NALS- ALGORITHM-1 kiran final.pptx

Neonatal resuscitation

1. NALS- ALGORITHM Presentor - Dr. Kiran Dyavanagoudar Moderat or - Dr. Srinivas (Pediatrician) Dr. Pooja Shah.

2. OBJECTIVE To describe the steps of Positive Pressure Ventilation. To describe the indications for Endotracheal Intubation and Chest Compressions. To discuss about the Medications used in NRP.

3. 4 key questions before birth: ( 1) What is the expected gestational age? (2) Is the amniotic fluid clear? (3) Are there any additional risk factors? (4) What is our umbilical cord management plan?

4. INTRODUCTION Approximately 85% of term newborns will begin breathing-spontaneously 10% will begin breathing - drying and stimulation.

5. INTRODUCTION 5% of term newborns - receive positive-pressure ventilation (PPV). 2% of term newborns -intubated. • 1 to 3 babies per 1,000 births will receive chest compressions or emergency medications.

6. INTRODUCTION Ventilation of the newborn's lungs is the single most important and effective step in neonatal resuscitation.

7. NRP ALGORITHM It is divided into 5 blocks beginning with birth and the initial assessment. Throughout the Algorithm, hexagons indicate assessments and rectangles show actions that may be required.

8. NRP ALGORITHM

9. RESUSCITATION TEAM Every birth should be attended by at least 1 qualified individual If risk factors are present, at least 2 qualified individuals should be present.

10. EQUIPMENT CHECKLIST

11. Anticipation A radiant heat source ready for use All resuscitation equipments immediately available & in working order At least 1 person skilled in neonatal resuscitation

12. Neonatal Resuscitation Supplies & Equipments -Suction Equipment Mechanical suction Suction catheters 10,12, or 14 F Meconium aspirator -Bag and Mask Equipment Neonatal resuscitation bags ( self limiting) Face-masks ( for both term & preterm babies) Oxygen with flow meter and tubing -Intubation Equipment Laryngoscope with straight blades no.0 (preterm)& no.1 (term) Extra bulbs & batteries ( for laryngoscope) Endotracheal tubes ( int diameter 2.5, 3, 3.5 & 4)

13. Medications Epinephrine Normal saline or Ringer Lactate Naloxone hydrochloride Miscellaneous Linen, shoulder roll, gauze Radiant warmer Stethoscope Syringes 1,2,5,10,20,50 ml Feeding tube 6 F Umbilical catheters 3.5, 5 F Three way stopcocks Gloves

14. RAPID EVALUATION High risk newborn: preterm, poor tone, not crying Low risk newborn: Term, good tone, crying

15. INITIAL STEPS Provide warmth Dry Stimulate Positioning the head and neck ( to maintain patency of airway) Clearing the airway of secretions if needed Vigorous term newborn – Skin to skin with mother while initial steps are performed

16. INITIAL STEPS Gentle suctioning Mouth before Nose (M before N) Suction catheter – Negative pressure 80 – 100mmHg

17. Evaluation of initial steps Initial steps should be completed within 30 seconds

18. INITIAL STEPS -EVALUATION Auscultation Measure for 6 seconds and multiply by 10. If heart rate not determined by physical examination - Pulse oximeter or cardiac monitor

19. APNEA/GASPING ? - NO HR < 100bpm ? - NO

20. PERSISTENT CYANOSIS Acral cyanosis Supplemental oxygen needed only if oxygen saturation below target. Free flow oxygen

21. TARGET OXYGEN SATURATION Supplemental oxygen 1.Start with Fio2 – 30% 2.Flow – 10L/min

22. LABORED BREATHING? - YES Laboured breathing or oxygen saturation cannot be maintained within target range despite oxygen. Trial of CPAP via Flow- inflating bag or T- piece.

23. T- piece PEEP – 5cm H2O Peak pressure 20 – 25mmHg Flow – 10L/min

24. POST RESUSCITATION POST RESUSCITATION CARE TEAM DEBRIEFING

25. POSITIVE PRESSURE VENTILATION Baby APNEA/GASPING or HR <100bpm Rate 40-60 breaths/ minute Rhythm – “Breathe, two, three”

26. POSITIVE PRESSURE VENTILATION Assess for increasing HR within 30 seconds of PPV, observe for chest movement.

27. MR SOPA 5 rescue breaths with each step to assess chest movement with PPV. Mask readjustment + Reposition the head and neck Suction the mouth and nose + Open the mouth Pressure increase Alternate airway

28. ENDOTRACHEAL INTUBATION Assess after 30 seconds of PPV HR < 60cpm Intubate if not already done. Start chest compressions

29. CHEST COMPRESSION Ratio of PPV to CC = 1:3 in 2 sec ( 1 and 2 and 3 and breathe) 100% Oxygen

30. MEDICATIONS If HR < 60bpm Continue co- ordinated PPV and CC Access Umbilical venous line Injection Adrenaline 1:10000 dilutions of 0.2ml/kg (0.1 – 0.3) followed by saline flush of 3ml. Every 3-5 minutes. ET adrenaline may be administered at a dose of 1.0ml/kg till umbilical venous access is established

31. MEDICATIONS Consider hypovolemia Consider Pneumothorax

32. No response to adrenaline Consider discontinuing resuscitation, if HR = 0 after 20 minutes of life. Post – resuscitation debriefing and family counselling.

33. TAKE HOME MESSAGES Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. Ventilation of the newborn's lungs is the single most important and effective step in neonatal resuscitation. A rise in heart rate is most important indicator of effective ventilation and response to resuscitative interventions.

34. REFERENCES Zaichkin J, Kamath-Rayne BD, Weiner G. Neonatal Resuscitation, 8th edition (2021), Jaypee Publication

35. THANK YOU