The Australian and New Zealand Council on Resuscitation (ANZCOR) Neonatal Guidelines 2016: Section 13: Guidelines 13.1 – 13.10 are used to guide initial care and resuscitation of the newborn or neonate in Australia.   The ANZCOR guidelines are based on the International Liaison Committee on Resuscitation (ILCOR, 2010) guidelines.  Ballarat Health Services understands it is imperative for staff to practice to the current standards of resuscitation for neonates and use the ANZCOR and ILCOR as a foundation of evidence based practice.

All staff will follow and practice to the ARC and ILCOR resuscitation guidelines as adopted by Ballarat Health Service in an emergency situation involving a neonate.

Ballarat Health Services outlines which clinical staff are required to complete Neonatal Basic Life Support in the Mandatory Requirements (Competencies) Matrix located on the BHS intranet.

Note: Operating Theatre and Emergency Department are listed under scope (area), as neonatal resuscitations will occur in these areas, but not all staff working there will be required to complete the annual competency (refer to the medical and nursing and midwifery matrixes).

Medical: Mandatory Requirements (Competencies) Matrix Medical Directorate, BHS

Nursing: Mandatory Requirements (Competencies) Matrix Nursing and Midwifery Services and Residential Services, BHS

Ballarat Health Services, in accordance with the requirements of the National Safety and Quality Health Services (NSQHS) Standards, Standard 8 - Recognising and Responding to Clinical Deterioration in Acute Health Care mandates that 100% of staff defined in the matrices attend a Neonatal Basic Life Support skills check within 30 days of commencing employment at Ballarat Health Services. Provision of documentation of compliance from another organisation is acceptable if it was obtained within the last 12 months. Annual skills checks are required to demonstrate currency of practise.

Neonate / Neonatal period: refers to the infant in the first 28 days of life (ARC, Guideline 13.1, Dec 2016)

ANZCOR: Australian and New Zealand Council on Resuscitation

ILCOR: International Liaison Committee on Resuscitation

Neonatal Response: A BHS internal emergency response that will alert and call paediatric medical staff, nursing and midwifery staff. If a staff member from Special Care Nursery is required to attend (if attendance requested or areas other than Maternity/theatre) staff will bring the Neonatal Response Trolley if the response occurs away from the 5th Floor.

SCN: Special Care Nursery

Infant / Infancy: includes the neonatal period and extends through the first 12months of life (ARC, Guideline 13.1, Dec 2016)

Neonatal Basic Life Support is required for the initial resuscitation of the neonate or in the event of a respiratory or cardiac arrest in the neonate.

For all intended purposes of this governance documentation the term neonate will be used as the consistent term which when used will cover both newborn and neonate as per the ARC definitions.

At every birth at BHS no matter how "low risk", suitable equipment and qualified staff must be available and prepared to resuscitate the neonate.

In the event a neonatal response is called with 2 staff rostered in SCN, to ensure patient safety a staff member from the Maternity Unit is required to provide immediate nursing resources to relieve SCN staff to attend the response. This will be achieved by the person in charge of SCN liaising with the co-ordinator of Midwifery at the beginning of each shift to ascertain if Midwifery staff are required to provide a nursing resource in the event of a neonatal response. The PFC is to be informed if midwifery staff are required but unable to assist, the PFC to attend SCN to relieve staff to attend neonatal response and assist/organise appropriate nursing resources. eg. on call SCN staff.

Early effective cardiopulmonary resuscitation increases the chance of survival.

Effective ventilation is the key to successful newborn resuscitation, therefore proficiency and competency in providing positive pressure ventilation is essential.

Optimal thermal control is essential and the neonate’s temperature should be maintained between 36.5 - 37.5C. Ensure overheating does not occur.

Preterm neonates who are less than 32 weeks gestation initially may require 30 - 40% oxygen to achieve and maintain transitional SpO₂ targets (as per graph later in document). The oxygen concentration can then be adjusted according to the neonate's needs.

