G R A N D R O U N D SA H M A D A A B O A Z I Z A M D
2 2 5 1 6
DISCLOSURE
bull I have nothing to disclose
OBJECTIVES
bull Review the steps in neonatal resuscitationbull Focus on the new updates in 2015 NRP 7th edition guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
READY TO RESUSCITATE
bull Most important step in delivering effective neonatal resuscitation is being ready
bull Personnel trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated
bull At least one healthcare provider is assigned primary responsibility for the newborn infant to evaluate the infant and if required initiate resuscitation procedures such as positive pressure ventilation and chest compressions
bull In the presence of significant perinatal risk factors for the need for resuscitation more additional personnel with resuscitation skills should be immediately available
READY TO RESUSCITATE (CONTrsquo)
bull All trained personnel who are immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications bull Equipment needed for resuscitation should be available at every delivery areabull Equipment need to be routinely checked to ensure they are functioning
properly
READY TO RESUSCITATE (CONTrsquo)
bull Readiness for neonatal resuscitation requires ndash assessment of perinatal risk ndash a system to assemble the appropriate personnel based on that risk ndash an organized method for ensuring immediate access to supplies and
equipment ndash standardization of behavioral skills that help assure effective teamwork and
communication
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
DISCLOSURE
bull I have nothing to disclose
OBJECTIVES
bull Review the steps in neonatal resuscitationbull Focus on the new updates in 2015 NRP 7th edition guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
READY TO RESUSCITATE
bull Most important step in delivering effective neonatal resuscitation is being ready
bull Personnel trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated
bull At least one healthcare provider is assigned primary responsibility for the newborn infant to evaluate the infant and if required initiate resuscitation procedures such as positive pressure ventilation and chest compressions
bull In the presence of significant perinatal risk factors for the need for resuscitation more additional personnel with resuscitation skills should be immediately available
READY TO RESUSCITATE (CONTrsquo)
bull All trained personnel who are immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications bull Equipment needed for resuscitation should be available at every delivery areabull Equipment need to be routinely checked to ensure they are functioning
properly
READY TO RESUSCITATE (CONTrsquo)
bull Readiness for neonatal resuscitation requires ndash assessment of perinatal risk ndash a system to assemble the appropriate personnel based on that risk ndash an organized method for ensuring immediate access to supplies and
equipment ndash standardization of behavioral skills that help assure effective teamwork and
communication
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
OBJECTIVES
bull Review the steps in neonatal resuscitationbull Focus on the new updates in 2015 NRP 7th edition guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
READY TO RESUSCITATE
bull Most important step in delivering effective neonatal resuscitation is being ready
bull Personnel trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated
bull At least one healthcare provider is assigned primary responsibility for the newborn infant to evaluate the infant and if required initiate resuscitation procedures such as positive pressure ventilation and chest compressions
bull In the presence of significant perinatal risk factors for the need for resuscitation more additional personnel with resuscitation skills should be immediately available
READY TO RESUSCITATE (CONTrsquo)
bull All trained personnel who are immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications bull Equipment needed for resuscitation should be available at every delivery areabull Equipment need to be routinely checked to ensure they are functioning
properly
READY TO RESUSCITATE (CONTrsquo)
bull Readiness for neonatal resuscitation requires ndash assessment of perinatal risk ndash a system to assemble the appropriate personnel based on that risk ndash an organized method for ensuring immediate access to supplies and
equipment ndash standardization of behavioral skills that help assure effective teamwork and
communication
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
READY TO RESUSCITATE
bull Most important step in delivering effective neonatal resuscitation is being ready
bull Personnel trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated
bull At least one healthcare provider is assigned primary responsibility for the newborn infant to evaluate the infant and if required initiate resuscitation procedures such as positive pressure ventilation and chest compressions
bull In the presence of significant perinatal risk factors for the need for resuscitation more additional personnel with resuscitation skills should be immediately available
READY TO RESUSCITATE (CONTrsquo)
bull All trained personnel who are immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications bull Equipment needed for resuscitation should be available at every delivery areabull Equipment need to be routinely checked to ensure they are functioning
