What are the steps for resuscitating a newborn infant in the NICU (Neonatal Intensive Care Unit)?

NICU Neonatal Resuscitation: Detailed Algorithmic Approach

Initial Assessment (First 10-30 Seconds)

Immediately assess three critical characteristics: term gestation, good muscle tone, and breathing or crying—if all are present, the infant remains with the mother for routine care; if any are absent, begin resuscitation under a radiant warmer. 1

• Warm the infant by placing under a radiant heat source and drying thoroughly—hypothermia increases oxygen consumption and worsens outcomes 2, 1
• Position the head in a "sniffing" position to open the airway 1
• Clear secretions only if visible or if the airway appears obstructed—routine suctioning causes bradycardia and should be avoided 2, 1
• Stimulate breathing through drying and gentle tactile stimulation 1
• Apply pulse oximetry to the right hand (preductal) within 1-2 minutes for accurate oxygen monitoring 2, 3
• Assess heart rate by auscultating the precordium or using 3-lead ECG for rapid, accurate measurement—heart rate is the primary vital sign guiding all resuscitation decisions 2, 3, 1

Critical Pitfall to Avoid

Do not perform routine endotracheal suctioning for meconium-stained amniotic fluid, even in non-vigorous infants—complete initial steps and begin PPV if heart rate is <100/min or breathing is inadequate 1

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Positive-Pressure Ventilation (PPV): When Heart Rate <100 bpm

If heart rate remains <100 bpm after initial steps, immediately initiate PPV with room air (21% oxygen) for term infants or 21-30% oxygen for preterm infants (<35 weeks), as effective ventilation is the single most critical intervention in neonatal resuscitation. 2, 1, 4

PPV Technical Parameters

• Rate: 40-60 breaths per minute 2, 1
• Initial pressure: 20 cm H₂O (may require 30-40 cm H₂O in some term infants) 2, 1
• Apply PEEP: Approximately 5 cm H₂O using flow-inflating bag, self-inflating bag, or T-piece resuscitator 1
• Primary indicator of effectiveness: Rising heart rate, not chest rise 1
• Reassess heart rate after 30 seconds of adequate ventilation 1

Oxygen Titration Strategy

• Start with room air (21%) for term infants ≥35 weeks gestation 2, 1
• Start with 21-30% oxygen for preterm infants <35 weeks gestation 2, 1
• Target preductal oxygen saturations: 60-65% at 1 minute, 70-80% at 5 minutes, 85-95% by 10 minutes 3, 1
• Increase oxygen concentration only if heart rate fails to improve despite effective ventilation or if saturations remain below target 3
• Never start with 100% oxygen—this increases mortality and provides no advantage 2, 3

Corrective Steps for Ineffective PPV (MR SOPA Algorithm)

If heart rate does not improve after 30 seconds of PPV, implement ventilation corrective steps before proceeding to chest compressions—the vast majority of bradycardic newborns will respond to effective ventilation alone. 1

• Mask adjustment: Ensure proper seal
• Reposition airway: Return to sniffing position
• Suction mouth and nose if secretions present
• Open mouth and lift jaw forward
• Pressure increase: Gradually increase to 30-40 cm H₂O if needed
• Alternative airway: Consider endotracheal intubation or laryngeal mask (for infants ≥34 weeks or ≥2000g) if all steps fail 1

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Chest Compressions: When Heart Rate <60 bpm After 30 Seconds of Effective PPV

Begin chest compressions only after 30 seconds of adequate ventilation with visible chest rise and 100% oxygen—do not start compressions until effective ventilation is established, as bradycardia in newborns results from inadequate lung inflation, not primary cardiac pathology. 2, 1

Chest Compression Technique

• Use the two-thumb, hands-encircling-the-chest method as the preferred technique 2
• Compression-to-ventilation ratio: 3:1 (90 compressions and 30 breaths to achieve approximately 120 events per minute) 2
• Compress one-third of the anterior-posterior diameter of the chest 2
• Coordinate compressions with ventilation—exhalation occurs during the first compression after each ventilation 2
• Continue 100% oxygen during chest compressions 1
• Reassess heart rate every 60 seconds 2

