Handbook on Neonatal ICU Neelam Kler, Pankaj Garg, Anup Thakur
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Aagenaes syndrome 152
Absolute neutrophil count 217f
Acetaminophen 246
Acetazolamide 190
Acid-base
disorders, management of 198
imbalance 194
Acidosis, correction of 24
Acinetobacter spp 215
Activated partial thromboplastin time 157
Adenosine triphosphate 67
Adrenal insufficiency 30
Adrenocorticotropic hormone 30
Air and oxygen, compressed source of 85
Air leak 62, 70, 237
management 71
Air transport, problems with 237
Alagille syndrome 149
Albumin transfusion 152
Albuterol 24
Alfentanil 245, 246
Alkaline phosphatase, elevations of 150
Amblyopia 213
American Academy of Pediatrics 46
American Heart Association 110fc
Amiel-Tison method 259
Amino acid 43
constitution 43
metabolism, hereditary defects in 30
Aminophylline 103
Anemia
algorithm of 165
clinical effects of 162
clinical features of 162
in neonate 161
management of 163
of prematurity 161
prevention of 165
Angiogenic growth factors 94
Angiotensin receptor blockers 198
Angiotensin-converting enzyme 196, 198
Antenatal corticosteroids 191
Antenatal steroids 140, 211
Antepartum risk factors 3
Anthropometric measures 258
Antibacterial prophylaxis 152
Antibiotics 224
Anticipatory guidance 257, 262
Antiepileptic drug 184
Antimicrobial treatment 221fc, 222fc
Antiplatelet antibodies 158
Antitrypsin deficiency 149
Anti-vascular endothelial growth factor treatment 212
Aortic root
left atrial to 121
left atrium to 127
Aortic stenosis 107
Apnea 192
monitors 102
of prematurity 100
Arginine vasopressin, low-dose 69
Arterial blood gas 133, 181
Arterial puncture 246
Arterial venous oxygen 126
Arthrogryposis renal
cholestasis 152
syndrome 149
tubular dysfunction-cholestasis syndrome 152
Asphyxia 27, 130, 173t
risk factors for 172t
Asphyxiated neonates 177
Asymptomatic baby with murmur 107
Atelectasis, multiple areas of 94f
Atelectotrauma 232
Atrial natriuretic peptide 13
Atrial septal defect 107, 114
Attention deficit hyperactivity disorder 256
Auditory brainstem response 259
Auditory evaluation 259
B
Baby on ventilator, acute deterioration of 78, 79fc
Baby's lung 2
ventilation of 12
Baroda development screening test 261
Basal ganglia 147
Bayley infant neurodevelopment screen 261
Beckwith-Wiedemann syndrome 30
Behavioral problems 256
Behavioral skills 2
Bell's staging 139t
Bernard-Soulier syndrome 156
Bile acid
synthetic defects 149, 152
synthetic disorders 150
Bile duct
obstruction 149
spontaneous perforation of 149
Bilirubin encephalopathy, acute 146
Bilirubin-induced auditory toxicity 146
Biphasic positive airway pressure 8284
Birth asphyxia, incidence of 172
Blalock-Taussig shunts 114
Bleeding neonate 155
age of onset of 156
diagnostic evaluation of 156
etiology 155
treatment 158
Blindness and deafness 256
Blood
ammonia 30
culture 218
exchange transfusion 222
for transfusion, volume of 163
group incompatibility 144
lactate levels 30
large amount of 190f
loss 161
transfusions, judicious of 211
urea nitrogen 199
Blood clot
large amounts of 189f
small amounts of 189f
Blood gas 87
analysis 111
approach to 203
parameter, normal 77
Blood glucose
level estimation, methods of 28
screening, indications for routine 28t
Blood pressure 130
fluctuations, phenobarbital modulates 191
Bloodstream infection 215
central-line-associated 214
Bolus feeding 52
Bone marrow 165
Bosentan 69
Brain
developing 247
natriuretic peptide 121
Brainstem nuclei 147
Breastfeeding 144
Breast milk 224, 233
expressed 48, 50
jaundice 144
Bronchodilators 96
Bronchopulmonary dysplasia 58, 91, 92, 98, 104, 227, 231, 234
C
Caffeine 103, 104
Calcium 41, 49
disorders of 26
Capillary blood gas 57
Capillary refill time 126
Carbohydrate 40
metabolism, hereditary defects in 30
Cardiac catheterization 112
Cardiac disease, suspected 108t
Cardiac function 127t
Cardiac size 111
Cardiovascular system 230
Care beyond technology 254
Care during transport 239
Cataract 213
Catastrophic deterioration 188
Cation exchange resins 24
Cell surface markers 219
Central apnea 101
Central arterial lines 232
Central cyanosis 109
Central line placement 246
Central nervous system 102, 112, 229, 230, 262
Central pattern generators 260
Central venous pressure 126
Cerebellum 147
Cerebral blood flow 187
Cerebrospinal fluid 102, 222
examination 218
indications for 190
Chest
compression 9
physiotherapy 247
Child psychologist 256
Chlorhexidine, use of 232
Chloride 41
Choledochal cyst 149
Cholestatic disorders, management of 153t
Cholestatic syndromes 149
Cholestyramine 152
Chorioamnionitis, criteria of 215
Chromosomal disorders 106
Chylothorax 11
Circulatory collapse 107, 109
Circulatory management 69
Claudin-3 138
Clear airway 4
Coagulation factor disorder 156
Coagulation protein disorders 156
Coagulopathies, treatment of 159
Coarctation of aorta 107
Cognitive 256
Collagen receptor deficiency 156
Communication and family support 238
Complete blood count 150
Congenital heart disease 11, 106
Congenital hyperinsulinism 30
Congenital hypopituitarism 30
Congenital hypothyroidism, screen for 256
Congenital infection 155
Congestive cardiac failure 107, 108
Congestive heart failure 149
Constricted ductus 119f
Continuous feeding 52
Continuous positive airway pressure 5, 83, 87, 89, 96, 103, 211, 227, 228, 231
Continuous renal replacement therapy 199
Conventional ventilation 76
Cord clamping 226228
Coronal cranial ultrasound scan 190f
Coronal ultrasound scan 188f
Corticosteroids 96
Cranial ultrasonography 233
C-reactive protein 101, 216, 220
Cryotherapy 211
Cyanosis 106, 107
Cyanotic heart disease 107
Cyclic adenosine monophosphate 67
Cyclic guanosine monophosphate 67
Cyclooxygenase-1 67
Cysteine 43
Cystic fibrosis 149
Cystic periventricular leukomalacia 260
Cytomegalovirus 150, 151
infection, prevention of 164
D
Deficit replacement strategy 15
Deficit repletion and maintenance 15
Dehydration 17
Delivery room
care in 226
continuous positive airway pressure 228
oxygen in 227
stabilization 58
Denver developmental materials 261
Detect readily treatable disorders 150
Development assessment tests 261
Developmental screening tools 260
Developmentally supportive care 252
implementation of 255
Dexmedetomidine 245
Dextrose 43
concentration 43
Diazoxide 30
Disability screen test 261
Discharge
advice 250
planning 249, 256
elements of 250t
preparation 249
Disseminated intravascular coagulation 157, 175
Dobutamine 129
effect of 131fc
Docosahexaenoic acid 40, 47
Documentation and consent forms 238
Donor blood, hematocrit of 164
Donor human milk 233
Dopamine 129, 130fc, 134