properly
READY TO RESUSCITATE (CONTrsquo)
bull Readiness for neonatal resuscitation requires ndash assessment of perinatal risk ndash a system to assemble the appropriate personnel based on that risk ndash an organized method for ensuring immediate access to supplies and
equipment ndash standardization of behavioral skills that help assure effective teamwork and
communication
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
READY TO RESUSCITATE
bull Most important step in delivering effective neonatal resuscitation is being ready
bull Personnel trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated
bull At least one healthcare provider is assigned primary responsibility for the newborn infant to evaluate the infant and if required initiate resuscitation procedures such as positive pressure ventilation and chest compressions
bull In the presence of significant perinatal risk factors for the need for resuscitation more additional personnel with resuscitation skills should be immediately available
READY TO RESUSCITATE (CONTrsquo)
bull All trained personnel who are immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications bull Equipment needed for resuscitation should be available at every delivery areabull Equipment need to be routinely checked to ensure they are functioning
properly
READY TO RESUSCITATE (CONTrsquo)
bull Readiness for neonatal resuscitation requires ndash assessment of perinatal risk ndash a system to assemble the appropriate personnel based on that risk ndash an organized method for ensuring immediate access to supplies and
equipment ndash standardization of behavioral skills that help assure effective teamwork and
communication
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
READY TO RESUSCITATE (CONTrsquo)
bull All trained personnel who are immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications bull Equipment needed for resuscitation should be available at every delivery areabull Equipment need to be routinely checked to ensure they are functioning
properly
READY TO RESUSCITATE (CONTrsquo)
bull Readiness for neonatal resuscitation requires ndash assessment of perinatal risk ndash a system to assemble the appropriate personnel based on that risk ndash an organized method for ensuring immediate access to supplies and
equipment ndash standardization of behavioral skills that help assure effective teamwork and
communication
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
READY TO RESUSCITATE (CONTrsquo)
bull Readiness for neonatal resuscitation requires ndash assessment of perinatal risk ndash a system to assemble the appropriate personnel based on that risk ndash an organized method for ensuring immediate access to supplies and
equipment ndash standardization of behavioral skills that help assure effective teamwork and
communication
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
READY TO RESUSCITATE (CONTrsquo)
bull When perinatal risk factors are identified ndash A team should be mobilized and a team leader identified ndash If time permits the leader should conduct a preresuscitation briefing
which would also include bull identify interventions that may be required
bull assign roles and responsibilities to the team members
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
READY TO RESUSCITATE (CONTrsquo)
bull It is vital during resuscitation that the team demonstrates effective communication and teamwork skills to help ensure quality and patient safety
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
EQUIPMENT
Intubation Equipmentbull Laryngoscope with straight blades (with sizes)bull Face masksbull Oxygen source with flowmeter
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
EQUIPMENT
bull Radiant warmerbull Warm towelsbull Pulse oximeter and probebull Oropharyngeal airwaysbull Oxygen blenderbull Plastic wrapbull Transport incubator
WHO IS AT HIGH RISK
bull Before DeliveryndashMaternal causesndash Fetal causes
bull During Delivery
WHO IS AT HIGH RISK
Maternal Conditionsbull Age (gt40yrs lt16yrs)bull Socioeconomic status (poverty
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHO IS AT HIGH RISK
bull Before DeliveryndashMaternal causesndash Fetal causes
bull During Delivery
WHO IS AT HIGH RISK
Maternal Conditionsbull Age (gt40yrs lt16yrs)bull Socioeconomic status (poverty
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHO IS AT HIGH RISK
Maternal Conditionsbull Age (gt40yrs lt16yrs)bull Socioeconomic status (poverty
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHO IS AT HIGH RISK
Maternal Medical Conditionsbull DMbull HTNbull Chronic heart lung or kidney diseasesbull Blood disorders (thrombocytopenia anemia)bull HO previous stillbirthearly neonatal deathbull Antepartum hemorrhagebull Premature rupture of membranesbull Infections UTIs GBS carrierbull Placental Anomalies (previa polyoligohydramnios)
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHO IS AT HIGH RISK
Fetal Conditionsbull Hydropsbull Abnormalities of presentation (transverse lie breech)
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHO IS AT HIGH RISK
During birthbull Prolapsed cordbull Utero-placental bleedingbull Foul-smelling or meconium-stained amniotic fluid
