Neonatal resuscitation

Neonatal resuscitation protocols latest edition

1. NEONATAL RESUSCITATION Presented by: Dr.Himanshu Dave Secondary DNB (1 st year) DEPARTMENT OF PEDIATRICS NRCH

2. Topics to be highlighted History Principles of Resuscitation Initial steps of resuscitation Positive – Pressure ventilation Endotracheal tube intubation and LMA insertion Chest compressions Medications Special considerations When to stop resuscitation

3. HISTORY Dr.William Keenan – Father of NRP Every five years, the International Liaison Committee on Resuscitation (ILCOR) comprising representation from 13 countries worldwide reviews the available resuscitation science.

4. It provides recommendations based on the available evidence at that time. The ILCOR guidelines were published in October 2015 and the AAP launched its 7th edition of NRP in May 2016.

5. PRINCIPLES OF RESUSCITATION Birth asphyxia accounts for about 1/4th of the neonatal deaths that occur each year worldwide. 90% of newborns make smooth transition from intrauterine to extra uterine life requiring little or no assistance. 1 0% of newborns need some assistance. Only 1% require extensive resuscitation.

6. WHAT CAN GO WRONG ? Compromise of uterine or placental blood flow Deceleration of FHS Weak cry I nadequate ventilation to push the alveolar fluid

7. In utero hypoxia Meconium passage May block the airways

8. Pulmonary arterioles remain constricted PPHN (Persistent Pulmonary Hypertension of New Born)

9. CONSEQUENCES Low muscle tone , apnoea or tachypnea , bradycardia or hypotension and cyanosis. Outcomes of these newborns can be improved with timely and effective resuscitation.

10. INITIAL PREPARATIONS There is increased focus throughout the 7th edition NRP on team preparation and role assignment. T eam briefing R ole assignment E quipment check.

11. Initial preparations cont… Every birth should be attended by at least 1 person whose only responsibility is care of the newborn. Meconium stained amniotic fluid- ensure a member with advanced airway and resuscitation skills is in attendance.

12. Equipment required

13. INITIAL ASSESSMENT Ask 4 questions to the obstetrician: 1) Gestational age? 2) MSAF? 3) Single or multiple gestation? 4) Risk factors in mother?

14. INITIAL STEPS Initial assessment after birth :Tone ? and breathing/crying? Warmth and position airway Suction if necessary Dry and stimulate Repositioning

15. Initial Steps cont… In stable infants , delayed cord clamping should be performed for at least 30 seconds Temperature should be maintained between 36.5 and 37.5 Celsius Focus on thermoregulation throughout resuscitation

16. ROUTINE CARE Vigorous term babies with no risk factors & who required but responded to initial steps: Skin to skin contact and can stay with mother Clear airway Dry newborn Provide ongoing evaluation: Breathing , Activity and Colour .

17. Role of supplemental oxygen in NRP Starting resuscitation gas for term infant should be 21% In infants <35 weeks, starting gas should be 21-30% and should be increased as per requirement. Continue to achieve target saturations using preductal saturation monitor.

18. TARGETED PREDUCTAL SPO2 AFTER BIRTH 1 min 60%-65% 2 min 65%-70% 3min 70%-75% 4min 75%-80% 5min 80%-85% 10min 85%-95%

19. The Golden Minute The Golden Minute (60-second) mark is for completing the initial assessment, initial steps, re-evaluating, and beginning ventilation if required . Evaluations and decision making are based on: a) Respiratory effort b) Heart rate

20. Evaluation For assessment of heart rate, the use of a 3-lead ECG is recommended. Pulse oximetry to evaluate the newborn’s oxygenation

21. Positive Pressure Ventilation (PPV) Indications for PPV : - Heart rate less than 100 bpm or - Ineffective respirations. Initial PIP (Peak Inspiratory Pressure) is suggested in the range of 20-25 cm H20. When PPV is administered to preterm infants, PEEP(Positive End Expiratory Pressure) should be used. Recommended starting PEEP is 5 cm H20.

22. PPV cont…. Rate of PPV is 40-60 / minute. (Breathe ,2,3..) Rising of HR Improvement in Oxygen Saturation PPV Equal and adequate breath sounds Effective B/L Good Chest rise If

23. PPV cont… After PPV started, reassess in 15 seconds . If no response; MR SOPA corrective measures should be incorporated.

24. Indication of CPAP If HR is >100 but has laboured breathing or Sp02 cannot be maintained within target range despite 100% free-flow oxygen: - consider a trial of Continuous Positive Airway Pressure (CPAP)

25. ADVANCED AIRWAY Intubation is recommended prior to chest compressions . If intubation is not feasible, the laryngeal mask airway should be used as an alternate advanced airway. Recommendations for depth of insertion are gestation-based or based on formula using nasal-tragus length (NTL) measurement.

26. NTL + 1

27. CHEST COMPRESSIONS The indication for chest compressions: - Heart rate less than 60 bpm in spite of 30 seconds of effective PPV. 100% oxygen to be given when administering chest compressions.

28. Chest compressions cont… The 2-thumb technique is recommended (Two finger technique is now obsolete).

29. Chest compression cont… Compress 1/3rd diameter of chest. Do not lift the fingers off the chest . 90 compressions to 30 ventilations/minute (3:1- One & two & three & breathe & One & two & three & breathe…)

30. Chest Compression Cont… Chest compressions should be continued for 60 seconds before reassessment of heart rate. Electronic cardiac monitor preferred for assessment of heart rate.

31. Technique of chest compressions with PPV

32. MEDICATIONS 1.EPINEPHRINE Indicated if : HR remains <60 bpm after at least 30 sec of effective PPV and another 60 seconds of chest compressions using 100% oxygen . One dose may be given through ETT. If no response, give intravenous dose via emergency UVC or IO access.

33. MEDICATIONS cont… Concentration - 1:10,000 (0.1mg/ml) . ETT dose - 0.5 – 1 ml/kg . UVC / IV dose 0.1- 0.3 ml/kg ,follow with a 1ml flush NS . Can repeat every 3-5 minutes.

34. MEDICATIONS cont… 2.OTHERS For hypovolemic shock: Normal saline and blood are the solutions of choice and the recommended volume is 10 ml/kg. Ringer’s lactate is no longer recommended.

35. The routine use of NaHCO3 to correct metabolic acidosis is not recommended. The use of naloxone to manage respiratory depression in infants born to mothers with narcotic exposure in labour is not recommended.

36. SPECIAL SCENARIOS DELAYED CORD CLAMPING : Recommendation that delayed cord clamping for 30 -60 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth. If placental circulation is not intact (placental abruption or bleeding due to any cause): The cord should be clamped immediately after birth.

37. SPECIAL SCENARIOS MECONIUM STAINED LIQUOR : If the infant born through meconium-stained amniotic fluid is non vigorous, the initial steps of resuscitation should be completed under the radiant warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed . Routine intubation for tracheal suction is not suggested.

38. SPECIAL SCENARIOS Pneumothorax : Percutaneous needle aspiration Pleural effusion : Percutaneous needle aspiration Congenital Diaphragmatic hernia : Intubation Therapeutic hypothermia for HIE : For >/= 36wks with severe birth asphyxia, initiated within 6 hours after birth , in facilities with multidisciplinary care.

39. WHEN TO STOP RESUSCITATION ? * An APGAR score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants, but decisions to continue or discontinue resuscitation efforts must be individualized. * Where GA ( < 23wks ), B.wt ( < 400g) and / or Congenital anomalies are associated with early death and high morbidity, resuscitation is not indicated.

40. THANK YOU