Double volume exchange transfusion 24
Down's syndrome 106
Downes' score 87t
Doxapram 103
Ductal arteriosus closure, factors controlling 117
Ductus arteriosus 119
Duke's abdominal assessment scale 137
Dyselectrolytemias, management of 197
E
Early intervention therapy 257
Electrolyte 43
deficit 14
imbalance 25
management, goals of 13
Encephalopathy
hypoxic-ischemic 172, 176t
severity of 174t
End stage liver disease 152
Endocrine causes 152
Endocrinopathies 149
Endoscopic variceal ligation 152
Endothelial cells 187
Endothelial nitric oxide synthase 67
Endothelin-1 67
Endotracheal intubation 5
Endotracheal suctioning 78
Endotracheal tube 5, 7f, 9
Enhanced potassium excretion 24
Enteral feedings
advancement of 50
initiation of 50
Enteral iron 165
Enteral nutrition
benefits of 46
options for 47
Enzymes 232
Epidermal stripping, risk of 232
Epinephrine 10, 129, 134
effect of 131fc
Epithelial and fibrotic markers 94
Erythropoietic stimulant agent 165
Erythropoietin 165
Escherichia coli 215
Essential fatty acid 40
Ethamsylate 191
Eutectic mixture 245
Euvolemic hyponatremia 18
Exogenous surfactant therapy 59
Expiratory limb 85
Extracellular fluid 13
Extracorporeal membrane oxygenation 182, 192, 196, 247
Extrahepatic biliary atresia 149
Eye drops 245
F
Familial intrahepatic cholestasis, progressive 149, 150, 152
Fanconi's syndrome 155
Fatty acid oxidation defects 30
Fecal calprotectin 138
Feeding
cue-based 253, 254
mode of 51, 51t
Fentanyl 245, 247
remifentanil 246
Fetal blood flow 172
Fetal echocardiography 109
Fetal platelets, antibodies against 158
Fetal tachycardia 215
Fibrinogen 157
Fibrocystic changes 94f
Flow inflating bag, parts of 7, 7f
Fluid
administration and nutrition 96
deficit volume 14
disorders of 17
estimation of 14
management 197
overload 17
replacement strategy 15t
schedule 20, 22
Fluid and electrolyte 231, 232
management 13
requirements 14t
status, monitoring of 17t
Fortification, types of 48
Free fatty acid levels 30
Free water deficit 14
Fresh frozen plasma 139, 159, 164
Fructose 1,6-diphosphatase deficiency 30
Fructose intolerance 30
Functional echocardiography 126
Furosemide 24, 190
G
G6PD of donor blood 164
Galactose-1 phosphate uridyltransferase 150
Galactosemia 30, 149, 150
Gallbladder 151
Gamma-glutamyltransferase 150
Gas chromatography-mass spectrometry 181
Gas conditioning effects 88
Gas exchange, maintain adequate 127
Gastrointestinal distension 88
Gastrointestinal inflammatory process 135
Gastrointestinal injury 175
Gastrointestinal system 229
Gaucher disease 149
General movements assessment 260
Genetic diseases 144
Genetic syndromes, familial predisposition of 109
Germinal matrix hemorrhage 187
factors in causation of 187f
Gestational age
large for 257
small for 26, 149, 257
Gestational alloimmune liver disease 150, 151
Gestational hypertension 167
Gestational thrombocytopenia 158
Glanzmann thrombasthenia 156
Glaucoma 213
Glomerular filtration rate 130
Glucagon 30
Glucose
disorders of 26
infusion rate 29
metabolism 26
Glutamine 223
Glycogen
storage disease 30
synthase deficiency 30
Glycosylation, congenital disorders of 149
Granulocyte colony-stimulating factor 224
Granulocyte macrophage colony stimulating factor 224
Granulocyte transfusion 223
Great arteries, transposition of 28
Growth and nutrition 258
Growth monitoring 52
H
Hearing 262
loss 234
screening 256, 259
Heart
disease, acyanotic 107
rate 5
Hebb rule 262
Heel stick 246
Hemangioma 157
Hematological system 230
Hemoglobin changes after birth 162t
Hemolysis 144
Hemolytic disease 144, 155
Hemophagocytic lymphohistiocytosis 150
Hemorrhage
acute 163
large 186
periventricular 58
small 188f
Hepatobiliary iminodiacetic acid 150
Hepatosplenomegaly 156
Herpes simplex virus 150, 151
Hindrance to developmentally supportive care 252
Home environment preparation 250
Hormone
deficiencies 30
excess 30
Human herpesvirus 150
Human immunodeficiency virus 257
Human milk 140
benefits of 47
fortification 47, 48
guidelines for 48t
fortifier 48, 233
Humidified incubators, use of 232
Humidifier 85
Hydrocortisone 30
Hydronephrosis 256
Hydrops 11
Hyperbilirubinemia 257
Hypercapnia produces 187
Hyperglycemia 31
Hyperinsulinemic hypoglycemia 27
Hyperkalemia 22
Hypernatremia 25
assessing severity of 21t
complications of 25
with increased weight 20
with weight loss 21
Hypernatremic disorders 15, 20
Hyperoxia test 111
Hypertension
management of 198
pregnancy-induced 172
Hypertonia, prevent development of 262
Hypoglycemia 26
Hypokalemia 22
Hyponatremia
acute 19
causes of 19t
chronic 20
etiology of 18
hypervolemic 19
hypovolemic 18
Hyponatremic dehydration 14
Hyponatremic disorders 18
Hypoplastic left heart syndrome 114
Hypothermia 27
Hypoxemia 67
I
Iatrogenic blood loss, reducing 165
Ibuprofen 120, 245
Immune thrombocytopenia 156
Immunization 257, 262
Immunological function 229
Impaired platelet function 156
Indomethacin 120
Infant and toddler development, Bayley scale of 262
Infant neurological international battery 259
Infection 92, 233
management of 231
prevention of 231
Inflammation 92
Inflammatory markers 94
Inhaled beta-2 agonists 96
Inhaled nebulized beta-agonist 24
Inhaled nitric oxide 67
Injury, chronic manifestation of 147
Inotropes, initiation of appropriate 128
Inspiratory and expiratory time 75
Inspiratory gases, humidification of 78
Inspiratory limb 85
Inspissated bile 149
Insulin infusion 23
Insulin-like growth factor 1 207
Intercostal drains 246
Interleukin 220
Intermittent hemodialysis 199
Intermittent mandatory ventilation 76
Intermittent positive pressure ventilation 187
Interstitial opacities 93f
Interventional catheterization 113
Intracellular fluid 13
Intracranial anomalies 169
Intracranial hemorrhage 169, 186
in term infant 191
Intracranial pressure 182
Intrahepatic cholestasis, benign recurrent 149
Intramuscular injection 246
Intratracheal intubation, assessment of 10
Intravenous catheter, removal of 247
Intravenous immunoglobulin 224
Intraventricular hemorrhage 79, 182, 186, 187, 187fc, 188f, 227, 228, 231, 233, 234
Intubation 10
indication for 10
procedure 10
Invasive ventilation 73, 103
complications of 81
T-piece concept of 74f
Ionotropes 129b
Iron 49
Isolated growth hormone deficiency 30
Isonatremic dehydration 14
Isonatremic disorders 17
J
Jaundice 156
K
Kangaroo mother care 253, 254, 256
Kayexalate 24
Kernicterus 142, 147
Ketogenic defects 30
Kidney
disease 195
injury, acute 175, 194, 199, 234
Klebsiella pneumoniae 215
L
Lactoferrin 223
Laryngeal mask airway 5, 9, 10
insertion of 11f
Laser photocoagulation 211
Learning disabilities 256
Left atrium 117