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHO IS AT HIGH RISK
During birthbull Abnormal fetal heart rate patternsbull Instrumented delivery (forceps vacuum or cesarean)
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
PREMATURITY
Preterm infants more likely to require resuscitation and develop complications from the resuscitative process particularly those with a birth weight lt1000g
Whybull Hypothermiandash
ndash large body surface area to mass
ndash thin skin
ndash decreased subcutaneous fat
The smaller the infant the more difficult it is to prevent hypothermia
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
PREMATURITY (CONTrsquo)
bull Inadequate ventilationndashndash Immature lungs may be deficient in surfactant and difficult to inflateventilate
ndash Immature respiratory drive and weak respiratory muscles-gt increase the chance of having apnea
The more premature the infant the more likely require intubation and positive pressure support
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
PREMATURITY (CONTrsquo)
bull Infectionndashndash Maternal infection is associated with premature delivery and offspring of infected
mothers are at risk for antenatal infection
ndash Have immature immune systems which increases the risk of acquiring postnatal infection
bull Organ damage-ndash Immature tissues and capillaries are more vulnerable to injury resulting in complications
ndash Example retinopathy of prematurity in the retina and intracranial hemorrhage in the germinal matrix
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
PREMATURITY (CONTrsquo)
bull Reduced antioxidant functionndash Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals
ndash This may contribute to many of the morbidities of prematurity like BPD and NEC
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CARRY A CARD
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CORD CLAMPING
bull In 2010 there was increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation but insufficient evidence for the infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CORD CLAMPING (CONTrsquo)
bull National recommendations were made for DCC to be practiced when possible-Only for infants not requiring resuscitationsbull No evidence regarding safetyutility for infants requiring resuscitation
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CORD CLAMPING (CONTrsquo)
NRP 2015 Updatesbull Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth
bull Delayed cord clamping is associated withndash Less intraventricular hemorrhage
ndash Higher blood pressure and blood volume
ndash Less need for transfusion after birth
ndash Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -gt need for more phototherapy
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CORD MILKING
bull Some studies suggested that cord ldquomilkingrdquo might have same results as DCCbull No recommendations were made for its routine use as there is insufficient
evidence its safety or utility
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
INITIAL STEPS
bull Maintain normal temperature of the infant
bull Position the infant
bull Clear secretions if needed
bull Dry the infant
bull Stimulate to breathe
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MAINTAINING THE TEMP
Why is it important
bull Its been recognized since 1907 in Budinrsquos publication of The Nursling that the admission temperature of newborns is a strong predictor of mortality at all gestational ages
bull Hypothermia is also associated with serious morbidities such as IVH Hypoglycemia late-onset sepsis
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MAINTAINING THE TEMP (CONTrsquo)
The goal is to minimize heat loss
bull Place in a warmed towel or blanket bull Under a pre-warmed radiant warmer bull Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infants abdomen
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MAINTAINING THE TEMP (CONTrsquo)
bull Donrsquot place probe onndash Bony prominencesndash Areas of brown fat deposits(neck mediastinum
scapular axillary areas near kidneys adrenals)ndash Poorly vascularized areasndash Excoriated areas
bull Keep probe exposed to heat sourcebull Make sure probe attached securely
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MAINTAINING THE TEMP (CONTrsquo)
Depending on the condition
bull Infants not requiring resuscitationndash Swaddling the infant after drying
ndash Skin to skinrdquo contact with mother
(if not the mother even the dad can work)
bull Infants with birth weights lt1500gndash Use of polyurethane bags or wraps
ndash Raise the room temperature to 26degC (788degF)
ndash Warming pads
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MAINTAINING THE TEMP (CONTrsquo)
bull Infants who require respiratory supportndash Use of humidified and heated air
bull All resuscitation procedures including endotracheal intubation chest compression and insertion of intravenous lines can be performed with temperature-controlling interventions in place
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MAINTAINING THE TEMP (CONTrsquo)
bull Temperature of newly born nonasphyxiated infants be maintained between 365degC and 375degC after birth through admission and stabilization
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WARMING THE COLD BABIES
