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Neonatal Resuscitation

by James W. Kendig, MD, Ursula Nawab, MD

About 10% of neonates require some respiratory assistance at birth. Less than 1% need extensive resuscitation. Causes are numerous (see Table: Problems in the Neonate That May Require Resuscitation), but most involve asphyxia or respiratory depression. Incidence rises significantly if birth weight is < 1500 g.

Problems in the Neonate That May Require Resuscitation

Problems

Possible Causes

Failure to breathe

Antepartum mechanism

Diabetes

Intrauterine growth restriction

Maternal toxemia

Renovascular hypertension

Recent intrapartum asphyxia

Cord compression

Cord prolapse

Fetal exsanguination

Maternal hypotension

Placenta previa

Placental abruption

Uterine tetany

CNS depression

Congenital abnormalities of the brain stem

Intracerebral hemorrhage

Spinal cord injury

Drugs

Analgesics or hypnotics

Anesthetics

Mg

Opioids, maternal drug abuse

Failure to expand the lungs

Airway obstruction

Blood

Meconium

Mucus

Prematurity (respiratory distress syndrome)

Malformations involving the respiratory tract

Agenesis

Diaphragmatic hernia

Hypoplasia

Stenosis or atresia

Assessment

The Apgar score is used at birth to evaluate a newborn's condition and possible need for resuscitation; it was not initially intended to determine long-term neurologic prognosis. The Apgar score assigns 0 to 2 points for each of 5 measures of neonatal health (Appearance, Pulse, Grimace, Activity, Respiration—see Table: Apgar Score). Scores depend on physiologic maturity, maternal perinatal therapy, and fetal cardiorespiratory and neurologic conditions. A score of 7 to 10 at 5 min is considered normal; 4 to 6, intermediate; and 0 to 3, low. A low Apgar score is not by itself diagnostic of perinatal asphyxia but is associated with a risk of long-term neurologic dysfunction. A persistently low Apgar score (0 to 3 at 5 min) is associated with increased neonatal mortality.

Apgar Score

Score*

Criteria

Mnemonic

0

1

2

Color

A ppearance

All blue, pale

Pink body, blue extremities

All pink

Heart rate

P ulse

Absent

< 100 beats/min

> 100 beats/min

Reflex response to nasal catheter/tactile stimulation

G rimace

None

Grimace

Sneeze, cough

Muscle tone

A ctivity

Limp

Some flexion of extremities

Active

Respiration

R espiration

Absent

Irregular, slow

Good, crying

*A total score of 7–10 at 5 min is considered normal; 4–6, intermediate; and 0–3, low.

The earliest sign of asphyxia is cyanosis, followed by decreases in respiration, muscle tone, reflex response, and heart rate. Effective resuscitation leads initially to increased heart rate, followed by improved reflex response, color, respiration, and muscle tone. Evidence of intrapartum fetal distress, persistence of an Apgar score of 0 to 3 for > 5 min; an umbilical arterial blood pH < 7; and a sustained neonatal neurologic syndrome that includes hypotonia, coma, seizures, and evidence of multiorgan dysfunction are manifestations of hypoxic ischemic encephalopathy. The severity and prognosis of posthypoxic encephalopathy can be estimated with the Sarnat classification (see Table: Clinical Staging of Posthypoxic Encephalopathy) in conjunction with EEG, neuroradiologic imaging, and brain stem auditory and cortical evoked responses.

Clinical Staging of Posthypoxic Encephalopathy

Factor

Stage I (Mild)

Stage II (Moderate)

Stage III (Severe)

Duration

< 24 h

2–14 days

Hours to weeks

Level of consciousness

Hyperalertness and irritability

Lethargy

Deep stupor or coma

Muscle tone

Normal

Hypotonia or proximal limb weakness

Flaccidity

Tendon reflexes

Increased

Increased

Depressed or absent

Myoclonus

Present

Present

Absent

Complex reflexes

Sucking

Active

Weak

Absent

Moro response

Exaggerated

Incomplete

Absent

Grasping

Normal to exaggerated

Exaggerated

Absent

Oculocephalic (doll’s eye)

Normal

Overreactive

Reduced or absent

Autonomic function

Pupils

Dilated

Constricted

Variable or fixed

Respiration

Regular

Variable in rate and depth, periodic

Irregular apnea

Heart rate

Normal or tachycardic

Low resting < 120 beats/min

Bradycardia

Seizures

None

Common (70%)

Uncommon

EEG

Normal

Low voltage, periodic or paroxysmal, epileptiform activity

Periodic or isoelectric

Risk of death

< 1%

5%

> 60%

Risk of severe handicap

< 1%

20%

> 70%

Adapted from Sarnat HB, Sarnat MS: Neonatal encephalopathy following fetal distress. Archives of Neurology 33:696–705, 1975.