Left ventricle 117, 127, 132, 133
Leukomalacia, periventricular 231
Levosalbutamol 96
Lidocaine 245
Life-threatening bleeding, severe 159
Lipid 40
emulsion 43
tolerance of 40
Liver
dysfunction 175
early onset severe 150b
function test 150
transplantation 152
Long chain polyunsaturated fatty acids 92
Lorazepam 245
Low birth weight 10, 215, 250
care of extremely 226
extremely 14, 130, 211, 226, 228, 229t
in delivery room, care of extremely 228t
infants, problems of extremely 228
Low gamma glutamyltransferase cholestasis, causes of 152b
Lower extremities, passive tone in 259f
Lumbar puncture 246
Lung
disease, chronic 13, 229, 231
malformations 64
recruitment 232
volume, increased 93f
Lymphedema cholestasis syndrome 152
M
Macronutrients 40t
Macular dragging 213
Magnesium 41
disorders of 26
Malpositioned nasal prongs 88
Manroe's chart 217f
Maple syrup urine disease 30
Marfan syndrome 109
Maternal leukocytosis 215
Maternal medical problems, antenatal management of 178
Maternal tachycardia 215
Mean airway pressure, strategies to increase 75f
Mean corpuscular volume 165
Mechanical ventilation 81, 246
Meconium aspiration syndrome 62, 64f
Medical social worker 256
Medicolegal issues during transport 240
Meningitis
indication 218
treatment 218
Metabolic abnormalities 169
Metabolic acidosis 203
etiology of 205
Metabolic alkalosis 203
Metabolic diseases 144
Metabolic disorders 149
compensation in 203
Metabolic problems 257
Metabolic screen 256
Metabolism, inborn errors of 102, 184, 257
Methionine 43
Methylmalonic acidemia 30
Micronutrients 40
Micturating cystourethrography 197
Midazolam 245
Milani-Comparetti and Gidoni method 259
Milrinone 69, 129
Minerals 41
Minimal enteral feeds 140
Minimally invasive surfactant therapy 228
Minimizing volutrauma 232
Mitochondrial disorders 30
Mitochondrial hepatopathies 149
Mitochondrial respiratory chain dysfunction 150
Modulating pathways, use of 262
Morphine 245, 246
Mouzinho's chart 217f
Multiple blood transfusion 206
Multivitamin 43
infusion 43
Myocardial dysfunction 175
N
Naloxone 152
Nasal airway 82
Nasal cannula
heated humidified high-flow 86f, 88, 96
high-flow 84
low-flow 82
setup for heated humidified high-flow 89f
Nasal continuous positive airway pressure 8284
interfaces for 86f
Nasal high frequency oscillatory ventilation 82, 84
Nasal injury 88
Nasal intermittent positive
airway pressure 88, 88t
pressure ventilation 8284, 103
Nasal oxygen, heated humidified high-flow 103
Nasal prongs 87
Nasal trauma, less 89
Nasogastric feeding 51
Nasopharyngeal prongs, bilateral 85
National neonatal perinatal database 215
National neonatology forum screening guidelines 210b
Necrotizing enterocolitis 13, 121, 135, 135f, 139, 139t, 224, 228, 234, 257
Negative predictive value 220
Neonatal acute kidney injury 194
Neonatal alloimmune thrombocytopenia 157, 158
Neonatal anemia, causes of 161
Neonatal cholestasis 148
Neonatal deaths 1
Neonatal encephalopathy 192
Neonatal hemochromatosis 149
Neonatal hepatitis 149
Neonatal hypoglycemia 27
Neonatal intensive care unit 41, 215, 226, 231, 234, 247, 250, 252, 256, 263
Neonatal iron storage disease 150
Neonatal meningitis 214, 218
Neonatal modified Kidney disease 195t
Neonatal pain
management 244
scoring tools 243t
Neonatal renal physiology 194
Neonatal resuscitation 1
pathophysiology 2
program 4, 5fc
Neonatal RIFLE classification 195t
Neonatal sclerosing cholangitis 149
Neonatal seizure 180, 185
Neonatal sepsis 214, 219, 224
Neonatal shock 124
Neonatal transport 239
system components 238
Neonatal unconjugated hyperbilirubinemia 142
Neonate with bleeding, workup of 157fc
Neurodevelopmental assessment 257, 260
Neurodevelopmental impairment 178
Neuroimaging assessment 257
Neurologic disorders 109
Neurological examination 256
abnormal 257
Neurological outcomes, risk for abnormal 263
Neuromotor assessment 257, 258, 263
Neuromuscular paralysis 17
Neuronal injury, site of 173t
Neurons 262
Neurosensory
assessment 259
examination 257
motor development assessment 260
Newborn
care, initial steps of 4
discharge of 249
high-risk 250
screening 250
Niemann-Pick type C 149
Nitric oxide 67
Noise and vibration 237
Noninvasive blood pressure 128
Noninvasive high frequency oscillatory ventilation 83
Noninvasive mechanical ventilation 232
Noninvasive neurally adjusted ventilatory assist 82, 83
Noninvasive respiratory
modes 84t
support 82
modes, types of 83fc
Noninvasive support, extubated to 60
Noninvasive ventilation 82
Nonopioid analgesics 245
Nonselective cyclooxygenase inhibitors, use of 120
Nonsteroidal anti-inflammatory drug 17, 121
Nonsyndromic bile duct paucity 149
Noonan's syndrome 106, 109
Norepinephrine 129
Norwood procedure 114
Nutrition 198, 231, 232
importance of 46
monitoring of 257
requirements 47
Nutritional supplementation 49, 50t
of preterm infants 49t
O
Obstetric cause 161
Obstructive apnea 101
Occipito-frontal circumference 46
Occupational therapist 256
Octreotide 30
Ophthalmic examination 259
Opioid 246
analgesics 245
Organ dysfunction, management of 177
Orogastric feeding 51
Oscillatory ventilation, high frequency 80
Osmolarity 43
Oxidant injury markers 94
Oxybuprocaine 245
Oxygen
inspired 80
judicious of 234
toxicity 232
Oxygenation 69
measures 211
P
Packed cell volume 128
Pain
assessment of 243
behavioral response to 242t
biobehavioral response to 242t
feel 247
long-term effect of 244
management 242, 246, 247, 253, 254
modalities of 244
physiological response to 242t
prevention, modalities of 244
source of 246, 247
Painful procedure, unnecessary 244
Pancreatic islet cells, hereditary defects of 30
Paracetamol 245
Parent understanding, assessment of 256
Parenteral and enteral nutrition strategies 92
Parenteral nutrition 39, 40, 149, 233
Partial external biliary diversion 152
Patent ductus arteriosus 13, 79, 92, 107, 114, 116, 117f, 118, 121, 127, 187
hemodynamically significant 119
management of 120
Patient-triggered ventilation, classification of 76
Peak inspiratory pressure 7476, 80, 88
Pelviureteric junction 196
Pentoxifylline 223
Peri-extubation care 80
Perinatal asphyxia 149
severe 198
Perinatal intensive care, advances in 256
Periodic breathing 100
Peripheral arterial line 246
Peritoneal dialysis 24, 199
Peroxide formation 43
Peroxisomal disorders 149
Persistent hypoglycemia, management of 30
Persistent pulmonary hypertension 62, 64, 66, 79, 132, 133, 169, 182
Phenylalanine 43
Phenylketonuria 106, 109
Phosphodiesterase inhibitor 223
Phosphorus 41, 49
PHOX2B gene mutation 101
Plasma
glucose level estimation, methods of 28
inter-alpha inhibitor protein 138
Platelet
count, decreased 155
