CME paediatrics

Neonatal resuscitation

Presenter :
Dr Afifi Syamil bin Abdul Razak
Supervised by :
Dr Muhaireen binti Arshad and
Dr Nurulhidayati binti Zakaria,
Paediatricians HSNZ
Introductions
Which babies require resuscitation?
• 90% of newborns make smooth transition from intrauterine to
extrauterine life requiring little or no assistance.
• 10% of newborns need some assistance.
• Only 1% require extensive resuscitation

• Ventilation of the baby’s lungs is the most important and effective

action in Neonatal Resuscitation.
Algorithm
Preparations
• Ask 4 questions
1. What is the expected gestational age?
2. Is the amniotic fluid clear?
3. How many babies are expected?
4. Are there any additional risk factors?
Equipments Checklist
Rapid evaluation at birth
• Ask 3 questions
1. Does the baby appear to be term?
2. Does the baby have good muscle tone?
3. Is the baby breathing or crying?

• If the answers are all yes,

proceed initial steps with the mother, otherwise,
if any of the answer is no,
the baby should be brought to a radiant warmer for further resuscitation
Initial steps
1. Provide warmth
2. Position the head and neck – sniffing position
3. Clear secretion if needed – mouth before nose
4. Dry
5. Stimulate
Assess the response
After the initial steps, what do you do if the baby is not breathing
or the heart rate is low?
• Start PPV if the baby is not breathing (apnea) OR if the baby has
gasping respirations
• Start PPV if the baby appears to be breathing, but the heart rate is
below 100 bpm
• Call for immediate additional help if you are the only provider at
the warmer.
What do you do if the baby is breathing and the heart rate is at least
100 bpm, but the baby appears persistently cyanotic?
1. Free flow oxygen 10L/min – not effective if the baby is not breathing
2. CPAP – if the baby has laboured breathing or persistently low
oxygen saturation
Algorithm
Ventilation
• Types of device
1. Self-inflating bag
2. T-piece resuscitator (neopuff)
3. Flow-inflating bag
Prepare to begin PPV
1. Clear secretions from the airway
2. Position yourself at the baby’s head
3. Position the baby’s head and neck

Position the mask

4. Select the correct mask
5. Place the mask on the baby’s face
• One hand technique
• Two hands technique with jaw thrust
Oxygen concentration :
• For the initial resuscitation of newborns greater than or equal to 35
weeks’ gestation, set the blender to 21% oxygen
• For the initial resuscitation of newborns less than 35 weeks’ gestation,
set the blender to 21% to 30% oxygen
• Flowmeter 10 L/minutes

Rate :
40 to 60 breaths per minute
“Breathe, Two, Three; Breathe, Two, Three; Breathe, Two, Three.”
PIP :
20 to 25cm H2O

PEEP :
Initial setting is 5 cm H2O
Assessment after PPV
Intubation
When to intubate?
• If PPV with a face mask does not result in clinical improvement, an
endotracheal tube or laryngeal mask is strongly recommended to improve
ventilation efficacy
• If PPV lasts for more than a few minutes, an endotracheal tube or a laryngeal
mask may improve the efficacy and ease of assisted ventilation.
• Insertion of an endotracheal tube is strongly recommended in the following
circumstances:
• If chest compressions are necessary
• An endotracheal tube provides the most reliable airway access in special
circumstances, such as (1) stabilization of a newborn with a suspected
diaphragmatic hernia, (2) for surfactant administration, and (3) for direct
tracheal suction if the airway is obstructed by thick secretions.
Size and placement of ETT
Laryngoscope blade (Miller)
Gestational age Size (No.)
Very preterm 00
Preterm 0
Term 1

ETT size
Weight (g) Gestational age (weeks) ETT size (mm ID)
< 1,000 < 28 2.5
1,000 – 2,000 28 - 34 3.0
> 2,000 > 34 3.5

Placement (length in cm at the lip)

