Neonatal Resuscitation

CHAPTER 180 Neonatal Resuscitation



Eric M. Hughes


The first few moments of a newborn’s life can be the most critical. If needed, effective emergency care during this transition can prevent lifelong consequences. Proper resuscitation requires essential equipment and knowledge of necessary protocols before delivery. Prior knowledge of the gestational age of the newborn is helpful in anticipating the need for resuscitation. Low birth weight and premature delivery predispose infants to the need for resuscitative efforts.



Indications


Neonate with the following:


• Inadequate or ineffective respirations

• Inadequate heart rate

• Central cyanosis

• Other evidence of cardiorespiratory distress


Equipment



• Suction equipment, including a bulb syringe, mechanical suction device, suction catheters (6, 8, 10 French), pediatric feeding tube (8 French), and meconium aspirator (Fig. 180-1)

• Oxygen source with flowmeter, infant resuscitation bag (750 mL) with appropriately sized face masks, laryngoscope with no. 0 and no. 1 straight blades, and sterile newborn endotracheal tubes (2.5, 3, 3.5, and 4 mm), CO2 monitor

• Drugs, including epinephrine 1 : 10,000 (0.1 mg/mL), naloxone (0.04 mg/mL), volume expanders (crystalloid or blood), and normal saline for injection

• Miscellaneous items, including a radiant warmer, pediatric stethoscope, needles (25, 21, and 18 gauge), syringes (1, 3, 10, 20 mL), adhesive tape (image-inch width), an umbilical catheter (3.5 or 5 French), and food grade heat-resistant plastic wrap

image

Figure 180-1 Meconium aspirator.



Technique


As with all medical procedures, universal precautions against exposure to blood and other body fluids should be followed during this procedure. Initial measures, including proper positioning, drying, suctioning, and stimulation, should be provided to all newborns. Figure 180-2 is a flow diagram of the protocol for neonatal resuscitation that is explained in the following sections.


image

Figure 180-2 Resuscitation flowchart. bpm, beats per minute; HR, heart rate; PPV, positive pressure ventilation. *Consider endotracheal intubation if meconium present and infant not vigorous.



Positioning, Suction, and Stimulation



1 Prevent heat loss by placing the infant under a radiant heat source, then quickly drying him or her and removing the wet linen. (Recovery from acidosis is delayed by hypothermia.) Infants of low birth weight (<1500 g) need extra equipment and effort to keep them warm because the traditional radiant warmer and blankets are insufficient. The body, but not the head, of the neonate may be covered with food grade heat-resistant plastic wrap in addition to providing radiant heat. Use of this technique requires constant monitoring to assure overheating does not occur.

2 Open the airway by positioning the infant on its back with the neck slightly extended. Avoid extreme hyperextension or flexion of the infant’s neck, which may diminish airflow.

3 Clear the airway by suctioning the mouth, then the nose, with a bulb syringe or mechanical device (suction catheter; see Chapter 178, Delee Suctioning). If mechanical suction is used, pressure should not exceed 100 mm Hg. Deep suctioning of the oropharynx may produce a vagal response and cause bradycardia and apnea. Infants with meconium-stained amniotic fluid should no longer be suctioned with mechanical devices after the head is delivered and prior to the body being delivered. Direct tracheal suctioning should be carried out only if the newborn has absent or depressed respirations, a heart rate below 100 bpm, or poor muscle tone. A meconium aspirator is very helpful in performing this procedure (see Fig. 180-1). This unique piece of equipment is used only for neonates. One end of the device is for a neonatal endotracheal tube, the other end is for suction, and the top hole is for the operator’s thumb.

4 Promote respiratory activity by providing tactile stimulation (e.g., slap the sole of the foot or gently rub the back).


Initial Assessment



1 Assess the infant’s respiratory status, heart rate, and color.

2 Infants with adequate respiratory and cardiac function (good ventilation and heart rate >100 bpm) and with no evidence of central cyanosis can be merely observed.

3 Infants with depressed respiratory function (shallow, slow, or absent respirations), an abnormal heart rate, or central cyanosis should undergo further resuscitation.


General Guidelines of Resuscitation


As with all resuscitations, the order of importance is airway, breathing, and circulation. The three cardinal indicators in neonatal resuscitation are respirations, heart rate, and color. In general, the initial assessment should take no more than 30 seconds; should the need for further resuscitation occur, reassessment of interventions should occur every 30 seconds. Apgar scores should be determined and recorded at appropriate intervals. Special circumstances may arise and may be treated with procedures used in general pediatric resuscitation (e.g., chest tube for pneumothorax).

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Neonatal Resuscitation

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