disorder 155
combined 156
transfusion, indication for 159
Pleural effusion 11
Plus disease 208, 209f
Pneumonia 64, 169
episode of 214
Pneumothorax 11, 70, 88
Polycythemia 27, 167
Polymerase chain reaction 150, 219
Polyunsaturated fatty acid 43
Portal hypertension 152
Positive end expiratory pressure 74, 75, 80, 88, 121, 231
Positive predictive value 220
Positive pressure ventilation 4, 5, 9, 227
Post-extubation care 80
Posthemorrhagic ventricular dilatation 190
Postlaser 212f
Postmenstrual age 91, 92
Postnatal growth failure 46
Postnatal systemic corticosteroids 96
Potassium 41
balance, disorders of 22
chloride 43
Predict cerebral palsy 260
Prenatal care 58
Pressure support ventilation 76
Preterm births, preventing 60
Preterm infant 116, 130
Preterm neonate
enteral nutrition in 46
monitoring in 102
Prethreshold classification 212b
Prilocaine 245
Probable sepsis 214
Probiotics supplementation 140
Procalcitonin 220
Propionic acidemia 30
Prostacyclin synthase 67
Prostaglandin 113, 117
Proteins 40
inter-alpha inhibitor 219, 220
Pseudomonas 215
Public-private partnership, model of 236
Pulmonary atresia 114
Pulmonary dysfunction 175
Pulmonary hemorrhage 58
Pulmonary hypertension 58
vascular mediators of 67f
Pulmonary hypoplasia 11
Pulmonary stenosis 114
Pulmonary valve stenosis 107
Pulmonary vascular resistance 130
Pulmonary vasodilators 69
Pulse oximetry 111
screening 110, 110fc
Q
Quality management 240
R
Radioisotope imaging 197
Reconstitution of red blood cell 164
Red blood cell 165
destruction, increased 161
production 161
decreased 161
Refractive errors 213
Refractory fluid overload 199
Refractory hyperkalemia 199
Refractory hypoglycemia 28, 30t
management of 30
Refractory metabolic acidosis 199
Renal disease 149
Renal functions resulting 194
Renal losses 15
Renal replacement therapy 199
indications of 199b
Renal ultrasound 113
Respiratory acidosis
acute 203
chronic 203
Respiratory alkalosis
acute 203
chronic 203
Respiratory disorders 109
compensation in 203
Respiratory distress 27
syndrome 54, 88, 130, 187, 206
Respiratory management 95
Respiratory rate 80
Respiratory support 59, 228, 238
and surfactant 60
in delivery room 227
Respiratory syncytial virus 229
Respiratory system 228, 229
Resuscitation 12
requirement of 1f
team 2
Retina, zones of 208f
Retinal detachment 213
Retinopathy of prematurity 206, 208f, 209f, 210, 210b, 211, 213, 233, 234
Rh hemolytic disease 257
Riboflavin 43
Ribosomal ribonucleic acid, amplification of 219
Rifampicin 152
Right atrium 117, 127
Right pneumothorax 64f
Right ventricle 117, 127, 132, 133
Right ventricular output 130
Rotor wing aircraft 237
Rubella 106
infection 109
S
Salbutamol 24, 96
Saline, normal 130
Saltatory syndrome 188
Sclerotherapy 152
Seizure 192
classification 180
management of 176t
Selective serotonin reuptake inhibitor 109
Self-inflating bag 6
parts of 6f
Sepsis 27, 64, 130, 138, 156, 232
peripartum risk factors for 233
quality improvement for 215
screen 216
Serum bilirubin, total 145
Shock 27
assessment of 126t
cause of 127
compensated 124
early identification of 126
in preterm infants, treatment of 133fc
in term infants 132fc
management of 124, 127t, 128
type of 125
uncompensated 124
Sick
babies 252
neonate 236
transport of 236
preterm neonates 102
Sildenafil 69
Silverman-Anderson score 55
Single gene defects 106
Skin care 231, 232
Skin-to-skin care 253, 254
Sodium 41
and water balance, disorders of 17
cutoffs 21t
excess 20
in hyponatremia, correction of 19
restriction of 18, 152
Solute fluid deficit 14
Solute potassium deficit 15
Solute sodium deficit 15
Stabilizes upper airway 85
Standard transfusion guidelines 164t
Staphylococcus aureus 215
Storage disorders 149
Strabismus 213
Streptokinase, intraventricular injection of 190
Subcutaneous injection 246
Subependymal germinal matrix 188f
Subtle seizure 180
Sufentanil 246
Supplemental oxygen, need for 91
Suprapubic bladder aspiration 246
Surfactant deficiency disorders 229
Surgical shunt procedure 152
Sustained inflation 227, 228
Synchronized intermittent mandatory ventilation 76
Syndrome of inappropriate antidiuretic hormone, diagnosis of 19t
Systemic blood flow 130
Systemic lupus erythematosus 158
T
Tachypnea, decreases 84
Tandem mass spectroscopy 30
Teratogenic drugs 109
Tetracaine 245
Tetralogy of Fallot 107
Thermoregulation 227, 228
Thrombocytopenia 155, 192
absent radius syndrome 155
incidental 158
Thrombosis 232
Thyroid
profile 30
stimulating hormone 150, 229
TORCH infection 155
Total leukocyte count 216
Total neutrophil ratio, immature to 220
Total parenteral nutrition, compounding of 41
T-piece resuscitator 8
parts of 7f
Trace elements 43
Tracheal aspirate 94
Tracheal extubation 247
Tracheal intubation 247
Transient hyperinsulinism 27
Transient hypoglycemia 27
Transient tachypnea 64
Tricuspid atresia 107, 114
Tricuspid stenosis 114
Triglyceride, medium change 47
Trisomy
13 106
18 106
Trivandrum screening chart 261
Trophic benefits 46
Tryptophan 43
Tuberous sclerosis 109
Tumor necrosis factor alpha 219, 224
Turner syndrome 109
Twin-to-twin transfusion 257
Tyrosine 43
Tyrosinemia 30, 149, 150
U
Umbilical arterial catheters 232
Umbilical catheterization 247
Umbilical venous catheter 5, 232
Upper extremities, passive tone in 259f
Urinary anion gap 205
Urinary tract infections 214
Urine
culture 219
output, low 13
Ursodeoxycholic acid 152
Uterine tenderness 215
V
Vascular endothelial growth factor 207
Vascular integrity, disorders of 156
Vascular resistance 130
Vasopressin 129
Vehicle, types of 237
Vena cava
inferior 127
superior 127, 128, 130, 132
Venipuncture 246
Venous thrombosis 169
Ventilated baby, bedside best practices for 78
Ventilation 69, 211, 231, 232
assist control 76
basic concepts 74
corrective steps 9, 9t
high frequency 80
in neonates, indications of high frequency 80
indications of 73
strategies 92
volume targeted 232
Ventilator settings, adjustment of 77
Ventilator-associated pneumonia 214
Ventilatory parameters 75
Ventricular septal defect 107, 114
Ventriculomegaly 260
decrease 190
Very low birth weight 217f, 250
babies 46t, 49, 50t, 51
infants, preterm 47t
Vesicoureteric junction 196
Visible tissue ridge 207
Vision 262
Vitamin 40, 43
A 152
supplementation 234
D 49, 152
E 152, 191
K 152
deficiency 156
supplementation 152
water-soluble 152
Vojta's neurokinesiologic method 259
von-Willebrand disease 157
W
Weaning and extubation 78
Weight gain 46
Weight measurement 230, 231
White blood cell 218
Williams's syndrome 106
Wiswell classification 63
Wolman disease 149
Wound treatment 247
X
Xanthine derivative 223
×
Chapter Notes

