implementing the new guidelines for neonatal...

Implementing Implementing New Guidelines New Guidelines

for Neonatal for Neonatal ResuscitationResuscitation

Susan Susan NiermeyerNiermeyer, MD, FAAP, MD, FAAPUniversity of Colorado at Denver and Health Sciences CenterUniversity of Colorado at Denver and Health Sciences Center

Denver, Colorado, USADenver, Colorado, USA

Changes in 2006 Neonatal Changes in 2006 Neonatal Resuscitation ProgramResuscitation Program

Rapid assessment criteria

Temperature control in preterm infants

Intrapartum suctioning with meconium-stained amniotic fluid

Use of free-flow oxygen

Variable oxygen concentrations for positive-pressure ventilation

Initial ventilation strategies

Route of administration and dosage of epinephrine

2006 Guideline Revisions2006 Guideline Revisions

•• IntrapartumIntrapartum suctioning with suctioning with meconiummeconium--stained amniotic fluidstained amniotic fluid

•• Use of oxygen concentrations Use of oxygen concentrations between 21% and 100% for positivebetween 21% and 100% for positive--pressure ventilation (PPV)pressure ventilation (PPV)

•• Route of administration and dosage Route of administration and dosage for epinephrine during persistent for epinephrine during persistent bradycardiabradycardia or or asystoleasystole

MeconiumMeconium--stained Fluidstained Fluid

MeconiumMeconium--stained fluidstained fluidCase #1Case #1•• Term, uncomplicated pregnancyTerm, uncomplicated pregnancy•• Reassuring fetal heart rate Reassuring fetal heart rate

monitoring during active labormonitoring during active labor•• Rupture of membranes with Rupture of membranes with

complete cervical dilation yielding complete cervical dilation yielding moderately moderately meconiummeconium--stained fluidstained fluid

•• Late decelerations to 80 Late decelerations to 80 bpmbpm

MeconiumMeconium--stained fluidstained fluid

Case #1 Case #1 –– Questions for AnalysisQuestions for Analysis•• Who should be present at delivery?Who should be present at delivery?•• What steps will be carried out during What steps will be carried out during

delivery?delivery?•• What criteria will guide resuscitation What criteria will guide resuscitation

of the infant?of the infant?


IntrapartumIntrapartum suctioningsuctioning–– DeLeeDeLee suctionsuction–– Bulb suctionBulb suction–– Wiping nose and Wiping nose and

mouthmouth

Goal: maximize removal of meconium and minimize vagal bradycardia

MeconiumMeconium--stained fluidstained fluidIntrapartumIntrapartum suctioningsuctioning•• Equivalence of bulb Equivalence of bulb

vs. vs. DeLeeDeLee suction on suction on perineumperineum

•• CohenCohen--AddadAddad et al. et al. 1987 1987

•• Locus et al. 1990Locus et al. 1990

•• Elimination of Elimination of suctioning on suctioning on perineumperineum

•• Vain et al. 2002 and Vain et al. 2002 and 20042004

IntrapartumIntrapartum Suction to Prevent MASSuction to Prevent MASVain NE et al. Lancet 2004; 364:597

•• RCT comparing RCT comparing perinealperineal suction to no suction to no suction with suction with meconiummeconium--stained amniotic fluid stained amniotic fluid (level 1)(level 1)–– 2514 infants2514 infants–– No significant differences in incidence of MAS No significant differences in incidence of MAS

(3.6% in suctioned vs. 3.5% in not)(3.6% in suctioned vs. 3.5% in not)–– No difference in need for mechanical ventilation or No difference in need for mechanical ventilation or

mortality, duration of treatmentmortality, duration of treatment

MeconiumMeconium--stained fluidstained fluid2006 Guideline2006 GuidelineRoutine Routine intrapartumintrapartum suctioning for suctioning for infants with infants with meconiummeconium--stained stained amniotic fluid is no longer amniotic fluid is no longer recommended recommended

–– However, However, intrapartumintrapartum suctioning is not suctioning is not prohibitedprohibited•• HighHigh--risk groups (thick risk groups (thick meconiummeconium, fetal , fetal

heart rate abnormalities, fetal heart rate abnormalities, fetal acidosis/asphyxia)acidosis/asphyxia)

MeconiumMeconium--stained fluid stained fluid Case #1 Case #1 -- AnalysisAnalysis•• PersonnelPersonnel

–– One person to attend motherOne person to attend mother–– Second person capable of Second person capable of intubationintubation

•• DeliveryDelivery–– Routine managementRoutine management–– No excessive stimulationNo excessive stimulation

•• ResuscitationResuscitation–– Assessment of vigor (breathing, tone, Assessment of vigor (breathing, tone,

heart rate)heart rate)–– IntubationIntubation vs. expectant managementvs. expectant management


