Newborn Resuscitation

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

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II. 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. Anticipate Neonatal Distress based on Neonatal Distress Risk Factors
    2. Primary apnea (initial) responds to simple measures
      1. See Neonatal Airway Assessment
      2. See Neonatal Breathing Assessment
    3. 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

III. Physiology: Transition from Fetal Circulation at birth

  1. See Fetal Circulation
  2. Alveolar fluid is absorbed by lung
  3. Umbilical vessels are clamped
    1. Increases systemic Blood Pressure
  4. Pulmonary circulation increases
    1. Pulmonary vessel vasodilation
    2. Ductus arteriosus Vasoconstriction

IV. Protocol

  1. Prepare equipment and providers before delivery (see prevention below)
  2. Initial evaluation
    1. Core questions to determine if Resuscitation is indicated
      1. Is this baby consistent with term gestation?
      2. Is the newborn breathing or crying?
      3. Does the newborn have good Muscle tone?
    2. Other questions
      1. See Newborn History
      2. Is the newborn clear of meconium?
      3. Is the skin pink centrally?
    3. When Resuscitation is not needed (good tone and respirations)
      1. Infant may be handed off to mother
  3. Consider Neonatal Distress Causes
    1. See THE MISFITS Mnemonic
    2. Fever (or Hypothermia)
      1. Associated with serious Bacterial Infection in 10% of age <2 weeks and 5% of age 2-4 weeks
      2. See Neonatal Sepsis for evaluation and management
    3. Congenital Heart Disease is most likely in a hemodynamically unstable infant with normal Temperature
      1. See Congenital Heart Disease for evaluation and management
      2. Obtain early Echocardiogram
      3. Distinguish ductal dependent pulmonary Blood Flow from ductal dependent systemic Blood Flow
    4. References
      1. Sloas, Checchia and Orman in Majoewsky (2013) EM: Rap 13(9): 8
  4. Step by step assessment (timer started at delivery)
    1. Precautions
      1. Only two markers guide Resuscitation
        1. Respiratory status and Heart Rate
      2. Only two medications are used in Neonatal Resuscitation
        1. Epinephrine and volume expanders (NS, Blood)
      3. Ventilations are the single most important measure in Neonatal Resuscitation
        1. Initiate Positive Pressure Ventilations (PPV) promptly within 30 seconds (if indicated)
        2. Coordinate PPV and compressions to ensure adequate ventilation until Advanced Airway placed
    2. Perineum management
      1. Perineal suction (peripartum suction) is no longer recommended
      2. Delay cord clamp for 30-60 seconds in newborn not requiring Resuscitation (term, good tone, breathing)
    3. Neonatal Airway Assessment
      1. Includes general measures performed for all infants
      2. Includes warming, suctioning, drying, stimulation
      3. Endotracheal suctioning is no longer recommended for thick meconium
        1. Regardless of whether infant is vigorous
        2. However, intubation may be needed as part of general Resuscitation
    4. Neonatal Breathing Assessment
      1. Positive Pressure Ventilation (PPV)
        1. Indicated at 30 second mark for apnea, gasping or Heart Rate <100/min
        2. Rate of 40-60/min for 30 seconds (one-and-two-and-three-and-breath)
        3. Peak inspiratory pressure (PIP) started at 20-25cm H2O (may require 30-40 cm H2O)
        4. Initial FIO2 set at 21% (room air) for term and 21-30% for Preterm Infants
