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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 10% of in hospital delivered newborns require resuscitation assistance to breathe at birth. Less than 1% require extensive 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 need for resuscitation of the newborn infant at birth cannot always be anticipated nor predicted. Therefore, at every birth, no matter how "low risk", suitable equipment and staff  must be available and prepared to resuscitate the newborn infant.

Preparation

• Personnel
  • at least two trained people are required for adequate resuscitation involving positive pressure ventilation and chest 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, and the infant's response to interventions.
    
    
• 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, positive pressure devices, resuscitation equipment, largyngoscope, and endotracheal tubes. If an infant is expected to be in poor condition have medication readily available (eg O negative red blood cells and 0.9% normal saline in the presence of massive antepartum haemorrhage).
    
    
• 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 the birth
• Environment
  • prevention of heat loss is important
  • where possible deliver infant into a warm draft free environment
  • the ambient temperature of the room should be at least 260C for very preterm infants

Assessment

The steps of evaluation and intervention are often simultaneous processes. Evaluation begins immediately after birth assessment of tone, breathing, and heart rate and continues throughout the resuscitation process until vital signs have normalized. Key features in ongoing evaluation are

• Breathing

The newly born infant should establish regular respirations in order to maintain HR > 100 bpm

• Heart Rate
  Determined from auscultation over the apex with a stethoscope or 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

During labour the uncompromised infant has oxygen saturations of about 60% which after birth usually take 75-10 minutes to reach 90%.
The well newly born infant should then be able to maintain a central pink colour in room air.  Assessment of of colour is a poor proxy for oxygenation. Assessment of oxygenation  can be aided by use of a pulse oximeter with neonatal probe attached to the infant's right hand

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 (appropriate size, food grade, heat resistant) with their head out and the body completely covered.  Drying the infant's body prior to covering is not recommended.
Aim for normothermia (36.5 to 37.5⁰C) in all newborn infants and avoid iatrogenic hyperthermia 

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

If meconium is present in a non-vigorous infant immediate suction below the vocal cords under direct vision may be appropriate. Delay tactile stimulation  to avoid gasping in the infant with an oropharynx full of particulate meconium. Repeated suctioning of the trachea is not recommended and may unnecessarily delay commencement of active resusciation

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

Suction is rarely required and 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 inflations per minure.

Positive pressure ventilation should be commenced in air (21% oxygen) initially. Supplemental oxygen administration should be guided by pulse oximetry. Hyperoxia should be avoided as even brief exposure to excessive oxygenation can be harmful to the newborn during and after resuscitation. Regardless of gestation, aim for oxygen saturations that resemble those of healthy term babies. Wean supplemental oxygen once the saturations reach 90%.

Target saturations

Time from birth	Target saturations during resuscitation
2 minutes	65 - 85%
3 minutes	70 - 90%
4 minutes	75 - 90%
5 minutes	80 - 90%
10 minutes	85 - 90%

Effective ventilation is confirmed by observing three signs 

•  Increase in the heart rate to about 100/min
•  A slight rise in the chest and upper abdomen with each positive pressure inflation
•  Oxygenation improves
  

Few infants require immediate intubation. The majority of infants can be managed with positive pressure ventilation via a face mask. With improve ment in the infant's condition the inflation pressures and breath rate can be progressively reduced.

See intubation section for technical details

• Circulation

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

Begin chest compressions for either

• HR < 60 fdespite effective positieve pressure ventialiton for at least 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

Supplemental oxygen should be increased to 100% when compressions are commenced

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 - preferred route
• ET - for adrenaline only
• peripheral intravenous line - difficult to cannulate in the collapsed infant
• intraosseous needle for failed or unsuccessful umbilical venous catheterization
• umbilical arterial catheter should not be used fordrug administration during resuscitation

Adrenaline
For HR < 60 for > 30 sec despite compressions and positive pressure ventilation
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.

             0.5 - 1.0ml/kg 1in 10,000 ET(if no IV access).

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

This may need to be followed with O negative red blood cells in the setting of massive blood loss, especially in babies who are not responding to resuscitation interventions.

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 -  may result in rapid withdrawal with seizures if given to infants of narcotic dependent women

Bicarbonate
Not indicated 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.

 

Ongoing Care

Infants require careful observation and management in a special or intensive care nursery following active resuscitation. Attention to management of temperature, cardio-respiratory status (oxygenation, heart rate, respiratory pattern, blood gas analysis), blood glucose sugars and infection risk are required

Term infants at risk of hypoxic ischemic encephalopathy should be considered for therapeutic  hypothermia therapy ("cooling") . Prompt discussion with NETS is recommended as cooling must be initiated within 6 hours of birth

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 10minutes 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

• Resuscitation for term infants should be commenced using medical air. Many preterm infants less than 32 weeks' gestation will not achieve target saturations in air. Supplemental oxygen administration in these babies should be guided by pulse oximetry. Hyperoxia and hypoxia should be avoided.  If a blend of medical air and oxygen is not available, resuscitation should be initiated with air (using a self inflating bag and room air). In all cases, the priority is to ensure adequate inflation of the lungs, followed by increasing the oxygen concentration.  (ARC and NZRC, 2010, Guideline 13.4).

 

• PEEP has been shown to be very effective for establishing and maintaining lung volume and improving oxygenation, especially in preterm babies. If suitable equipment is available,  PEEP of at least 5cm H2O should be used during resuscitation. It is possible to provide PEEP either by use of
   
  o  A T-piece device (eg Neopuff or similar). This technique can be easily applied but the device requires a flow of gas to operate
  o  An anaesthetic bag and mask. Considerable practice is required to develop competence with this technique.  
  

References

Section 13 Neonatal Guidelines Australian Resuscitation Council On Line http://www.resus.org.au/ December 2010
The updated online guidelines for neonatal resuscitation

The Victorian Newborn Resusciation Project: NeoResus   http://www.neoresus.org.au  26 January 2011
A great learning resource for neonatal resuscitation

Updated 01/10/2011

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