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Resuscitation

• Summary
• Introduction
• Preparation
• Assessment
• Management
• Stopping Resuscitation
• Areas of Uncertainty in Clinical Practice

Summary

• newborn resuscitation is a critical skill that requires constant practice
• effective ventilation  is the key to successful resuscitation
• evaluation and resuscitation interventions are ongoing, continuous and simultaneous processes

• preparation for resuscitation and organization of personnel, particularly assignment of roles is critical

Introduction

Approximately 1 - 10% of in hospital delivered newborns require resuscitation.

The aim of resuscitation is to prevent neonatal death and adverse longterm neurodevelopmental sequelae associated with perinatal asphyxia.

Substantial physiologic changes occur in the transition from fetal to extrauterine life including

• the role of the placenta in gas exchange is taken over by the lungs

• changes from fluid-filled to air filled lungs

• dramatic increase in blood flow to the lungs with reversal, then closure of intra and extra cardiac shunts

Failure or disruption of these changes may result in further difficulties with resuscitation in the newborn infant. For example, failure to increase alveolar oxygen and reduce pulmonary vascular resistance may lead to persistence of fetal circulation or pulmonary hypertension.

The phases of asphyxia are well described from experimental evidence in animal models.

• After a few shallow breaths the asphyxiated infant stops breathing. This phase of primary apnoea may last for as long as 10 minutes. Most infants with primary apnoea respond to stimulation alone. During this phase heart rate and pH are maintained.
• Following this period, the infant begins to gasp. The period between the last gasp and cardiac arrest is secondary apnoea. In the phase of secondary or terminal apnoea the newborn has a mixed acidosis and active intervention is required to stimulate respiration.

It is not possible to clinically distinguish primary from secondary apnoea and for this reason it is important to assume the apnoiec infant is in secondary apnoea. If there is no response to simple interventions the infant requires the immediate commencement of active resuscitation.

Preparation

• Personnel
  • at least two trained people are required for adequate resuscitation involving ventilation and cardiac compressions. Therefore, always call for help
  • the most senior person available needs to co-ordinate resuscitation
  • each person must have a dedicated job, for example with three people, one should be solely responsible for airway, one solely responsible for chest compressions and the third person should co-ordinate the resuscitation and administer medication as necessary. If possible have another person record events including time of administration of drugs, HR response.
    
    
• Check equipment
  • resuscitation equipment should be checked at least daily and after each usage
  • when use is anticipated at a birth recheck equipment including medical air and oxygen supply, suction, resuscitation equipment, largyngoscope, and endotracheal tubes. If an infant is expected to be in poor condition have medication readily available
    
    
• Communication is vital to smooth resuscitation
  • with anaesthetic and obstetric staff regarding maternal condition, fetal condition, maternal therapies
  • if time permits, meet the family before delivery
    
    
• Environment
  • prevention of heat loss is important
  • where possible deliver infant into a warm draft free environment
  • dry infant, remove wet towelling and replace with dry, warm towels

Assessment

The steps of evaluation and intervention are often simultaneous processes. Evaluation begins immediately after birth and continues throughout the resuscitation process until vital signs have normalized. Key features to evaluate are

• Respiration
  The newly born infant should establish regular respirations in order to maintain HR > 100 bpm
  
  
• Heart Rate
  Determined from direct palpation of cord or with stethoscope. Peripheral pulses are often difficult to feel
  If no pulsation is felt on palpation of the cord do not assume there is no heart beat but auscultate the chest.The HR should be > 100 bpm in a well newly born infant
  
  
• Colour
  The well newly born infant should be able to maintain a central pink colour in room air

Management

• Temperature Control

A warm draft free environment should be available. Drying the infant with prewarmed towels will help minimise heat loss in addition to use of a radiant warmer.

Infants less than 28 weeks gestation should be placed immediately after birth in a polyethylene bag or wrap and the body completely covered (appropriate size, food grade, heat resistant).

•  Stimulation
   Drying with a soft towel will stimulate most newborns to breath

If meconium is present in a non-vigorous infant suction under direct vision. Delay tactile stimulation  to avoid gasping in the infant with an oropharynx full of particulate meconium.

• Airway
  The head should be in a neutral or slightly extended 'sniffing' position.

Suction should not exceed -100 mmHg. It should be limited in depth to 5 cm below the lips.

• Breathing
  Attend to adequate inflation and ventilation before oxygenation

The rate for assisted ventilation is 60 bpm
Tidal volume is assessed clinically, that is adequate chest excursion with each breath

Few infants require immediate intubation. The majority of infants can be managed with bag and mask ventilation.

See intubation section for technical details

• Circulation

In the majority of infants establishment of adequate ventilation will restore circulation.

Begin chest compressions for either

• absent HR or
• HR < 60 for 30 seconds.

