What is the management of neonatal asphyxia?

Management of Neonatal Asphyxia

The management of neonatal asphyxia requires a systematic approach focused on effective ventilation first, followed by circulatory support if needed, with careful oxygen titration and consideration for therapeutic hypothermia in moderate to severe cases. 1

Initial Assessment and Resuscitation

• Heart rate should be the primary vital sign to judge the need for and efficacy of resuscitation, with auscultation of the precordium as the primary means of assessment 2
• Attach pulse oximeter to the right upper extremity (wrist or hand) to guide oxygen titration, as readings from this location are higher than postductal values 2, 1
• Color should not be used as an indicator of oxygenation or resuscitation efficacy; instead, rely on pulse oximetry 2, 1

Ventilation Management

• Begin with effective positive-pressure ventilation using air (21% oxygen) rather than 100% oxygen for term infants 2
• For preterm infants <32 weeks' gestation, consider starting with 21-30% oxygen rather than higher concentrations (60-100%) 2, 1
• Initial ventilator settings for a 3kg newborn should include:
  • Peak Inspiratory Pressure (PIP): 20-25 cmH₂O 1
  • Positive End-Expiratory Pressure (PEEP): 5 cmH₂O 1
  • Respiratory Rate: 40-60 breaths/minute 1
• Target oxygen saturation should mimic that of healthy term babies: initially 60-65% at birth, gradually increasing to 85-95% by 10 minutes 1
• If intubation is not feasible or unsuccessful, consider using a laryngeal mask airway as an alternative airway device for near-term (>34 weeks) or term infants 2

Circulatory Support

• If heart rate remains below 60 bpm despite effective ventilation for 30 seconds, initiate chest compressions 2, 1
• Use the 2-thumb, hands-encircling-the-chest method as the preferred technique for chest compressions 2, 1
• Maintain a 3:1 compression-to-ventilation ratio, as asphyxia is the predominant cause of cardiovascular collapse in newborns 2
• This ratio provides 90 compressions and 30 ventilations per minute, emphasizing the importance of ventilation in asphyxiated newborns 2

Oxygen Management During Resuscitation

• If heart rate does not increase despite effective ventilation or if oxygenation remains unacceptable despite using air, consider increasing oxygen concentration 2
• If chest compressions are required, it is prudent to increase supplementary oxygen concentration despite animal evidence showing no advantage to 100% oxygen 2
• If supplementary oxygen is used, wean it as soon as the heart rate has recovered to avoid potential hyperoxic injury 2
• Both hyperoxemia and hypoxemia should be avoided, as exposure to high concentrations of oxygen may increase oxidative injury 2

Medication Administration

• If heart rate remains below 60 bpm despite effective ventilation and chest compressions, administer epinephrine 0.01-0.03 mg/kg IV 2, 1
• If IV access is not available, consider endotracheal administration of epinephrine at a higher dose (0.05-0.1 mg/kg), although this is less effective 2
• Consider volume expansion with normal saline 10 ml/kg if signs of hypovolemia are present 1
• For neonates with severe perinatal asphyxia at high risk of acute kidney injury, consider administering a single dose of theophylline to improve fluid control and glomerular filtration rate 3

Post-Resuscitation Care

• Consider therapeutic hypothermia for newborns born near term with evolving moderate to severe hypoxic-ischemic encephalopathy 2, 1
• Cooling should be initiated within 6 hours of birth and conducted under clearly defined protocols 2, 1
• Provide multidisciplinary care in a neonatal intensive care unit with capabilities for multidisciplinary care 2, 1
• Monitor for and manage potential multi-organ dysfunction, as asphyxia can affect multiple organ systems 2, 3
• Ensure adequate protein intake (2-3 g/kg/d) and total energy intake (20-30 kcal/kg/d) for nutritional support 3

Common Pitfalls to Avoid

• Do not use 100% oxygen for initial resuscitation, as it provides no advantage over air and may increase oxidative injury 2, 1
• Avoid excessive ventilation, which can lead to lung injury and decreased cerebral blood flow 1
• Do not delay initiating therapeutic hypothermia when indicated, as timing is critical for neuroprotection 1
• Avoid overzealous fluid resuscitation, which may worsen outcomes in certain conditions 3
• Be cautious with hyperchloremic solutions (normal saline) as they can induce metabolic acidosis; consider balanced electrolyte solutions when appropriate 3