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Neonatal resuscitation (NNR)
Dr. Renu Singh
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Burden of the problem
• Birth asphyxia• 23% of the 1 million neonatal deaths in India• Long term neurological complications• Death• NNR (Neonatal resuscitation) :simple,
inexpensive, cost effective method• Problem: NNR often not initiated, incorrect
use of methods
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Successful NNR: factors
1. Anticipation: call a skilled personnel2. Adequate preparation3. Accurate evaluation, algorithm based4. Prompt initiation of support
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1.Anticipation: High risk delivery • Maternal condition– Advanced maternal age ,DM, HT, stillbirth, fetal loss, early
neonatal death
• Fetal condition– Prematurity, post maturity, congenital anomalies, multiple
gestations
• Ante partum complications: APH, oligo /polyhydramnios
• Delivery complications– Malpresentation, MSAF, instrumental delivery, antenatal
asphyxia with abnormal FHR
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2. Adequate preparation
• Radiant warmer is turned on,& is heating• Oxygen source is open with adequate flow
through the tubing• Suction apparatus tested, functioning properly• Laryngoscope is functional with bright light• Resuscitation bag & mask demonstrates an
adequate seal & generation of pressure
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Radiant warmer
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Successful NNR: factors
1. Anticipation: call a skilled personnel2. Adequate preparation3. Accurate evaluation, algorithm based4. Prompt initiation of support
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Evaluation, algorithm based
• Rapid assessment of neonate clinical status
• Is the infant full term?• Is the infant breathing or crying?• Does the infant has good muscle tone?
• Yes: no resuscitation, routine neonatal care• No: needs resuscitation
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Approach to resuscitation2010 AHA, AAP
• A: initial steps(provide warmth, clear airway if necessary, dry, stimulate)
• B: breathing(ventilation)• C: chest compressions (circulation)• D: administration of drugs &/or volume
expansion
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Resuscitation: initial steps
• Provide warmth• Head position “ sniffing position”• Clearing the airway, if necessary• Drying the baby• Tactile stimulation for breathing
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AAP Algorithm
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AAP Algorithm
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PPV: Positive pressure ventilation
• Form of assisted ventilation• Needed when there is no improvement in HR• Also assess chest wall movements• Should be delivered at rate of 40-60
breaths /min, maintain HR>100 /min• Devices: BMV, ET (endotracheal
tube),LMA(laryngeal mask airway)
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Bag & mask ventilation
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Endotracheal tube
• If BMV is ineffective/prolonged• When chest compressions are performed• Initial endotracheal suctioning of non vigorous
meconium stained newborn
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Endotracheal tube
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LMA(Laryngeal mask airway)
• Soft mask, fits over laryngeal inlet when inflated, occludes the oesophageal opening
• Done when BMV is unsuccessful & tracheal intubation is unsuccessful or not feasible
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LMA(Laryngeal mask airway)
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Targeted SPO2 after birth
1 minute 60-65%
2 minutes 65-70%
3 minutes 70-75%
4 minutes 75-80%
5 minutes 80-85%
10 minutes 85-90%
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1. Initial steps in resuscitation2. PPV
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AAP Algorithm
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Chest compressions
• Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec
• Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest
• 2 techniques: – 2 thumb-encircling hands technique– Compression with 2 fingers ,second hand
supporting the back– 3:1 ratio::[ 90 comp:30 ventilations]
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1. Initial steps of resuscitation2. PPV(ET)3. CHEST COMPRESSIONS
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AAP Algorithm
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Medications
• Rarely indicated• Most important step to treat bradycardia is
establishing adequate ventilation• HR remains <60bpm,despite adequate
ventilation(ET) with 100% Oxygen & chest compressions
• Epinephrine or volume expansion or both
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Epinephrine
• Route of administration: intravenous(IV),ideal• Recommended dose: 0.01-0.03 mg/kg per
dose• Desired concentration: 1:10,000 0.1 mg/ml
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Volume expansion
• Suspected or known blood loss• Isotonic crystalloid solution ; normal saline• Blood• Dose calculation: 10 ml/kg
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The golden minute
• <30 seconds: complete initial steps• Warmth• Drying• Clear airway if necessary• Stimulate
• 30-60 seconds: assess 2 vital characteristics• Respiration (apnea/gasping/labored/unlabored)• Heart rate (<100/>100bpm)
• Golden Minute Project: skill based training
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AAP Algorithm
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Post resuscitation care
• Needed for those who required PPV• At risk of deterioration– Hypo/hyperthermia ,hypoglycemia, CNS
complications(apnea, HIE), pulmonary complications(TTN, Pneumonia), hypotension
• Need monitoring ,evaluation• NICU may be necessary
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NNR : not indicated
• Conditions with certainly early death• Extreme prematurity(GA<23 weeks)• Birth weight<400g• Anencephaly• Chromosomal abnormality: Trisomy 13
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NNR: nearly always indicated
• High rate of survival• Acceptable morbidity• GA≥ 25 weeks• Those with most congenital malformations
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NNR?
