This post contains a link to and excerpts from the review of Neonatal Resuscitation Program Guidelines [Link to Podcast] [Link to Transcript] from PedsCases*.
*Here is the complete list of the Table Of Contents of the PedsCases website. On this page the site has organized all of the contents into two groups: Clinical Presentation and Specialty Area.
The podcast is based on the 7th edition of the NRP Textbook, 2016.
Here are excerpts:
Neonatal Resuscitation Program Guidelines
Developed by Drs. Julia DiLabio, Emer Finan, Colin Siu, and Chloe Joynt for PedsCases.com. May 23, 2018.
Pre-Delivery Briefing
Preparation for neonatal resuscitation should begin prior to the delivery.
The textbook states that “a qualified team with full resuscitation skills should be identified and immediately available for every resuscitation [and remember that the need for resuscitation can occur when not anticipated].
Necessary equipment should be prepared and checked prior to delivery. In addition, pre-delivery briefing is essential to discuss the resuscitation plan, assign team roles, and anticipate potential complications.
[Be sure to turn on the radiant warmer prior to delivery so it is ready if you need it.]
Initial Stabilization
When you are presented with a newborn, ask yourself 3 questions:
- Is it a term gestation?
- Does the newborn have good muscle tone?
- Is the newborn crying or breathing effectively?
If the answer is “yes” to all of these 3 questions, no resuscitation is needed. Delayed cord clamping should be performed for at least 30-60 seconds for vigorous term and preterm infants. Then, routine newborn care is provided and the infant is typically placed skin-to-skin with a parent with continued observation.
If the answer is “no” to one or more of these questions, resuscitation procedures should be initiated.
Firstly, the baby should be dried, placed under a heat source such as a radiant warmer and have their head tilted back in the “sniffing” position to open the airway.
If necessary, suction is provided using a bulb syringe or suction catheter with a negative pressure of 80 to 100 mmHg. The mouth should be suctioned before the nose with avoidance of deep or overly vigorous suction which could elicit a vagal response or cause tissue damage.
Suctioning should be reserved for situations where the airway is thought to be obstructed by secretions or positive pressure ventilation is required.
Of note, unlike the previous version of NRP, the 7th edition NRP does not recommend routine endotracheal intubation and suctioning below the cords as initial management for nonvigorous infants born through meconium-stained amniotic fluid.2
The infant should then be dried with subsequent removal of wet linen to avoid hypothermia.
If after initial stimulation, the infant is still not effectively breathing,
additional stimulation may be provided by rubbing the back or the soles of the feet. Such stimulation should be provided for a brief period; if the infant remains apneic or has ineffective respirations in spite of these manoeuvres, positive pressure ventilation is required.Ventilation
If the baby remains apneic, gasping, or the heart rate is below 100 bpm after initial stimulation, positive pressure ventilation, or PPV, should be started immediately. For infants with ineffective respirations or bradycardia, positive pressure ventilation should be started within 60 seconds of birth.
The minimum pressure required to achieve adequate chest movement should be used. Inflation pressures should be monitored and an initial inflating pressure of 20-25 cm H2O is recommended.
Assisted ventilation should be given at a rate of 40-60 breaths per minute.
The efficacy of ventilation should be assessed after 15 seconds of PPV by evaluating heart rate response.
If an increase in heart rate is not observed and inadequate chest movement is noted, ventilation is ineffective and corrective steps are required.
The efficacy of ventilation should be assessed after 15 seconds of PPV by evaluating heart rate response.
If an increase in heart rate is not observed and inadequate chest movement is noted, ventilation is ineffective and corrective steps are required.
These steps include readjusting the mask, re-positioning the airway, suctioning the mouth and then nose, opening the mouth, increasing the pressure or using an alternative airway.
The mnemonic, MR. SOPA can help recall [the above] corrective steps.
After thirty seconds of effective ventilation the heart rate should be reassessed.
If non-invasive PPV is required for a prolonged period of time or fails to produce adequate chest rise or heart rate response, an alternative airway is indicated.
Alternative airways include endotracheal tubes and laryngeal mask airways; the latter of which may be appropriate for infants >34 weeks gestation and >2 kg if non-invasive PPV or endotracheal intubation are unsuccessful or challenging.
If intubation is deemed necessary, the size of uncuffed endotracheal tube, or ETT, can be approximated based on the newborn’s estimated weight as follows: infants >2 kg receive size 3.5, infants 1-2 kg receive size 3, and infants <1 kg receive size 2.5.
The appropriate depth of ETT insertion can be approximated using gestation-based guidelines or the nasal [septum to the] tragus measurement (in cm) plus 1 cm.
Table 5-4. Initial endotraheal tube insertion depth (“tip to lip”) for orotracheal intubation from Textbook of Neonatal Resucitation 7th Ed
|
Gestation Weeks |
Endotracheal tube insertion depth at the lips (cm) |
Baby’s Weight (grams) |
| 23-24 | 5.5 | 500-600 |
| 25-26 | 6.0 | 700-800 |
| 27-29 | 6.5 | 900-1000 |
| 30-32 | 7.0 | 1,100-1,400 |
| 33-34 | 7.5 | 1,500-1,800 |
| 35-37 | 8.0 | 1,900-2,400 |
| 38-40 | 8.5 | 2,500-3,100 |
| 41-43 | 9.0 | 3,200-4,200 |
Ventilation (cont.)
