Neonatal resuscitation

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA,

Dip. Software statistics PhD (physio)Mahatma Gandhi Medical college and research institute , puducherry India

The need

• Approximately 10% of newborns require some assistance to begin breathing at birth.

• Less than 1% require extensive resuscitative measures

• only 60% of asphyxiated newborns can be predicted antepartum.

The need is continuous

Initial queries ??

• Term gestation? • Crying or breathing? • Good muscle tone?

yes

• the baby does not need resuscitation • should not be separated from the mother.• The baby should be dried, placed skin-to-skin

with the mother, and covered with dry linen to maintain temperature.

• Observation of breathing, activity, and color should be ongoing.

“no”

• 1.Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)

• 2.Ventilation • 3.Chest compressions

• 4.Administration of epinephrine and/or volume expansion

The golden minute

• Approximately 60 seconds (“the Golden

Minute”) are allotted for completing the initial

steps, reevaluating, and beginning ventilation

if required.

The goals of resuscitation

to assist • with the initiation and maintenance of

adequate ventilation and oxygenation, • adequate cardiac output and tissue perfusion, • normal core temperature • serum glucose

To achieve goals, be ready

• risk factors are identified early,• neonatal problems are anticipated, • equipment is available,• personnel are qualified and available• a care plan is formulated

Respiration equipment

• Oxygen supply, Assorted masks• Neonatal bag and tubing to connect to an oxygen source• Manometer, Endotracheal tubes (2.5-4)• Tape and scissors• Laryngoscope (0 and 1 sized blades)• Extra bulbs and batteries• CO2 detectors• Stylettes for endotracheal tubes• Laryngeal mask Airway (optional)

Suction equipment

• Bulb syringe• Regulated mechanical suction• Suction catheters (6F, 8F, 10F)• Suction tubing• Suction canister• Replogle or Salem pump (10F catheter)• Feeding tube (8F catheter)• Syringes catheter tipped – 20 ml • Meconium aspirator

Fluid equipment

• Intravenous catheters (22 g)• Tape and sterile dressing material• Dextrose 10% in water (D10W)• Isotonic saline solution• T-connectors• Syringes, assorted (1-20 mL)

Advanced procedure ready

• Umbilical catheters (2.5F, 5F)• Chest tube (10F catheter)• Sterile procedure trays

Trained Personnel

• One present • Two or more • -- problems • --- twins

Temperature control

• Dry and keep warm

• Others

• prewarming the delivery room to 26°C

• 13 covering the baby in plastic wrapping

• placing the baby on an exothermic mattress

• the baby under radiant heat

• prewarming the linen

• The goal is to achieve normothermia and avoid iatrogenic hyperthermia

Temperature range

• Normal 36.5-37.5o C Continue

• Potential cold stress 36-36.5o C concern

• Moderate hypothermia 32-36o C Danger

• Severe hypothermia < 32o C• Outlook grave, skilled care urgently needed

Airway

• Clear liquor

• Meconium stained liquor

Clear liquor – suctioning routine ??

• be associated with worsening of pulmonary compliance and oxygenation

• reduction in cerebral blood flow velocity when performed routinely (ie, in the absence of obvious nasal or oral secretions)

• Apnea, bradycardia, hypotension, and laryngospasm

• Think about routine suctioning ??

Clear liquor – suctioning routine ??

• suctioning immediately following birth

(including suctioning with a bulb syringe)

should be reserved for babies who have

obvious obstruction to spontaneous breathing

or who require positive-pressure ventilation

(PPV)

What is routine • Drying and suctioning ,• If no response, • more vigorous stimulation, slapping the soles of

the feet or rubbing the back.• The back should be visualized.• If there is no response to stimulation,• it may be assumed the infant is in secondary

apnea, and PPV should be initiated. • infant's respiratory rate, heart rate, and color

should be evaluated

Meconium stained liquor

• Historically • Suction before delivery of shoulders –• not proved useful

• routine endotracheal intubation and direct suctioning of the trachea ??