• Conditions associated with uncertain prognosis
• Survival borderline
• Parental desires concerning initiation of resuscitation should be supported
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Discontinuing resuscitative efforts
• Newborn with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes
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Summary
• Most infants transfer from intrauterine to extra uterine life
• 10% need some intervention,1% need extensive resuscitation
• Anticipate the need for NNR• Adequate preparation for NNR• Evaluate the newborn as per AHA/AAP
guidelines & follow the recommended protocol
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MCQ1
For successful neonatal resuscitation following is/are needed except:
1.Anticipation2.Adequate preparation3.Skilled personnel4.Delayed initiation of support
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MCQ1
• For successful neonatal resuscitation following is/are needed except:
1.Anticipation2.Adequate preparation3.Skilled personnel4.Delayed initiation of support
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MCQ2
• Following are true in relation to initial steps of neonatal resuscitation except
1.Provide warmth2.Tactile stimulation3.Endotracheal intubation4.Drying the baby
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MCQ2
• Following are true in relation to initial steps of neonatal resuscitation except
1.Provide warmth2.Tactile stimulation3.Endotracheal intubation4.Drying the baby
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MCQ3
• The following is the primary measure of adequate ventilation
1.Chest wall movement2.Improvement in heart rate3.Pink extremities4.Spo2 of 100%
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MCQ3
• The following is the primary measure of adequate ventilation
1.Chest wall movement2.Improvement in heart rate3.Pink extremities4.Spo2 of 100%
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MCQ4
Endotracheal intubation may be indicated at several points during neonatal resuscitation except
1. Ineffective BMV 2. During chest compressions 3. Vigorous meconium stained newborn4. Non vigorous meconium stained newborn
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MCQ4
• Endotracheal intubation may be indicated at several points during neonatal resuscitation except
1. Ineffective BMV 2. During chest compressions 3. Vigorous meconium stained newborn4. Non vigorous meconium stained newborn
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MCQ5
• The recommended compression to ventilation ratio in neonatal resuscitation is
1.2:12.3:13.4:14.5:1
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MCQ5
• The recommended compression to ventilation ratio in neonatal resuscitation is
1.2:12.3:13.4:14.5:1
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MCQ6
• The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation
1.0.01-0.03,IV2.0.01-0.03,IM3.0.03-0.05,1V4.0.05-0.1,IV
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MCQ6
• The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation is
1.0.01-0.03,IV2.0.01-0.03,IM3.0.03-0.05,1V4.0.05-0.1,IV
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MCQ7
• Recommended method/clinical indicator of confirming ET placement is
1.Condensation in ET2.Chest movement3.Equal breath sounds on auscultation4.Exhaled C02 Detection
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MCQ7
• Recommended method/clinical indicator of confirming ET placement is
1.Condensation in ET2.Chest movement3.Equal breath sounds on auscultation4.Exhaled C02 Detection