Neonatal resuscitation

Thee presentation describes in detail the present guidelines to help a newborn to adopt to the extra-uterine life successfully.

1. Neonatal Resuscitation. Dr. P K Maharana.

2. Incidences Vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life. Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures .

3. How to asses whether resuscitation is required or not? Answering these 3 questions. Is it Term gestation? Is the baby Crying or breathing? Is there Good muscle tone?

4. Answer : yes. If all the questions are yes; then the baby does not need resuscitation and 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, clear the airway if necessary. Observation of should be ongoing for he followings  Breathing, activity & Color .

5. If answer to any of these : No. The infant should receive one or more of the following 4 categories of action in sequence: 1. Initial steps in stabilization : ( Dry, warmth, clear airway if necessary & stimulate ). 2. Ventilation & monitor SPO2. ( Gasping, Apnea, HR < 100 ) Chest compressions (HR < 60 ) ( Intubation, chest compression, IPPV ) 4. Consider administration of epinephrine and/or volume expansion.

6. “The Golden minutes” Initial 60 seconds is the Golden minute. Stabilize; complete the initial steps & revaluate at end of this period . Monitor two parameters only. a. Respiration ( breathing regular or irregular) b. HR ( Precordial auscultation of heart sounds).

7. Success of Resuscitation Depends on : 1. Anticipation, 2. Adequate preparation, 3. Accurate evaluation & 4. Prompt initiation of support.

8. Problems with Preterm Babies Immature lungs; that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. Immature blood vessels; in the brain that are prone to hemorrhage. Thin skin and a large surface area; which contribute to rapid heat loss. Increased susceptibility to infection. Increased risk of hypovolemic shock ; related to small blood volume.

9. Thermoregulation and Stabilization of Preterm Newborns(<32 Weeks) In preparation for the birth of a preterm newborn, increase the temperature in the room where the baby will receive initial care to approximately 23-25° C (74-77° F). • Cover the newborn in food-grade plastic wrap or bag and use a hat and thermal mattress. • Use a 3-lead electronic cardiac monitor (ECG) with chest leads or limb leads to provide a rapid and reliable method of continuously displaying the baby’s heart rate if the pulse oximeter has difficulty acquiring a stable signal. • Consider using CPAP immediately after birth as an alternative to routine intubation and prophylactic surfactant administration. Many preterm babies can be treated with early CPAP and avoid the risks of intubation and mechanical ventilation. Criteria for CPAP usage and the administration of prophylactic surfactant should be developed in coordination with local experts

10. Suctioning of Mouth.   Routine  intrapartum oropharyngeal and nasopharyngeal suctioning is not recommended . (for infants born with clear and/or meconium-stained amniotic fluid) .   Attempts to shock meconium from mouth & nose in an unborn neonate while head is still in the perineum is no recommended .

11. Suction of Airway immediately Following Birth. Therefore it is recommended that 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). (Class IIb, LOE C)

12. When should consider Suctioning of Oroppharynx . The presence of thick viscous meconium in a non-vigorous infant is the only indication for   considering visualising the oropharynx and suctioning material, which might obstruct the airway . If an infant born through meconium-stained amniotic fluid and is also floppy and makes no immediate respiratory effort ,  then it is reasonable to  rapidly   inspect the oropharynx with a view to removing any particulate matter that might obstruct the airway.

13. Criteria to identify a healthy infant? Heart Rate Tone Color Respiration Healthy Infant 120- 150 Good Blue Good respiration Unhealthy infant 90-120 Less good tone Blue No good respiration Sick infant ( unwell) < 100 not acceptable Floppy Blue No respiration

14. Recent changes in the guidelines . Cord clamping is delayed up to 1 minute after delivery of the neonate unless immediate resuscitation is required . Milking of chord is no more recommended . The temperature is maintained between 36.5-37.5 C.   The emphasis should be on initiating lung inflation within the first minute of life and this should not be delayed  ( in non-breathing or ineffectively breathing infants ) .

15. Cord Clamping 1. Current evidence suggests that cord clamping should be delayed for at least 30 to 60 seconds; for most vigorous term and preterm newborns . 2 . If the placental circulation is not intact the cord should be clamped immediately after birth; (such as after a placental abruption, bleeding placenta previa, bleeding vasa previa, or cord avulsion) , There is insufficient evidence to recommend an approach to cord clamping for newborns who require resuscitation at birth.