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Neonatal ResuscitationChapter 1

Koshy Marucoickal George,
Nirupama Laroia
 
INTRODUCTION
  • Of approximately 4 million neonatal deaths globally, 23% are accounted by birth asphyxia.
  • The outcome of thousands of newborns born each year can be improved by widespread use of resuscitation taught and practiced appropriately and systematically. Studies show that resuscitation training has significantly reduced neonatal and perinatal mortality and morbidity.
  • About 8–10% of the newborns require some assistance at birth and less than 1% need extensive resuscitative measures including chest compressions or emergency medications (Fig. 1).
  • It is difficult to predict requirement of assistance at birth; therefore, teams capable of performing neonatal resuscitation should be prepared to act promptly and efficiently in providing lifesaving interventions at every birth.
  • At the time of delivery, focus should be on providing interventions such as drying, keeping the baby warm, clearing the airway, stimulation to breathe, and providing positive pressure breaths. These simple interventions can save many babies.
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Fig. 1: Requirement of resuscitation.Source: Adapted from Wall SN, Lee AC, Niermeyer S, et al. Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynaecol Obstet. 2009;107:S47-62, S63-4.
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PATHOPHYSIOLOGY
  • Ventilation of the baby's lung is the most important and effective step in neonatal resuscitation. The most common cause for need of resuscitation is inability to breathe effectively at birth leading to inadequate gas exchange. This can result in respiratory failure before, during or after birth.
  • In utero, respiratory function is performed by the placenta. The placenta functions in transfer of oxygen from the mother to fetus and removal of CO2. In case placental diffusion fails, there is insufficient transfer of oxygen to fetus causing inability to support normal cellular functions and CO2 cannot be removed. Fetal monitoring may show a decrease in fetal activity, loss of heart rate (HR) variability, and HR decelerations.
  • Before birth only a small quantity of blood flows to the lungs because of the increased resistance to flow [increased pulmonary vascular resistance (PVR)] in the pulmonary vessels. There is no gas exchange in the lung and lung sacs are filled with fluid. Blood returning to the right side of the heart from the umbilical vein has the highest oxygen saturation.
  • After birth, baby breathes and the umbilical cord is clamped (loss of the placenta—low resistance circuit), systemic vascular resistance (SVR) increases, fluid in alveoli absorbed and replaced by air, blood vessels in lung relax (decreased PVR) with dramatic increased blood flow and reversal of shunt occurs through ductus arteriosus leading to increased left atrial pressure resulting in functional closure of foramen ovale.
  • If this transition does not happen smoothly then infant could present with irregular respiratory effort, tachypnea, respiratory depression with apnea, bradycardia, tachycardia, hypotonia, low oxygen saturation, persistent cyanosis, or hypotension.
 
