Neonatal Resuscitation and Pediatric Advanced Life Support - 2nd Edition

Educational Objectives

Summary

Neonatal Resuscitation and Pediatric Advanced Life Support

M. Concetta Lupa, MD, Assistant Professor Anesthesiology and Pediatrics, University of North Carolina Children’s Hospital, Chapel Hill, North Carolina

Neonatal resuscitation

Neonatal Resuscitation Program: learning program instituted in 1987; ensure at least 1 person trained in neonatal resuscitation techniques present at every hospital birth; practice recommendations — ensure adequate ventilation of neonate while avoiding lung injury, hypoxia, and hyperoxia; guidelines underwent major changes in 2011

Identifying neonates requiring resuscitation: if infant at term, breathing or crying, with good tone, should remain with mother, where further stabilization and assessment take place; if above criteria not met, continue to initial steps of resuscitation and evaluation

Apgar scores: gathered on infants at time of birth; objective measurements to convey information about overall status in response to resuscitation; not used to determine need for resuscitation or necessary steps in resuscitation; initial Apgar score given 1 minute after birth; resuscitation (if required) must proceed prior to first Apgar score

Neonatal resuscitation guidelines: airway, breathing, circulation, and drug (ABCD)

Airway: ensure baby warm; place under radiant warmer on resuscitation table and position head to open airway; ensure airway clear; if no meconium present, remove secretions by wiping nose and mouth with towel or by suctioning with bulb syringe or suction catheter (may need to turn to baby’s head to side for copious secretions); suction mouth before nose to help prevent aspiration; if meconium present, determine whether baby vigorous (normal respiratory effort, normal muscle tone, and heart rate >100 beats/minute [bpm]); if vigorous, use bulb syringe or large-bore suction catheter to clear secretions from mouth and nose as needed; if not vigorous, intubation required to suction trachea; use laryngoscope, suction as needed, and insert endotracheal tube; attach endotracheal tube to suction source, suction for approximately 3 seconds, then withdraw tube while continuing to suction; positioning and suctioning secretions usually provides enough stimulation to initiate breathing; drying may help provide stimulation and protects against heat loss; discard wet towels and keep baby on warm dry towels

Breathing: if baby apneic or bradycardic with heart rate <100 bpm, provide positive pressure ventilation; if breathing but persistent respiratory stress, deliver continuous positive airway pressure (CPAP) by mask; attach pulse oximeter on hypothenar eminence of right arm to determine need for supplemental oxygen; skin color (especially in central part of body) provides most rapid and visible indicator of oxygenation; supplemental oxygen not routinely needed at beginning of resuscitation; current recommendations use oxygen blender to administer <100% oxygen; controversy surrounds amount of oxygen during neonatal resuscitation; 2010 guidelines recommend starting with 21% oxygen and increasing as needed, guided by oximetry to achieve saturations of 60% to 90%; if blender not available, start resuscitation with room air or self-inflating bag without reservoir to deliver approximately 40% inspired oxygen; recommended rate of positive pressure ventilation 40 to 60 breaths/minute; after 30 seconds CPAP, reevaluate; if heart rate <100 and >60, continue to administer positive pressure ventilation as long as improvement shown; consider inserting orogastric tube if ventilation continues (due to inflation of air in stomach); if heart rate <60 bpm, proceed to step C

Circulation: supported with chest compressions; endotracheal intubation recommended (if not already in place); ensure effective ventilation; confirm endotracheal tube placement with end-tidal CO2 monitor, then determine other complications (eg, pneumothorax or hypovolemia); if heart rate <60 bpm, start chest compressions; continue ventilation; thumb technique — use 2 thumbs to depress sternum while hands encircle torso and fingers support spine; 2-finger technique — use tips of middle finger and index or ring finger of 1 hand to compress sternum, supporting baby’s back with other hand; thumb technique preferred because depth of compression better controlled and pressure more consistent; apply pressure to lower third of sternum between xiphoid and line drawn between nipples; do not put pressure directly on xiphoid (may cause fracture or further damage); compress to depth approximately 1/3 anterior/posterior diameter of chest, then release; downward stroke of compression shorter than duration of release; target 30 breaths and 90 compressions per minute, ensuring compression and breath do not occur simultaneously; reassess 45 to 60 seconds after chest compressions start; once heart rate ≥60 bpm, stop chest compressions and deliver ventilation 40 to 60 breaths/minute; once baby begins to breath spontaneously and heart rate >100, slow rate of ventilation and decrease positive pressure ventilation; if baby not improving, determine whether ventilation and chest compressions adequate and appropriately coordinated; if heart rate <60, consider administering epinephrine; intubate (if not already done); consider laryngeal mask airway in difficult tube placement