Aim for approximately a ratio of 90 chest compressions to 30 breaths per minute (3:1). (120 events per minute) - count one-and-two-and-three-and-breath etc

The "two thumb" technique is preferred. Both thumbs meet over the sternum with fingers around the chest wall. The sternum should be compressed to one third of the antero-posterior chest dimension.

• Medications

Route of Delivery

• umbilical venous catheter
• ET - for either adrenaline
• peripheral intravenous line - difficult to cannulate in the collapsed infant
• umbilical arterial catheter should not be used fordrug administration during resuscitation

Adrenaline
For HR < 60 for > 30 sec despite compressions
Dosage: 0.1 -0.3 ml/kg 1 in 10,000 as a quick push IV repeated at 3-5 minutely intervals. It should be followed by a small saline flush. 0.3 - 1.0ml/kg 1in 10,000 ET.

Volume (preload)
10 - 15 ml/kg normal saline repeated 2 or 3 times

Naloxone
Naloxone does not form part of the initial resuscitation of newborns with respiratory depression in the delivery room.

Dosage - 0.1mg/kg of 0.4mg/ml solution
Contra-indication - infants of narcotic dependent mothers, may result in rapid withdrawal with seizures.

Any infant treated with naloxone should be carefully monitored for several hours as retreatment may be required.

Bicarbonate
Currently there is insufficient evidence for routine use

Argument for correction of acidosis includes theoretical concerns about hypoxia and elevated pulmonary vascular bed pressure and poor cardiac contractility with acidosis.
Argument against correction includes concerns regarding hyperosmolarity and CO₂ generation with intracellular acidosis from alkali infusion.

Stopping Resuscitation

• it is difficult to accurately define a time beyond which active support worsens brain injury
• it is reasonable to consider stopping treatment if the infant has not responded with a spontaneous circulation by 15 minutes of age
• it is helpful to be able to review events during resuscitation and this is made easier when events are recorded during resuscitation

Areas of Uncertainty in Clinical Practice

• Recent animal studies suggest that cerebral hypothermia may be beneficial to the asphyxiated infant. There is not enough current evidence to recommend this practice for routine care. This should only be undertaken in the context of a properly controlled trial
  
  

• The question of whether air or oxygen should be used is not fully resolved. Published studies are of variable quality. If a supply of medical air is not available, oxygen should be used. Current Australian Resuscitation Guidelines recommend that air should be used initially, with supplemental oxygen reserved for infants whose condition does not improve during the first minutes of life.

  
  
• Theoretically, by its effect on lung volume PEEP preserves surfactant function. PEEP sets up FRC and is therefore important in ventilation and oxygenation. It is possible to provide PEEP during the acute either by use of either an anesthetic bag and mask (considerable practice is required to develop competence with this technique) or the Neopuff (this technique can be easily applied but the device will require a flow of gas to operate).

References

Cooling the newborn after Asphyxia - physiologic and experimental background and its clinical use. Thoresen M Semin Neonatol 2000 Feb;5(1):61-73

Neonatal Guidelines. Australian Resuscitation Council 2006

Rapid correction of early metabolic acidosis versus placebo, no intervention or slow correction in LBW infants. Kecskes Z, Davies MW Cochrane Database of Systematic Reviews. Issue 1, 2001

 

Air versus oxygen for resuscitation of infants at birth. Tan A, Schulze A, Davis PG Cochrane Database of Systematic Reviews. Issue 1, 2001

Tidal ventilation at low airway pressures can augment lung injury. Muscedere JG etal. Am J Respir Crit Care Med. 1994 May;149(5):1327-34

Ventilator-induced lung injury: lessons from experimental studies. Dreyfuss D, Saumon G. Am J Respir Crit Care Med. 1998 Jan;157(1):294-323

The open lung during small tidal volume ventilation: concepts of recruitment and "optimal" positive end-expiratory pressure Rimensberger PC, Cox PN, Frndova H, Bryan AC. Crit Care Med 1999;27:1946-52

Cardiopulmonary resuscitation of apparently stillborn infants: survival and long-term outcome. Jain L, Ferre C, Vidyasagar D, Nath S, Sheftel D. J Pediatr. 1991 May;118(5):778-82.

Survival after cardiopulmonary resuscitation in babies of very low birth weight. Is CPR futile therapy? Lantos JD, miles Sh, Silverstein MD, Stocking CB N Engl J Med. 1988 Jan 14;318(2):91-5.

Outcome of resuscitation following unexpected apparent stillbirth. Casalaz DM, Marlow N, Speidel BD. Arch Dis Child Fetal Neonatal Ed. 1998 Mar;78(2):F112-5.
Outcome of resuscitated apparently stillborn infants: a ten year review. Yeo Cl, Tudehope DI. J Paediatr Child Health. 1994 Apr;30(2):129-33

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