Routes of Administration for Medications
National Neonatal Resuscitation Guidelines
Insertion of an umbilical venous line
Although the ET tube is usually the easiest route for giving medications during neonatal resuscitation, an intravenous line should be established as soon as possible. The IV route is preferred for all medication. Adrenaline, at higher doses, can be given via the ET tube, but the ET route is not recommended for naloxone or caustic agents like sodium bicarbonate. The simplest intravenous access in the neonate is via the umbilical vein.
Peripheral veins are suitable but may be more difficult to cannulate, especially during resuscitation. Intraosseous lines are not commonly used as the umbilical vein is more accessible, the baby’s bones are fragile and the intraosseous space is small, especially in preterm infants. The intraosseous route can be used if venous access has not been established using the other routes.
Insertion of an umbilical venous line
Indications
In the emergency setting, the umbilical vein is catheterised to get good venous access for giving fluids or drugs.
Equipment required
- Disinfecting solution
- 5F umbilical catheter or feeding tube 3-way stopcock
- 10ml normal saline 5ml syringe
- Blade for cutting umbilical cord
- Cotton wool or gauze swabs
- Umbilical tie
- Silk suture
- Needle holder and scissors
Procedure (for resuscitation)
In the emergency setting, full scrubbing is not done. Nonetheless, the procedure should be done as cleanly as possible without wasting time. Clean the umbilical cord and surrounding skin with an antiseptic solution. (Note that strong disinfectant solutions, especially those containing alcohol, may burn the neonate’s skin, especially in preterm infants.)
Cut the umbilical cord 2cm from the base and identify the three vessels (two arteries and one vein). The vein gapes open, while the arteries are tightly closed. The cord will not bleed because of arterial spasm.
Catheterise the vein with a 5F catheter or feeding tube. Flush the catheter prior to insertion with a flushing solution (e.g. saline) and attach a 3-way stopcock and close it.
Hold the cord in one hand and advance the catheter into the umbilical vein with the other. The catheter should feed easily with minimal resistance.
Stop advancing the catheter once blood flows back when suction is applied to the catheter. Secure the catheter in that position with an umbilical tie or suture.
Note: if the umbilical venous line is being inserted as a central catheter to be left in situ for a prolonged period, do the catheterisation as a full sterile procedure.
In addition, confirm on X-ray that the position of the tip of the catheter is in the inferior vena cava. Remove any catheter that ends in the liver.
Special circumstances
It is beyond the scope of this booklet to discuss detailed emergency management of all neonatal problems, but a few special circumstances will be mentioned briefly. A person skilled in neonatal resuscitation should attend all such deliveries where possible.
Preterm infants
Babies born preterm are especially prone to perinatal asphyxia due to complications related to preterm labour and the immaturity of all systems in the preterm infant. In addition, lack of surfactant and poor lung compliance may mean that the baby requires assisted ventilation early. The management of preterm infants varies among different units e.g. some units immediately intubate all preterm infants below a certain weight category and give surfactant. It is particularly important to prevent heat loss in preterm infants and to avoid procedures that may increase the risk of intraventricular haemorrhage e.g. the bolus administration of colloid or hypertonic solutions.
Surgical problems
Any baby born with a “surgical” abnormality should be transported to a centre capable of treating the problem. A baby born with a diaphragmatic hernia, requiring positive pressure ventilation, needs to be intubated immediately to prevent distension of the gut with air.
Prevent fluid loss and give sufficient intravenous fluids to prevent shock in a baby with gastroschisis or exomphalos. A baby with oesophageal atresia and tracheo-oesophageal fistula should be nursed prone with the head slightly raised (20 degrees) to prevent aspiration of stomach contents. A Replogle (double lumen) tube on continuous suction in the oesophageal pouch also prevents aspiration.
Multiple gestation
There is an increased need for resuscitation with multiple births due to the increased incidence of preterm delivery, malposition / malpresentation, abnormalities of the placenta and compromised cord blood flow. It is recommended that, ideally, a skilled person is available to resuscitate each baby. This is unlikely to be achieved in South Africa, but at least one skilled person should be available.
Other problems
If a baby fails to respond adequately to resuscitation, a treatable cause such as a pneumothorax, haemorrhage, pleural effusion, cyanotic congenital heart malformation or shock should be ruled out and the baby managed accordingly e.g. insert intercostal drain, give a fluid bolus or urgent cardiology consult.
Post resuscitation issues
Ongoing neonatal care
A baby who has been resuscitated requires ongoing monitoring and treatment after adequate respiration and circulation have been established. Any baby who has been resuscitated must be monitored for at least 6 hours.
Don’t forget to check the baby’s blood glucose level. Ensure that the baby is kept warm but not overheated.
Monitoring of a baby after resuscitation may include heart rate, oxygen saturation, blood glucose level, arterial blood gas, blood pressure and chest X-ray. Very often the baby will have an ongoing need for oxygen. There may be an underlying problem that requires specific management. Babies with ongoing respiratory distress in the delivery room should be treated with CPAP initially, rather than immediate intubation and ventilation. The baby may need to be transferred to the NICU for ventilation. Observe for signs of hypoxic ischaemic organ damage, especially convulsions.
Blood glucose levels
Both hypo and hyperglycaemia may be associated with a worse neurological outcome after perinatal asphyxia. Blood glucose levels need to be monitored and maintained within the normal range (2.6 to 8mmol/l).
Induced hypothermia
Where possible, infants born close to term with moderate to severe hypoxic-ischaemic encephalopathy (HIE) should be offered therapeutic hypothermia. If this is not possible, hyperthermia should be avoided in such infants
Therapeutic hypothermia must be initiated and conducted under clearly defined protocols i.e. cooling started within 6 hours of life, strict temperature control at 33 to 34oC for 72 hours and then re-warming over 4 hours.
This should be done in NICU where there is the facility for multidisciplinary care and follow up.
Documentation
Birth asphyxia is a medico legal hazard and it is very important to make adequate notes regarding the resuscitation.
Record relevant maternal and obstetric information, causes for the asphyxia, the baby’s initial condition and response to resuscitation, the time and type of interventions performed and drugs given. The Apgar scores must be recorded at 1 minute, 5 minutes, 10 minutes, and every five minutes thereafter until full recovery or 30 minutes have elapsed. The time to the onset of spontaneous respiration is also of prognostic importance.
Family support
Birth is an emotional time for all parents and birth asphyxia, with the need for resuscitation, is an added stress. The parents need to be properly counselled and supported regarding their baby’s condition. If the baby survived a severe asphyxial insult, warn the parents of the possibility of subsequent brain damage and the need for ongoing follow up and care. Discuss any concerns that the parents may have regarding their baby and its management.
Grief support and counselling must be given to parents whose baby has died.
The help of other staff such as social workers or referral to a support group may help. Parents need ongoing emotional support and counselling and staff must be available to answer their questions and talk to them.