guided by SpO2 (pulse ox on upper right extremity; ie, wrist or palm)

Targeted Preductal SpO2 after Birth

Notes:
 Assess simultaneously, HR, RR and SpO2

If no O2 available, give PPV with room air
Guide administration with pulse oximetry
Avoid excessive O2 in the premature infant
Healthy term babies may take > 10 min to reach preductal O2 Sat > 95% and 1 hr to reach postductal
O2 Sat > 95%.
Pallor or mottling may be a sign of ↓ CO, severe anemia, hypovolemia, hypothermia, or acidosis.

Once O2 is administered, periodic assessment should consist of simultaneous evaluation of HR, RR and oxygenation (by a pulse oximeter, rather than color of patient) every 30 sec.

 (6) BREATHING (PPV)

Consider CPAP as an option.

Initial Parameters

Rate: 40 – 60 breaths/min (to achieve/maintain HR > 100)
(Assess chest wall movement if HR does not improve)
PIP: 20 – 40 cm H2O
(Individualize to achieve ↑ HR and/or chest movement)
If monitored, 20 cm H2O may be effective
If not monitored, use minimum inflation required to achieve ↑ HR.
  Preterm infants
  PIP: 20 to 25 cm H2O
Adequate for most
↑ if no prompt ↑ in HR or chest movement
Avoid excessive chest wall movement.
Monitor PIP if possible
PEEP or CPAP may be beneficial
  
 Endotracheal intubation 

INDICATIONS
    Bag/mask ineffective or prolonged
When chest compressions are performed
Tracheal suctioning for meconium
Administration of medications
CDH or extremely low birthweight (< 1000 g)

Check tube position:
    Best indicator is ↑ HR
Chest movement (present or absent)
Condensation during exhalation
Confirm visually during intubation
Confirm with exhale CO2 detector after intubation

 (7) CHEST COMPRESSIONS
Ensure assisted ventilation is being delivered optimally before starting chest compressions.
Ventilation/compressions are synchronized (pause compressions)

Method:
  2 thumb-encircling technique – recommended
2 finger technique – optional
Position: lower 1/3 of sternum
Depth: 1/3 of chest A-P dia
I:E: slightly > 1:1
Rate: 90 compressions/min
Ratio: 3:1
(90 compressions + 30 breaths)
(120 events/min; ½ sec each)

Consider 15:2 ratio, if 2 rescuers and known cardiac etiology

Continue until HR ≥ 60/min

Guidelines for Withholding and Discontinuing Resuscitation

Withholding:

• When congential anomalies, birth weight, and gestation are associated with high morbidity and almost certain early death, resuscitation is not indicated.

Discontinuation:

• Discontinuation is justified after 10 min of continuous and adequate resuscitation if the HR remains undetectable for 10 min.
• Consideration factors include: presumed etiology, gestation, presence or absence of complications, potential role of therapeutic hypothermia, and the parents’ previously expressed feelings.