• Equipment & drugs for resuscitation of the newborn
  Refer to APPENDIX 2 EQUIPMENT & DRUGS FOR RESUSCITATION OF THE NEWBORN
• Equipment list as per http://www.neoresus.org.au/pages/documents/Recommended_equipment_anddrugs_March_2011.pdf

Sections

1. Danger

2. Response

3. Temperature Control

4. Airway

5. Send for Help

6. Breathing

7. Circulation

8. Continuing CPR

9. Advanced Resuscitation Interventions

Section 1: Danger

• Check for danger to the neonate and to staff

• If necessary move the neonate away from danger without causing injury to them, yourself or other staff

Section 2: Response

• Stimulation of the neonate is vital in terms of initial response to life

• Drying with a soft towel may stimulate the newborn to breathe

• Assessment of tone, breathing, heart rate and crying should be completed

• A neonate with good tone (moving limbs and flexed posture) is unlikely to be severely compromised

• A 'floppy' neonate (not moving and extended posture) is likely to need active resuscitation

Section 3: Temperature Control

• Aim for normothermia (36.5C to 37.5C) in all newborns and avoid iatrogenic hyperthermia

• A warm draft free environment is ideal for resuscitation

Neonates less than 28 weeks gestation or <1500gms become cold very quickly and should be placed in a polyethylene bag or wrap immediately after birth:

• Polyethylene bag - appropriate size, food grade, heat resistant

• Place the 'wet' neonate in the bag

• Keep the neonate's head outside the bag and the body completely covered, apply a hat

• This effectively reduces heat loss during resuscitation which can improve the neonate's condition and stabilization after the resuscitation

For neonates greater than 28 weeks gestation:

• Dry and warm with pre-warmed towels to minimise heat loss

• Remove wet wraps and apply a hat

• Place under radiant heater

Section 4: Airway

Assess the airway for signs of obstruction and clear.

Signs of obstruction include:

• Flaring of the nostrils

• Use of accessory muscles

• Retraction or indrawing of the lower ribs and sternum

• Audible grunt

• Tracheal tug

Clearing the airway:

• Open the neonates airway by positioning the head in a neutral position, support the lower jaw at the chin, without applying pressure to the soft tissues

• Suction the oropharynx only, mouth first then the nares, and ensure low-pressure suction is used, that is 100cms HO. Use a size 8Fr, 10Fr or 12Fr suction catheter

• Briefly suction the airway if there is obvious blood or meconium in the airway (or if secretions obstructing the airway are suspected)

Oropharyngeal suctioning:

• Can cause laryngeal spasm, trauma and bradycardia

• Should be done efficiently and gently and not past the oropharynx

• Should not exceed 13 kPa or 100cms H20 of pressure or take longer than 5 seconds to complete

• Should be limited in depth to 5cm below the lips

• Measure suction tubing from tragus to side of mouth which is approximately the same distance from mouth to pharynx

Management of the neonate born through meconium stained amniotic fluid:

If the neonate is vigorous:

• Only clear the mouth, followed by the nose, if the airway appears obstructed by meconium

• Endotracheal suctioning is discouraged because it does not alter outcome and may cause harm

If the neonate is not vigorous:

• If the neonate is born in poor condition (not breathing or crying and decreased muscle tone) AND a medical clinician suitably qualified and with clinical expertise to perform laryngoscopy is present, then suctioning around the vocal cords under direct vision, or intubation and suction of the airway should be performed before the neonate is dried and stimulated to breathe

Section 5: Send for Help

• Activate Neonatal Response by calling emergency response phone number in your area, state location

• Call out for help and medical assistance

• Activate the closest emergency buzzer

• Note the time of the event

• Begin documentation of the event - if staff available

Section 6: Breathing

• Mouth to mouth rescue breathing is not advocated in the hospital setting

• An appropriate airway adjunct/device such as the Neopuff or bag/valve/mask are to be used for the delivery of breaths. Out of these the Neopuff is the preferred method

Assessment of breathing:

• Look for a rise and fall of the chest and abdomen

• Listen for breathing with a stethoscope

Establish Breathing:

