Critical Concepts NICU Brian M. Barkemeyer, MD LSUHSC Division of Neonatology

by user








Critical Concepts NICU Brian M. Barkemeyer, MD LSUHSC Division of Neonatology
Critical Concepts
Brian M. Barkemeyer, MD
LSUHSC Division of Neonatology
At birth
• 100% of infants need someone present
dedicated to the infant and capable of initial
steps in neonatal resuscitation
• 10% of infants require some level of
resuscitation at birth
• 1% of infants require major resuscitation
“Golden hour”
• At no other time in one’s life will necessary
critical concepts in resuscitation have a
potential lifelong impact
– Appropriate interventions (or the lack thereof) can
make the difference between life or death, or
normal life vs. life of disability
• NRP - Neonatal Resuscitation Program
– Evidence-based, standardized program jointly
sponsored by American Academy of Pediatrics and
American Heart Association
• Proper equipment
• Knowledge
– In most cases, the need for neonatal
resuscitation is predictable
– But not always!
Risk Factors Predictive of
Need for Neonatal Resuscitation
• Maternal illness
– Hypertension
– Diabetes
– Infection
Multiple gestation
Maternal bleeding
Maternal drug abuse
No prenatal care
Fetal distress
Abnormal fetal position
Abnormal labor
Fetal anomalies
Placental abnormalities
amniotic fluid
Transition to
Extrauterine Life
• Fluid-filled alveoli to air-filled alveoli
• Circulatory changes
– Decreased pulmonary vascular resistance resulting
in increased pulmonary blood flow and cessation
of flow through foramen ovale and ductus
– Cessation of flow to placenta resulting in
increased systemic vascular resistance
Lack of Appropriate Resuscitation
• Interrupts normal transition to extrauterine
• Hypoxia
• Respiratory and metabolic acidosis
• Ischemia
• Potential for death or long term adverse
Three Basic Questions
• Term infant?
• Breathing/crying at birth?
• Normal tone at birth?
• If the answer to these three questions is yes,
infant doesn’t need resuscitation, but does
deserve initial steps
Initial Steps
Clear airway
• Necessary for all newborns!
Appropriate room temperature
Rapid drying to avoid evaporative heat loss
Remove wet towels
Mother – skin to skin
Radiant heat warmer
Blankets, cap
• Premature infants and IUGR infants at highest
risk for hypothermia
Establishment of the Airway
• Suction mouth then nose (“M before N”)
• Shoulder roll to aid in positioning
• Head positioned in slight extension, or
“sniffing position”
– Not too extended
– Not too flexed
• Airway
– Suction secretions, assess for anomalies
• Breathing
– Stimulate respiratory effort
• Tactile
• Bag-mask positive pressure ventilation (PPV)
• Circulation
– Assess heart rate
• Chest compressions if PPV ineffective at restoring heart rate
Skills to Learn
• Neonatal assessment
• Use of bulb suction
• Administration of positive pressure ventilation
by bag-mask
• Intubation and assistance with intubation
• Chest compressions
Sequential steps in resuscitation
• Initial steps
[30 seconds]
[30 seconds]
• Chest compressions
[30 seconds]
• Medications
[30 seconds]
Neonatal Assessment
• Respirations
– Normal rate and depth, good chest movement
• Heart rate
– Normal > 100
– Count for 6 seconds, multiply x 10
• Color
– Pink lips and trunk
– Acrocyanosis vs. central cyanosis
Indications for PPV
• If after initial steps in resuscitation [30 sec],
assessment reveals
– Apnea
– Gasping respirations
– Heart rate < 100
Indications for Chest Compressions
• If after initial steps in resuscitation [30 sec]
and effective PPV [30 sec], assessment reveals
– Heart rate < 60
Indications for Epinephrine
• Heart rate persists < 60 after
– Initial steps
– Chest compressions
[30 seconds]
[30 seconds]
[30 seconds]
• Dosage given IV (UVC preferred), or
endotracheal (higher dose given)
Indications for Volume Administration
• History of blood loss at delivery suggesting
• Infant appears to be in shock (pallor, poor perfusion,
failure to respond appropriately to resuscitation
• IV, 10-20 mL/kg, Normal saline, Ringer’s lactate, or Oblood
Meconium-stained Amniotic Fluid
• 15% of deliveries; at risk for meconium
aspiration syndrome
• Suctioning of upper airway and trachea in
infants who are not vigorous may help
prevent meconium aspiration syndrome
– Vigorous defined by
• Heart rate > 100
• Normal respiratory effort
• Normal tone
Positive Pressure Ventilation
Appropriate size mask and bag
Self-inflating vs. flow-inflating bag
Forming a good seal with mask
Achieve adequate chest rise
40-60 breaths per minute
• When done appropriately, PPV should result
in improvement in heart rate and color
Ineffective PPV
Reposition mask on face
Reposition head
Suction upper airway
Ventilate with mouth open
Increase ventilatory pressure
Replace bag
Endotracheal intubation
Self-inflating bag
Flow-inflating bag
Chest Compressions
• Should be coordinated with PPV
• 2 thumb method preferred
• Compression of sternum 1/3 depth of AP
diameter of chest
• 120 events per minute (compressions and
respirations combined)
• “One and two and three and breathe”
Chest Compressions
Endotracheal Intubation
• ET tube size similar to size of patient’s little
< 28 wks, < 1000 g
28-34 wks, 1000-2000 g
34-38 wks, 2000-3000 g
38-42 wks, > 3000 g
= 2.5 ETT
= 3.0 ETT
= 3.5 ETT
= 4.0 ETT
• Insertion depth
– “Tip to lip” measurement = weight in kg plus 6
• 2 kg patient should have ETT secure at 8 cm mark at lip
Endotracheal Intubation
Unique Aspects of Endotracheal
Intubation in Infants
• Narrowest part of airway is subglottic area
• Uncuffed ET tubes typically utilized
• Increased airway resistance associated with
more narrow airway diameter
• Relative lack of structural support for neonatal
Unique Anatomic Challenges
• Choanal atresia
– Endotracheal intubation may be required
• Pierre-Robin sequence
– Prone positioning
– NG tube into posterior pharynx
• Congenital diaphragmatic hernia
– Endotracheal intubation
– Gastric decompression
Key Points
• Appropriate resuscitation requires a rapid
series of assessments, interventions, and
• All infants deserve basic steps of resuscitation
– Drying, warming, positioning, clear airway
• Prompt initiation of respiratory support with
positive pressure ventilation by bag-mask is
the key to successful resuscitation of most
Fly UP