Newborn Resuscitation

Aka: Newborn Resuscitation, Neonatal Advanced Life Support, Resuscitation of the Newborn, Advanced Life Support for Newborns, NALS, NRP

1. See Also
   1. Neonatal Distress Causes
   2. Neonatal Respiratory Distress
   3. Newborn History
   4. Newborn Exam
   5. Neonatal Airway Assessment
   6. Neonatal Breathing Assessment
   7. Neonatal Circulation Assessment
   8. Neonatal Perfusion Assessment
   9. Pediatric Resuscitation
2. Epidemiology
   1. Five million neonatal deaths per year worldwide
      1. Birth Asphyxia accounts for 19% of neonatal deaths
   2. Newborns in United States: 4 million births per year
      1. Newborns requiring respiratory assistance at birth: 10%
      2. Newborns requiring extensive Resuscitation at birth: 1%
      3. Newborns developing severe hypoxic-ischemic encephalopathy: 0.2%
         1. Mortality ranges between 6-30%
         2. Cerebral Palsy and other long-term disabilities in survivors: 20-30%
   3. Early Resuscitation is key (intervene at primary apnea)
      1. Primary apnea (initial) responds to simple measures
         1. See Neonatal Airway Assessment
      2. Secondary apnea requires PPV and other interventions
         1. Does not respond to continued stimulation
         2. Associated with prolonged Resuscitation
         3. Associated with poorer outcomes
         4. Associated with decreased Heart Rate and BP
3. Physiology: Transition from fetal circulation at birth
   1. Alveolar fluid is absorbed by lung
   2. Umbilical vessels are clamped
      1. Increases systemic Blood Pressure
   3. Pulmonary circulation increases
      1. Pulmonary vessel vasodilation
      2. Ductus arteriosus Vasoconstriction
4. Protocol
   1. Prepare equipment and providers before delivery (see prevention below)
   2. Initial questions to consider
      1. See Newborn History
      2. Is the newborn clear of meconium?
      3. Is the newborn breathing or crying?
      4. Does the newborn have good muscle tone?
      5. Is the skin pink centrally?
      6. Is this baby consistent with term gestation?
   3. Consider Neonatal Distress Causes
   4. Step by step assessment (timer started at delivery)
      1. Neonatal Airway Assessment
         1. Includes general measures performed for all infants
         2. Includes warming, suctioning, drying, stimulation
         3. Endotracheal suctioning if thick meconium AND only if non-vigorous infant
      2. Neonatal Breathing Assessment
         1. Positive Pressure Ventilation (PPV) for apnea, gasping or Heart Rate <100/min
            1. Rate of 40-60/min for 30 sec
            2. Peak inspiratory pressure (PIP) started at 20-25cm H2O (may require 30-40 cm H2O)
         2. Apply O2 Sat monitor if PPV needed
         3. Endotracheal Tube intubation or laryngeal mask airway (LMA) if PPV for >2-3 minutes (confirm wirh etCO2)
      3. Neonatal Circulation Assessment
         1. Positive Pressure Ventilation for continued Heart Rate <100/min or apnea
         2. Chest Compressions for Heart Rate <60/min after 30 seconds of PPV
            1. Rate - 3:1 compressions to breaths
            2. Reassess 45-60 seconds after starting compressions
         3. Epinephrine for persistent Heart Rate <60/min after 60 seconds of compressions (and 90 seconds of PPV)
            1. Umbilical Venous Catheter: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine
            2. Endotracheal Tube: 0.05 to 0.10 mg/kg (0.5 to 1 ml/kg) of 1:10,000 Epinephrine
      4. Neonatal Perfusion Assessment
         1. Central Cyanosis: Free flow Oxygen starting at 21% or blended and titrating up
         2. Blood loss suspected: Normal Saline 10 cc/kg bolus (consider pRBC when available)
      5. Post-Resuscitation after extensive efforts for severe event
         1. Intravenous Dextrose infusion (prevent Hypoglycemia)
         2. Developing severe hypoxic-ischemic encephalopathy in newborns >36 weeks
            1. Offer Therapeutic Hypothermia protocol (started within 6 hours of event at NICU)
5. Management: Indications to Discontinue Resuscitation Efforts
   1. No detectable Heart Rate after 10 minutes of full Resuscitation efforts
   2. Lethal anomalies (Informed consent with parents if withholding care)
      1. Very premature (gestational age <23 weeks or weight <400 grams)
      2. Anencephaly
      3. Trisomy 13 Syndrome
6. Prevention
   1. Prepare for complicated deliveries
      1. NRP-certified Resuscitation team available at all times
      2. NRP-certified physician present for high-risk deliveries
   2. Hospital delivery rooms stocked with adequate equipment
      1. Pulse oximeter
      2. Fully working warmer
      3. Oxygen supply with air oxygen blender
      4. Suction device
      5. Positive Pressure Ventilation device (e.g. Anesthesia Bag, ambu-bag, T-piece device)
      6. Endotracheal Tubes, laryngeal mask airway, working laryngoscope, CO2 Detection device
      7. Resuscitation medications (e.g. Epinephrine, normal saline)
7. Precautions: Major changes in neonatal Resuscitation as of 2010
   1. Perineal suctioning for meconium is no longer recommended
   2. Do not endotracheal suction vigorous infants despite thick meconium presence
   3. Monitor Resuscitation efforts with pulse oximetry
   4. End Tidal CO2 (etCO2) detector or monitor to confirm proper Endotracheal Tube placement
   5. Laryngeal mask airway (LMA) size 1 may be used instead of ET for ventilation in infants >2kg or >34 weeks gestation
   6. Naloxone and Sodium Bicarbonate are no longer recommended in newboen Resuscitation
   7. Consider Therapeutic Hypothermia protocol in newborns >36 weeks with developing severe hypoxic-ischemic encephalopathy
8. Preparations: Medications no longer recommended in Newborn Resuscitation (listed for completeness)
   1. Sodium Bicarbonate (Use only 4.2% solution)
      1. Not recommended as worse outcomes with use
      2. Primary treatment of acidosis is by maximizing ventilation, not with bicarbonate
      3. Dose: 4 ml/kg (2 meq/kg of 4.2%) very slowly via large vessel (Umbilical Vein Catheter)
   2. Naloxone
      1. Not recommended as of 2010 as no evidence for improved outcomes with use
      2. Primary treatment of apnea is with Positive Pressure Ventilation
      3. Dose: 0.1 mg/kg of 1.0 mg/ml IV, ET, IM or SQ
      4. Indications (old)
         1. Respiratory depression despite PPV (with normal Heart Rate and color)
         2. Maternal Narcotic Analgesics within 4 hours
9. References
   1. (1995) World Health Report, WHO
   2. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA
   3. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA
   4. Raghuveer (2011) Am Fam Physician 83(8): 911-8