PostpartumPostpartumVigor of infant, not Vigor of infant, not

consistency of consistency of meconiummeconiumdetermines determines managementmanagement–– Respiratory effortRespiratory effort–– Good muscle toneGood muscle tone–– Heart rate > 100 Heart rate > 100

bpmbpm

Suctioning Suctioning MeconiumMeconium

Click on the image to play videoClick on the image to play video


Case #1 Case #1 -- AnalysisAnalysisSkills and organizationSkills and organization•• Alerting personnel to new risk factorAlerting personnel to new risk factor•• Evaluation of need to suction on Evaluation of need to suction on

perineumperineum•• Immediate availability of personnel Immediate availability of personnel

capable of capable of intubationintubation•• Monitoring of infant after deliveryMonitoring of infant after delivery

Oxygen Concentration for PPVOxygen Concentration for PPV

Case #2Case #2•• Premature, prolonged rupture of Premature, prolonged rupture of

membranes at 31 weeksmembranes at 31 weeks•• BetamethasoneBetamethasone (48 hours), antibiotic (48 hours), antibiotic

treatment to prolong latencytreatment to prolong latency•• After 4 days, maternal After 4 days, maternal leukocytosisleukocytosis

and contractionsand contractions•• Augmentation of labor Augmentation of labor

Oxygen concentration for PPVOxygen concentration for PPV

Case #2 Case #2 –– Questions for AnalysisQuestions for Analysis•• Who should be present at delivery?Who should be present at delivery?•• What equipment should be What equipment should be

prepared?prepared?•• What will be the initial approach to What will be the initial approach to

ventilation (oxygen concentration ventilation (oxygen concentration and method of PPV)?and method of PPV)?

Oxygen concentration for PPVOxygen concentration for PPVDavis PG et al. Lancet 2004; 364:1329 and Tan A et al. The Cochrane Database of Systematic Reviews 2005; Issue 2

MetaMeta--analysis of 21% vs. 100% oxygenanalysis of 21% vs. 100% oxygen•• Onset of regular breathing faster with Onset of regular breathing faster with

21% oxygen21% oxygen•• Minimal difference in Minimal difference in ApgarApgar scoresscores•• Reduced odds of death by 28 days Reduced odds of death by 28 days

among infants resuscitated with 21% among infants resuscitated with 21% oxygen oxygen

Ramji S et al. Pediatr Res 1993; 34:809Saugstad O et al. Pediatrics 1998; 102(1):e1Vento M et al. Pediatrics 2001; 107:642Vento M et al. J Pediatr 2003; 142:240Ramji S et al. Indian Pediatrics 2003; 40:510

Oxygen Concentration for PPVOxygen Concentration for PPV2006 Guideline2006 Guideline• Supplementary oxygen is recommended

whenever positive-pressure ventilation is indicated for resuscitation.

• There is insufficient evidence to specify the concentration of oxygen to be used at the initiation of resuscitation.– 100% - standard approach– < 100% - acceptable alternative– 21% - acceptable alternative


2006 Guideline2006 Guideline•• Lung inflation/ventilation should be the Lung inflation/ventilation should be the

priority.priority.•• Excessive tissue oxygen may cause Excessive tissue oxygen may cause

oxidant injury and should be avoided, oxidant injury and should be avoided, especially in the premature infant.especially in the premature infant.

•• Where supplementary oxygen is not Where supplementary oxygen is not available, PPV should be administered available, PPV should be administered with room air.with room air.

Oxygen concentration for PPVOxygen concentration for PPVCase #2 Case #2 -- AnalysisAnalysis•• PersonnelPersonnel

–– PerinatologistPerinatologist–– Pediatrician(sPediatrician(s), ), nurse(snurse(s), respiratory therapist), respiratory therapist–– Clearly assigned rolesClearly assigned roles

•• Equipment for PPVEquipment for PPV–– Oxygen blender, pulse Oxygen blender, pulse oximeteroximeter–– Bag and mask or TBag and mask or T--piece device (PEEP, CPAP)piece device (PEEP, CPAP)–– EndotrachealEndotracheal intubationintubation, surfactant, surfactant–– OrogastricOrogastric tubetube

Equipment for PPVEquipment for PPV

TT--piece Resuscitator: piece Resuscitator: Adjusting Pressure SettingsAdjusting Pressure Settings

Click on the image to play videoClick on the image to play video

Oxygen Concentration for PPVOxygen Concentration for PPVSaO2 in the first minutes after birthSaO2 in the first minutes after birth

Mariani G. J Pediatr 2007; 150:418

Oxygen Concentration for PPV Oxygen Concentration for PPV SaO2 in the first minutes after birthSaO2 in the first minutes after birth

