The neonatal code cart contains more specialized equipment for resuscitation of neonates, typically <28 days old.
Having to resuscitate such a tiny baby is a daunting task, and fortunately very rare, but unfortunate as we are not well-versed with all the moving parts. In these cases, just like with the Broselow cart, familiarizing ourselves with the contents of the neonatal code cart will be essential to a proper resuscitation.
Setting the scene...
We get a call that a mother just delivered in the ambulance and the baby is not responsive: not crying, not moving; ETA 5 minutes.
First: ask a PCT to locate the baby warmer and get it to resus 51 along with a bunch of dry towels.
Head to resus 51 and clear all the obstacles to the neonatal code cart and take note of several things outside the code cart that are important:
We open the neonatal airway box which sits on top of the neonatal code cart and hook up the infant ambu bag, have suction ready, and lay out the intubation supplies.
Next, we open the first drawer which is the medications:
As the nurses are opening the rest of the drawers, EMS rolls in with mother and baby, another team is taking care of mom, and the baby is handed over to us into the baby warmer and we are using the abundance of dry towels to dry off the baby and stimulate, stimulate, stimulate!
EMS reports: Baby is mother's 3rd baby, ex-39 weeks female, no known complications during pregnancy as she had no prenatal care, baby is 4kg. Vitals en route: HR 70bpm, O2 sat 85%, BP 65/35, BGM 80
Meanwhile, the nurses are hooking up the baby to the monitor, getting vitals, and attempting to start an IV.
Drawers 2-4 has IV materials, fluids, EKG leads, suction, etc:
It has been 2 minutes since the baby arrived in the ER and the HR is 75 bpm and the baby is not breathing spontaneously or crying. You've already dried, stimulated, suctioned, and have been using the infant ambu bag to give some positive pressure support with good bilateral chest rise and positive breath sounds bilaterally and O2 saturation is 95%.
Someone taking care of the mother comes in and reports that the mother had taken several tabs of morphine for the painful contractions that her father had left over for back pain.
Patient is 4kg, and so 0.1mg/kg is 0.4mg, 0.4mL of Naloxone is given to the patient via IV (can be given IM or through an ETT).
Patient starts breathing spontaneously with O2 sat 100%, heart rate improves to 90, but BP is still 65/35. You ask the nurse to start IV fluids but after the Narcan was administered the IV stopped working and they are having difficulty obtaining a 2nd IV for access.
You decide to do an umbilical vein catheterization and look to the last drawer:
Umbilical vein catheterization:
Sterile prep of the umbilical area and drape
Securely tie a cord tie around the base of the umbilical stump
Cut cord horizontally at the distal end of the stump to expose vessels about 1-2 cm distal to the cord tie
Identify the umbilical vein (thin-walled, larger, single vessel vs. two thicker arteries)
Dilate gently with forceps and insert catheter (3.5 Fr for neonates <3.5kg, 5Fr for neonates >3.5kg)
Aspirate for blood return, then advance to appropriate depth
For a full term infant insert to about 4-5cm (about 2cm further than where you get blood return) for emergency access and approximately 10-12cm for long term access (based on umbilicus to shoulder measurement).
Flush with saline to ensure patency
Secure catheter with umbilical tape or suture
Verify position with Chest/abdominal X-ray to confirm tip location at inferior vena cava–right atrial junction, typically at T8–T9
Adjust as needed based on imaging
Patient received IV fluids and blood pressure improved to 80/45, vitals otherwise stable. Patient admitted to the NICU.
Takeaways:
All the equipment and medications used for resuscitations are included in the neonatal code cart.
Streamlines processes as we do not need to waste time and search for the proper equipment when time is so important during a resuscitation.
Familiarity with the equipment and medications in the code cart helps us prepare for those rare and unexpected resuscitations
Umbilical vein catheterization can be done for patients who have poor peripheral access, requires further resuscitative medications, or for central venous monitoring.
References:
Aziz K, Lee CHC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2021 Jan;147(Suppl 1):e2020038505E. doi: 10.1542/peds.2020-038505E. Epub 2020 Oct 21. PMID: 33087555.
Chen, Linda & Law, Brenda. (2023). Use of eye-tracking to evaluate human factors in accessing neonatal resuscitation equipment and medications for advanced resuscitation: A simulation study. Frontiers in pediatrics. 11. 1116893. 10.3389/fped.2023.1116893.
Drone E, Vera AE, Lucas JK. Umbilical venous catheters. In: Ganti L, eds. Atlas of emergency medicine procedures. New York, NY: Springer; 2020