bull Previous recommendations for rewarming neonates who are hypothermic after resuscitation was that slower is preferable to faster rewarming To avoid apnea and arrhythmias bull However there is insufficient current evidence to recommend a preference for
either rapid (05degCh or greater) or slow rewarming (less than 05degCh) of unintentionally hypothermic newborns (lt36degC)
NRP 2015 Updatesbull Either approach may be reasonable
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MAINTAINING TEMP IN RESOURCE-LIMITED SETTINGS NRP 2015 Updatesbull To maintain temperature during transition (birth until 1
- 2 hrs of life) in well newborns it may be reasonable to ndash Put them in a clean food-grade plastic bag up to the level
of the neck ndash Swaddle them after drying ndash Nurse with skin-to-skin contact
bull No data examining the use of plastic wraps or skin-to-skin contact during resuscitationstabilization in resource-limited settings
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
ASSESSING THE HEART RATE
bull Auscultation of the precordium and the use of pulse oximetry have been routinely used to assess heart rate in the delivery room bull Per the 2010 guidelines
ndash Assessment of heart rate should be done by intermittently auscultating the precordial pulse
ndash If pulse is detectable palpation of the umbilical pulse can provide a rapid estimate of the pulse
ndash A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures
bull The use of ECG was not mentioned in 2010
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
THE USE OF 3-LEAD ECG
Why consider it bull The ECG has been found to display an accurate heart rate faster than
pulse oximetry
bull Pulse oximetry may often display a lower rate in the first 2 minutes of life
bull Pulse oximetry may not function during states of very poor cardiac output or perfusion
bull Underestimation of the heart rate may lead to unnecessary resuscitation
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
THE USE OF 3-LEAD ECG (CONT)
bull Study show that auscultation and palpation is inaccurate and unreliable
bull Other studies shown ECG to be a must faster way (within 1min) and more reliable way to assess HR
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
THE USE OF 3-LEAD ECG (CONT)
bull The new guidelines suggest that electrocardiography (ECG) may be a reasonable option to provide rapid and accurate estimation of neonatal heart rate in the delivery room
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHATrsquoS THE BEEF WITH USING ECGS
bull ECG does not replace the need for pulse oximetry which is still important to assess oxygenation bull Would the extra time needed to place ECG leads be detrimentalbull Is information provided by ECG will be more beneficialbull Would the leads injure the fragile skin of very premature infants
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CLEARING THE AIRWAY
bull The proper position aligns the posterior pharynx larynx and trachea and facilitates air entry
Per 2010 guidelinesbull Suctioning immediately after birth for
ndash Babies with obvious obstruction due to secretions
ndash Babies who require positive pressure ventilation
bull The mouth is suctioned first and then the nares to decrease the risk for aspiration M-gtN
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CLEARING THE AIRWAY (CONT)
bull Suctioning should be avoided if not indicatedBut Whybull It can produce a vagal response resulting in apnea andor bradycardia
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CLEARING THE AIRWAY (CONT)
bull Same goes for tracheal suctioning in intubated infants as it can cause deterioration ofndash pulmonary compliancendash oxygenationndash cerebral blood flow velocity
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
IS WIPING MOUTHNOSE EFFECTIVE
bull Randomized not masked equivalency trial conducted in a single center n=488
bull Wiping the face mouth and nose with a towel was equivalent to suctioning the mouth and nose with a bulb syringe after delivery in babies gt35week gestation
bull Primary outcome based on mean respiratory rate in the first 24 hrs
bull Nonvigorous babies with meconium-stained amniotic fluid and babies with major malformations were excluded
bull No significant differences in APGAR scores and secondary outcomes babies requiring intubation PPV chest compression and NICU admissions
bull There were protocol deviations in 117 of the 488 cases (24 ) and almost all occurred in patients assigned to wiping who received suctioning
bull Further investigations are needed to compare wiping to suctioning
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHAT TO DO WHEN MECONIUM HITS THE FAN
2015 Guidelinesbull If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -gt initial steps of resuscitation ndash warming and maintaining temperature ndash positioning the infant amp clearing the airway of secretions if needed ndash dry and stimulate the infant
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHAT TO DO WHEN MECONIUM HITS THE FAN
bull PPV should be initiated if the infant is not breathing or the heart rate is less than 100min after the initial steps are completed bull Routine intubation for tracheal suction in this setting is
NOT suggested bull Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as for those with clear fluid