PREPARING FOR RESUSCITATION
 
Resuscitation Team
  • Every birth should be attended by at least one individual trained in neonatal resuscitation.
  • In case of presence of any of the risk factors (Table 1), minimum two qualified persons should attend the resuscitation.
  • The number and qualifications of personnel will increase if higher risk such as an extremely premature birth or high likelihood for extensive resuscitation such as cord prolapse is present. Always identify need for additional help.
 
Behavioral Skills
Behavioral skills which are key to resuscitation include anticipated preparation, prebriefing, effective communication, assumed leadership role, delegation of roles, proper documentation, and identification of additional help and resources. The role of effective communication is extremely essential.
 
Four Prebirth Questions
  • At every delivery, following four prebirth questions should be asked to the obstetrics care provider:3
    Table 1   Risk factors that increase the likelihood for need of resuscitation.
    Antepartum risk factors
    GA <36 0/7 weeks or >41 0/7 weeks
    Polyhydramnios, oligohydramnios
    Preeclampsia, eclampsia, gestational hypertension
    Fetal macrosomia, prior history of shoulder dystocia
    Gestational diabetes
    Intrauterine growth restriction
    Multiple gestation
    Fetal malformations or anomalies
    Premature rupture of membranes
    Inadequate prenatal care
    Previous preterm delivery
    Maternal infections
    Previous neonatal/fetal deaths
    Maternal systemic diseases
    Bleeding in second or third trimester
    Maternal medications
    Placental abnormalities
    Lack of maternal steroids use for fetal lung maturation
    Fetal anemia
    Adrenergic agonists
    Isoimmunization
    Decreased fetal movements
    Hydrops
    Fetal heart tracing and duration
    Intrapartum risk factors
    Reason for emergency cesarean delivery
    Maternal blood loss
    Precipitous delivery
    Placental abruption
    Prolonged labor
    Placenta previa/percreta/accreta
    Instrument-assisted delivery
    Maternal abdominal trauma
    Breech or other abnormal presentations
    PROM >18 hrs
    Shoulder dystocia
    Chorioamnionitis
    Category II or III fetal heart rate pattern and duration
    Meconium staining of fluid
    Maternal general anesthesia
    Prolapsed cord
    Maternal narcotic administration
    Nuchal cord
    Maternal magnesium therapy
    Cord avulsion
    (GA: general anesthesia; PROM: premature rupture of membranes)
    1. Expected gestational age
    2. Amniotic fluid clear or not
    3. Number of babies expected
    4. Any other additional risk factors.
  • Importance of prenatal counseling in the presence of risk factors is also pertinent for improved resuscitation.
 
Delayed Cord Clamping
  • Current evidence suggests delayed cord clamping (DCC) for at least 30–60 seconds is beneficial for vigorous term and preterm newborns.
  • Delayed cord clamping is not performed in cases of maternal hemorrhage, placental abruption, bleeding placenta previa, bleeding vasa previa, uterine rupture, cord avulsion, 4severe intrauterine growth restriction (IUGR) with abnormal cord Doppler studies, suspected twin-to-twin transfusion, hydrops, severe chromosomal, or structural anomalies.
  • Benefits include improved transitional circulation hemoglobin levels, improved iron stores, decreased need for blood transfusions, lower incidence of necrotizing enterocolitis, intraventricular hemorrhage (IVH), and neurodevelopmental outcome.
 
INITIAL STEPS OF NEWBORN CARE
 
Evaluation at Birth (Neonatal Resuscitation Program Algorithm—Flowchart 1)
  • All neonates should have a prompt evaluation at birth on three questions to decide if they can stay with their mother for transition or moved under warmer for further assessment and initial steps.
    1. Does the baby appear to be term?
    2. Does the baby have good muscle tone?
    3. Is the baby breathing or crying?
  • If answer to all three is yes, then baby can transition to skin-to-skin care with the mother (routine care). If answer to any of the questions is NO, one should move the baby under radiant warmer and perform initial steps of resuscitation.
 
Initial Steps
  • Providing warmth: Place the baby under radiant warmer. For preterm infants <32 weeks, additional warming methods like thermal blanket, covering the head with a hat and placing a plastic wrap over the body without drying can be used. Maintaining the temperature between 36.5°C and 37.5°C in the delivery room is associated with better perinatal outcome.
  • Position the head and neck to open the airway: Slightly extend the head in sniffing position to open the airways and allow unrestricted air entry. One may place a small rolled towel under the baby's shoulder.
  • Clear airway (if necessary): Clear secretions, if baby is not breathing/gasping/has poor tone/secretions are obstructing the airways or when positive pressure ventilation (PPV) is anticipated. Suction only when visible secretions are present. Suction pressure should not exceed 80–100 mm Hg. Suction mouth before nose (remember M comes before N). Routine tracheal suction is no longer recommended for nonvigorous babies with meconium stained fluid.
  • Dry: The baby should be thoroughly dried to decrease evaporative heat loss and wet linen should be discarded. Preterm infants <32 weeks should be covered immediately in a polyethylene plastic to decrease heat loss.
  • Stimulate: The initial steps provided so far will frequently provide enough stimulation for the baby to breathe. If the newborn does not have adequate respiration, providing brief stimulation by gently rubbing of back, trunk or extremities will stimulate breathing. One should begin PPV immediately if the newborn remains apneic despite brief stimulation. Vigorous use of tactile stimulation in a baby, who is not breathing, wastes valuable time.
 
POSITIVE PRESSURE VENTILATION
The most important effective action in resuscitating a compromised newborn is assisted ventilation.5
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Flowchart 1: Neonatal Resuscitation Program (NRP) algorithm.
(CPAP: continuous positive airway pressure; ET: endotracheal tube; ETT: endotracheal intubation; HR: heart rate; IV: intravenous; LMA: laryngeal mask airway; PPV: positive pressure ventilation; UVC: umbilical venous catheter; ECG: electrocardiogram; AP: anterior posterior)
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Indication
  • After initial steps of resuscitation, if the baby is apneic or gasping or has HR <100 beats/min, PPV should be started.
  • Additional indication is if baby is breathing and has HR >100 beats/min but baby is not maintaining saturations in target range despite free flow oxygen or continuous positive airway pressure (CPAP).
Whenever indicated, it should be started within 1 minute of birth called the golden minute.
Pulse oximeter should be placed on right wrist (preductal). Probe is attached first to hand and then cable is attached to monitor for better signal acquisition.
 
