Follow new guidelines for newborn resuscitation
Follow new guidelines for newborn resuscitation
Are you ready to resuscitate a newborn? "Mothers often present to the ED in preterm labor and may actually deliver in the ED," says Robin Clifton-Koeppel, MS, RNC, CPNP, a neonatal clinical nurse specialist and pediatric nurse practitioner at University of California — Irvine Medical Center in Orange. For the first time in eight years, there are new emergency cardiovascular guidelines for the neonate from the American Academy of Pediatrics and American Heart Association, says Clifton-Koeppel.1,2
Here are changes you should make in your practice:
• The need for tracheal suctioning is no longer determined by the consistency of the meconium, but by whether the baby has strong respiratory effort, good tone, and a heart rate of more than 100 beats per minute.
"Every effort should be given to suctioning the mouth, pharnyx, and nose as soon as the head is delivered when meconium staining is present, regardless of the consistency," says Michele Wolff, RN, MSN, CCRN, professor of nursing at Saddleback College in Mission Viejo, CA. You can use a 12F or 14F suction catheter or bulb syringe, she adds. If an infant born with meconium staining has apnea or respiratory distress, suctioning should occur before positive-pressure ventilation (PPV) whenever possible, says Wolff. "After birth, tracheal suctioning of infants with meconium staining is recommended for depressed infants," she explains. "This includes [infants with] decreased muscle tone, absent or depressed respirations, or heart rate less than 100 [beats per minute]."
She points to data showing that tracheal suctioning for meconium of vigorous infants does not improve outcomes. "Direct laryngoscopy and intubation with direct suctioning via the tracheal tube is recommended, since particulate meconium may be too thick to remove using a small-bore suction catheter," adds Wolff.
The bottom line is, you won’t be intubating as many infants as in the past, says Barbara Weintraub, RN, MSN, MPH, coordinator for pediatric emergency services at Northwest Community Hospital in Arlington Heights, IL. In the past, even infants with good respiratory effort who were born with thick meconium were intubated, says Weintraub. "Now, if the infant has good respiratory effort, they only need to be watched for signs of respiratory distress, and not necessarily intubated and suctioned," she explains.
• There are new indications for chest compressions.
Chest compressions should be initiated if the heart rate remains below 60 beats per minute, despite 30 seconds of adequate ventilation with 100% oxygen, says Wolff. "This changes the emphasis to supporting the infant’s airway and ensuring adequate ventilation with oxygen," she says. "Inadequate airway management and breathing are the most common reasons for bradycardia in the newborn."
Discontinue chest compressions when the heart rate is more than 60 beats per minute, but continue PPV until the heart rate is more than 100 beats per minute and the newborn has established spontaneous breaths, says Clifton-Koeppel.
The vast majority of babies who are born needing resuscitation require only the oxygenation/ventilation component, notes Weintraub. "Ventilation with 100% oxygen for 30 seconds should clarify exactly which of these infants will respond to oxygen and which truly need chest compressions," she says.
PPV always should accompany chest compressions, says Clifton-Koeppel. "Additionally, PPV and chest compressions should be coordinated so that a breath is given after every third compression," she says. After 30 seconds of PPV and chest compressions, compressions are stopped to evaluate the heart rate while continuing PPV, says Clifton-Koeppel. If the resuscitator is unable to feel a pulse at the base of the umbilical cord, stop PPV momentarily to auscultate the heart rate, she advises. "Remember, ventilation of the lungs is the most effective action in resuscitation of the newborn," says Clifton-Koeppel.
• The new recommendation is to depress the sternum to a depth equal to one-third of the anterior-posterior diameter of the chest.
Chest compressions should have enough pressure to depress the sternum a third of the anterior-posterior diameter of the chest and deep enough to generate a palpable pulse, she adds. "The thumb technique is preferred as it is less tiring, easier to control the depth of compressions, and generates a higher systolic pressure," says Clifton-Koeppel. The former guidelines directed rescuers to perform chest compressions by depressing the sternum ½ to ¾ inch, she notes.
Chest compressions should be at a depth to generate a palpable pulse, says Wolff. "The compression ratio should be three compressions to one ventilation — with 90 compressions and 30 breaths with a total of 120 events per minute," she explains. "These should be coordinated to avoid simultaneous compressions and ventilations."
For chest compressions, the two-thumb technique with the hands encircling the chest is preferred, though the two-finger technique to depress the sternum may still be utilized, says Weintraub.
"Data suggest that the hands encircling the chest may result in a higher thoracic pressure and coronary perfusion as compared to the two-finger technique," adds Wolff.
References
1. American Academy of Pediatrics and American Heart Association. Textbook of Neonatal Resuscitation. 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics; 2000.
2. Niermeyer S, Kattwinkel J, Van Reempts P. International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Pediatrics 2000; 106:e29.
Sources and resources
For more information about neonatal resuscitation in the ED, contact:
• Robin Clifton-Koeppel, MS, RNC, CPNP, Neonatal Clinical Nurse Specialist/Pediatric Nurse Practitioner, University of California, Irvine Medical Center, 101 The City Drive, Orange, CA 92868. Telephone: (714) 456-6528. Fax: (714) 456-8877. E-mail: [email protected].
• Barbara Weintraub, RN, MPH, MSN, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: [email protected].
• Michele Wolff, RN, MSN, CCRN, Saddleback College, 28000 Marguerite Parkway, Mission Viejo, CA 92692. Telephone: (949) 582-4222. Fax: (714) 536-6269. E-mail: [email protected].
Guidelines 2000 for Emergency Cardiovascular Care and Resuscitation: International Consensus on Science was published as a supplement to the journal Circulation on Aug. 22, 2000. The neonatal portion of the guidelines is available for review at www.pediatrics.org/cgi/content/full/106/3/e29.
An updated course in neonatal resuscitation has been developed by the American Heart Association and the American Academy of Pediatrics. This course has been designed to teach an evidence-based approach to resuscitation of the newborn, including the causes, prevention, and management of mild-to-severe neonatal asphyxia. To find a course in your area, go to the AAP web site (www.aap.org) and click on "Professional Education," "Life Support Programs," "Neonatal Resuscitation Program (NRP)," "Courses & Instructors," "Find a Course." For more information, contact: American Academy of Pediatrics, Division of Life Support Programs, 141 Northwest Point Blvd., Elk Grove Village, IL 60007. Telephone: (800) 433-9016, ext. 4798. Fax: (847) 228-1350. E-mail: [email protected].
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