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NEONATAL RESUSCITATION- WHAT YOU MUST KNOW

Neonatal Resuscitation and in fact any resuscitation of children can be very stressful. However we know that most of it has been simplified by the Resuscitation powers that be. We can make it even more straightforward.

In neonatal resuscitation, all we need you to remember are the numbers 60 and 100……I’ll explain.

Most resuscitation issues in Neonates and infants are airway related. Fix the airway and its OK. 

Ask the following questions:

  • ​Does the neonate have good tone, limbs moving and flexing?
    • If no, then slight stimulation by drying with a warm towel may start breathing.
  • It is important to maintain correct temperature aim 36.5-37.5 C
  • Is the neonate adequately ventilating? i.e. is there intercostal retraction and grunting? Also is the Heart Rate>100. 
    • If no use positive pressure ventilation, until it does so. Alter the pressure and oxygen to suit the situation.
  • Is the Heart rate is below 60?
    • If yes, then 3:1 chest compressions, 100% oxygen, consider intubation or laryngeal mask.
      If the neonate continues to have heart rate below 60bpm then adrenaline 1:10,000 at 0.1-0.3mL/kg
  • Therefore remember the numbers 60 and 100.

A little more detail

Remember the simple physiology of what occurs:

  • The lungs transition from fluid filled to air filled- this may not occur as perfectly in those children that are preterm, or those that are via caesarean.
  • Pulmonary blood flow increases by 5-6 times
  • Intra/extra cardiac shunts close.

​Because of this, it takes 5-10 minutes for oxygen levels to rise to 90%

If airway needs attending, place the newborn on its back in the sniffing position.
DO NOT perform pharyngeal suction as this can lead to laryngeal spasm (unless there are objects that need to be cleared)
If meconium is present in a vigorous baby- suctioning is discouraged. If in a non-vigorous baby, it may assist although no great evidence.

Positive pressure Ventilation should be initiated with a T-piece device, but a bag-valve-mask can be used for backup.
On devises that deliver PEEP use 5cm H2O- beware as >8cm H2O is associated with pneumothorax.
Initial pressures are 30cm H2O for term infants and 20-25cm H2O for premature infants. Beware high pressures in preterm infants.
Judge the effectiveness of the ventilation by:

  • chest rise
  • Heart rate > 100
  • Improved oxygenation

The pressure may need to be altered.

Beware too much oxygen. It may be harmful to neonates after resuscitation.
The table shows targets to aim for. However the maximum at 10 minutes should be 90%

AIRWAY

When To Intubate

The resuscitation guidelines give us some recommendations:

  • If ventilation via a facemask (or laryngeal mask) has been unsuccessful (heart rate remains low, oxygen saturation falling or failing to rise) or prolonged
  • ​In special circumstances, such as congenital diaphragmatic hernia, or extremely low birth weight
  • For infants born without a detectable heartbeat, consideration should be given to intubation as soon as possible after birth.

Weight
< 1kg (all < 30 weeks)
1-2 kg
2-3
​>3kg

Ett size
2.5
3
3.5
​4

Laryngoscope
00 -0
0-1
1
​1

Ett at lip
Can use (weight + 6cm)

Laryngeal Mask
Consider this as an alternative when bag valve mask ventilation is not possible, or when endotracheal intubation is unsuccessful or not feasible.

Chest Compressions

When to Start
​Ensure that ventilation is being delivered adequately before chest compressions and at minimum of 30 seconds, as chest compressions may interfere with ventilation.
When the heart rate is < 60 bpm and assisted ventilation has not helped-CPR is needed.

How to do it
Use 2 thumb technique around lower third of the sternum and aim for compression of one third of the chest height.
Use 3:1 ratio of compressions to ventilation aiming at 90 compressions per minute (stop for ventilation)
If the infant is intubated, can use 120 compressions per minute.
Use 100% oxygen, but turn down when return of spontaneous circulation occurs.

Adrenaline

When you start chest compressions, prepare for IV access as adrenaline is needed.
Adrenaline should be given as soon as possible after chest compressions are commenced.( this is based on animal studies showing that chest compressions without adrenaline do not achieve cerebral blood flow.

Fluids

If there is blood loss expected, or the infant appears shocked use 0.9% Normal Saline 10mL/kg IV over several minutes. This may be repeated.

Intravenous Access

Umbilical Vein
This is the most appropriate access point. It can be used for medications and fluids and is not that difficult to obtain.
The Royal Childrens’ Hospital has an excellent PDF on Umbilical Vein Cannulation
Cannulate the VEIN NOT the Artery

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