• No to active crying babies !!

Mec. staining

• endotracheal suctioning of nonvigorous babies with meconium-stained amniotic fluid

• If intubation difficult and causing brady , don’t try – go back to mask ventilation

Administration of Oxygen

• Oxyhemoglobin saturation may normally remain in the 70% to 80% range for several minutes following birth

• clinical assessment of skin color is a very poor indicator of oxyhemoglobin saturation

SPO2 monitor

• a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm).

• Term infants keep SaO2 – 90- 94% • Preterm – 88-92% • 8- 10 litres- oxygen Hood • Monitor progress

Temperature

• unheated non humidified oxygen sources for the bag-valve-mask device

• Intubated ventilated patient – humidified warmed ventilator circuits

Positive pressure ventilation

• If the infant remains apneic or gasping,• or• if the heart rate remains <100 per minute

after administering the initial steps. • Assisted ventilation rates of 40 to 60 breaths

per minute • Heart rate , SPo2, monitor

CPAP

• CPAP • recommend administration of continuous

positive airway pressure (CPAP) to infants who are breathing spontaneously,

• but with difficulty, following birth, although its use has been studied only in infants born preterm

Laryngeal mask airways and PPV

• Laryngeal mask airways that fit over the laryngeal inlet - effective for ventilating newborns

• weighing more than 2000 g • delivered ≥34 weeks gestation• meconium-stained fluid,• during chest compressions, • or for administration of emergency intratracheal

medications

Endotracheal Tube Placement

• Initial endotracheal suctioning of nonvigorous meconium-stained newborns

• If bag-mask ventilation is ineffective or prolonged • When chest compressions are performed • For special resuscitation circumstances, such as

congenital diaphragmatic hernia or extremely low birth weight

Effective ventilation

• Heart rate • CO2 • SPo2

Chest Compressions

• Chest compressions are indicated for a heart rate that is <60 per minute despite adequate ventilation with supplementary oxygen for 30 seconds

• Ventilation priority • the 2 thumb–encircling hands technique• the 2-finger technique,

DRUGS

• Drugs are rarely indicated in resuscitation of the newly born infant.

• Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia

• Atropine ???

Drugs

if the heart rate remains <60 per minute despite adequate ventilation (usually with endotracheal intubation) with 100% oxygen and chest compressions, administration of epinephrine or volume expansion, or both, may be indicated.

• The recommended IV dose is 0.01 to 0.03 mg/kg per dose

Drugs and infusions

• Rarely, buffers, a narcotic antagonist, or vasopressors may be useful after resuscitation, but these are not recommended in the delivery room.

• An isotonic crystalloid solution – 10 ml /Kg • Intravenous glucose infusion should be considered

as soon as practical after resuscitation, with the goal of avoiding hypoglycemia

Discontinue resuscitation

• In a newly born baby with no detectable heart

rate, it is appropriate to consider stopping

resuscitation if the heart rate remains

undetectable for 10 minutes

After reading neonatal resuscitation

• What is shocking ??

• NO APGAR score at all.

The Apgar score

• Evaluate the newborn baby on five simple criteria on a scale from zero to two,

• then summing up the five values thus obtained.

• The resulting Apgar score ranges from 0 to 10. • The five criteria are summarized using words

chosen to form a backronym• (Appearance, Pulse, Grimace, Activity, Respiration.)

SCORES

0 1 2• Appearance - red peri. Blue total blue• Pulse ? < 100 > 100• Grimace stim.no mild active • Active tone less flexion good resist• Respir. Absent weak ,gasps active cry

APGAR score

• Score of 10 ?? • >7 ok • 4 – 7 -- to act

• 1 min, 5 , 10, 15 minutes• Score of 3 0r less persistent – neuro damage

What we do - follows ??

Prewarm clothes

Tray, oxygen weighing machine

Equipment

Bulb syringe

Gentle back massage

Ryles tube and aspiration

Inj. Vit. K , temperature monitoring with hood oxygen

Breast feeds

Thank you all