Critical ConceptsNICU

Brian M. Barkemeyer, MD

LSUHSC Division of Neonatology

2011-12

At birth

• 100% of infants need someone present dedicated to the infant and capable of initial steps in neonatal resuscitation

• 10% of infants require some level of resuscitation at birth

• 1% of infants require major resuscitation

“Golden hour”

• At no other time in one’s life will necessary critical concepts in resuscitation have a potential lifelong impact– Appropriate interventions (or the lack thereof) can

make the difference between life or death, or normal life vs. life of disability

Preparation

• NRP - Neonatal Resuscitation Program– Evidence-based, standardized program jointly

sponsored by American Academy of Pediatrics and American Heart Association

• Proper equipment

• Knowledge– In most cases, the need for neonatal

resuscitation is predictable

– But not always!

Risk Factors Predictive ofNeed for Neonatal Resuscitation

• Maternal illness– Hypertension– Diabetes– Infection

• Prematurity• Post-maturity• Multiple gestation• Maternal bleeding• Maternal drug abuse• No prenatal care

• Fetal distress• Abnormal fetal position• Abnormal labor• Fetal anomalies• Macrosomia• IUGR• Placental abnormalities• Meconium-stained

amniotic fluid

Transition toExtrauterine Life

• Fluid-filled alveoli to air-filled alveoli

• Circulatory changes– Decreased pulmonary vascular resistance resulting

in increased pulmonary blood flow and cessation of flow through foramen ovale and ductus arteriosus

– Cessation of flow to placenta resulting in increased systemic vascular resistance

Lack of Appropriate Resuscitation

• Interrupts normal transition to extrauterine life

• Hypoxia

• Respiratory and metabolic acidosis

• Ischemia

• Potential for death or long term adverse outcome

Three Basic Questions

• Term infant?

• Breathing/crying at birth?

• Normal tone at birth?

• If the answer to these three questions is yes, infant doesn’t need resuscitation, but does deserve initial steps

Initial Steps

• Drying

• Warming

• Stimulation

• Positioning

• Clear airway

• Necessary for all newborns!

Warming

• Appropriate room temperature• Rapid drying to avoid evaporative heat loss• Remove wet towels• Mother – skin to skin• Radiant heat warmer• Blankets, cap

• Premature infants and IUGR infants at highest risk for hypothermia

Establishment of the Airway

• Suction mouth then nose (“M before N”)

• Shoulder roll to aid in positioning

• Head positioned in slight extension, or “sniffing position”– Not too extended

– Not too flexed

ABC’s

• Airway– Suction secretions, assess for anomalies

• Breathing– Stimulate respiratory effort

• Tactile

• Bag-mask positive pressure ventilation (PPV)

• Circulation– Assess heart rate

• Chest compressions if PPV ineffective at restoring heart rate

Skills to Learn

• Neonatal assessment

• Use of bulb suction

• Administration of positive pressure ventilation by bag-mask

• Intubation and assistance with intubation

• Chest compressions

Assessment/Reassessment:Sequential steps in resuscitation

• Initial steps [30 seconds]

• PPV [30 seconds]

• Chest compressions [30 seconds]

• Medications [30 seconds]

Neonatal Assessment

• Respirations– Normal rate and depth, good chest movement

• Heart rate– Normal > 100

– Count for 6 seconds, multiply x 10

• Color– Pink lips and trunk

– Acrocyanosis vs. central cyanosis

Indications for PPV

• If after initial steps in resuscitation [30 sec], assessment reveals– Apnea

– Gasping respirations

– Heart rate < 100

Indications for Chest Compressions

• If after initial steps in resuscitation [30 sec] and effective PPV [30 sec], assessment reveals– Heart rate < 60

Indications for Epinephrine

• Heart rate persists < 60 after– Initial steps [30 seconds]

– PPV [30 seconds]

– Chest compressions [30 seconds]

• Dosage given IV (UVC preferred), or endotracheal (higher dose given)

Indications for Volume Administration

• History of blood loss at delivery suggesting hypovolemia

AND

• Infant appears to be in shock (pallor, poor perfusion, failure to respond appropriately to resuscitation efforts)

• IV, 10-20 mL/kg, Normal saline, Ringer’s lactate, or O-blood

Meconium-stained Amniotic Fluid

• 15% of deliveries; at risk for meconium aspiration syndrome

• Suctioning of upper airway and trachea in infants who are not vigorous may help prevent meconium aspiration syndrome– Vigorous defined by

• Heart rate > 100

• Normal respiratory effort

• Normal tone

Positive Pressure Ventilation

• Appropriate size mask and bag• Self-inflating vs. flow-inflating bag• Forming a good seal with mask• Achieve adequate chest rise• 40-60 breaths per minute

• When done appropriately, PPV should result in improvement in heart rate and color

Ineffective PPV

• Reposition mask on face

• Reposition head

• Suction upper airway

• Ventilate with mouth open

• Increase ventilatory pressure

• Replace bag

• Endotracheal intubation

Self-inflating bag

Flow-inflating bag

Chest Compressions

• Should be coordinated with PPV

• 2 thumb method preferred

• Compression of sternum 1/3 depth of AP diameter of chest

• 120 events per minute (compressions and respirations combined)

• “One and two and three and breathe”

Chest Compressions

Endotracheal Intubation

• ET tube size similar to size of patient’s little finger

• < 28 wks, < 1000 g = 2.5 ETT

• 28-34 wks, 1000-2000 g = 3.0 ETT

• 34-38 wks, 2000-3000 g = 3.5 ETT

• 38-42 wks, > 3000 g = 4.0 ETT

• Insertion depth– “Tip to lip” measurement = weight in kg plus 6

• 2 kg patient should have ETT secure at 8 cm mark at lip

Endotracheal Intubation

Unique Aspects of Endotracheal Intubation in Infants

• Narrowest part of airway is subglottic area

• Uncuffed ET tubes typically utilized

• Increased airway resistance associated with more narrow airway diameter

• Relative lack of structural support for neonatal airway

Unique Anatomic Challenges

• Choanal atresia– Endotracheal intubation may be required

• Pierre-Robin sequence– Prone positioning

– NG tube into posterior pharynx

• Congenital diaphragmatic hernia– Endotracheal intubation

– Gastric decompression

Key Points

• Appropriate resuscitation requires a rapid series of assessments, interventions, and reassessments

• All infants deserve basic steps of resuscitation– Drying, warming, positioning, clear airway

• Prompt initiation of respiratory support with positive pressure ventilation by bag-mask is the key to successful resuscitation of most infants