Drug: placement of line in umbilical vein by skilled provider; if intravenous (IV) access not established when epinephrine deemed necessary, administer via endotracheal tube; limited data for interosseous approach (use as last resort); recommended IV dose for newborns 10 to 30 μg/kg; dose through endotracheal tube 50 to 100 μg/kg; check heart rate 1 minute after epinephrine administered; repeat dose every 3 to 5 minutes if heart rate not >60 bpm; if not good response, consider other complications such as hypovolemia (most common); treat hypovolemia with isotonic crystalloid in normal saline or Ringer’s lactate; if severe fetal anemia documented or suspected (eg, placenta previa), consider O-negative emergency release blood, starting with dose of 10 mL/kg

Considerations for premature infants: call for assistance early; prevent heat loss by warming room and having transport incubator ready; consider polyethylene plastic wrap for babies delivered <29 weeks gestation; saturation range should be 60% at 1 minute, 80% at 5 minutes, and 90% at 10 minutes; if using positive pressure ventilation, use lowest inflation pressure necessary to achieve adequate response; use positive end-expiratory pressure for intubation (2-5 cm of water sufficient); consider giving surfactant if baby <30 weeks gestation; handle babies gently to decrease chance of neurologic injury; avoid head-down position; avoid excessive pressure when using positive pressure ventilation or CPAP; use oximeter and blood gases to adjust ventilation and oxygen concentration gradually and appropriately; never give rapid infusions of fluid

Postresuscitation management: move to higher-intensity care; obtain arterial blood gas to estimate extent of compromise from resuscitation; risks include pneumonia, pulmonary hypertension, metabolic acidosis, hypotension, seizures, apnea, renal dysfunction, hypoglycemia, feeding problems, and temperature instability

Therapeutic hypothermia: temperature 33.5° to 34.5° C; shown in some studies to improve neurologic outcomes in late preterm and term babies with moderate to severe hypoxic ischemic encephalopathy; criteria — gestational age ≥36 weeks; evidence of acute perinatal hypoxic ischemic event; ability to initiate hypothermia within 6 hours after birth

Pediatric advanced life support

Cardiac arrest: most commonly caused by respiratory problems; early identification and treatment critical

Upper airway obstruction: occurs outside of thorax; causes — swelling, infection, aspirated foreign body, anatomic variances (large tongue or small chin), or poor control of upper airway due to decreased level of consciousness; infants and children at great risk for upper airway obstruction due to anatomy; treatment — optimize position of airway using jaw thrust or chin lift; use suction; use medications such as dexamethasone to reduce airway swelling; if severe, call for assistance early; recognize when airway adjunct (oral airway or nasal trumpet) or intubation needed; decide whether tracheostomy or cricothyroidotomy needed; croup — treat with steroids, racemic nebulized epinephrine, or heliox (in severe circumstances); anaphylaxis — treat with epinephrine and albuterol nebulizer; foreign body airway obstruction — manual techniques; if child <1 year, give 5 back slaps followed by 5 chest thrusts; child >1 year, give abdominal thrusts; be prepared to start cardiopulmonary resuscitation (CPR) in unresponsive child; blind finger sweep no longer recommended, as it may push foreign body further into airway

Lower airway obstruction: causes — bronchiolitis, pneumonia, acute asthma; treatment — for bronchiolitis, have suction available; nebulizer therapy can be considered, but may not be helpful; supplemental oxygen may be necessary; for pneumonia, give oxygen and antibiotics plus inhaled albuterol if wheezing present; acute asthma may require oxygen, albuterol, and in severe cases, steroids, magnesium, or positive pressure ventilation

