What are the recommended ventilator settings and supportive medications for a 3 kg newborn with birth asphyxia who is not maintaining oxygen saturation on hood?

Management of Birth Asphyxia in a 3kg Newborn Not Maintaining Saturation on Oxygen Hood

For a 3kg newborn with birth asphyxia not maintaining oxygen saturation on hood, immediate intubation and mechanical ventilation should be initiated with initial settings of PIP 20-25 cmH2O, PEEP 5 cmH2O, rate 40-60 breaths/min, and starting with 21-30% oxygen titrated by pulse oximetry. 1

Initial Ventilation Settings

• Begin with endotracheal intubation using appropriate sized tube (3.0-3.5 mm) 1
• Initial ventilator settings:
  • Mode: Synchronized Intermittent Mandatory Ventilation (SIMV) 2
  • Peak Inspiratory Pressure (PIP): 20-25 cmH2O 1
  • Positive End-Expiratory Pressure (PEEP): 5 cmH2O 1
  • Respiratory Rate: 40-60 breaths/minute 1
  • Inspiratory Time: 0.3-0.5 seconds 1
  • FiO2: Start with 21-30% (room air to low oxygen) and titrate based on pulse oximetry 1

Oxygen Management

• Attach pulse oximeter to right upper extremity to guide oxygen titration 1
• Target oxygen saturation levels similar to those of healthy term newborns (initially 60-65% at birth, gradually increasing to 85-95% by 10 minutes) 1
• Avoid both hyperoxemia and hypoxemia by careful titration of oxygen 1
• If despite effective ventilation there is no increase in heart rate or if oxygenation remains unacceptable, consider gradually increasing oxygen concentration 1

Circulatory Support

• Monitor heart rate continuously - this is the most sensitive indicator of resuscitation efficacy 1
• If heart rate remains below 60 bpm despite effective ventilation:
  • Initiate chest compressions using the 2-thumb, hands-encircling-the-chest method 1
  • Use a 3:1 compression-to-ventilation ratio 1
  • Ensure compressions are at least one-third the anterior-posterior dimension of the chest (approximately 4 cm) 1

Medication Management

• If heart rate remains below 60 bpm despite effective ventilation and chest compressions:
  • Administer epinephrine 0.01-0.03 mg/kg IV 1
  • If IV access is not available, consider endotracheal administration at higher dose (0.05-0.1 mg/kg) 1
• Consider volume expansion with normal saline 10 ml/kg if signs of hypovolemia are present 1

Monitoring and Assessment

• Use exhaled CO2 detection to confirm endotracheal tube placement 1
• Monitor vital signs continuously (heart rate, oxygen saturation, blood pressure) 1
• Obtain arterial blood gases at 10 and 30 minutes of age to guide ventilator adjustments 3
• Assess neurological status frequently 1

Post-Resuscitation Care

• Consider therapeutic hypothermia for moderate to severe hypoxic-ischemic encephalopathy 1
• Initiate cooling within 6 hours of birth under clearly defined protocols 1
• Maintain multidisciplinary care in a neonatal intensive care unit 1
• Monitor for complications of asphyxia including seizures, pulmonary hypertension, and multi-organ dysfunction 4

Ventilator Weaning Strategy

• Once stabilized, gradually decrease ventilator settings based on clinical improvement and blood gas results 1
• Consider extubation when minimal ventilatory support is required (PIP <15-18 cmH2O, rate <20/min, FiO2 <0.3) 2
• SIMV has been shown to result in shorter duration of mechanical ventilation compared to conventional IMV in infants >2000g 2

Common Pitfalls to Avoid

• Avoid using 100% oxygen for initial resuscitation as it provides no advantage over air and may increase oxidative injury 1, 3
• Avoid excessive ventilation which can lead to lung injury and decreased cerebral blood flow 1
• Avoid delays in initiating therapeutic hypothermia when indicated 1
• Do not rely on color as an indicator of oxygenation; use pulse oximetry instead 1
• Avoid routine endotracheal suctioning in meconium-stained amniotic fluid as evidence does not support this practice 1