Critical Concepts NICU

1. Critical ConceptsNICU Brian M. Barkemeyer, MD LSUHSC Division of Neonatology 2011-12

2. 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

3. “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

4. Preparation • 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!

5. Risk Factors Predictive ofNeed for Neonatal Resuscitation • Maternal illness • Hypertension • Diabetes • Infection • Prematurity • Post-maturity • Multiple gestation • Maternal bleeding • Maternal drug abuse • No prenatal care • Fetal distress • Abnormal fetal position • Abnormal labor • Fetal anomalies • Macrosomia • IUGR • Placental abnormalities • Meconium-stained amniotic fluid

6. Transition toExtrauterine 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 arteriosus • Cessation of flow to placenta resulting in increased systemic vascular resistance

7. Lack of Appropriate Resuscitation • Interrupts normal transition to extrauterine life • Hypoxia • Respiratory and metabolic acidosis • Ischemia • Potential for death or long term adverse outcome

8. 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

9. Initial Steps • Drying • Warming • Stimulation • Positioning • Clear airway • Necessary for all newborns!

10. Warming • 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

11. 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

12. ABC’s • 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

13. Skills to Learn • Neonatal assessment • Use of bulb suction • Administration of positive pressure ventilation by bag-mask • Intubation and assistance with intubation • Chest compressions

14. Assessment/Reassessment:Sequential steps in resuscitation • Initial steps [30 seconds] • PPV [30 seconds] • Chest compressions [30 seconds] • Medications [30 seconds]

15. 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

17. Indications for PPV • If after initial steps in resuscitation [30 sec], assessment reveals • Apnea • Gasping respirations • Heart rate < 100

18. Indications for Chest Compressions • If after initial steps in resuscitation [30 sec] and effective PPV [30 sec], assessment reveals • Heart rate < 60

19. Indications for Epinephrine • Heart rate persists < 60 after • Initial steps [30 seconds] • PPV [30 seconds] • Chest compressions [30 seconds] • Dosage given IV (UVC preferred), or endotracheal (higher dose given)

20. Indications for Volume Administration • History of blood loss at delivery suggesting hypovolemia AND • Infant appears to be in shock (pallor, poor perfusion, failure to respond appropriately to resuscitation efforts) • IV, 10-20 mL/kg, Normal saline, Ringer’s lactate, or O- blood

21. 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

22. 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

23. Ineffective PPV • Reposition mask on face • Reposition head • Suction upper airway • Ventilate with mouth open • Increase ventilatory pressure • Replace bag • Endotracheal intubation

24. Self-inflating bag

25. Flow-inflating bag

26. 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”

27. Chest Compressions

28. Endotracheal Intubation • ET tube size similar to size of patient’s little finger • < 28 wks, < 1000 g = 2.5 ETT • 28-34 wks, 1000-2000 g = 3.0 ETT • 34-38 wks, 2000-3000 g = 3.5 ETT • 38-42 wks, > 3000 g = 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

29. Endotracheal Intubation

30. 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 airway

31. 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

32. Key Points • Appropriate resuscitation requires a rapid series of assessments, interventions, and reassessments • 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 infants