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WHAT TO DO WHEN MECONIUM HITS THE FAN
Why not routinely intubate and mec aspiratebull Avoid potential harm in
ndash Delays in providing bag-mask ventilation ndash The procedure itself
bull Because there is insufficient evidence to continue recommending this practice
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MECONIUM VIDEO
bull httpsyoutubebSg48AQTRsA
>
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
DIGITAL INTUBATION
bull Technique that uses the index and middle finger to blindly direct the endotracheal tube into the larynx bull Donrsquot try this at home
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
ASSESSMENT OF OXYGEN NEED
bull Blood oxygen levels generally do not reach extrauterine values until approximately 10 minutes following birthbull O2 sats may remain in the 70 - 80 range for
several minutes following birthbull Both insufficient or excessive oxygenation can be
harmful to the newborn infant
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
PLACING THE PULSE OXIMETRY
bull Probe should be placed on preductal location (right upper extremity usually wrist or medial surface of the palm)
bull 100 sats = not good
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
GIVING OXYGEN TO TERM INFANTS
bull Two meta-analyses of several randomized controlled trials comparing neonatal resuscitation with room air vs 100 oxygen showed increased survival when resuscitation was initiated with air
No change in the 2010 guidelinesbull Initiate resuscitation with air (21 oxygen at sea level)bull May titrate the oxygen concentration to achieve an SpO2 in the target range bull May give oxygen if baby is bradycardic
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
GIVING OXYGEN TO PRETERM INFANTS
bull Meta-analysis of 7 randomized studies bull Initiating resuscitation of preterm newborns
(lt35 weeks of gestation) with high oxygen (ge65) and low oxygen (21-30) showed no improvement in survival to hospital discharge with the use of high oxygen
bull No benefit was seen for the prevention of BPD IVH or retinopathy of prematurity
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull When oxygen targeting was used as a cointervention the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life
bull In all studies irrespective of whether air or high oxygen (including 100) in initiating resuscitation most infants were in approximately 30 oxygen by the time of stabilization
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
GIVING OXYGEN TO PRETERM INFANTS (CONT)
bull Resuscitation of preterm newborns should be initiated with low oxygen (21-30) and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range bull Initiating resuscitation of preterm newborns with high oxygen (ge65) is NOT
recommended
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
POSITIVE PRESSURE VENTILATION (PPV)
bull Initial inflation pressure of 20 cm H2O may be effective but ge30 to 40 cm H2O may be required in term babies without spontaneous ventilation
bull Insufficient evidence to recommend an optimum inflation time
bull Quick improvement in heart rate is the primary measure of adequate initial ventilation
bull Assess the chest wall movement if the heart rate does not improve
bull Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to achievemaintain a heart rate gt100 per minute
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull Animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from fluid-filled to air-filled lungs after birth
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
POSITIVE PRESSURE VENTILATION (PPV) (CONT)
bull 2015 review of literature includes 3 randomized controlled trials and 2 cohort studies which shownndash A benefit of sustained inflation for reducing need for mechanical ventilation ndash No benefit in reduction of mortality BPD or air leak
bull The low quality of evidence was downgraded for variability of interventions bull Insufficient data to support routine application of sustained inflation of greater
than 5 secondsrsquo duration to the transitioning newborn
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
END-EXPIRATORY PRESSURE (PEEP)
bull One trial states that when using PEEP the maximum supplementary oxygen required to achieve target oxygen sats may be slightly less (low-quality evidence) bull In 2015 the 2010 recommendation was repeated
ndash ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
bull This will require the addition of a PEEP valve for self-inflating bags
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
UPDATES ON THE LARYNGEAL MASK
bull Can achieve effective ventilation in term and preterm newborns at ge34 weeks gestation bull Data are limited for their use in preterm infants
delivered at lt34 weeks of gestation or weigh lt2000 g bull Recommended when tracheal intubation is
unsuccessful or not feasiblebull Its use has not been evaluated during chest
compressions or in administering emergency meds
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
ENDOTRACHEAL INTUBATION
bull Indicated when bag-mask ventilation is ineffective or prolonged or for special circumstances such as CDHbull CO2 detectors are effective even in the very low-birth-weight infants bull Causes of undetected exhaled CO2
