Neonatal Resuscitation Procedure

Initial Steps
Prevent hypothermia—place infant on preheated radiant warmer, dry infant, then rewrap in warm, dry blankets. Polyethylene (food grade) bags may help maintain body temperature of very-low-birth weight infants.

Position—place the infant in a supine position with the head slightly extended (“sniffing position”); a small roll placed under the shoulders may be helpful.

Airway—if there are copious secretions compromising the airway, suction the mouth first and then the nose using either a suction bulb or 8F or 10F suction catheter; avoid prolonged and deep suctioning. Negative pressure should not exceed 100 mm Hg.

Tactile stimulation—if the infant remains apneic after drying, positioning, and suctioning, further tactile stimulation is unlikely to help; brief, gentle back rubbing or flicking the soles of feet, may be tried, but these efforts should not delay onset of positive-pressure ventilation.

Oxygen Administration
Free-flow 100% oxygen (at least 5 L/min) should be provided to any infant who has central cyanosis, pending further intervention(s). If positive-pressure ventilation (PPV) is begun, 100% supplemental oxygen is recommended. To reduce potential harm from excessive tissue oxygenation in preterm infants, the use of an oxygen blender and pulse oximetry is recommended in order to titrate supplemental oxygen delivery, maintaining oyxgen saturations between 90% and 95%. In any infant, if the heart rate does not respond by increasing to >100 beats per minute, 100% oxygen should be given.

Bag/Mask Ventilation
Indications—apnea or gasping; heart rate less than 100 beats per minute; central cyanosis despite free-flow oxygen.

Technique—proper mask size and shape, tight seal between mask and face, proper head position, clear airway, and adequate inflation pressure, ventilation rate of 40 to 60 breaths per minute. If ventilation pressure is being monitored, PPV with an initial inflation pressure of 20 cm H2O may be effective, but ?30 to 40 cm H2O may be required in some term babies without spontaneous ventilation.

Assessment—increasing heart rate is the primary sign of effective ventilation. Also look for improving color, spontaneous respirations, and improving muscle tone. If the heart rate is not improving, chest wall movement should be assessed and sufficient ventilating pressure should be used to move the chest wall with each breath.

Gastric decompression—if bag/mask ventilation is prolonged, an 8F orogastric tube should be inserted, aspirated, and left open as a vent to prevent gastric distension.

Special note: Flow-controlled pressure-limited mechanical devices (e.g., T-piece resuscitators) are recognized as an acceptable method of administering positive-pressure ventilation during newborn resuscitation; however, self-inflating and flow-inflating bags remain the preferred method for prolonged resuscitation.

Endotracheal Tube (ET) Ventilation
Indications—failure to achieve adequate ventilation with bag/mask; prolonged resuscitation (especially if chest compressions are needed); very-low-birthweight infant; need for ventilation in a patient with contraindication to bag/mask ventilation (e.g., diaphragmatic hernia or abdominal wall defect).

Technique—ET tube size and length rules of thumb: ET size in mm (internal diameter) = estimated gestational age divided by 10; length in cm to insert ET (“tip to lip”) = estimated weight in kg + 6; if less than 750 g, insert to 6 cm . Ventilation rate is 40 to 60 breaths per minute, or 30 breaths per minute if chest compressions are being given.

Assessment—increasing heart rate is the primary sign of effective ventilation. Also look for improving color, spontaneous respirations, and improving muscle tone. Use of a CO2 detector may facilitate confirmation of ET tube placement. If the heart rate is not improving, chest wall movement should be assessed and sufficient ventilating pressure should be used to move the chest wall with each breath. Also, check for equal breath sounds bilaterally (if absent, suspect intubation of the right mainstem bronchus).

Chest Compressions
Note: Hypoventilation and hypoxia are by far the most common causes of bradycardia in newly born infants, so almost all depressed infants can be revived by ventilation with oxygen.

Indication—heart rate less than 60 beats per minute after 30 seconds of adequate ventilation (good chest wall movement and breath sounds).—two-thumb, encircling-hands method is preferred if the infant’s size permits; the depth of compression is one-third the anterior-posterior dimension of chest (should produce a palpable pulse).

Coordination with ventilations—3:1 ratio (i.e., 3 compressions followed by 1 ventilation) for a total of 120 “events” per minute (90 compressions and 30 ventilations).

Epinephrine
Indications—heart rate less than 60 beats per minute despite adequate ventilation and chest compressions for at least 30 seconds (earlier if no detectable heart rate).

Dose—IV: 0.1 to 0.3 mL/kg of 1:10,000 solution, drawn up in a 1-mL syringe. Endotracheal: 0.3 to 1.0 mL/kg of a 1:10,000 solution, drawn up in a 3- or 5-mL syringe. Doses may be repeated every 3 to 5 minutes if heart rate is less than 60 beats per minute.
Route—initial dose or two may be given via the ET tube; subsequent doses, if needed, should be given IV.

Volume Expanders
Indications—poor response to resuscitation; known or suspected acute blood loss; signs of shock (pallor, poor pulses, perfusion).

Dose—10 mL/kg of normal saline or Ringer solution over 5 to 10 minutes IV.
O-negative red blood cells if large-volume blood loss.
Repeat volume bolus may be indicated, but caution against inappropriate volume expansion especially in small, preterm infant.

Naloxone Hydrochloride
Not indicated during the initial steps of resuscitation, but may be given if there is continued respiratory depression after positive-pressure ventilation has restored a normal heart rate and color, and there is a history of maternal narcotic administration within the past 4 hours.

Dose—0.1 mg/kg with either the 0.4 mg/mL or 1.0 mg/mL solution.
Route—IV preferred; can also be given IM but onset of action will be delayed.

Patients who respond to naloxone hydrochloride must be monitored for recurrence of apnea (duration of action may be shorter than that of the depressant narcotic).
Avoid in patients whose mothers are suspected of recent narcotic abuse (may precipitate acute withdrawal).

Bicarbonate
Not indicated in routine neonatal resuscitation.
May be detrimental because of hyperosmolarity and CO2 production.
Possible indication—prolonged resuscitation with documented metabolic acidosis after establishment of adequate ventilation and circulation.
Dose is 1 to 2 mEq/kg of an 0.5-mEq/mL solution infused over at least 2 minutes.