Overview
Definition:
Neonatal resuscitation is a set of interventions performed immediately after birth to support infants who are not breathing spontaneously or who have inadequate ventilation
It is a critical component of neonatal care aimed at preventing mortality and morbidity
Temperature management is an integral part of resuscitation and post-resuscitation care to maintain normothermia, as neonates are particularly vulnerable to heat loss and cold stress.
Epidemiology:
Approximately 10% of newborns require some form of resuscitation at birth, while about 1% require positive-pressure ventilation or chest compressions
Prematurity, intrapartum events like meconium aspiration, and congenital anomalies are common reasons for requiring resuscitation
Hypothermia is common in newborns due to immature thermoregulation and large surface area to mass ratio.
Clinical Significance:
Effective neonatal resuscitation can prevent hypoxic-ischemic brain injury, organ damage, and death
Maintaining normothermia is crucial as hypothermia increases metabolic rate, oxygen consumption, and the risk of intraventricular hemorrhage, hypoglycemia, and mortality
Conversely, hyperthermia can also be detrimental
Proper technique and prompt intervention are paramount for optimal outcomes and are frequently tested in DNB and NEET SS examinations.
Initial Assessment And Steps
Assessment At Birth:
Assess breathing effort, muscle tone, and heart rate at birth
If the infant is term, has good muscle tone, and is breathing or crying, routine care is provided
If apneic or gasping, with poor muscle tone, positive-pressure ventilation (PPV) is indicated
A heart rate below 100 bpm also requires PPV.
Positive Pressure Ventilation Ppv:
Initiate PPV with a rate of 40-60 breaths per minute
Ensure a good mask seal and watch for chest rise
If the heart rate remains below 60 bpm despite effective PPV, consider chest compressions.
Chest Compressions:
If the heart rate is less than 60 bpm despite 30 seconds of effective PPV, initiate chest compressions using a 3:1 compression-to-ventilation ratio (90 compressions: 30 breaths per minute)
Continue until spontaneous circulation returns or the infant stabilizes.
Medications And Fluids:
Epinephrine is the primary drug for bradycardia (HR < 60 bpm despite CPR)
It is administered intravenously or intraosseously
Volume expansion with normal saline may be considered for presumed hypovolemia
Sodium bicarbonate, naloxone, and surfactant are used in specific circumstances.
Airway Management:
For infants not responding to PPV, consider intubation for more effective ventilation, administration of medications, or management of airway obstruction
Use of suctioning should be judicious and only if there is obvious obstruction.
Temperature Management
Importance Of Normothermia:
Neonates have limited ability to regulate body temperature, making them susceptible to hypothermia and hyperthermia
Maintaining a core body temperature between 36.5°C and 37.5°C is vital for metabolic stability, oxygen consumption, and reducing complications.
Prevention Of Heat Loss:
Prevent heat loss by drying the infant immediately after birth, removing wet linen, placing the infant skin-to-skin with the mother, and covering with a dry blanket
Use a radiant warmer for infants requiring resuscitation or separated from their mother.
Monitoring Temperature:
Continuous temperature monitoring using a rectal or esophageal probe is recommended, especially for infants requiring resuscitation or those at risk for temperature instability
Axillary and skin probes are less accurate for core temperature.
Management Of Hypothermia:
For hypothermic infants (rectal temp < 36.5°C), gradually rewarm using a radiant warmer or incubator with controlled temperature settings
Avoid rapid rewarming, which can cause complications
Target a gradual increase of 0.5-1°C per hour.
Management Of Hyperthermia:
Hyperthermia (rectal temp > 37.5°C) can occur due to excessive external heat or immaturity
Reduce external heat sources, remove blankets, and promote evaporation
In severe cases, a tepid sponge bath may be considered, but caution is advised to avoid chilling.
Resuscitation Algorithm And Guidelines
Neonatal Resuscitation Program Nrp:
The Neonatal Resuscitation Program (NRP) guidelines, developed by the American Academy of Pediatrics and the American Heart Association, provide a standardized approach to neonatal resuscitation
These guidelines are updated periodically based on the latest evidence.
Initial Steps In Algorithm:
The NRP algorithm begins with the assessment of term gestation, muscle tone, and crying
If any of these are absent, the infant requires PPV
The algorithm then guides decisions on chest compressions and medications based on heart rate.
Steps For Inadequate Respiratory Effort:
If the infant is apneic or gasping, PPV is initiated
If the heart rate is <100 bpm, PPV is continued
If the heart rate is <60 bpm despite 30 seconds of effective PPV, chest compressions are started
If the heart rate is >60 bpm, PPV is continued.
Guidelines For Temperature Management:
Current guidelines emphasize active warming for hypothermic infants and avoiding overheating
Skin-to-skin contact and radiant warmers are key interventions for maintaining normothermia
Monitoring is crucial for infants at risk.
Common Challenges And Pearls
Mask Seal And Ventilation:
Achieving a good mask seal is critical for effective PPV
Use the correct size mask and a C- or E-shaped hand position
Chest rise is the primary indicator of effective ventilation.
Chest Compression Technique:
Use the two-thumb encircling hand technique for infants, with compressions covering the lower third of the sternum
Ensure adequate depth (approximately one-third of the anteroposterior chest diameter) and rate (100-120 compressions per minute).
Recognizing Bradycardia:
Persistent bradycardia (HR < 60 bpm) despite effective PPV is an indication for chest compressions and epinephrine
Careful monitoring of heart rate is essential.
Post Resuscitation Care:
After successful resuscitation, continued monitoring of cardiorespiratory status, temperature, and glucose levels is crucial
Therapeutic hypothermia may be indicated for neonates with hypoxic-ischemic encephalopathy, following specific protocols.
Team Communication:
Effective communication among the resuscitation team is vital
Clear roles, closed-loop communication, and debriefing after events improve outcomes and learning.
Key Points
Exam Focus:
Understand the stepwise approach to neonatal resuscitation, indications for PPV, chest compressions, and medications
Be familiar with the NRP algorithm and temperature management goals
DNB and NEET SS often ask about specific heart rates triggering interventions.
Clinical Pearls:
Always dry the baby first
skin-to-skin contact is best for thermoregulation
Chest rise is your guide for PPV efficacy
If HR < 60 despite PPV, think compressions and Epi
Temperature is a vital sign in neonates.
Common Mistakes:
Inadequate mask seal leading to ineffective PPV
Incorrect compression rate or depth
Delayed initiation of chest compressions or epinephrine
Overlooking temperature management or rapid rewarming
Ineffective team communication.