Newborn resuscitation: Difference between revisions
(updated for NRP 2015) |
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**D10W 2mL/kg IV | **D10W 2mL/kg IV | ||
===Congenital Diaphragmatic Hernia=== | ===Congenital Diaphragmatic Hernia=== | ||
*Persistent respiratory distress | *Persistent respiratory distress with "seesaw" pattern | ||
*Treat via immediate intubation, OG tube placement | *Treat via immediate intubation, OG tube placement | ||
**Use lowest peak insp presure that allows for adequate chest rise | **Use lowest peak insp presure that allows for adequate chest rise |
Revision as of 17:00, 11 July 2016
Use this note for immediate after-delivery resuscitation; see neonatal resuscitation for the non-delivery related resuscitation of the newborn.
Background
Newborn Vital Signs
- HR RR SBP^
- >100 40-80 60-70
^<3kg (premature) SBP = 40-60
Differential Diagnosis
Newborn Problems
- Newborn resuscitation
- Hypoxia
- Primary apnea
- Secondary apnea
- Hypothermia
- Hypoglycemia
- Meconium aspiration syndrome
- Anemia (abruption)
- Infant scalp hematoma
- Transient tachypnea of the newborn
- Respiratory distress syndrome
- Congenital pneumonia
- Congenital heart disease
- Neonatal sepsis
- Pneumothorax
- Pulmonary hypertension
Diagnosis
Assessment Triad
- Term?
- Tone?
- Breathing or crying?
- If yes, stay with mother for routine care
- If no:
- Respiration: adequacy, difficulty
- Circulation: HR >100, palpate at umbilical base
- Color - central cyanosis?
Apgar score
Score of 0 | Score of 1 | Score of 2 | |
---|---|---|---|
Appearance | blue or pale all over (central cyanosis) |
peripheral cyanosis (acrocyanosis) body pink |
no cyanosis body and extremities pink |
Pulse | absent | <100 beats per minute | >100 beats per minute |
Grimace | no response to stimulation | grimace on suction or aggressive stimulation | cry on stimulation |
Activity | none | some flexion | flexed arms and legs that resist extension |
Respiration | absent | weak, irregular, gasping | strong, lusty cry |
Score at 1 minute and 5 minutes post delivery.
Management
See newborn critical care quick reference for drug doses and equipment sizes.
Resuscitation Algorithm
- Dry, warm, position, suction, stimulate
- Gently dry newborn with warm towel
- Position: neutral (sniffing position)
- Suction: oral then nasal
- Mouth before nose, M before N in alphabet
- Stimulate: along spine or feet
- Check glucose^
- Oxygen
- Initial resuscitation >35 wks 21% FiO2, < 35 wks 21-30% FiO2
- Place O2 sat monitor preductal (right hand or wrist)
- Titrate O2 to target sat
Min of life | Target sat |
---|---|
1 min | 60-65% |
2 min | 65-70% |
3 min | 70-75% |
4 min | 75-80% |
5 min | 80-85% |
10 min | 85-95% |
- Persistent cyanosis
- Reposition and clear airway
- Consider CPAP
- Ventilate (40-60 breaths/min @ 20-25 cmH20)
- BVM (indications)
- Apnea/gasping
- HR <100/min
- ET (indications); ETT size = Gest age (wks) / 10^^
- BVM ineffective after 30s
- Suction meconium no longer recommended
- Laryngeal mask airway alternative
- BVM (indications)
- Chest compressions (indications)
- HR <60 after above x 30 sec
- 120 events/min (cc:resp 3:1)
- Stop when HR > 60
- HR <60 after above x 30 sec
- Medications^^^
- Epi (0.01-0.03 mg/kg)
- HR<60 despite above
- Use only 1:10,000
- D10W (2 mL/kg = 0.2gm/kg)
- Nalaxone (0.1 - 0.4 mg/kg)
- In past, for opioid use <4hrs
- No longer recommended
- Assist ventilation as needed instead
- NS (10 mL/kg boluses)
- PRBC 10mL/kg if abruption with anemia
- Dopamine drip
- (5-20 mcg/kg/min)
- NaHCO3 - prolonged resus
- (1-2 meQ/kg)
- Epi (0.01-0.03 mg/kg)
Key
^Hypoglycemia (give D10W)
- >2.5 kg = <40 mg/dL
- <2.5 kg = <30 mg/dL
^^Newborn Vent Settings
- Pressure Cycled: RR 30+, PIP 20/2 (Preemie 15/2)
^^^Umbilical vein catheterization
Airway
- Optimize
- Position head in sniffing position
- Suction mouth then nose
- Intubate
- Indicated if patient is poorly responsive or fails BVM
- If have time precut ET tube at 13cm mark
- Lip placement = 6 + wt (kg)
- Or, lip placement = measure nasal septum to tragus length (NTL) in cm + 1
- After intubation suction trachea to prevent aspiration (if +meconium)
Tube Size / age / wt | Blade | Suction Catheter | Insertion Depth (cm) |
2.5 / <28 / <1000 | Miller 0 | 5F or 6F | 6-7 |
3.0 / 28-34 / 1000-2000 | Miller 0 | 6F or 8F | 7-8 |
3.5 / 34-38 / 2000-3000 | Miller 0 | 8F | 8-9 |
3.5-4.0 />38 / >3000 | Miller 0-1 | 8F or 10F | 9-10 |
Breathing
- Apneic and/or bradycardic (<100 bpm)
- Attempt tactile stimulation first
- If unsuccessful perform BMV at 40-60 breaths/min
- After intubation use:
- Inflation pressure ~ 20
Circulation
- CPR
- Begin if despite assisted ventilation x30s HR still <60
- 3 compressions:1 breath (total 90 compresions:30 breaths per min)
Vascular Access
- Umbilical vein is site of choice
Volume Expansion
- NS 10mL/kg IV or umb vein over 5-10min
- O Rh-negative blood if abruption/anemic
Medications
- Epinephrine
- Indicated for asystole or HR < 60 despite CPR >30s
- 0.01-0.03mg/kg IVP q3-5min
- Sodium Bicarbonate
- Helps to counteract negative inotropy/pulm HTN caused by acidosis
- Only give once adequate ventilation is established
- 1-2 mEq/kg of 4.2% solution (2-4 mL/kg)
- Naloxone
- Previously given if persistent resp depression AND maternal narcotics w/in 4hr
- No longer recommended; assist ventilations as needed until narcotics wear off
- 0.1-0.4mg/kg IV
Other
- Delay cord clamping 30-60 seconds if able
- Keep infant warm; heat loss leads to apnea, acidosis
Disposition
- Admission
Withholding Resuscitation
- Consider if:
- <22wk or <400g
- No signs of life after 10min of CPR
Special Problems
Cyanosis
- Must distinguish between central and peripheral
- Consider prostaglandin E1 0.05-0.1 mcg/kg/min for cyanotic heart dz and ductus closing
Pneumothorax
- Tension PTX is highly related to subsequent ICH
- Place 18-20ga catheter into 4th IC in ant axillarly line
Hypoglycemia
- <30-35 in preterm newborn
- <35-40 in term newborn
- Treatment
- D10W 2mL/kg IV
Congenital Diaphragmatic Hernia
- Persistent respiratory distress with "seesaw" pattern
- Treat via immediate intubation, OG tube placement
- Use lowest peak insp presure that allows for adequate chest rise
- Transfer to tertiary center with NICU and pediatric surgeon
See Also
- Neonatal Resuscitation
- Umbilical Vein Catheterization
- Transient tachypnea of the newborn
- Emergent delivery
- Pediatric Advanced Life Support (PALS)