Different Types of Positive Pressure Ventilation Devices (Figs. 2 to 4)
 
Self-inflating Bag
  • Unless squeezed, a self-inflating bag remains in a fully expanded state. It recoils and re-expands drawing fresh air on its release. When the bag is connected to a source of oxygen, it gets filled with the gas that depends on the supplied oxygen concentration. In case an oxygen source is not attached to the bag, it gets refilled by drawing room air (21% oxygen).
  • Because of its self-inflating nature, there is no need of compressed gas or a tight seal at the outlet to keep it inflated.
  • The rate of ventilation is decided by how frequently you squeeze the bag and the inspiratory time (IT) is determined by the duration of the squeeze. Peak inspiratory pressure (PIP) is controlled by how hard the bag is squeezed. Positive end expiratory pressure (PEEP) cannot be delivered unless an accessory PEEP valve is attached.
  • Because gas only flows out of the mask when the bag is being squeezed, a self-inflating bag cannot be used to administer CPAP or free-flow oxygen. It is possible to administer free-flow oxygen in some self-inflating bags through the open reservoir (“tail”) on them.
  • To limit the peak inflating pressure, there is a pressure-release valve, also called a pop-off valve in most self-inflating bags. The limiting pressure in these valves is usually set at 30–40 cm H2O pressure beyond which they are released.
    zoom view
    Fig. 2: Parts of self-inflating bag.
    Parts: Air inlet and attachment site for oxygen reservoir, oxygen inlet, patient outlet, valve assembly, oxygen reservoir, pressure-release pop-off valve, and pressure gauge.
    7
    zoom view
    Fig. 3: Parts of flow-inflating bag. (ET: endotracheal tube)
    Parts: Oxygen inlet from blender, patient outlet, flow control valve, and pressure gauge.
    zoom view
    Fig. 4: Parts of T-piece resuscitator.
    Parts: Gas inlet, patient outlet PIP (peak inspiratory pressure), control, PEEP (positive end expiratory pressure), cap, circuit pressure gauge reading, and maximum pressure relief.
    However, at times, they may not be very reliable and may not release until higher pressures are achieved. In some self-inflating bags, the pressure-release valve can be temporarily occluded, to allow higher pressures to be delivered.
  • It can be used even in the absence of compressed air or oxygen source.
 
Flow-inflating Bag
  • It requires source of compressed gas and gets inflated only when the gas is flowing into it and the outlet is sealed, such as when the mask is tightly applied to a baby's face. In the 8absence of a compressed gas source or improper seal, the bag will collapse and look like a deflated balloon. In case the bag fails to inflate or gets partially inflated, it indicates that the seal is not tight.
  • The ventilation rate will depend on how many times one squeezes the bag and how fast is the bag squeezed and released will determine the IT. PIP is controlled by how hard the bag is squeezed to ensure that the appropriate pressure is used. To measure the delivered PIP, one should use a manometer with a self-inflating or a flow-inflating bag.
  • Can be used to deliver 100% free-flow oxygen.
  • Positive end expiratory pressure is adjusted using a flow control valve adjustment.
  • Cannot be used outside the setting of delivery room as it fills only when compressed air flows into it.
  • Needs practice and the importance of a good seal is extremely important for use for this device.
 
T-piece Resuscitator
  • It is a mechanical device that uses valves to regulate the compressed gas flowing toward the patient. A compressed gas source is needed for this device.
  • A finger is used to alternately occlude and release an opening on the top of the T-piece cap to deliver a breath. On occlusion of the opening, gas flows through the device toward the baby and on releasing the opening, some gas will escape through the cap.
  • The ventilation rate will depend on how often the opening on the cap is occluded and how long the cap is occluded will decide the IT.
  • Peak inspiratory pressure during each assisted breath is limited by the inspiratory pressure control.
  • To prevent inadvertent delivery of PIP beyond predetermined preset value, the device has a maximum pressure relief control.
  • Inspiratory and expiratory pressure are measured by a built-in manometer. Hence PEEP and free-flow oxygen can be given and a predetermined consistent PIP can be provided to prevent over inflation.
  • Disadvantage of the device is that it cannot be used outside the delivery room setting.
 
Important Considerations during PPV
  • Indicators of successful PPV are rising HR, chest rise, bilateral breath sounds, and improvement in oxygen saturation.
  • Effective seal with the mask is one of the key elements missed. Mask should be applied on the face such that the pointed edge is over the nose and mask covers the mouth and nose and the tip of the chin rests within the rim of the mask. The thumb and the index fingers encircle the rim of the mask and the other three fingers are snugly placed under the bony angle of the jaw to gently lift the jaw upward toward the mask. When the correct position of the mask is ensured, one should apply even downward pressure on the rim of the mask to obtain an airtight seal with the head held in sniffing position. In a large baby, it may be difficult to achieve a correct head position and a good seal using one hand. In such a scenario, one can use both hands to hold the mask with the jaw thrust technique by gently lifting the jaw toward the mask.
  • Timing of PPV: Use the rhythm, “Breathe, two, three… Breathe, two, three…. breathe, two, three.” During PPV, 40 to 60 breaths per minute should be delivered. Count out loudly to help maintain the correct rate.9
Table 2   Ventilation corrective steps.
Corrective steps
Actions
M
Mask readjustment
Reapply mask to assure good seal, consider two-hand technique
R
Reposition airway
Head in sniffing position
Reattempt PPV and reassess chest movements
S
Suction
Suction mouth then nose, use bulb/suction catheter
O
Open mouth
Open mouth, lift jaw forward
Reattempt PPV and reassess chest movements
P
Pressure increase
Increase pressure in slow increments, maximum of 40 for adequate chest movements
Reattempt PPV and reassess chest movements
A
Alternate airway
Place an ET/LMA
Reattempt PPV and reassess chest movements
(ET: endotracheal tube; LMA: laryngeal mask airway; PPV: positive pressure ventilation)
  • Initial PIP settings of 20–25 cm H2O should be used. In some infants, this may need to be increased up to 30–40 cm H2O for opening up alveoli.
  • Initial PEEP should be set at 5 cm H2O.
  • FiO2 setting: 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 21–30% oxygen.
  • PPV is stopped: When HR is >100 beats/min and baby has sustained spontaneous breaths.
  • Ventilation corrective steps: When PPV is ineffective, one needs to take ventilation corrective steps (Table 2).
The assistant needs to tap out the HR and also say out if HR is improving or getting worse. HR is counted for 6 seconds and multiplied by 10 to give an approximate HR. After prolonged PPV, consider inserting an orogastric (OG) 8 F feeding tube and 20 mL syringe measured by the distance between bridge of the nose to the earlobe to the point midway between xiphoid and umbilicus.
 