        5. Consider reasons if inadequate Positive Pressure Ventilation (Mnemonic: MR SOPA)
          1. Mask adjustment, Reposition
          2. Suction, Open mouth, PPV, Alternate airways
          3. Consider Pneumothorax
      2. Apply O2 Sat monitor if PPV needed
        1. Apply Oxygen Saturation monitor preductally (e.g. right palm or wrist)
        2. See Oxygen Saturation for normal levels for newborns
        3. Oxygen Saturation is normally 60-65% in the first minute of life (and increases 5% every minute)
        4. Oxygen Saturation does not normally increase to >85% until after 10 minutes of life
      3. Endotracheal Tube intubation or Laryngeal Mask Airway (LMA) if PPV for >2-3 minutes (confirm with etCO2)
        1. Cuff inflation pressure: term <30 cm H2O and preterm <20-25 cm
        2. PEEP 5 cm H2O
      4. Consider CPAP for moderate respiratory support
    5. Neonatal Circulation Assessment
      1. Measure Heart Rate with three lead ekg
        1. Palpation of Umbilicus and chest auscultation are no longer considered reliable (2015 guidelines)
        2. Place an infant needing Resuscitation on monitor as soon as possible
      2. Positive Pressure Ventilation for continued Heart Rate <100/min or apnea
      3. Chest Compressions
        1. Indicated at 60 second mark for Heart Rate <60/min after 30 seconds of PPV
        2. Two thumb wrap-around technique is preferred for Chest Compressions
        3. Rate of 3:1 compressions to breaths (90 compressions and 30 breaths per minute)
          1. Count "one-and-two-and-three-and-breath" with one event every 0.5 seconds
          2. Unless cardiac etiology is suspected and then change to 15:2 compressions to breaths
        4. Reassess 45-60 seconds after starting compressions
      4. Obtain Umbilical Vein Catheter
        1. Insert 5 F umbilical catheter to 4-5 cm or until blood returns
          1. Use sterile technique (Betadine stump and fresh cut)
      5. Epinephrine
        1. Indicated at 2 min for Heart Rate <60/min after 60 sec of compressions (and 90 seconds of PPV)
        2. Umbilical Venous Catheter: 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg) of 1:10,000 Epinephrine
        3. Endotracheal Tube: 0.05 to 0.10 mg/kg (0.5 to 1 ml/kg) of 1:10,000 Epinephrine
    6. Neonatal Perfusion Assessment
      1. Keep infant warm (36.5 to 37.5 Celcius)
        1. Skin to skin with mother
        2. Radiant warmer
      2. Central Cyanosis
        1. Initial FIO2 set at 21% (room air) for term and 30% for Preterm Infants
          1. Increase to 100% FIO2 if performing Chest Compressions
        2. Oxygen free flow starting at 21% or blended and titrate up as needed
          1. Higher mortality with 100% FIO2 than 21% FIO2 (NNH 22)
          2. https://costr.ilcor.org/document/initial-oxygen-concentration-for-term-neonatal-resuscitation
      3. Blood loss suspected
        1. Normal Saline 10 cc/kg bolus
        2. Transition to pRBC when available (if indicated)
    7. Post-Resuscitation after extensive efforts for severe event
      1. Intravenous Dextrose infusion (prevent Hypoglycemia)
        1. Indicated after core Resuscitation
        2. Maintenance with D10W at 80 ml/kg/day (3.3 ml/kg/hour)
        3. If hypoglycemic (Serum Glucose <35-45 mg/dl)
          1. Give 2 cc/kg D10W
      2. Developing severe hypoxic-ischemic encephalopathy in newborns >36 weeks
        1. Offer Therapeutic Hypothermia protocol (started within 6 hours of event at NICU)
        2. Prevent fever
      3. Portable Chest XRay
        1. Evaluate for Pneumothorax