16. Drying , Covering & Maintaining Temperature In all cases; the term or near-term infants , whether intervention is required or not ; dry , remove the wet towels , & cover the with dry towels . Significantly preterm infants are best placed, without drying , into polyethylene wrapping under a radiant heater . In infants of all gestations:  the head should be covered with an appropriately sized hat. Whatever the situation it is important that the infant does not get cold.

17. How to maintain body Temperature B ody temperature should be maintained between 36.5°C and 37.5°C after delivery. through the following measures  Radiant warmer. Use of Plastic rap with a cap. Increased room temperature. Warmed humidified respiratory gases . Thermal mattress alone . A combination of increased room temperature with plastic wrapping of head and body with thermal mattress goes a long way.

18. Delivery Room Temperature . The delivery room temperature should be at least 26°C for the most immature infants.

19. Breath Most infants have a good heart rate after birth and establish breathing by about 90s . If the infant is not breathing adequately aerate the lungs by giving 5 inflation breaths, preferably using air. Until now the infant's lungs will have been filled with fluid.

20. Inflation breaths Aeration of the lungs in these circumstances is likely to require sustained application of pressures of about 30 cm H 2 O for 2–3 s. Begin with lower pressures (20–25 cm H 2 O) in preterm infants.

21. If the lungs have not been aerated then consider:   1.Checking again that the infant’s head is in the neutral position? 2 . Is there a problem with face mask leak? 3. Do you need jaw thrust or a two-person approach to mask inflation? 4. Do you need a longer inflation time? were the inspiratory phases of your inflation breaths really of 2–3 s duration? 5 . Is there an obstruction in the oropharynx ? ( laryngoscope and suction ). 6. Will an oropharyngeal ( Guedel’s airway) HELP ? 7. Is there a tracheal obstruction?

22. Monitoring Respiration Heart rate Color Tone Reflexes Temperature Pulse Oxymetry Temperature ECG

23. Monitoring Heart Rate. During resuscitation of term and preterm newborns, the use of 3-lead ECG for the rapid and accurate measurement of the newborn’s heart rate may be reasonable.  (Class IIb, LOE C-LD)

24. Methods to asses Heart Rate Auscultation of heart sound. Pulse Oximetry ECG

25. Preductal & Postductal Oximetry .

26. SPO2% 1 minute - 60-65% 2 minute – 65-70% 3 minute – 70-75% 4 minute – 75 80% 5 minute – 80-85% 10 minutes – 85-95% Oxymetry in a full term vigorous neonate at birth.

27. Ventilation The emphasis is on initiating ventilation within the first minute of life  in non- breathing or ineffectively breathing infants and this should not be delayed, especially in the bradycardic infant . 

28. Adequacy of ventilation Assisted ventilation : 40 to 60 breaths per minute to promptly, to achieve or maintain a heart rate >100. An initial inflation pressure of 20 cm H 2 O may be effective, but ≥30 to 40 cm H 2 O may be required in some term babies without spontaneous ventilation (Class IIb, LOE C). Inflation pressure should be monitored ;

29. Effectiveness of ventilation. The primary measure of adequate initial ventilation is prompt improvement in heart rate.

30. Tracheal Intubation Tracheal intubation should not be routine . It is only in the presence of thick meconium , and is performed only for suspected tracheal obstruction or where IPPV is necessary.

31. Indications for Intubation 1. Meconium stained non vigorous newborn. 2. Bag mask ventilation is ineffective or for a prolonged period. 3. Newborn without detectable HR . 4. Expected to need prolonged ventilation . 5. Special situations( Congenital diaphragmatic hernia, Extreme low birth weight ). 6. When chest compression is required .

32. Intubation In the absence of randomized, controlled trials, there is insufficient evidence to recommend a change in the current practice of;  Performing endotracheal suctioning of nonvigorous babies with meconium-stained amniotic fluid (Class IIb, LOE C). However, if attempted intubation is prolonged and unsuccessful,  bag-mask ventilation should be considered, particularly if there is persistent bradycardia .

33. Indicators of correct endotracheal tube placement After endotracheal intubation and administration of intermittent positive pressure, a prompt increase in heart rate is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation Moisture condensation in the endotracheal tube, Chest movement, Presence of equal breath sounds bilaterally, Capnography ( Exhaled Carbon dioxide ETCO2.) Other clinical indicators have not been systematically evaluated in neonates (Class 11b, LOE C).