CHEST COMPRESSION
  • Indications for chest compressions: When HR remains <60 beats/min despite 30 seconds of effective PPV.
  • Considerations during chest compressions:
    • Application of electrocardiogram (ECG) leads if available.
    • Intubation if not done so far.
    • Increase oxygen concentration to 100% FiO2.
    • Coordination with PPV.
    • Preparing for placement of umbilical venous (UV) line.
  • Methods of chest compression: There are two methods—(1) thumb technique and (2) two-finger technique. In thumb technique, two thumbs are used to depress the sternum while hands encircle the torso and finger supports the spine. This is the preferred technique as it is superior in generating peak systolic and coronal perfusion pressure. Two-finger technique where the tips of the middle and index fingers are used to compress the sternum 10perpendicularly. Pressure is applied to the lower third of the sternum and sternum is depressed to a depth of approximately one-third of antero-posterior (AP) chest diameter. The thumbs/tip of fingers should remain in contact with the chest during both compression and release.
  • Timing of chest compression: Coordinated by counting loud “one and two and three and breathe and...” Each 2-second cycle of events comprises three compressions and one ventilation in 2 seconds [a total of 120 events—90 compression and 30 breaths (3:1) in 60 seconds; Ratio of 3:1]. Wait for 45–60 seconds and then assess HR again.
  • Indications to stop chest compression: If HR is ≥60 beats/min, stop chest compressions and continue PPV with 40–60 breaths per minute.
 
INTUBATION
  • Indication for intubation: Endotracheal intubation is considered when PPV with face mask is not resulting in clinical improvement or lasts more than few minutes, when chest compressions are needed and for reliable airway access in special situations such as need for surfactant, suspected congenital diaphragmatic hernia (CDH) or direct tracheal suction if the airway is obstructed with thick secretions.
  • Intubation procedure: Determine size of endotracheal tube (ET), position the baby in sniffing position, ask for neck roll if needed, check light of the laryngoscope, hold the laryngoscope with left hand, use the stylet in tube if needed, insert tube to length of weight in kilograms + 6 or nasal-tragus length + 1, request/apply cricoid pressure if needed, and pass the tube into glottis beyond the markings on the tube. Stabilize ET tube against the hard palate and tape the tube.
  • Time to intubate: Not more than 30 seconds for each trial.
  • Assessment of successful intratracheal intubation: The operator watches tube pass through cords, symmetric adequate chest rise, bilateral breath sounds, increasing HR and improving saturations, mist in tube, change in colorimetric CO2 detector from purple to yellow, and decreased or absent breath sounds over the stomach. Confirm with chest X-ray, if available, checking also for tube position and pneumothorax. Babies with poor cardiac output and extremely low birth weight (ELBW) babies may take time to show reliable color change. If epinephrine is given through ET tube it could falsely turn the color yellow.
  • Laryngeal mask airway (LMA): May be used if PPV is ineffective and intubation is not feasible. Other indications include congenital anomalies involving mouth, lip, palate, tongue, neck, jaw, Pierre Robin sequence, and trisomy 21. Use size 1 for neonates. For insertion of LMA, position baby in sniffing, hold device like a pen and advance with the opening facing away from the operator. Inflate with 2–4 mL of air (Fig. 5).
 
MEDICATION
 
Epinephrine
  • Indication: When HR is <60 beats/min after 30 seconds of effective ventilation and another 60 seconds of coordinated chest compression and effective ventilation.
  • Dose: Epinephrine 1:10,000 solution 0.1–0.3 mL/kg IV (given rapidly followed by a flush of 0.5–1 mL normal saline) and 0.5–1 mL/kg endotracheally.11
    zoom view
    Fig. 5: Insertion of laryngeal mask airway.
    After epinephrine check HR in 1 minute and continue chest compressions and PPV with 100% oxygen. If HR is still less than 60 beats/min, repeat the dose of epinephrine every 3–5 minutes.
  • Volume expanders: Volume expanders are indicated if the baby is not responding to the steps of resuscitation and has signs of shock or a history of acute blood loss. The recommended solution for treating hypovolemia is 0.9% NaCl (10 mL/kg normal saline). In case of severe fetal anemia one can use type-O Rh-negative blood (10 mL/kg). This can be given over 5–10 minutes and pausing to give the epinephrine flushes as needed if chest compressions are being done. Ringer's lactate is no longer recommended for treating hypovolemia.
 
SPECIAL SITUATIONS
If HR <60 beats/min in spite of effective ventilation, consider hypotension, pneumothorax, and other structural reasons like airway malformation, hydrops, abdominal ascites, CDH, pulmonary hypoplasia, chromosomal defects, metabolic acidosis, hypoxic-ischemic encephalopathy (HIE) or congenital heart disease (CHD).
  • In prenatally diagnosed CDH, minimize face mask ventilation, perform early planned intubation, and use OG tube for gastric decompression.
  • For pneumothorax/chylothorax/pleural effusion needle decompression at bedside if needed.
  • For pulmonary hypoplasia and hydrops, higher PIPs need to be considered for adequate chest movement.
  • For extreme prematurity, use of plastic bags, warm mattresses, and surfactant should be considered.12
 
AFTER RESUSCITATION
  • At the end of each resuscitation, it is important to debrief. Discuss briefly what went well during the resuscitation, was the leader effective and delegated tasks well, and was there good communication and team work, what was not done well, what could have been done better to improve. The goal is not to assign blame but to improve the process.
  • Reasons to stop resuscitation: Resuscitation may be discontinued after 10 minutes of asystole, after maximal resuscitation effort.
SELF ASSESSMENT
1. Baby is born limp and apneic. You place her under radiant warmer, position her airway, remove secretions, dry and stimulate her. If she remains still apneic, next step is to:
  1. Provide positive pressure ventilation
  2. Provide free-flow oxygen
  3. Consider CPAP
2. What should be size of endotracheal tube for a baby weighing <1,000 g?
  1. 2.0 mm
  2. 2.5 mm
  3. 3.0 mm
  4. 3.5 mm
3. Ratio of chest compression to ventilation is:
  1. 1:3
  2. 3:1
  3. 5:2
  4. 2:5
4. Which of the following devices provide PEEP during resuscitation (more than one may be true)?
  1. Self-inflating bag
  2. T-piece resuscitator
  3. Flow-inflating bag