Neonatal resuscitation

Neonatal resuscitation

1. SAKSHI RANA MSc NURSING NEONATAL RESUSCITATION

2. NEONATAL RESUSCITATION Neonatal Resuscitation is a set of interventions used to assist the airway, breathing and circulation of a newborn following birth.

3. CONTT.. The Neonatal Resuscitation Program (NRP) is a set of educational guidelines established by the American Academy of Pediatrics that outline the proper procedures for resuscitation of a newborn.

4. 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 extrauterine life requiring little or no assistance. 10 % of newborns need some assistance. Only 1% require extensive resuscitation.

5. HAZARDS Compromise of uterine or placental blood flow Deceleration of FHR Weak cry Inadequate ventilation to push the alveolar fluid In utero hypoxia Meconium passage M ay block the airways

6. CONTT.. Fetal blood loss (abruption) Systemic Hypotension Fetal Hypoxia/ischemia Poor cardiac contractility & fetal bradycardia Systemic Hypotension Pulmonary arterioles remain constricted

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

8. INITIAL STEPS OF RESUSCITATION In anticipation of delivery, counselling should be done along with team briefing, role assignment and equipment check. Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and PPV perfectly, and whose only responsibility is care of the newborn.

9. CONTT.. When perinatal risk factors are identified, a resuscitation team should be present and a team leader identified. The leader should conduct a pre-resuscitation briefing, identify interventions that may be required, and assign roles and responsibilities to the team members.

10. CONTT.. During resuscitation, the team should demonstrate effective communication and teamwork skills to help ensure quality and patient safety. MSAF is a risk factor for abnormal transition and team must ensure a member with advanced airway and resuscitation skills is in attendance.  

11. NRP’s 10 Key Behavioral Skills Know your environment Anticipate and plan Assume the leadership role Communicate effectively Delegate workload optimally

12. CONTT.. Allocate attention wisely Use all available information Use all available resources Call for help when needed Maintain professional behavior

13. CONTT.. Initial assessment of the neonate and initial resuscitation steps remain unchanged Emphasis on thermoregulation throughout resuscitation. Temperature should be maintained between 36.5 and 37.5 Celsius.

14. CONTT.. For preterm infants, combination of interventions 1. Radiant warmers 2. plastic wrap with a cap thermal mattress warmed humidified gases increased room temperature to 26 deg c Portable incubator

15. CONTT.. Routine Care for vigorous term infants with no risk factors & babies who required but responded to initial steps , can stay with mother, Skin to skin contact recommended, clear airway, dry newborn, provide ongoing evaluation: 1.Breathing 2.Activity 3.Color

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

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

18. PPV

19. CONTT .. Indications for PPV remain unchanged,those being a heart rate less than 100 bpm or ineffective respirations. Initial PIP is suggested in the range of 20-25 cm H20. When PPV is administered to preterm infants, PEEP should be used. Recommended starting PEEP is 5 cm H20.

20. CONTT.. Rate of PPV is 40-60 / minute. Rising of HR Improvement in Oxygen Saturation Equal and adequate breath sounds B/L Good Chest rise After PPV started, reassess in 15 seconds. If no response, MR SOPA corrective measures should be incorporated.

21. ACTIONS M Adjust Mask to assure good seal on the face R Reposition airway by adjusting head to sniffing position S Suction mouth and nose of secreation s, if present O Open mouth slightly and move jaw forword P Increase Pressure to achieve chest rise A Consider Airway alternative ( endotracheal intubation or laryngeal mask airway)

22. SUPPLEMENTAL OXYGEN

23. CONTT .. If HR is >100 but has labored breathing Term infants start resuscitation with 21% O2, Preterm less than 35 Weeks should be initiated with low oxygen (21% to 30%) and the oxygen titrated to achieve preductal oxygen saturation similar to that in healthy term infants.

24. CONTT.. Initiating resuscitation of preterm newborns with high oxygen (65% or greater) is not recommended. If HR is >100 but has labored breathing or Sp02 cannot be maintained within target range despite 100% free-flow oxygen, consider a trial of continuous positive airway pressure (CPAP).

25. 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%

26. CONTT.. 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.

27. CONTT.. If heart rate is not increasing and there is no chest movement, despite MR SOPA corrective steps including intubation, obstruction should be considered and suction can be performed either using a catheter through the ETT or a meconium aspirator.

28. CHEST COMPRESSIONS

29. CONTT .. The indication for chest compressions remains unchanged, this being a heart rate less than 60 bpm in spite of 30 seconds of effective PPV. 100% oxygen continues to be recommended when administering chest compressions.

30. CONTT.. The 2-thumb technique is recommended and once the airway has been secured, the team member administering compressions should switch to the head of the bed and the team member providing PPV should move to side. Compress 1/3rd diameter of chest. Do not lift the fingers off the chest.

31. CONTT.. 90 compressions to 30 ventilations/minute (3:1- One & two & three & breathe & One & two & three & breathe…) Chest compressions should be continued for 60 seconds before reassessment of heart rate. Electronic cardiac monitor preferred for assessment of heart rate.

32. MEDICATIONS 1.EPINEPHRINE: Indicated if HR remains <60 bpm after at least 30 secs 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. CONTT.. Give rapidly. 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. CONTT.. 2.OTHERS: For treatment of 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. CONTT.. 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 : There is a new 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, such as after a placental abruption, bleeding placenta previa , bleeding vasa previa or cord avulsion, the cord should be clamped immediately after birth.

37. CONTT.. MECONIUM STAINED LIQUOR : If the infant born through meconium -stained amniotic fluid is nonvigorous , 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

38. CONTT.. Routine intubation for tracheal suction is not suggested. Pneumothorax : Percutaneous needle aspiration Pleural effusion : Percutaneous needle aspiration

39. CONTT.. Congenital Diaphragmatic hernia : Intubation Therapeutic hypothermia for HIE : used for >/= 36wks & should meet special criteria,initiated before 6 hours after birth,in facilities with multidisciplinary care

40. 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 Cong. Anomalies are associated with early death and high morbidity , resuscitation is not indicated.  

41. RESUSCITATION STEP RECOMMENDATIO NS (2005) RECOMMENDATIONS (2010) LATEST First step Counselling,team briefing,equipment check Assessment Four questions • Amniotic fluidclear or not? Three questions Gestation-term or not? Breathing /Crying? Tone- Good? • Term/not? • Tone-good? • Breathing/crying? Assessment (after initial steps ) Look for 3 signs • Hear rate • Color • Respiration Look for 2 signs • Heart rate • Respiration( Labored, unlabored, apnea, gasping) = HR Palpation of umbilical cord pulsations Auscultation of heart Auscultation + 3 -lead ECG Oxygenation Pulse oximetry recommended for only preterm < 32weeks with need for PPV pulse oximetry for both term and preterm = Target saturation Not defined Target SpO2 ranges provided as a part of algorithm = Intubation Before chest compressions Therapeutic Hypothermia (pre- ductal ) No sufficient evidence Recommended for infants ≥ = 36weeks with moderate to severe HIE =