V. Prevention

  1. Prepare for complicated deliveries
    1. Review Neonatal Distress Risk Factors and anticipate Neonatal Distress
    2. NRP-certified Resuscitation team available at all times
    3. NRP-certified provider present for high-risk deliveries
  2. Hospital delivery rooms stocked with adequate equipment
    1. Pulse Oximeter and skin Temperature probe
    2. Cord clamp and scissors
    3. Infant stethoscope
    4. Fully working warmer, blankets, hat
    5. Oxygen supply with air oxygen blender, masks
    6. Suction devices (bulb suction, suction catheters 5F to 10F)
    7. Positive Pressure Ventilation device 500cc (e.g. Anesthesia Bag, ambu-bag) with newborn and premature masks
    8. Endotracheal Tubes (2.5 to 4.0), Laryngeal Mask Airway, working Laryngoscope (0-1 Straight), CO2 Detection device, tape
    9. Resuscitation medications (e.g. Epinephrine 1:10,000, Normal Saline, D10W)
    10. Umbilical Vein Catheter equipment (3.5, 5.0 F catheter, scapel, Betadine, forceps, saline flush, umbilical tie)

VI. Precautions: Major changes in Neonatal Resuscitation

  1. As of 2015
    1. Do not endotracheal suction infants regardless of thick meconium or non-vigorous infant
    2. Delay cord clamping for 30-60 sec in term infants, with normal tone and breathing, not needing Resuscitation
    3. Prevent Hypothermia and keep infant Temperature 36.5 to 37.5 (monitor with Temperature sticker over liver)
    4. Monitor Heart Rate with 3 lead ekg (cord palpation and auscultation are considered unreliable)
    5. Resuscitate with FIO2 21% in term infants and 21-30% in Preterm Infants
      1. Higher mortality with 100% FIO2 than 21% FIO2 (NNH 22)
  2. As of 2010
    1. Perineal suctioning for meconium is no longer recommended
    2. Monitor Resuscitation efforts with Pulse Oximetry (but do not expect O2 Sat >85% until after 10 min of life)
    3. End Tidal CO2 (etCO2) detector or monitor to confirm proper Endotracheal Tube placement
    4. Laryngeal Mask Airway (LMA) size 1 may be used instead of ET for ventilation in infants >2kg or >34 weeks gestation
    5. Naloxone and Sodium Bicarbonate are no longer recommended in Newborn Resuscitation

VII. Management: Indications to Discontinue Resuscitation Efforts

  1. Lethal anomalies (Informed Consent with parents if withholding care)
    1. Very premature (Gestational age <22 weeks, NO weight cutoff - previously cited as <400 grams)
    2. Anencephaly
    3. Trisomy 13 Syndrome
  2. No detectable Heart Rate (Asystole) with APGAR Score of 0 after 10 minutes of full Resuscitation efforts
    1. No longer limited to 10 minutes (10 minute mark has been extended to 20 minutes)
    2. Survival to discharge >50% for >32 week infants
    3. Zhong (2019) Resuscitation 143:77-84 +PMID: 31421194 [PubMed]

VIII. Management: Therapeutic Hypothermia Protocol

  1. Indications
    1. Gestational age >36 weeks AND
    2. High risk of severe hypoxic-ischemic encephalopathy
      1. pH <7 (or pH <7.15 if follows acute perinatal event)
      2. Base Deficit >16 mmol/L (or >10 mmol/L if follows acute perinatal event)
      3. APGAR Score <5
      4. Encephalopathy or Seizures
  2. Protocol
    1. Start within 6 hours of birth
    2. Initiated for 72 hours and then gradual rewarming over 4 hours
    3. Consult with accepting neonatologist
    4. Goal Temperature: 92.3 to 94.1 F (33.5 to 34.5 C)
      1. Turn off the warmer and remove all blankets, hats
  3. References
    1. Olsen (2013) Pediatrics 131(2): e591-603 [PubMed]

IX. 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 Opioid Analgesics within 4 hours
    5. Adverse effects
      1. Opioid Withdrawal in newborn if mother was on Chronic Opioids (use or abuse)

X. References

  1. (2016) CALS Manual, 14th ed, p. I-199-211
  2. (1995) World Health Report, WHO
  3. Bhalla (2014) Crit Dec Emerg Med 28(1): 2-11
  4. Claudius in Herbert (2021) EM:Rap 21(5): 18-20
  5. Claudius, Behar, Nichols in Herbert (2015) EM:Rap 15(1): 3-4
  6. Spangler, Claudius, Behar and Nicholas in Herbert (2016) EM:Rap 16(9): 11-3
  7. Kattwinkel (2000) Neonatal Resuscitation, AAP-AHA
  8. Kattwinkel (2010) Neonatal Resuscitation, AAP-AHA
  9. (2015) Pediatrics 136(suppl 2): 196-218 +PMID:26473001 [PubMed]
  10. Raghuveer (2011) Am Fam Physician 83(8): 911-8 [PubMed]

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