Algorithms in Pediatrics Nitin K Shah, Anand S Vasudev
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NEONATOLOGY

Neonatal ResuscitationCHAPTER 1

Rhishikesh P Thakre
 
INTRODUCTION
Birth of newborn is a potential medical emergency. Up to half of newborns who require resuscitation have no identifiable risk factors before birth. Preparation and anticipation is the key. All babies need assessment for resuscitation at birth. Up to 10% of babies need some resuscitation and less than 1% need major resuscitation.
 
STANDARD PRECAUTIONS
All resuscitation should be conducted under strict asepsis. All resuscitation apparatus should be clean and sterile, and where indicated, disposable. Suction catheters, mucus extractor, umbilical catheters, syringes, needles, endotracheal (ET) tubes, feeding tubes should be single use, sterile, and disposable.
 
PREPARATION PRIOR TO BIRTH
 
Equipment Check
  • All equipment should be available in various sizes for different gestation
  • A checklist should be used to ensure that the equipment is functional
  • Following equipment are “desirable” for resuscitation: compressed air, blender, continuous positive airway pressure (CPAP), pulse oximeter + probe and plastic wrap.
 
Personnel
  • At every delivery, there should be at least one person whose primary responsibility is the baby and who is capable of initiating resuscitation positive pressure ventilation (PPV) and chest compression (CC). Skilled personnel for complete resuscitation be readily available, if needed
  • Two persons or more are required in “high risk” delivery.
 
Identifying High Risk Delivery
Focused questions (help prepare and anticipate problems during resuscitation) include: (1) What is the gestational age? (2) Is the amniotic fluid clear? (3) How many babies are expected? (4) Are there any additional risk factors?
 
ASSESSMENT AT BIRTH
Need for resuscitation can generally be identified by a rapid assessment by asking “Is the infant breathing or crying?” If the baby is breathing or crying, the newborn does not require any further resuscitation. Early skin-to-skin contact with mother be practiced and newborn assessed for breathing, color, and activity.
If the baby is not breathing or crying, a series of steps may be needed to establish breathing sequentially performing initial steps, PPV, CC, intubation, and/or administration of drugs.
Assessing the breathing is by observing the baby's chest movements. Breathing is adequate if a baby is vigorously crying or has good regular chest movements with no pauses or indrawing with associated good tone. Gasping or labored breathing should not be mistaken for normal breathing.
 
CORD CLAMPING
All babies who establish spontaneous respiration at birth should have cord clamping delayed for more than 1 minute. It is a safe procedure in term, preterm, and low birth weight (LBW) babies with improved iron status, higher blood pressures during stabilization, and a lower incidence of intraventricular hemorrhage (IVH) and fewer blood transfusions in preterms.
 
STEPS IN NEONATAL RESUSCITATION
A baby who is not breathing or crying at birth should undergo following steps of resuscitation with ongoing assessment and reassessment at every step (Algorithm 1).2
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*In meconium stained depressed neonates after oral suction, endotracheal suction may be considered.#Endotracheal intubation may be considered at several steps.CPAP, continuous positive airway pressure, HR, heart rate; ET, endotracheal; IV, intravenous; NICU, neonatal intensive care unit.
 
Initial Steps
A baby who is not breathing or crying should be received in dry, prewarmed cloth with immediate cord clamping and placed under a heat source. The head, trunk, and the limbs should be dried firmly and quickly. Suction of mouth followed by nose may be done if there is obvious obstruction to airway. Stimulation is done by rubbing the back or flicking the soles. The newborn is repositioned and simultaneous assessment of respiration and heart rate (HR) is done.
Response to resuscitation is best judged by increasing HR and later by establishment of spontaneous breathing. The HR is easiest and quickest assessed by palpating at the base of umbilical cord, but auscultation of precordium is most reliable.
 
Positive Pressure Ventilation
Positive pressure ventilation is indicated if the newborn has apnea or gasping respiration, HR less than 100 beats per minute or SpO2 below target values despite supplemental oxygen being increased to 100%. A flow-inflating bag, a self-inflating bag, or a pressure-limited T-piece resuscitator can be used for PPV. Call for help and ask assistant to apply pulse oximeter, if available, to right hand/wrist of the newborn. In all newborns (term or preterm), PPV should be started with room air. Provide breaths at a rate of 40–60 per minute using “breathe–two-three” and assess for efficacy after 5–10 breaths. Check for rise in HR and oximetry. If there is no HR rise, check for air entry and chest movement. If not, take corrective measures for ventilation—mask reposition, reposition airway, suction, open mouth and ventilate, pressure increase, and consider alternate airway measures (MRSOPA). Heart rate is assessed every 30 seconds. Consider inserting orogastric tube if ventilation is prolonged.
Positive pressure ventilation is discontinued if there is rise in HR greater than 100 beats per minute and onset of spontaneous respiration. If despite adequate PPV, there is no desired response, one may consider intubation or initiate CC if HR is less than 60 beats per minute.
 
Intubation
Intubation is considered if ventilation is ineffective, newborn is nonvigorous with meconium stained liquor, need for CC, administration of drugs, or suspected congenital diaphragmatic hernia. Intubation is performed in time limit of 30 seconds. There is no role of cuffed ET tubes. Two common and serious errors of ET intubation are malplacement of the ET tube and the use of the wrong sized tubes.
 