34. Size of ET tube A small leak should be resent between the ET tube and tracheal wall when a breath is delivered at a pressure of 25cm of water. 1 kg ------------2.5mm ID 1.5-2.5 kg ---- 3.0 mm ID 2.5 – 3.5 kg and above 3.5 mm ID

35. Ideal Length of Tube When a tube is placed the tip should 1- 2 cm below the cords. 1 kg ----------- 7cm 2 kg ----------- 8cm 3 kg ------------ 9 cm 4 kg ------------- 10 cm

36. CPAP If you are dealing with a preterm infant then initial CPAP of approximately 5 cm H 2 O, either via a face mask or via a CPAP machine, is an acceptable form of support: in infants who are breathing but who show signs of or are at risk of developing, respiratory distress . In preterm infants who do not breathe or breathe inadequately , you should use PEEP with your inflation breaths and ventilations,( as lungs in these infants are more likely to collapse again at the end of a breath).

37. CPAP 1. Nasal CPAP, continuous positive airways pressure  rather than routine intubation may be used to provide initial respiratory support of all spontaneously breathing preterm infants with respiratory distress . 2. Early use of nasal CPAP should also be considered in those spontaneously breathing preterm infants who are at risk of developing respiratory distress syndrome  

38. Usefulness of CPAP Starting infants on CPAP  reduces a. the rates of intubation, b. mechanical ventilation, c. surfactant use & d. duration of ventilation . But increased the rate of pneumothorax .

39. PEEP Although positive end–expiratory pressure (PEEP) has been shown to be beneficial . Its use is routine during mechanical ventilation of neonates in intensive care units. There have been no studies specifically examining PEEP versus No PEEP when PPV is used during establishment of an FRC following birth. Nevertheless, PEEP is likely to be beneficial and should be used if suitable equipment is available (Class IIb, LOE C).

40. Use of Oxygen Term infants should be resuscitated with Air only. For preterm baby low concentration (21-30)% blended Oxygen should be used. Higher concentration oxygen is administered only if oximetry is not acceptable.

41. Chest Compression If the heart remains slow (HR < 60 min -1 ) or absent after 5 effective inflation breaths and 30 seconds of effective ventilation, start chest compressions. Chest compression should be started only when you are sure that the lungs have been aerated successfully . 

42. Two techniques have been described: compression with 2 thumbs with fingers encircling the chest and supporting the back (the 2 thumb–encircling hands technique) or compression with 2 fingers with a second hand supporting the back.

43. 2 thumb–encircling hands technique . Because the 2 thumb–encircling hands technique may generate higher peak systolic and coronary perfusion pressure than the 2-finger technique ,  the 2 thumb–encircling hands technique is recommended for performing chest compressions in newly born infants (Class IIb , LOE C).

44. Technique of 2 thumb–encircling hands technique . In infants, the most efficient method of delivering chest compression is to  Grip the chest in both hands in such a way that the two thumbs can press on the lower third of the sternum , just below an imaginary line joining the nipples, with the fingers over the spine at the back. Compress the chest quickly and firmly, reducing the antero -posterior diameter of the chest by about one third . The ratio of compressions to inflations in new born resuscitation is 3:1. 

45. The 2-finger technique The 2-finger technique may be preferable when access to the umbilicus is required during insertion of an umbilical catheter , although it is possible to administer the 2 thumb–encircling hands techniq ue in intubated infants with the rescuer standing at the baby's head , thus permitting adequate access to the umbilicus (Class IIb, LOE). 

46. CPR( Compression: ventilation ratio) The recommended C ompression : ventilation ratio for CPR  remains at 3:1 for newborn resuscitation . It should be synchronous , asynchronous compressions are not recommended .

47. Compressions : Ventilations There is evidence from animals and non-neonatal studies that sustained compressions or a compression ratio of 15:2 or even 30:2 may be more effective when the arrest is of primary cardiac etiology . One study in children suggests that CPR with rescue breathing is preferable to chest compressions alone when the arrest is of noncardiac etiology

48. Important facts ( Chest Compression ) Intubation is strongly recommended prior to beginning chest compressions. If intubation is not successful or not feasible, a laryngeal mask may be used. Chest compressions are administered with the two-thumb technique . • Once the endotracheal tube or laryngeal mask is secured, the compressor administers chest compressions from the head of the newborn . • Chest compressions continue for 60 seconds prior to checking a heart rate.

49. Oxygen Requirement? Optimal management of oxygen during neonatal resuscitation becomes particularly important because of the evidence that either insufficient or excessive oxygenation can be harmful to the newborn infant. Hypoxia and ischemia are known to result in injury to multiple organs. that adverse outcomes may result from even brief exposure to excessive oxygen during and following resuscitation .