Kamlin COF et al. J Pediatr 2006; 148:585

Oxygen concentration for PPVOxygen concentration for PPV

Case #2 Case #2 -- AnalysisAnalysisSkills and organizationSkills and organization•• Sharing information about highSharing information about high--risk risk

patientspatients•• Assembling a team of skilled personnelAssembling a team of skilled personnel•• Specialized equipment in centers Specialized equipment in centers

providing care to providing care to prematuresprematures and highand high--risk patientsrisk patients

•• Continuous feedback and adjustment Continuous feedback and adjustment during resuscitation on the basis of heart during resuscitation on the basis of heart rate and saturationrate and saturation

Epinephrine for Epinephrine for BradycardiaBradycardia

Case #3Case #3•• Pregnant woman at 37 weeks injured Pregnant woman at 37 weeks injured

in a motor vehicle accidentin a motor vehicle accident•• In emergency triage, heavy vaginal In emergency triage, heavy vaginal

bleeding and sinusoidal fetal heart bleeding and sinusoidal fetal heart rate pattern with baseline 90 rate pattern with baseline 90 bpmbpm

•• Emergency cesarean sectionEmergency cesarean section


Case #3 Case #3 –– Questions for AnalysisQuestions for Analysis•• Who should be present at delivery?Who should be present at delivery?•• What equipment should be What equipment should be

prepared?prepared?•• What other services should be What other services should be

involved?involved?

Epinephrine for BradycardiaEpinephrine for BradycardiaVentilation is the key to successful neonatal resuscitation

Provided that arterial blood pressure is above a critical value

••Positive pressure ventilation Positive pressure ventilation alone is effective for alone is effective for resuscitation of apneic, resuscitation of apneic, bradycardic, asphyxiated bradycardic, asphyxiated newborn animalsnewborn animals

••The first sign of successful The first sign of successful resuscitation is an increase in resuscitation is an increase in heart rateheart rate

Dawes GS et al. J Physiol 1963; 169:167


Wyckoff MH et al. Pediatr 2006; 118:1028


2006 Guideline2006 Guideline•• Intravenous administration of epinephrine Intravenous administration of epinephrine

0.01 0.01 –– 0.03 mg/kg/dose is the preferred 0.03 mg/kg/dose is the preferred route (Class route (Class IIaIIa).).

•• While access is being obtained, While access is being obtained, administration of a higher dose (up to 0.1 administration of a higher dose (up to 0.1 mg/kg) through the mg/kg) through the endotrachealendotracheal tube may tube may be considered.be considered.

Epinephrine for Epinephrine for BradycardiaBradycardiaCase #3 Case #3 -- AnalysisAnalysis•• PersonnelPersonnel

–– Obstetrician/Obstetrician/perinatologistperinatologist + general surgeon+ general surgeon–– Pediatrician/Pediatrician/neonatologistneonatologist, nurses, respiratory , nurses, respiratory

therapisttherapist•• EquipmentEquipment

–– IntubationIntubation, pulse , pulse oximetryoximetry–– Umbilical venous catheter, saline, epinephrineUmbilical venous catheter, saline, epinephrine

•• Other servicesOther services–– Blood bankBlood bank–– RadiologyRadiology

Epinephrine for Epinephrine for BradycardiaBradycardiaCase #3 Case #3 ResuscitationResuscitation•• Bloody amniotic fluid Bloody amniotic fluid ––

limp, hr 30 limp, hr 30 bpmbpm, pale, pale•• Initial stepsInitial steps•• PPV, no reading on pulse PPV, no reading on pulse

oximeteroximeter•• IntubationIntubation –– hr 30 hr 30 bpmbpm•• EndotrachealEndotracheal epinephrineepinephrine•• UVC UVC –– epinephrine, volumeepinephrine, volume

Umbilical Vein Catheter InsertionUmbilical Vein Catheter Insertion


Case #3 Case #3 -- AnalysisAnalysis•• Communicating among emergency Communicating among emergency

services, obstetrics, pediatricsservices, obstetrics, pediatrics•• Assembling an expanded team for Assembling an expanded team for

neonatal resuscitationneonatal resuscitation•• Preparing equipment/drugs in Preparing equipment/drugs in

advanceadvance•• Blood banking Blood banking –– trauma bloodtrauma blood

Implementing New Guidelines Implementing New Guidelines for Neonatal Resuscitationfor Neonatal Resuscitation

•• Teach new knowledge and skillsTeach new knowledge and skills–– Assessment, decisionAssessment, decision--making, actionmaking, action

•• Identify necessary changes in Identify necessary changes in processprocess–– Personnel, equipment, communicationPersonnel, equipment, communication

•• Initiate new routines systematicallyInitiate new routines systematically–– Rehearse, launch, evaluateRehearse, launch, evaluate

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