Persistent Bradycardia and Hypoperfusion in an Infant Despite Neonatal Resuscitation.

Preventing those so-called stillbirths

Is 100% oxygen a sticking plaster for sore neonatal ventilation skills?

Supraglottic Airways, Tennis, and Neonatal Resuscitation.

NOTE: To learn to perform a procedure, there are both cognitive and procedural steps that should be followed. These steps are explained and demonstrated in this month’s Video Corner and are summarized for quick reference in the list below.⇓ Figure 1. Click here to view the video. Below are the steps to follow for this procedure. ### 1. Indications Evacuation of a pneumothorax diagnosed clinically and/or radiographically. Evacuation of a suspected pneumothorax in a neonate who has persistent bradycardia despite resuscitation according to the guidelines of the Neonatal Resuscitation Program. Needle aspiration may be the definitive therapy or may be performed before inserting a chest tube. ### 2. Contraindications If a decision to redirect from intensive to compassionate care has been made after discussions with the parents, this procedure may then be contraindicated. This decision to perform the procedure would depend on the limits of interventions set during those discussions between the parents and the health-care team. ### 3. Consent No consent (written or verbal) is obtained before the procedure. The procedure is explained to parents before the procedure is performed in neonates who have a pneumothorax who are hemodynamically stable. ### 4. Time out (pause)

Please read the following vignette and watch the video clip.A 40-1/7 week gestation infant is delivered through clear amniotic fluid after an uncomplicated pregnancy. Immediately after birth the infant is non-vigorous. The infant is warmed, dried, stimulated, and the airway is opened. At 30 seconds after birth, the heart rate is 80 beats/min and positive pressure ventilation (PPV) is started at a rate of 60 breaths/min. The heart rate does not increase after 15 seconds of positive pressure ventilation. What is the correct intervention?Now, stop reading and watch the video.Ventilation is the most important intervention in neonatal resuscitation; a rise in heart rate is the most sensitive indicator of effective ventilation. In the video vignette, positive pressure ventilation is started at 30 seconds after birth for a heart rate of 80 beats per minute. If the heart rate is not rising after 10 seconds of effective ventilation, one must troubleshoot the effectiveness of ventilation using MR SOPA. (Mask, Reposition head, Suction, Open mouth, increase Pressure, consider an alternative Airway). The correct intervention at this point in the algorithm is to reapply the Mask and Reposition the head (answer “c”.) It is critical that such interventions are stated out loud in order to establish a shared mental model, one of the principles of effective communication (Fig).If the heart rate is not rising, PPV is not effective and continuing PPV without troubleshooting will not improve ventilation. Establishing functional residual capacity is critical at this point of the resuscitation; improving ventilation is the most effective intervention at this stage.Chest compressions are NOT indicated at this stage of resuscitation. Ideally ventilation is established prior to beginning chest compressions. In most circumstances this means the infant should be intubated and a trial of PPV with the endotracheal tube should be given. Most infants will not require chest compressions; starting chest compressions when they are not indicated can be harmful. This infant needs effective positive pressure ventilation and that should be the focus at this stage of the resuscitation.Intubation may be indicated if mask ventilation fails, in this case there is more that can be done to improve mask ventilation. Stating MR SOPA aloud creates a shared mental model and encourages the team to troubleshoot the effectiveness of mask ventilation. Intubation is indicated if mask ventilation cannot be improved and the heart rate remains less than 100 bpm. One should consider intubating before starting chest compressions.Oxygen is not indicated at this point. Resuscitation should begin with 0.21 FiO2, and pulse oximetry should be applied after PPV is initiated. Oxygen should be increased incrementally to match the expected oxygen saturation range. At this stage 0.21 FiO2 is recommended.Correct Response: c. Reposition the head and reapply the mask, continue PPV.Efforts must be taken to optimize teamwork during crisis situations which occur during neonatal resuscitation. For a team to work together there needs to be a shared mental model; this is achieved through effective communication. In this case, the problem needs to be specified and stated out loud: “Ventilation is not working, we need to improve ventilation by reapplying the mask and repositioning the head.” In order to prepare the team to respond cohesively, one must also share what is anticipated. Anticipating and planning for potential problems in this case would involve stating which steps should be taken if these initial efforts to improve ventilation are not effective: “If the heart rate doesn't rise and the chest is not rising, we need to increase peak inspiratory pressure.” Drawing from the 6th edition 2011 Neonatal Resuscitation Program, we have a simple way to create the shared mental model and prepare the team for next steps: MR SOPA.

Emergent umbilical venous catheter (UVC) placement for persistent bradycardia in the delivery room is a rare occurrence that requires significant skill and involves space constraints. Placement of an intraosseous needle (ION) in neonates has been well described. The ION is already used in the pediatric population and is placed at an anatomic location distant from where chest compressions are performed. In this study we compared time to placement, errors in placement, and perceived ease of use for UVCs and IONs in a simulated delivery room. Forty health care providers were recruited. Subjects were shown an instructional video of both techniques and allowed to practice placement. Subjects participated in 2 simulated neonatal resuscitations requiring intravenous epinephrine. In 1 scenario they were required to place a UVC and in the other an ION. Scenarios were recorded for later analysis of placement time and error rate. Subjects were surveyed regarding the perceived level of difficulty of each technique. The average time required for ION placement was 46 seconds faster than for UVC placement (P < .001). There was no significant difference in the number of errors between UVC and ION placement or in perceived ease of use. In a simulated delivery room setting, ION placement can be performed more quickly than UVC insertion without any difference in technical error rate or perceived ease of use. ION insertion should be considered when rapid intravenous access is required in the neonate at the time of birth, especially by health care professionals who do not routinely place UVCs.