ndash esophageal intubation
ndash Poor or absent pulmonary blood flow (ex during cardiac arrest)
bull Additional indicators for correct tube placement includendash Chest movement
ndash Presence of equal breath sounds bilaterally
ndash Condensation in the endotracheal tube
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
bull 3 randomized controlled trials enrolling 2358 preterm infants born lt30 weeks of gestation demonstrated that starting newborns on CPAP may be beneficial when compared with endotracheal intubation and PPV
bull Starting CPAP resulted in ndash Decreased rate of intubation
ndash Decreased duration of mechanical ventilation
ndash No significant increase in air leak or severe IVH
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Based on this evidence NRP 2015 updatesbull Spontaneously breathing preterm infants with
respiratory distress may be supportedwith CPAP initially rather than routine intubation for administering PPV
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CHEST COMPRESSIONS
bull Indicated if HR lt60min despite adequate ventilation bull Make sure that assisted ventilation is being delivered
correctly before starting chest compressions
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CHEST COMPRESSIONS
bull Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chestbull 2-thumb technique preferred over 2-finger technique
ndash Generates higher blood pressures and coronary perfusion pressure
ndash Less rescuer fatigue
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CHEST COMPRESSIONS
bull Always keep your thumbs on the chest even during relaxation when allowing the chest to re-expand fully
bull 31 ratio of compressions to ventilation (90 compressions and 30 breaths in one minute) bull May use higher ratios (152) if the arrest is believed to be of cardiac originbull Avoid frequent interruptionsbull Highly suggested not to use of any single feedback device such as ETCO2 monitors or
pulse oximeters for detection of return of spontaneous circulation in asystolicbradycardic neonates
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
CHEST COMPRESSIONS
bull The Neonatal Guidelines Writing Group supports increasing the oxygen concentration to 100 whenever chest compressions are provided
bull Lack of clinical studies regarding oxygen use in neonatal CPRbull Animal evidence shows no advantage to 100 oxygen
during CPRbull As the heart rate recovers the supplementary oxygen
should be weaned
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
MEDICATIONS
bull 2010 dosing remained unchangedbull Intravenous administration of epinephrine may be considered at a dose
of 001 to 003 mgkg of 110 000 epinephrine bull For endotracheal administration higher dosing at 005 to 01 mgkg bull Recommended to be administered intravenously
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
VOLUME EXPANSION
bull Suspected blood loss ndash pale skin ndash poor perfusion ndash weak pulsendash heart rate not responding adequately to other resuscitative measures
bull An isotonic crystalloid solution or blood may be useful for volume expansion the recommended dose is 10 mLkgbull Rapid infusions of large volumes have been associated with IVH
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
POSTRESUSCITATION CARE
bull Once effective ventilation andor the circulation has been established transfer to the NICU bull Intravenous glucose infusion should be given as needed in avoiding
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
Its recommended that infants born gt36 weeks of gestation with evolving moderate-to-severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-upbull 2015 This recommendation goes for both resource-
abundant and resource-limited areas
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WITHHOLDING AND DISCONTINUING
bull There should be a consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents
bull Clinicians should not hesitate to withdraw support when functional survival is highly unlikely
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WITHHOLDING AND DISCONTINUING
bull It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of resuscitation with undetectable heart rate
bull Variables to be taken into account ndash whether the resuscitation was considered optimal
ndash availability of advanced neonatal care (ex therapeutic hypothermia)
ndash family expressed wishes
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
WITHHOLDING AND DISCONTINUING
bull Resuscitation is not indicated when the gestation birth weight or congenital anomalies are associated with early death
bull Variables to take into consideration when counseling a family and making a prognosis for survival at gestations lt25 weeks ndash accuracy of gestational age assignment
ndash the presenceabsence of chorioamnionitis
ndash level of care available
bull Decisions about appropriateness of resuscitation lt25 weekers will be influenced by region-specific guidelines
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
LECTURE GUIDEbull Preparation for resuscitation
ndash Getting ready to resuscitate
ndash Equipment
ndash Assessing risk
bull Reviewing the algorithm
bull Delayed cord clampingmilking
bull Initial steps ndash Maintaining temperature
ndash Assessing heart rate and the use of EKGs