Resuscitation

Initial measures for all neonates include providing warmth, drying, and stimulating breathing (eg, flicking the soles of the feet, rubbing the back). If there is obvious obstruction to spontaneous breathing, the airway is cleared using bulb suction or a suction catheter. Suctioning has not proved beneficial in infants without obvious obstruction, even if amniotic fluid was stained with meconium (suctioning was previously recommended in such infants). If deep suctioning is required, appropriately sized catheters and pressure limits of 100 mm Hg (136 cm H 2 O) must be used. Infants not responding with appropriate respirations and heart rate may require positive pressure ventilation (PPV), O 2 therapy, and, less commonly, chest compressions.

The infant is quickly dried and placed supine under a preheated overhead warmer in the delivery room. The neck is supported in the neutral position (sniffing position) to maintain an open airway.

If spontaneous respirations are absent, the infant is gasping, or heart rate is < 100 beats/min, respirations are assisted with PPV via mask, or sometimes laryngeal mask airway or endotracheal tube. Note that infants with a sunken, convex (scaphoid) abdomen may have a congenital diaphragmatic hernia, in which case ventilation using a mask can be dangerous; if such infants require ventilatory assistance, they should undergo endotracheal intubation. O 2 saturation is monitored using a pulse oximeter placed to measure preductal saturation (typically on the right hand or wrist). Resuscitation should be started with room air or a blend of O 2 and air and titrated to achieve O 2 saturations within the target range, which increases over the first 10 min of life (see Table: Neonatal Oxygen Saturation Targets). Inspiratory and end-expiratory pressures should be monitored and kept at the lowest level necessary to maintain heart rate > 100 beats/min. It is particularly important to keep pressures low in extremely premature and/or extremely low-birth-weight infants, whose lungs are easily injured by PPV.

Neonatal Oxygen Saturation Targets

Time After Delivery

Preductal* SpO 2

1 min

60–65%

2 min

65–70%

3 min

70–75%

4 min

75–80%

5 min

80–85%

≥ 10 min

85–95%

*The right upper extremity receives preductal blood.

SpO 2 = O 2 saturation.

Bradycardia (heart rate < 60) in a distressed child is a sign of impending cardiac arrest; neonates tend to develop bradycardia with hypoxemia. If bradycardia persists > 90 sec, O 2 concentration is increased to 100% until recovery. If heart rate is < 60 despite adequate ventilation for 30 sec, begin chest compressions using a 3:1 compression:ventilation ratio (see Figure: Algorithm for resuscitation of neonates.). Advanced resuscitation techniques, including endotracheal intubation, and selection of equipment size, drugs and dosages, and CPR parameters are discussed elsewhere (see Cardiopulmonary Resuscitation in Infants and Children).

Algorithm for resuscitation of neonates.

*PPV: Initiate resuscitation with room air. If SpO 2 targets are not achieved, titrate inhaled O 2 concentration upward. If HR is < 60 beats/min after 90 sec of resuscitation with a lower O 2 concentration, increase O 2 concentration to 100% until normal HR is recovered.

For SpO 2 monitoring targets.

3:1 compression:ventilation ratio with a total of 90 compressions and 30 breaths/min. Compressions and ventilations are delivered sequentially, not simultaneously. Thus, give 3 compressions at a rate of 120/min, followed by 1 ventilation over 1/2 sec.

HR = heart rate; PPV = positive pressure ventilation; SpO 2 = O 2 saturation.

Adapted from Perlman JM, Wyllie J, Kattwinkel J, et al: American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science, part 15: neonatal resuscitation. Circulation122(supplement 2):S516–38, 2010.

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