50. How safe is the oxygen therapy? In healthy term infants, oxygen saturation increases gradually from approximately 60% soon after birth to over 90% at 10 min . In preterm infants hyperoxaemia is particularly damaging and if oxygen is being used and the saturation is above 95% the risk of hyperoxaemia is high . Therefore the rate of rise in oxygen saturation after birth in preterm infants should not exceed that seen in term infants, although some supplemental oxygen may be required to achieve this.

51. Oxygen Therapy If blended oxygen is not available , resuscitation should be initiated with air (Class IIb, LOE B). If the baby is bradycardic (HR <60 per minute) after 90 seconds of resuscitation with a lower concentration of oxygen , oxygen concentration should be increased to 100% until recovery of a normal heart rate ( Class IIb, LOE B).

52. Retinopathy Retinopathy can occur in premature infants( Gestational age< 34 weeks ), if PaO2 equal or more than 150mm Hg or above for 2-4 hours . In premature infants PaO2 should be maintained between 55-75 or SaO2 87-94%,which is normal for that age . If higher FIO2 used Oxymetry should be used and accordingly percentage of Oxygen should reduced.

53. Apgar Score Virginia Apgar . Anesthesiologist  at  NewYork –Presbyterian Hospital Developed a score in 1952 to quantify the effects of  obstetric anesthesia  on babies. In 1953, she introduced the first test, called the  Apgar score , to assess the health of newborn babies.

54. Interpretation of scores The test is generally done: at 1 and 5 minutes after birth and may be repeated later if the score is and remains low. Scores of 7 and above are normal ;(nothing is required) 4 to 6, fairly low ; ( responds to Vigorous stimulation & blowing of Oxygen over face ) 3 and below are critically low ( immediate resuscitative efforts are recommended, mostly responds to bag mask ventilation). 2 and below ( Vigorous resuscitation)

55. Implementation of scores. In cases where a newborn needs resuscitation , it should be initiated before the Apgar score is assigned at the 1-minute mark. Apgar score is not used to determine if initial resuscitation is needed or not, rather it is used to determine if resuscitation efforts should be continued . Variation between the 1-minute and 5-minute used to assess an infant's response to resuscitation. If the score is below 7 at the 5-minute mark, then Apgar score should be reassessed at 5-minute intervals for up to 20 minutes. To reduce the risk of negative outcomes, it is recommended umbilical artery blood gas to be done when Apgar score of 5 or less at the 5-minute mark .

56. Limitations. There are numerous factors that contribute to the Apgar Score, several of which are subjective , includes but not limited to  color, tone, and reflex irritability . Preterm infants may receive a lower score in these categories due to lack of maturity rather than asphyxia. Other factors that may contribute to variability among infants are  birth defects, sedation of the mother during labor, gestational age or trauma. Inappropriately using the Apgar Score has led to errors in diagnosing asphyxia.

57. Drugs The drugs used include:- 1. Adrenaline ( 1:10,000 ), 2. Glucose (10 %). 3.Occasionally sodium Bicarbonate (ideally 4.2%),

58. Drugs( Adrenaline ) The recommended intravenous dose for is 10 microgram kg - 1  (0.1 mL kg -1  of 1:10,000 solution). If this is not effective, a dose of up to 30 microgram kg -1  ( 0.3 mL kg -1  of 1:10,000 solution) may be tried. 

59. Drugs( Sodium bicarbonate) I s not recommended during brief resuscitation . If it is used during prolonged arrests unresponsive to other therapy, it should be given only after adequate ventilation and circulation ( with chest compressions ) is established. The dose for sodium bicarbonate is: 1 and 2 mmol of bicarbonate kg -1  ( 2–4 mL kg -1  of 4.2% bicarbonate solution). A diluted solution is used.

60. Drugs( Glucose ) GLUCOSE : Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia (Class IIb, LOE C). The dose for glucose 10% : 2.5 mL kg- 1  (250 mg kg -1 .) ( and should be considered if there has been no response to other drugs delivered through a central venous catheter ) .  

61. Role of Glucose New born at increase risk of brain injury if hypoglycemia . BG should be maintained at 2.5 mmol/kg or mor e. Start with 0.5 -1ml/kg bolus, maintain 5-7ml/kg/min.

62. Crystalloid Infusion Required very rarely : the heart rate cannot increase because the infant has lost significant blood volume . If this is the case, there is often a clear history of blood loss from the infant , but not always. Use of isotonic crystalloid rather than albumin is preferred for emergency volume replacement . In the presence of hypovolaemia : a bolus of 10 mL kg -1  of 0.9% sodium chloride or similar given over 10–20 s will often produce a rapid response and can be repeated safely if needed . 

