Newborn resuscitation

Use this note for immediate after-delivery resuscitation; see neonatal resuscitation for the non-delivery related resuscitation of the newborn.

Background

Newborn Vital Signs

• HR RR SBP^
• >100 40-80 60-70

^<3kg (premature) SBP = 40-60

Differential Diagnosis

Common Newborn Problems

• Hypoxia
  • Primary apnea
  • Secondary apnea
• Hypothermia
• Hypoglycemia
• Meconium aspiration

Diagnosis

Assessment Triad

• Respiration- adequacy, difficulty
• HR >100, umbilical
• Color

Treatment

Resucitation Inverse Pyramid

1. Dry, warm, position, suction, stimulate
   • position: neutral (towel --> thorax)
   • suction: oral then nasal
   • stim: along spine or feet
   • check glucose^
2. Oxygen (use liberally)
3. Ventilate (40-60 breaths/min @ 20-25 cmH20)
   • BVM (indications)
     • Apnea/gasping
     • HR <100/min
     • Persistent cyanosis
   • ET^^ (indications); ETT size = Gest age (wks) / 10
     • BVM ineffect after 30s
     • Suction meconium**
4. Chest compressions (indications)
   • HR <60 after above x 30 sec
     • 120/min (resp 3:1)
     • Stop when HR > 60
5. Medications^^^^
   • Epi (0.01-0.03 mg/kg)
   • D10W (4 mL/kg = 0.2gm/kg)
   • Nalaxone (0.4 mg/kg)
     • For opiod use <4hrs
   • NS (10 mL/kg boluses)
   • Dopamine drip
     • (5-20 mcg/kg/min)
   • NaHCO3 - prolonged resus
     • (1-2 meQ/kg)

^Hypoglycemia (give D10W)

• >2.5 kg = <40 mg/dL
• <2.5 kg = <30 mg/dL

^^Meconium Suctioning Indications

• Meconium + -->
  • absent/depressed resp
  • poor muscle tone
  • HR <100

(2 passes w/ ET + suction)

^^^Newborn Vent Settings

Pressure Cycled: RR 30+, PIP 20/2 (Preemie 15/2)

Preemie (<23-24 wks or 500 gms)

• rapid volume may inc risk of IVH
• usually ETT immed

Equipment

• blankets, warmer, umbilical clamps
• Bulb suction or wall suction
• Catheters (5F,8F,10F)
• Meconium aspirators
• BVM
• ETT 2.5-4.0 w/ stylets
• Blades 0 & 1
• IV catheters (22 & 24 g)
• Umbilical caths (3.5 F & 5F)
• syringes, 3 way stop cocks
• Epi 1:10,000
• Naloxone 0.4 mg/ml or 1 mg/ml
• NaHCO3 4.2% or 8.4%
• NS & D10W

See Also

• Neonatal Resuscitation
• PALS (Main)
• Umbilical Vein Catheterization
• Transient tachypnea of the newborn
• Emergent delivery

Principles of Resuscitation

Thermal Regulation

• Place newborn in neutral thermal environment even before initiate ABCs
• Gently dry newborn with warm towel

Airway

• Optimize
  • Position head in sniffing position
  • Suction nose and mouth
• Intubate
  • Indicated if pt is poorly responsive or fails BVM
  • If have time precut ET tube at 13cm mark
  • Lip placement = 6 + wt (kg)
  • After intubation suction trachea to prevent aspiration (if +meconium)

Tube Size / age / wt	Blade	Suction Catheter
2.5 / <28 / <1000	Miller 0	5F or 6F
3.0 / 28-34 / 1000-2000	Miller 0	6F or 8F
3.5 / 34-38 / 2000-3000	Miller 0	8F
3.5-4.0 />38 / >3000	Miller 0-1	8F or 10F

Breathing

• Apneic and/or bradycardic (<100 bpm)
  • Attempt tactile stimulation first
  • If unsuccessful perform BMV at 40-60 breaths/min
  • After intubation use:
    • Inflation pressure ~ 20

Circulation

• CPR
  • Begin if despite assisted ventilation x30s HR still <60
  • 3 compressions:1 breath (total 90 compresions:30 breaths per min)

Vascular Access

• Umbilical vein is site of choice

Volume Expansion

• NS 10-20mL/kg IV over 5-10min
• O Rh-negative blood

Medications

• Epinephrine
  • Indicated for aystole or HR < 60 despite CPR >30s
  • 0.01-0.03mg/kg IVP q3-5min
• Sodium Bicarbonate
  • Helps to counteract negative inotropy/pulm HTN caused by acidosis
  • Only give once adequate ventilation is established
  • 1-2 mEq/kg of 4.2% solution (2-4 mL/kg)
• Naloxone
  • Give if persistent resp depression AND maternal narcotics w/in 4hr
  • 0.1mg/kg IV

Special Problems

Cyanosis

• Must distinguish between central and peripheral
• Consider prostaglandin E1 0.05-0.1 mcg/kg/min for cyanotic heart dz

Pneumothorax

• Tension PTX is highly related to subsequent ICH
  • Place 18-20ga catheter into 4th IC in ant axillarly line

Hypoglycemia

• <30-35 in preterm newborn
• <35-40 in term newborn
• Treatment
  • D10W 2mL/kg IV

Congenital Diaphragmatic Hernia

• Persistent respiratory distress w/ "seesaw" pattern
• Treat via immediate intubation, OG tube placement
  • Use lowest peak insp presure that allows for adequate chest rise

Withholding Resuscitation

• Consider if:
  • <22wk or <400g
  • No signs of life after 10min of CPR

See Also

Pediatric Advanced Life Support (PALS)

Source

Tintinalli