Weight in kg + 6cm
Preparing for intubation
1. Select the appropriate laryngoscope blade and attach it to the
handle
2. Turn on the light by clicking
3. Prepare the suction equipment
4. Prepare a PPV device with a mask to ventilate the baby
5. Place a CO2 detector, stethoscope, measuring tape or insertion
depth table, waterproof adhesive tape, and scissors (or a tube
stabilizer) within reach
6. Position the baby’s head in the midline, the neck slightly extended,
and the body straight
Performing the intubation
• Correctly position the baby
• Right index finger to gently open the baby’s mouth
• Insert the laryngoscope blade
• Lift the entire laryngoscope
• Identify the key landmarks. The vocal cords appear as thin vertical
stripes in the shape of an inverted letter “V”
• Maintain your view of the vocal cords, and ask an assistant to place
the endotracheal tube in your right hand
• Insert the tube into the right side of the
baby’s mouth with the concave curve in
the horizontal plane
• Advance the tip toward the vocal cords
• As the tip approaches the vocal cords,
pivot the tube into the vertical plane so the tip is directed upward
• Wait until the vocal cords open, advance the tube until the vocal cords are
positioned between the vocal cord guide lines
• Use your right hand to hold the tube securely against the baby’s hard palate.
Carefully remove the laryngoscope without displacing the tube
• An assistant should attach a CO2 detector and PPV device to the
endotracheal tube
Confirmation of ETT placement
• CO2 during exhalation using CO2 detector
• Audible and equal breath sounds near both axillae during PPV
• Symmetrical chest movement with each breath
• Little or no air leak from the mouth during PPV
• Decreased or absent air entry over the stomach
• Obtain a chest x-ray for final placement confirmation
• Tip of ETT at midtrachea adjacent to the first or second thoracic vertebra
• The tip should be above the carina, which is generally adjacent to the third or
fourth thoracic vertebra
Secure the ETT
If condition worsens after intubation?
The DOPE mnemonic :
• Displaced endotracheal tube
• Obstructed endotracheal tube
• Pneumothorax
• Equipment failure
6 HOL, Term, SVD with LMSL
1 HOL, Term, EMLSCS for fetal distress
15 MIN OL, Term, SVD, clear liquor, No risk
of sepsis
Chest compression
• Chest compressions are indicated if the
baby’s heart rate remains less than 60
bpm after at least 30 seconds of PPV that
inflates the lungs, as evidenced by chest
movement with ventilation
• Neonate rarely required if ventilation is
adequate
• Once intubation is completed and the tube is
secure, the compressor should move to the
head of the bed while the person operating the
PPV device moves to the side
• Pressure should be applied to the lower third
of the sternum
• Place thumbs on the sternum just below an
imaginary line connecting the baby’s nipples,
either side-by-side or one on top of the other
• Encircle the baby’s chest with your hands and
place your fingers under the baby’s back to
provide support
• Press the sternum downward to compress the heart between the sternum
and the spine approximately one-third of the anterior-posterior (AP)
diameter of the chest and then release the pressure to allow the heart to
refill
• Give 3 rapid compressions followed by 1 ventilation every 2 seconds
• “One-and-Two-and-Threeand-Breathe-and; One-and-Two-and-Three-and-
Breathe-and; Oneand-Two-and-Three-and-Breathe-and...”
• Reassess the heart rate 60 seconds after starting coordinated chest
compressions and ventilation
• Stop chest compressions when the heart rate is 60 bpm or higher
• Once compressions are stopped, return to giving PPV at the faster rate of
40 to 60 breaths per minute
• If heart rate not improve after 60
seconds of compression, ask :
o Is the chest moving with each breath?
o Are bilateral breath sounds audible?
o Is 100% oxygen being administered
through the PPV device?
o Is the depth of compressions adequate
(one-third of the AP diameter of the
chest)
o Is the compression rate correct?
o Are chest compressions and
ventilations well-coordinated?

• If ventilation and compressions are being correctly administered,

epinephrine administration is indicated.
Medications
• Most newborns requiring resuscitation will improve without
emergency medications. Before administering medications, you
should check the effectiveness of ventilation and compressions
• Epinephrine to improve coronary artery perfusion and oxygen
delivery
• Newborns with shock from acute blood loss (eg, bleeding vasa previa,
fetal trauma, cord disruption, severe cord compression) may also
require emergency volume expansion
Epinephrine
• Indication :
• if the baby’s heart rate remains below 60 bpm after
• At least 30 seconds of PPV that inflates the lungs (moves the chest), and
• Another 6 seconds of chest compressions coordinated with PPV using 100% oxygen
• Concentration
• Only the 1:10,000 preparation (0.1 mg/mL) should be used
• Route and dose
• Intravenous (preferred) or intraosseous : 0.1-0.3ml/kg preferably via UVC,
followed by 0.5-1ml flush of normal saline
• Endotracheal (less effective) : 0.5-1ml/kg follow by several PPV
• Assess the heart rate 1 minute after epinephrine administration
• If the heart rate is less than 60 bpm after the first dose of intravenous
or intraosseous epinephrine, repeat the dose every 3 to 5 minutes
• Consider volume expansion if
• Signs of shock
• History of acute blood loss
• The persistent absence of a detectable heart rate (Apgar 0) at 10
minutes is a strong, but not absolute, predictor of mortality and
serious morbidity in late preterm and term newborns
• If there is a confirmed absence of heart rate after 10 minutes of
resuscitation, it is reasonable to stop resuscitative efforts; however,
the decision to continue or discontinue should be individualized.
Establish rapid intravascular access
during resuscitation
1. Umbilical vein
1. Put on gloves and quickly prepare an area for your equipment
2. Fill a 3.5F or 5F single lumen umbilical catheter with normal saline using a syringe
3. Quickly clean the umbilical cord with an antiseptic solution. Place a loose tie at the
base of the umbilical cord
4. Cut the cord with a scalpel below the umbilical clamp and about 1 to 2 cm above the
skin line
5. The umbilical vein will be seen as a larger, thin-walled structure, often near the 12-
o’clock position
6. Insert the catheter into the umbilical vein until you get free flow of blood (2 to 4 cm)
7. After administering the medications, secure the UVC by suturing and “goal post” tape