63. Blood or Crystalloids If > 50% of Blood volume is lost( placenta abrupted or placenta is transected). 10-20ml/kg transfusion restores arterial pressure to normal. It should be titrated and slow infusion 10ml/kg over 10 minutes.

64. Therapeutic Hypothermia Infants born ≤ 36 weeks Gestations involving with moderate to severe ischemic encephalopathy at 6 hours of birth should be offered therapeutic hypothermia . Temperature maintained between ( 33.5 – 34.5⁰C). Begins at 6hours & continues up to 72 hours. Rewarming should be slow, ( at 0.2- 0.5 °C per hour till 36.5⁰C).

65. Indications of Hypothermia 1. Neonates ≥ 36 weeks gestational age and less than 6 hours of age 2. Any one of the following: • sentinel event prior to delivery, such as uterine rupture, profound fetal bradycardia, or cord prolapse. • low Apgar scores ➔ ≤ 5 at 10 minutes of life. • prolonged resuscitation at birth ➔ chest compressions and/or intubation and/or mask ventilation at 10 minutes. • severe acidosis ➔ pH < 7.0 from cord or neonate blood gas within 60 minutes of birth. • abnormal base excess ➔ ≤ -16 mEq/L from cord gas or neonate blood gas within 60 minutes of birth. 3. Any one of the following:  • clinical event concerning for seizure • neonatal encephalopathy

66. Communication to Parents . It is important that the team caring for the newborn baby informs the parents of the baby’s progress. At delivery, adhere to the routine local plan and, if possible, hand the baby to the mother at the earliest opportunity . If resuscitation is required inform the parents of the procedures undertaken and why they were required . Record all discussions and decisions in the baby’s records as soon as possible after birth .

67. When to stop resuscitation In a newly-born infant with no detectable cardiac activity, and with cardiac activity that remains undetectable for 10 min , it is appropriate to consider stopping resuscitation .

68. Decision to continue resuscitation efforts beyond 10 min The decision to continue resuscitation efforts beyond 10 min with no cardiac activity is often complex and may be influenced by issues such as: the availability of therapeutic hypothermia and intensive care facilities, the presumed aetiology of the arrest, the gestation of the infant, the presence or absence of complications , and the parents’ previous expressed feelings about acceptable risk of morbidity.

69. Apnea Infant  apnea  is defined: by the American Academy of Pediatrics as " an unexplained episode of cessation of breathing for 20 seconds or longer , or a shorter respiratory pause associated with bradycardia , cyanosis, pallor , and/or marked hypotonia."   Apnea is more common in preterm infants.(Feb 13, 2018)

70. Primary Apnea . When a fetus or infant is deprived of oxygen, an initial period of rapid breathing occurs . If the asphyxia continues,  the respiratory movements cease,  the heart rate begins to fall, and the infant enters  a period of apnea known as primary apnea. This is the first sign of oxygen deprivation, usually related to labor and delivery events. When in primary apnea, the infant responds to - o Tactile stimulation such as drying or slapping the infant's feet o Free flow oxygen.

71. Primary Apnea A self-limited condition characterized by an absence of respiration.  It may follow a blow to the head and is common immediately after birth in the newborn who breathes spontaneously when the carbon dioxide level in the circulation reaches a certain value.  Reflexes are present and the heart is beating,  but  the skin may be pale or blue and muscle tone is diminished.  No treatment is necessary, but careful observation, maintenance of body temperature, and oral pharyngeal aspiration are usually performed.  Within seconds the newborn usually begins breathing, becomes pinker, moves the arms and legs, and cries. 

72. Secondary apnea Occurs when oxygen deprivation continues following several gasps. Breathing stops. Bradycardia will progress to asystole. • The BP falls as secondary apnea begins. • When in secondary apnea – o Tactile stimulation will not help.

73. Points to note If an infant begins breathing with stimulation, he is in primary apnea. • If an infant does not begin breathing with stimulation, he has secondary apnea and will require positive-pressure ventilation (PPV). • The longer a baby remains in secondary apnea, the longer it will take for spontaneous breathing to occur. • Initiation of PPV results in rapid improvement in the compromised infant--don't waste time continuing to stimulate the infant. • Knowledgeable and skilled caregivers capable of responding to events surrounding birth should be present at every delivery.

74. Newborn Life Support Algorithm.