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?

Bag, Mask, & Oxygen

Suction Equipment

Laryngoscope and ETT Tube

Warmer & Blankets

Universal Precautions

Assessment: Then

• Appearance

• Pulse

• Grimace

• Activity

• Respirations

Assessment: Now

• Breathing

• Heart Rate

• Color

• Clear of Meconium?

• Breathing or Crying?

• Good Muscle tone?

• Color Pink?

• Term Gestation?

Physiologic Parameters (Apgar’s best)

Questions to ask yourself

Initial Management: For all deliveries

• Provide warmth

• Position and Clear Airway

• Dry

• Give Oxygen (as necessary)

Providing Warmth: The cycle of hypothermia

Anaerobic metabolism

Acidosis

Tissue hypoxia

Hypoxemia

Pulmonary Vasoconstriction

Pulmonary Hypertension

Right to left 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 manometerattaches

PEEP valve port

200-750ml Bag size

Neopuff

• CPAP• Pressure limited

ventilation with PEEP• Blended oxygen• Eliminates variability

associated with bag ventilation

Smallest sizes are for preterm infants

Masks

• 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

3.0

2.5

Stylet

>2000 gm

1000-2000 gm

<1000 gm

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 bpm after 30sec of PPV

• Coordinate with ventilation– 4 events in 2 seconds

– 90 compressions and 30 breaths per minute

One and Two and Three and Breathe2 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