ndash Clearing airway
ndash Meconium aspiration
bull Assessing and providing Oxygen
bull PPV PEEP CPAP
bull Chest compressions
bull Medications
bull Post resuscitation care
bull Withholding and discontinuing care
bull Briefing and debriefing
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
BRIEFINGDEBRIEFING
bull Briefings or debriefings of resuscitation team performance have been shown to improve knowledge and skills
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
REFERENCESbull Perlman JM Wyllie J Kattwinkel J Atkins DL Chameides L Goldsmith JP Guinsburg R Hazinski MF Morley C Richmond S Simon WM Singhal N Szyld E Tamura M
Velaphi S Neonatal Resuscitation Chapter Collaborators Part 11 neonatal resuscitation 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2010122(suppl 2) S516ndashS538 doi 101161CIRCULATIONAHA110971127
bull American Academy of Pediatrics Statement of endorsement timing of umbilical cord clamping after birth Pediatrics 2013131e1323
bull Committee Opinion No543 Timing of umbilical cord clamping after birth Obstet Gynecol 20121201522ndash1526
bull Perlman JM Wyllie J Kattwinkel J Wyckoff MH Aziz K Guinsburg R Kim HS Liley HG Mildenhall L Simon WM Szyld E Tamura M Velaphi S on behalf of the Neonatal Resuscitation Chapter Collaborators Part 7 neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015132(suppl 1)S204ndashS241 doi 101161CIR0000000000000276
bull Hosono S Mugishima H Fujita H Hosono A Minato M Okada T Takahashi S Harada K Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeksrsquo gestation a randomised controlled trial Arch Dis Child Fetal Neonatal Ed 200893F14ndashF19 doi 101136adc2006108902
bull MarchMIHackerMRParsonAWModestAMdeVecianaMThe effects of umbilical cord milking in extremely preterm infants a randomized con- trolled trial J Perinatol 201333763ndash767 doi 101038jp201370
bull Wyckoff MH Perlman JM Effective ventilation and temperature control are vital to outborn resuscitation Prehosp Emerg Care 20048191ndash195
bull Frascone RJ Wayne MA Swor RA Mahoney BD Domeier RM Olinger ML Tupper DE Setum CM Burkhart N Klann L Salzman JG Wewerka SS Yannopoulos D Lurie KG OrsquoNeil BJ Holcomb RG Aufderheide TP Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device Resuscitation 2013841214ndash1222 doi 101016j resuscitation201305002
bull Perlman JM Wyllie J Kattwinkel J et al Part 7 Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132S204
bull Kelleher J Bhat R Salas AA et al Oronasopharyngeal suction versus wiping of the mouth and nose at birth a randomised equivalency trial Lancet 2013 382326
bull Gungor S Kurt E Teksoz E Goktolga U Ceyhan T Baser I Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section a prospective random- ized controlled trial Gynecol Obstet Invest 2006619ndash14 doi 101159 000087604
bull Waltman PA Brewer JM Rogers BP May WL Building evidence for practice a pilot study of newborn bulb suctioning at birth J Midwifery Womens Health 20044932ndash38 doi 101016jjmwh200310003
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
REFERENCESbull Carrasco M Martell M Estol PC Oronasopharyngeal suction at birth effects on arterial oxygen saturation J Pediatr 1997130832ndash834
bull Perlman JM Volpe JJ Suctioning in the preterm infant effects on cerebral blood flow velocity intracranial pressure and arterial blood pressurePediatrics 198372329ndash334
bull Davis PG Tan A ODonnell CP Schulze A Resuscitation of newborn infants with 100 oxygen or air a systematic review and meta-analysis Lancet 20043641329ndash1333
bull Rabi Y Rabi D Yee W Room air resuscitation of the depressed newborn a systematic review and meta-analysis Resuscitation 200772353ndash 363
bull Armanian AM Badiee Z Resuscitation of preterm newborns with low concentration oxygen versus high concentration oxygen J Res Pharm Pract 2012125ndash29 doi 1041032279-042X99674
bull Kapadia VS Chalak LF Sparks JE Allen JR Savani RC Wyckoff MH Resuscitation of preterm neonates with limited versus high oxygen strat- egy Pediatrics 2013132e1488ndashe1496 doi 101542peds2013-0978
bull Lundstroslashm KE Pryds O Greisen G Oxygen at birth and prolonged cere- bral vasoconstriction in preterm infants Arch Dis Child Fetal Neonatal Ed 199573F81ndashF86
bull Rabi Y Singhal N Nettel-Aguirre A Room-air versus oxygen adminis- tration for resuscitation of preterm infants the ROAR study Pediatrics 2011128e374ndashe381 doi 101542peds2010-3130
bull Rook D Schierbeek H Vento M Vlaardingerbroek H van der Eijk AC Longini M Buonocore G Escobar J van Goudoever JB Vermeulen MJ Resuscitation of preterm infants with different inspired oxygen fractions J Pediatr 20141641322ndash6e3 doi 101016jjpeds201402019
bull Vento M Moro M Escrig R Arruza L Villar G Izquierdo I Roberts LJ 2nd Arduini A Escobar JJ Sastre J Asensi MA Preterm resusci- tation with low oxygen causes less oxidative stress inflammation and chronic lung disease Pediatrics 2009124e439ndashe449 doi 101542 peds2009-0434
bull Wang CL Anderson C Leone TA Rich W Govindaswami B Finer NN Resuscitation of preterm neonates by using room air or 100 oxygen Pediatrics 20081211083ndash1089 doi 101542peds2007-1460
bull Klingenberg C Sobotka KS Ong T Allison BJ Schmoumllzer GM Moss TJ Polglase GR Dawson JA Davis PG Hooper SB Effect of sus- tained inflation duration resuscitation of near-term asphyxiated lambs Arch Dis Child Fetal Neonatal Ed 201398F222ndashF227 doi 101136 archdischild-2012-301787