When to Consider Higher Compression Ratios

Consider using 15:2 or 30:2 compression-to-ventilation ratios only if the arrest is believed to be of primary cardiac origin (rare in neonates) 2

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Medications: When Heart Rate <60 bpm Despite Adequate Ventilation and Chest Compressions

Epinephrine is indicated only after adequate ventilation with 100% oxygen and chest compressions have failed to achieve heart rate ≥60 bpm—drugs are rarely needed in neonatal resuscitation. 2

Epinephrine Administration

• Preferred route: Intravenous (umbilical venous catheter) 2
• IV dose: 0.01-0.03 mg/kg per dose 2
• Preparation: 1:10,000 concentration (0.1 mg/mL) 2
• Do not use higher IV doses (0.1 mg/kg)—these cause exaggerated hypertension, decreased myocardial function, and worse neurological outcomes 2
• Endotracheal epinephrine is not recommended as initial therapy—it is ineffective at currently recommended doses and should only be considered while establishing IV access 2

Volume Expansion

Consider volume expansion only when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and heart rate has not responded to other resuscitative measures. 2

• Fluid choice: Isotonic crystalloid (normal saline or Ringer's lactate) or blood 2
• Dose: 10 mL/kg IV over 5-10 minutes, may repeat 2
• Caution in preterm infants: Avoid rapid infusions—these are associated with intraventricular hemorrhage 2

Medications NOT Recommended in Delivery Room

• Naloxone: Not recommended as part of initial resuscitation—restore heart rate and oxygenation by supporting ventilation 2
• Sodium bicarbonate: Not recommended in delivery room 2

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Special Considerations for Preterm Infants (<35 Weeks Gestation)

Enhanced Temperature Management

• Preheat delivery room to 26°C 2
• Cover infant in plastic wrapping (food or medical grade, heat-resistant plastic) up to neck level immediately after birth without drying 2, 1
• Place on exothermic mattress under radiant warmer 2
• Target temperature: 36.5-37.5°C—avoid both hypothermia and hyperthermia (>38.0°C) 1
• Monitor temperature closely as combination techniques carry slight risk of hyperthermia 2

Oxygen Management for Preterm Infants

• Start with 21-30% oxygen rather than room air or high oxygen concentrations 2, 1
• Titrate oxygen based on pulse oximetry to match target saturations 2

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Endotracheal Intubation: Indications

Consider endotracheal intubation when mask ventilation is ineffective despite corrective steps, prolonged ventilation is required, chest compressions are needed, or suspected diaphragmatic hernia is present. 1

• Confirm tube placement with exhaled CO₂ detection as the primary method—clinical assessment alone is insufficient 1
• All resuscitation procedures including intubation can be performed with temperature-controlling interventions (plastic wrapping) in place 2

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Post-Resuscitation Care

Infants who require resuscitation are at risk for deterioration after vital signs normalize—transfer to an environment where close monitoring and anticipatory care can be provided. 2

Glucose Management

• Initiate IV glucose infusion as soon as practical after resuscitation to avoid hypoglycemia 2
• Monitor blood glucose closely—hypoglycemia increases risk for brain injury after hypoxic-ischemic insult 2

Ongoing Monitoring

• Monitor for complications: Persistent pulmonary hypertension (PPHN), pneumothorax, congenital heart disease, sepsis 5, 3
• Do not delay evaluation for serious conditions if infant fails to improve as expected or deteriorates 5, 3
• Assess therapeutic endpoints: Capillary refill ≤2 seconds, warm extremities, normal pulses, urine output >1 mL/kg/hour 3

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Critical Pitfalls to Avoid

• Never delay ventilation to establish IV access or prepare for intubation 1
• Never start with 100% oxygen for term infants—begin with room air and titrate based on pulse oximetry 2, 3, 1
• Never start chest compressions before achieving 30 seconds of effective ventilation with visible chest rise 1
• Never use routine suctioning in the absence of visible secretions—this causes bradycardia 2, 1
• Never perform routine endotracheal suctioning for meconium-stained amniotic fluid 1
• Never use sedatives or CNS depressants in respiratory distress—these worsen hypoventilation 5