Chest Compression
Heart rate less than 60 beats per minute despite adequate ventilation is indication to start CC. One should ensure that assisted ventilation is being delivered optimally before starting CCs. Consider intubation if CC is to begin. The 32 thumb encircling hands technique may generate higher peak systolic and coronary perfusion pressure than the 2 finger technique, hence the 2 thumb encircling hands technique is recommended for performing CCs in newly born infants. The 2 finger method should be reserved only for brief applications while an emergent umbilical venous catheter is established and then should be converted back to the 2 thumb method. A ratio of three CC to one ventilation is delivered in 2 seconds for uninterrupted 45–60 seconds compressing the 1/3 anteroposterior diameter of the chest and HR is checked every 45–60 seconds.
If the HR less than 60 beats per minute, CC with intubation is continued with administration of adrenaline; if the HR is 60–100 beats per minute, CC is stopped and ventilation continued and if the HR is greater than 100 beats per minute with spontaneous breathing, PPV is discontinued.
 
Medications
Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia, and establishing adequate ventilation is the most important step to correct it. Medications are indicated if the HR is less than 60 beats per minute despite 45–60 seconds of adequate CC and ventilation. The preferred mode of drug delivery is umbilical venous route. Epinephrine is administered in 1:10,000 concentration at dose of 0.1–0.3 mL/kg, IV (ET: 0.5–1 mL/kg) as fast as possible. Heart rate is assessed after 1 minute of adrenaline administration.
Volume expanders, normal saline or ringer lactate, 10 mL/kg over 5–10 minutes may be administered if there is no response to resuscitation and signs of poor peripheral perfusion or history suggestive of blood loss. There is no role of naloxone in delivery room. Endotracheal drug administration does not give reliable effects.
 
PRETERM RESUSCITATION
Additional personnel and equipment are required. Preterm/LBW babies not requiring resuscitation at birth can be kept on mother's chest in skin-to-skin contact for thermoregulation. Ensure the area is preheated using a warmer or portable pad. Food grade, clean, plastic wrapping may be done before drying in less than 32 weeks’ gestation as soon as the baby is born to ensure thermal care. If preterm is breathing spontaneously with labored respiration or is cyanotic or low SpO2, consider initiating CPAP. Gentle handling, avoiding head-down position, avoiding excess pressures of PPV or CPAP, administering surfactant after stabilization, using pulse oximeter as a guide to oxygenation and avoiding rapid infusions are good resuscitation practices.
 
SPECIAL CIRCUMSTANCES
 
Meconium Stained Liquor
The resuscitation is based on whether the newborn is vigorous or not. A vigorous infant is defined as one who has strong respiratory efforts, good muscle tone, and a HR greater than 100 beats per minute, and needs no intervention.
A nonvigorous infant needs immediate intubation, under vision tracheal suction skipping the initial steps of resuscitation. If tracheal intubation is unsuccessful or there is severe bradycardia, then proceed to PPV.
 
Role of Oxygen
Need for oxygen is based on oximetry. Pulse oximeter working on a “signal extraction technique” that is designed to reduce movement artifact with a neonatal probe is ideal. Administration of supplementary oxygen should be regulated by blending oxygen and air, and the concentration delivered is guided by oximetry. Healthy infants born at term may take more than 10 minutes to achieve a preductal oxygen saturation greater than 95% and nearly 1 hour to achieve postductal saturation greater than 95%. If the saturation is less than desired, start supplemental oxygen. Use 100% oxygen if the newborn needs CC. Minute specific oxygen saturation targets for newborns are provided in table 1.
 
Pneumothorax
Transillumination using a cold light source may be used for diagnosing pneumothorax bedside, if facility exists. In absence of cold light source, use a butterfly with a three way and syringe to tap in the second intercostal space on the suspected side.
 
Therapeutic Hypothermia
Currently, therapeutic hypothermia is not defined as standard of care in India. However, if facility exists, such therapy may be used but only after taking informed consent from parents.
 
Resuscitation of Babies Outside Hospital/Home Delivery
Special attention should be paid to maintaining normal temperature of the baby by closing the windows to prevent draughts, use dry warm cloth, baby cap, and skin-to-skin contact. Resuscitation can also be performed keeping baby on mother's abdomen. Baby should be transferred to facility in skin-to-skin contact with mother.
 
To Resuscitate or Not
The decision of when not to resuscitate or how much to resuscitate is complex. Such decisions are best made with 4an understanding of the relevant neonatal data and ethical issues, including the rights of the newborn and the parents. The ideal situation is one where the healthcare team and family come together and make the best possible decision for all involved.
TABLE 1   Target oxygen saturation
Time (min)
Preductal SpO2 after birth
1
60–65%
2
65–70%
3
70–75%
4
75–80%
5
80–85%
10
85–95%
 
POSTRESUSCITATION CARE
The postresuscitation care has been described in table 2.
 
HARMFUL PRACTICES IN NEWBORN RESUSCITATION
  • Routine suction of mouth and nose
  • Routine stomach-wash of the baby
  • Prolonged flicking the soles or rubbing or slapping the back when baby is depressed
  • Putting the baby upside down for postural drainage.
TABLE 2   Postresuscitation care
Routine care
Observational care
Postresuscitation care
When?
For all spontaneous breathing newborns not requiring resuscitation
Post initial steps or brief positive pressure ventilation (<1 min)
Post positive pressure ventilation (>1 min), need for chest compressions, intubation or drugs
Where?
Mother
Supervised in nursery
Neonatal intensive care unit
Care?
Assess for color, activity, and breathing
Observe for temperature, respiration, heart rate, blood sugar
Sick newborn care and monitoring
SUGGESTED READINGS
  1. NRP Addendum. Consensus document by IAP NNF NRP India Task Force (2012).
  1. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, et al. Part 11: neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010; 122 (Suppl 2): S516-38.