bull te Pas AB Siew M Wallace MJ Kitchen MJ Fouras A Lewis RA Yagi N Uesugi K Donath S Davis PG Morley CJ Hooper SB Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits Pediatr Res 200966295ndash300 doi 101203PDR0b013e3181b1bca4
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
QUESTIONSCOMMENTS
Neonatal Resuscitation
disclosure
Objectives
Lecture guide
Ready to Resuscitate
Ready to Resuscitate (contrsquo)
Ready to Resuscitate (contrsquo) (2)
Ready to Resuscitate (contrsquo) (3)
Ready to Resuscitate (contrsquo) (4)
Equipment
Equipment (2)
Equipment (3)
Equipment (4)
Who is at High risk
Who is at High risk (2)
Who is at High risk (3)
Who is at High risk (4)
Who is at High risk (5)
Who is at High risk (6)
Who is at High risk (7)
prematurity
Prematurity (contrsquo)
Prematurity (contrsquo) (2)
Prematurity (contrsquo) (3)
Lecture guide (2)
Carry a card
Slide 27
Slide 28
Slide 29
Lecture guide (3)
Cord Clamping
Cord Clamping (contrsquo)
Cord Clamping (contrsquo) (2)
Cord Milking
Lecture guide (4)
Initial steps
Maintaining the Temp
Maintaining the Temp (contrsquo)
Maintaining the Temp (contrsquo) (2)
Maintaining the Temp (contrsquo) (3)
Maintaining the Temp (contrsquo) (4)
Maintaining the Temp (contrsquo) (5)
Warming the cold babies
Maintaining TEMP in Resource-Limited Settings
Assessing the heart rate
The Use of 3-Lead ECG
The Use of 3-Lead ECG (cont)
The Use of 3-Lead ECG (cont) (2)
Whatrsquos the beef with using ecgs
Clearing the Airway
Clearing the Airway (cont)
Clearing the Airway (cont)
Is Wiping mouthnose effective
What to do when meconium hits the fan
What to do when meconium hits the fan (2)
What to do when meconium hits the fan (3)
Meconium video
Digital Intubation
Lecture guide (5)
Assessment of Oxygen Need
Placing the Pulse oximetry
Giving oxygen to Term infants
Giving oxygen to preterm infants
Giving oxygen to preterm infants (cont)
Giving oxygen to preterm infants (cont) (2)
Lecture guide (6)
Positive Pressure Ventilation (PPV)
Positive Pressure Ventilation (PPV) (cont)
Positive Pressure Ventilation (PPV) (cont) (2)
End-Expiratory Pressure (peep)
Updates on the Laryngeal Mask
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure (CPAP) (2)
Lecture guide (7)
Chest Compressions
Chest Compressions (2)
Chest Compressions (3)
Chest Compressions (4)
Lecture guide (8)
Medications
Volume Expansion
Lecture guide (9)
Postresuscitation Care
Induced Therapeutic Hypothermia
Lecture guide (10)
Withholding and Discontinuing
Withholding and Discontinuing (2)
Withholding and Discontinuing (3)
Lecture guide (11)
BriefingDebriefing
references
references (2)
references (3)
Questionscomments
REFERENCESbull Lista G Boni L Scopesi F Mosca F Trevisanuto D Messner H Vento G Magaldi R Del Vecchio A Agosti M Gizzi C Sandri F Biban P Bellettato M Gazzolo D
Boldrini A Dani C SLI Trial Investigators Sustained lung inflation at birth for preterm infants a randomized clini- cal trial Pediatrics 2015135e457ndashe464 doi 101542peds2014-1692
bull Lista G Fontana P Castoldi F Cavigioli F Dani C Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome Neonatology 20119945ndash50 doi 101159000298312
bull Szyld E Aguilar A Musante GA Vain N Prudent L Fabres J Carlo WA Delivery Room Ventilation Devices Trial Group Comparison of devices for newborn ventilation in the delivery room J Pediatr 2014165 234ndash239e3 doi 101016jjpeds201402035
bull Morley CJ Davis PG Doyle LW Brion LP Hascoet JM Carlin JB COIN Trial Investigators Nasal CPAP or intubation at birth for very preterm infants N Engl J Med 2008358700ndash708 doi 101056 NEJMoa072788
bull SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network Finer NN Carlo WA Walsh MC Rich W Gantz MG Laptook AR Yoder BA Faix RG Das A Poole WK Donovan EF Newman NS Ambalavanan N Frantz ID 3rd Buchter S Sanchez PJ Kennedy KA Laroia N Poindexter BB Cotten CM Van Meurs KP Duara S Narendran V Sood BG OrsquoShea TM Bell EF Bhandari V Watterberg KL Higgins RD Early CPAP versus surfactant in extremely preterm infants N Engl J Med 20103621970ndash1979
bull Dunn MS Kaempf J de Klerk A de Klerk R Reilly M Howard D Ferrelli K OrsquoConor J Soll RF Vermont Oxford Network DRM Study Group Randomized trial comparing 3 approaches to the initial respi- ratory management of preterm neonates Pediatrics 2011128e1069ndash e1076 doi 101542peds2010-3848
bull Clay AS Que L Petrusa ER Sebastian M Govert J Debriefing in the intensive care unit a feedback tool to facilitate bedside teaching Crit Care Med 200735738ndash754
bull KamlinCOOrsquoDonnellCPEverestNJDavisPG MorleyCJAccuracy of clinical assessment of infant heart rate in the deliveryr oom Resuscitation 200671319ndash321 doi 101016jresuscitation200604015
bull DawsonJA SaraswatA SimionatoLThioMKamlinCOOwenLS SchmoumllzerGMDavisPG Comparison of heartrate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants Acta Paediatr 2013102955ndash960doi 101111 apa12329
bull Kamlin CO Dawson JA OrsquoDonnell CP Morley CJ Donath SM Sekhon J Davis PG Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room J Pediatr 2008152756ndash760 doi 101016jjpeds200801002
bull Katheria A Rich W Finer N Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation Pediatrics 2012130e1177ndashe1181 doi 101542peds2012-0784