• If the neonate is breathing adequately place in the lateral position, keep warm, remove wet wraps and replace with dry warm ones

• If the neonate is not breathing or is not breathing normally (i.e. taking occasional gasp), commence positive pressure ventilation

Positive Pressure Ventilation (PPV):

Neopuff:

• Set PEEP 5 cm

• Set PIP 30 cm

• Maximum pressure 50 cms HO

• Set flow rate at 10 litres/minute

• Ventilate at a rate of 40-60 inflations per minute

• Higher inflation pressures (>30 cm H2O and even as high as 60 cm H2O) may be needed for the first few inflations, especially if the neonate has never made any respiratory effort

• Avoid excessive volumes - deliver only the volume needed to produce visible rise of the chest

• Observe the rise and fall of the chest while delivering the breaths

• Do not hyper-extend the head as this will obstruct the airway

• Neonates requiring positive pressure ventilation need to be on a resuscitaire

• Bag/valve/mask suitable for neonates have a ventilation bag volume of 240 mls

• A neonate who gasps will be easier to ventilate with lower pressures than a neonate who has never breathed (i.e. whose lungs remain fluid filled)

Deliver 30 seconds of EFFECTIVE positive pressure ventilation prior to commencing chest compressions

Choosing the face mask:

• Choose an appropriate size mask according to the size of the neonate

• The mask should cover the nose and the mouth, but not the eyes

• The mask should not overlap the chin

Obtaining a face/mask seal:

• Achieving a good seal can be difficult to establish and maintain - just because the mask fits on the face does not mean that the seal is adequate

• Face mask leaks are common (averaging 60%)

• Clinician's need to be aware of the different options to maintain a face/mask seal

Different options for maintaining a seal with the face mask on the neonate:out of these the "Two point top hold" is the preferred method for less leakage

Reference:

Wood, F. E., Morley, C. J., Dawson, J. A., Kamlin, C. O. F., Owen, L. S., Donath, S., & Davis, P. G. (2008). Improved techniques reduce face mask leak during simulated neonatal resuscitation: study 2. Archives of Disease in Childhood-Fetal and Neonatal Edition, 93(3), F230-F234.

Pulse Oximetry:

• Hyperoxia should be avoided as even brief exposure to excessive oxygenation can be harmful to the neonate during and after resuscitation

• Supplemental oxygenation should be guided by pulse oximetry

• 10 minutes is the average length of time a neonate takes to achieve an oxygen saturation (SpO2 >90%)

Set up of Pulse Oximetry:

• Ensure the sensor is NOT CONNECTED to the oximeter cable

• Turn the pulse oximeter ON

• Attach the sensor to the neonate's RIGHT hand or wrist (pre-ductal) (applies to the immediate neonate only) otherwise hand or foot

• Connect the sensor to the end of the oximeter cable

• Ensure the infra red light lines up with the other side of the sensor

• Ideally use the outer aspect of the right hand to maximise the accuracy of the reading

http://www.masimo.co.uk/eve/

Neonatal Target Oxygen Saturations 0 - 10 minutes post birth:

 (ARC, 2010 Guideline 13.4, p. 11)

Otherwise titrate oxygen concentration percentage to SpO2

For all other neonatal resuscitation situations SpO2 should be targeted at 91-95% (in oxygen) unless otherwise directed by medical staff.

Effective ventilation is confirmed by:

• Increase in heart rate above 100 beats/min

• A slight rise in the chest and upper abdomen with each positive pressure inflation

• Oxygenation levels improve

Section 7: Circulation

Establish circulation:

• Quickly reassess for the presence or absence of signs of life

• Absent signs of life include: unresponsive, poor tone, absent breath sounds, absent heart rate

• Chest compressions are indicated whenever the heart rate remains below 60beats/min despite effective PPV

Measuring heart rate:

• The heart rate can be measured by auscultation over the apex with a stethoscope, palpation of the umbilicus, by ECG monitoring or by pulse oximetry

Chest compressions are indicated whenever the heart rate remains below 60 beats per minute despite 30 seconds of EFFECTIVE positive pressure ventilation