• UVC = UAC/2, UAC = weight x 3 + 9

2. Intraosseous
1. Identify the insertion site. For term newborns, the preferred site is the flat
surface of the lower leg, approximately 2 cm below and 1 to 2 cm medial to
the tibial tuberosity
2. Hold the intraosseous needle perpendicular to the skin and advance the
needle through the skin to the surface of the bone
3. Direct the needle perpendicular to the bone and advance the needle
through the bone cortex into the marrow space
4. Removing the stylet and securing the needle
5. Flush the needle, and administer the medication or fluid
6. Monitor the insertion site for evidence of swelling or fluid extravasation
Resuscitating preterm babies
• Preterm baby’s anatomic and physiologic immaturity
• Thin skin, decreased subcutaneous fat, large surface area relative to body mass, and a
limited metabolic response to cold lead to rapid heat loss
• Weak chest muscles and flexible ribs decrease the efficiency of spontaneous breathing
efforts
• Immature lungs that lack surfactant are more difficult to ventilate and are at greater risk of
injury from PPV
• Immature tissues are more easily damaged by oxygen
• Infection of the amniotic fluid and placenta (chorioamnionitis) may initiate preterm labor,
and the baby’s immature immune system increases the risk of developing severe infections
such as pneumonia, sepsis, and meningitis
• A smaller blood volume increases the risk of hypovolemia from blood loss
• Immature blood vessels in the brain cannot adjust to rapid changes in blood flow, which
may cause bleeding or damage from insufficient blood supply
• Limited metabolic reserves and immature compensatory mechanisms increase the risk of
Additional resources for
resuscitating a preterm newborn
• Polyethylene bag/wrap and a thermal
• Servo-controlled radiant warmer with a temperature sensor
• Oxygen blender and oximeter with an appropriate-sized sensor
• ECG monitor with 3 chest leads or limb leads provides a rapid and reliable method of
continuously displaying the baby’s heart rate if the pulse oximeter has difficulty acquiring a
stable signal
• Resuscitation device capable of providing PEEP and CPAP, such as a T-piece resuscitator or
flow-inflating bag, is preferred
• Preterm-sized resuscitation mask, size-0 laryngoscope blade (size 00 optional), and
appropriate-sized endotracheal tubes (3.0 mm and 2.5 mm) should be prepared
• Consider having surfactant available if the baby is expected to be less than 30 weeks’
gestation
• Pre-warmed transport incubator with blended oxygen and a pulse oximeter
Keep the preterm newborn warm
• Increase the temperature in the room where the baby will receive initial care
• Set the room temperature to approximately 23oC to 25oC
• Preheat the radiant warmer well before the time of birth
• Place a hat on the baby’s head
• For babies born at less than 32 weeks’ gestation,
• Place a thermal mattress under the blanket on the radiant warmer
• Wrap the baby in a polyethylene plastic bag or wrap
• Food-grade reclosable 1-gallon plastic bag, a large plastic surgical bag, food wrap, or sheets of
commercially available polyethylene plastic
• If the newborn requires insertion of an umbilical catheter, cut a small hole in the plastic
• Monitor the baby’s temperature frequently
• Use a pre-warmed transport incubator
• Maintain the baby’s axillary temperature between 36.5°C and 37.5°C
Special consideration
1. Pneumothorax
• 2. Pierre Robin syndrome
3. Choanal atresia
4. Congenital diaphragmatic hernia
5. Pulmonary hypoplasia
Reference
• Textbook of Neonatal Resuscitation, 7th Edition