Bilateral chest auscultation and an exhaled carbon dioxide detector should be used to ascertain correct ETT placement, though an increase in heart rate is the best sign that PPV via an endotracheal tube is effective.
Oxygenation
Non-invasive PPV may be supplemented with oxygen and monitored using pre-ductal pulse oximetry using a probe attached to the neonate’s right hand or wrist.
Pulse oximetry is recommended whenever supplemental oxygen or PPV are required.
The recommended initial oxygen concentrations for resuscitation are 21% for term infants and 21-30% for infants <35 weeks gestation.
Oxygen concentrations can then be
titrated to target minimum pre-ductal oxygen saturations of 60% at 1 minute, 70% at 3 minutes, and 80% at 5 minutes of life. If the neonate’s heart rate is less than 60 bpm after optimal ventilation for 30 seconds, the oxygen concentration should be increased to 100% with commencement of chest compressions.An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation and thus providers should ensure that optimal ventilation has been provided before proceeding to chest compressions.
CPAP
If a neonate is breathing effectively with a heart rate >100 bpm, but is exhibiting signs of respiratory distress or has persistently low oxygen saturations, continuous positive airway pressure, or CPAP can be administered.
Positive-end expiratory pressure, or PEEP of 5-8 cm H2O is suggested.
If the neonate does not improve with administration of CPAP, positive pressure ventilation, and/or endotracheal intubation may be required.
Chest Compressions
Less than 1% of neonates requiring resuscitation will require chest compressions, as the vast majority of infants will respond to effective ventilation.
The indication for chest compressions is a heart rate <60 bpm after 30 seconds of effective ventilation, ideally through an alternative airway such as an ETT.
[Use an electronic cardiac monitor for continuous heart rate evaluation if possible. Alternatives are pulse ox or auscultation.]
The infant should receive 100% oxygen during chest compressions.
The compressor should move to the head of the bed once the airway is secured, to allow access to the abdomen for potential emergency umbilical venous catheter placement.
Compressions should be performed on the lower third of the sternum (just below the nipple level) at a depth of approximately 1/3 of the anterior-posterior diameter of the neonate’s chest.
Both thumbs should compress the sternum while the other fingers
encircle the neonate’s body and support the back, allowing the chest to re-expand fully between compressions.The compression to ventilation ratio is 3:1 and each set of 3 compressions to 1 breath should take 2 seconds such that there are 120 “events” per
minute. After 60 seconds of chest compressions, the heart rate should be reassessed.Medication Administration
If the heart rate remains below 60 bpm despite adequate ventilation and 60 seconds of chest compressions, administration of epinephrine is indicated.
The preferred route of administration is the intravenous route, at a dose of 0.01 mg/kg (equivalent to 0.1 mL/kg of 1:10,000 concentration).
This should be followed with a 0.5-1 mL flush of normal saline.
While the most common route of emergency medication administration is the intravenous route (through an emergency umbilical venous catheter placement)*, the 7th edition NRP also recommends the intraosseous route as an alternate route for term infants >3 kg.
*Please review [note to myself] the excellent seven minute YouTube video 3×3 Method for Placing Emergency Umbilical Venous Catheters 7th edition from Franciscan Health, Feb 14, 2018.
Medication Administration (cont.)
If the heart rate remains less than 60 bpm in spite of aforementioned interventions, alternative etiologies should be considered including hypovolaemia and tension pneumothorax.
As per the most recent NRP guidelines, the use of naloxone is not recommended in the management of the infant with respiratory depression following maternal intrapartum administration of narcotics.
Ineffective respirations should be managed with positive pressure ventilation as required.
Volume Expansion
Volume expansion is indicated if there is a history suggestive of blood loss and clinical signs such as poor perfusion, pallor and a weak pulse.
Normal saline or blood can be given at a dose of 10 mL/kg. If there is no response to an initial bolus of fluid, a further 10 mL/kg can be administered.
The 7th edition NRP no longer recommends the use of Ringer’s Lactate solution as a crystalloid volume expander.
It should be noted that routine administration of volume expansion is not recommended and should be reserved for situations where there are clinical signs of shock, suspicion of blood loss, and the infant is not responding to resuscitative efforts1.
Post-Resuscitation Care
If the heart rate rises above 60 bpm, chest compressions can be stopped.
Positive pressure ventilation can be stopped once the heart rate is above 100 bpm and there is adequate and effective breathing from the neonate.
Oxygen supplementation can be weaned once the recommended saturation values are met.
After resuscitation, the neonate’s heart rate, oxygen saturation, blood pressure, and temperature should be monitored continuously or at regular intervals.
Blood glucose should also be closely monitored with administration of intravenous dextrose solution as required.
Regulation of temperature and glucose is particularly important for preterm infants <32 weeks gestational age.
Infants born at 36 weeks or greater of gestation and who have clinical evidence of moderate to severe hypoxic-ischemic encephalopathy, according to unit specific guidelines, should be considered for therapeutic hypothermia.
Therapeutic hypothermia should be started within 6 hours of birth for patients that meet prescribed criteria for cooling and after discussions with a referral centre which can provide this therapy.
After resuscitation, debriefing with the team is essential to discuss aspects of the resuscitation that went well and identify areas for improvement. This is also an opportunity for members of the resuscitation team to provide and receive feedback.