FiO2 should be increased to 100% whenever chest compressions are required

Chest compressions:

• The rescuer performing chest compressions should count out loud to assist the rescuer responsible for delivery of breaths and minimising interruptions to compressions

• The recommendation is to count out loud 1 & 2 & 3 & Breathe and "1 & 2 & 3 & Breathe" and so on

• Chest compressions over the lower third of the sternum are more effective

• Neonate must be positioned supine on a firm, flat surface to maximise effectiveness of the chest compressions

Chest Compression Techniques:

The two thumb, hand encircling technique (recommended technique for neonate resuscitation)

Place two thumbs on the lower third of the sternum, (one finger breadth below an imaginary line drawn between the nipples) with the thumbs superimposed onto one another or side by side with the fingers encircling the infants torso to support the back.

Depth of compression: Aim to compress one third of the anterior-posterior diameter of the chest

Reference: Kattwinkel, J. (2011). Neonatal Resuscitation (NRP) Textbook (6th Edition), page 136

The two finger technique

Place two fingers onto the lower third of the sternum, using the pads of the second and middle finger to compress the chest. The other hand is used to support the neonate's back.

Reference: Kattwinkel, J. (2011). Neonatal Resuscitation (NRP) Textbook (6th Edition), page 137

Rate of Chest Compressions to Ventilation

• Chest compressions / external cardiac compressions (ECC) should be provided with positive pressure ventilation at a ratio of 3:1

• This will achieve 90 chest compressions and 30 inflations every minute

• Deliver chest compressions at a rate of 2 per second

• Verbalising the 3:1 chest compressions to inflation rate aims to minimise simultaneous compressions and inflations

• Pausing chest compressions for half of a second allows the delivery of a breath

Section 8: Continuing CPR

Continue the sequence of CPR until:

• Signs of life return and heart rate is >60beats/min

• Advanced life support providers arrive and direct you to pause CPR so that they can manage care and deliver advanced resuscitation including intubation and medications

• Medical personnel pronounces the neonate deceased (length of time of resuscitation will be part of the decision making)

Section 9: Advanced Resuscitation Interventions

In the sequence of delivering CPR:

• If the neonate's heart rate does not increase above 60 beats/min with effective chest compressions and positive pressure ventilation using FiO2 100%, advanced resuscitation interventions are indicated

Routes of administration of medications and fluids in the neonate include (ARC, 2010 Guideline 13.7, P2):

• Umbilical vein - using an umbilical vein catheter is the most rapidly accessible intravascular route

• Endotracheal Tube

• Peripheral vein - difficult to insert in a shocked neonate

• Intraosseous

Adrenaline

Dosage: 1:10,000

Intravenous (IV): 0.1 to 0.3mls/kg or 10 to 30micrograms/kg

• dose can be repeated every 4minutes

Endotracheal Tube (ETT): 0.5 to 1mls/kg or 50 to 100micrograms/kg

• dose can be repeated

Normal Saline 0.9% (or consider O Negative Blood):

Dosage:

• 10 to 20 mls/kg

• can be repeated

Endotracheal Tube:

There are circumstances in which intubation is indicated if a person with the professional expertise to perform this procedure is available for example

• Mask ventilation (with a T- piece device or bag) is difficult or does not result in the neonate's heart rate increasing to above 100 bpm and the neonate has not made adequate breathing efforts

• The neonate is born without a detectable heart rate

Endotracheal size and length

Estimating the depth of insertion of the endotracheal tube:

The "rule of 6" can be used as an estimate as to where the endotracheal tube should be tied.

Verification of endotracheal tube position:

• An end tidal CO detector attached to the outside end of the endotracheal tube is recommended for verification of correct tube placement (ARC, Guideline 13.5, 2016)

• Positive detection of exhaled CO via a colorimetric carbon dioxide detector (e.g. Pedi-Cap CO detector or similar) attached between the end of the endotracheal tube and the manual ventilation device confirms tracheal intubation

Nellcor/Tyco Healthcare

Pedi-Cap CO detector (1 kg - 15 kg Pediatric)