Critical Concepts NICU Brian M. Barkemeyer, MD LSUHSC Division of Neonatology 2011-12

At birth 100% of infants need someone present dedicated to the infant and capable of initial steps in neonatal resuscitation 10% of infants require some level of resuscitation at birth 1% of infants require major resuscitation

“Golden hour” At no other time in one’s life will necessary critical concepts in resuscitation have a potential lifelong impact Appropriate interventions (or the lack thereof) can make the difference between life or death, or normal life vs. life of disability

Preparation NRP - Neonatal Resuscitation Program Proper equipment Evidence-based, standardized program jointly sponsored by American Academy of Pediatrics and American Heart Association Proper equipment Knowledge In most cases, the need for neonatal resuscitation is predictable But not always!

Risk Factors Predictive of Need for Neonatal Resuscitation Maternal illness Hypertension Diabetes Infection Prematurity Post-maturity Multiple gestation Maternal bleeding Maternal drug abuse No prenatal care Fetal distress Abnormal fetal position Abnormal labor Fetal anomalies Macrosomia IUGR Placental abnormalities Meconium-stained amniotic fluid

Transition to Extrauterine Life Fluid-filled alveoli to air-filled alveoli Circulatory changes Decreased pulmonary vascular resistance resulting in increased pulmonary blood flow and cessation of flow through foramen ovale and ductus arteriosus Cessation of flow to placenta resulting in increased systemic vascular resistance

Lack of Appropriate Resuscitation Interrupts normal transition to extrauterine life Hypoxia Respiratory and metabolic acidosis Ischemia Potential for death or long term adverse outcome

Three Basic Questions Term infant? Breathing/crying at birth? Normal tone at birth? If the answer to these three questions is yes, infant doesn’t need resuscitation, but does deserve initial steps

Initial Steps Drying Warming Stimulation Positioning Clear airway Necessary for all newborns!

Warming Appropriate room temperature Rapid drying to avoid evaporative heat loss Remove wet towels Mother – skin to skin Radiant heat warmer Blankets, cap Premature infants and IUGR infants at highest risk for hypothermia

Establishment of the Airway Suction mouth then nose (“M before N”) Shoulder roll to aid in positioning Head positioned in slight extension, or “sniffing position” Not too extended Not too flexed

ABC’s Airway Breathing Circulation Suction secretions, assess for anomalies Breathing Stimulate respiratory effort Tactile Bag-mask positive pressure ventilation (PPV) Circulation Assess heart rate Chest compressions if PPV ineffective at restoring heart rate

Skills to Learn Neonatal assessment Use of bulb suction Administration of positive pressure ventilation by bag-mask Intubation and assistance with intubation Chest compressions

Assessment/Reassessment: Sequential steps in resuscitation Initial steps [30 seconds] PPV [30 seconds] Chest compressions [30 seconds] Medications [30 seconds]

Neonatal Assessment Respirations Heart rate Color Normal rate and depth, good chest movement Heart rate Normal > 100 Count for 6 seconds, multiply x 10 Color Pink lips and trunk Acrocyanosis vs. central cyanosis

Indications for PPV If after initial steps in resuscitation [30 sec], assessment reveals Apnea Gasping respirations Heart rate < 100

Indications for Chest Compressions If after initial steps in resuscitation [30 sec] and effective PPV [30 sec], assessment reveals Heart rate < 60

Indications for Epinephrine Heart rate persists < 60 after Initial steps [30 seconds] PPV [30 seconds] Chest compressions [30 seconds] Dosage given IV (UVC preferred), or endotracheal (higher dose given)

Indications for Volume Administration History of blood loss at delivery suggesting hypovolemia AND Infant appears to be in shock (pallor, poor perfusion, failure to respond appropriately to resuscitation efforts) IV, 10-20 mL/kg, Normal saline, Ringer’s lactate, or O- blood

Meconium-stained Amniotic Fluid 15% of deliveries; at risk for meconium aspiration syndrome Suctioning of upper airway and trachea in infants who are not vigorous may help prevent meconium aspiration syndrome Vigorous defined by Heart rate > 100 Normal respiratory effort Normal tone

Positive Pressure Ventilation Appropriate size mask and bag Self-inflating vs. flow-inflating bag Forming a good seal with mask Achieve adequate chest rise 40-60 breaths per minute When done appropriately, PPV should result in improvement in heart rate and color

Ineffective PPV Reposition mask on face Reposition head Suction upper airway Ventilate with mouth open Increase ventilatory pressure Replace bag Endotracheal intubation

Self-inflating bag

Flow-inflating bag

Chest Compressions Should be coordinated with PPV 2 thumb method preferred Compression of sternum 1/3 depth of AP diameter of chest 120 events per minute (compressions and respirations combined) “One and two and three and breathe”

Chest Compressions

Endotracheal Intubation ET tube size similar to size of patient’s little finger < 28 wks, < 1000 g = 2.5 ETT 28-34 wks, 1000-2000 g = 3.0 ETT 34-38 wks, 2000-3000 g = 3.5 ETT 38-42 wks, > 3000 g = 4.0 ETT Insertion depth “Tip to lip” measurement = weight in kg plus 6 2 kg patient should have ETT secure at 8 cm mark at lip

Endotracheal Intubation

Unique Aspects of Endotracheal Intubation in Infants Narrowest part of airway is subglottic area Uncuffed ET tubes typically utilized Increased airway resistance associated with more narrow airway diameter Relative lack of structural support for neonatal airway

Unique Anatomic Challenges Choanal atresia Endotracheal intubation may be required Pierre-Robin sequence Prone positioning NG tube into posterior pharynx Congenital diaphragmatic hernia Endotracheal intubation Gastric decompression

Key Points Appropriate resuscitation requires a rapid series of assessments, interventions, and reassessments All infants deserve basic steps of resuscitation Drying, warming, positioning, clear airway Prompt initiation of respiratory support with positive pressure ventilation by bag-mask is the key to successful resuscitation of most infants