Shock: types — hypovolemic, distributive, cardiogenic, obstructive; thorough evaluation should be undertaken; cause of cardiac arrest should guide treatment

Changes to Pediatric Advanced Life Support guidelines: high-quality CPR stressed; 2010 American Heart Association Guidelines for CPR in Emergency Cardiovascular Care recommended change in CPR sequence from ABC to CAB, primarily affecting single rescuers who perform actions in sequence; when multiple care providers present, many actions performed simultaneously; if resuscitation leads to shockable rhythm, deliver 1 unsynchronized shock and perform CPR while defibrillator charging; for manual defibrillation, initial dose of 2 to 4 J acceptable; do not exceed 10 J/kg, or maximum adult dose; if ventricular fibrillation or ventricular tachycardia persist, administer epinephrine once IV or intraosseous while compressions continue; dose of intraosseous or IV epinephrine 10 μg/kg; dose for endotracheal administration 100 μg/kg; guidelines do not state specific time for delivery of first epinephrine dose after ventricular fibrillation or ventricular tachycardia shock; immediate delivery not recommended because may not be necessary

Changes to 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science: compressions — rescuers unable or unwilling to provide ventilations should be encouraged to perform compression-only CPR; rescuers should compress at least 1/3 anterior/posterior dimension of chest (approximately 4 cm in most infants and 5 cm in most children); shocks — when shocks indicated for ventricular fibrillation or pulseless ventricular tachycardia in infants and children, initial energy dose 2 to 4 J/kg reasonable; if not effective, >4 J/kg may be safe and effective (especially if delivered with biphasic defibrillator); tracheal tubes — more data support safety and effectiveness of cuffed tracheal tubes in infants and young children; formula for selecting appropriate tube updated; cricoid pressure — safety and value during emergency intubation not clear; cricoid pressure should be modified or even discontinued if impeding ventilation or speed or ease of intubation; monitoring — capnography or capnometry recommended to confirm proper endotracheal position and may be helpful during CPR to ensure quality of chest compressions; oxygen — once spontaneous circulation restored, inspired oxygen concentration should be titrated to limit risk for hyperoxemia

Postresuscitation care: hemodynamic compromise may result from inadequate intervascular volume, decreased cardiac contractility, increased systemic vascular or pulmonary vascular resistance, or low systemic vascular resistance in children with early septic shock; support of systemic perfusion often necessary; manipulate preload, contractility, afterload, and heart rate as necessary; optimize ventilation and oxygenation by titrating fraction of inspired oxygen to achieve saturation 94% to 99%; assess and treat persistent shock; consider boluses of isotonic crystalloid; may need to administer 20 mL/kg or less (if cardiac function compromised); consider administering inotropic or vasopressor support when fluids not adequate; evaluate possible contributing factors including hypovolemia, hypoxemia, hydrogen ions, hypoglycemia, hypokalemia, hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (coronary or pulmonary), and trauma; during and after resuscitation, monitor and treat agitation, seizures, and hypoglycemia; assess blood gases, electrolytes, and calcium; if patient unresponsive after resuscitation from cardiac arrest, consider therapeutic hypothermia at 32° to 34° C; transport to tertiary care center; administer sedation and analgesia to all responsive intubated patients; use caution with sedatives in patients who are hemodynamically unstable

Questions and answers

Managing metabolic acidosis after resuscitation: use of sodium bicarbonate controversial; if given too early in resuscitation, can increase serum pH but worsen intracellular acidosis; if sodium bicarbonate required, administer in large vein; standard dose 2 mEq/kg very slowly (no faster than 1 mEq/kg/minute)

Consensus on use of vasopressin in children: little evidence for or against routine use of vasopressin in children during cardiac arrest; when epinephrine fails to return spontaneous circulation, vasopressin has sometimes been shown to help; large pediatric national registry suggested vasopressin therapy associated with lower return of spontaneous circulation and trend toward lower 24-hour and discharge survival rates; use caution when giving vasopressin; give only in dire circumstances

Readings

Disclosures

Acknowledgements

CME/CE INFO

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Lecture ID:

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