Neonatal resuscitation [autosaved]

neonatal resuscitation

1. Neonatal Resuscitation
Dr. BikashBhandari
Lecturer
Department of Pediatrics

2. Objectives
•Warm up
•Historical aspects
•Spectrum of the problem
•Adult vs neonatal resuscitation
•NRP 2015 guidelines
•Refreshment

3. Historical aspects
•18
th
CenturyScottishObstetricianBlundellfirstusedmechanical
devicefortrachealintubationinlivingnewborn
•In1920JosephB.DeLeeintroducedsimplerubbercatheterandglass
traptoclearupperairwaysandstomach.
•In1953ApgarScorewasgivenbyVirginiaApgar.Sheisalsothefirst
tocatheteriseUAinnewborn

4. Historical aspects
•1966nationalguidelinesforresuscitationofadultswas
recommendedbyNationalAcademyofSciences.
•In2000theconsensusdocumentonadvancedlifesupportofthe
newbornconvertedthepreviouslypublishedadvisorystatementsinto
asetofguidelines.
•In2010revisedguidelineswaspublished.
•In2015theguidelineshavebeenupdated.

5. William Keenan –Father of NRP
Professor of Pediatrics and Director of the
Neonatology Department at Saint Louis
University in St. Louis, Missouri.

6. INTRODUCTION
•Majorityofbabiesundergoasmoothphysiologictransitionand
breatheffectivelyafterdelivery
•Approximately10%ofthenewbornsrequiresomeassistance
•Lessthan1%requireextensiveresuscitativemeasures
•Alwaysbepreparedtoresuscitate,asevensomeofthosewithnorisk
factorswillrequireresuscitation

7. SDG target of NMR is
11/1000 live births

8. High Risk Delivery
•Maternalconditions–Advancedorveryyoungmaternalage,
maternaldiabetesmellitusorhypertension,substanceabuse,history
ofstillbirth,H/Ofetalloss,earlyneonataldeathintheprevious
pregnancies
•Fetalconditions–Prematurity,postmaturity,congenitalanomalies,
multiplegestations

9. High Risk Delivery
•Antepartumcomplications–Placentalanomalies(placentaprevia),
oligohydramniosorpolyhydramnios.
•Deliverycomplications–Transverselieorbreechpresentation,
chorioamnionitis,foul-smellingormeconium-stainedamnioticfluid,
antenatalasphyxiawithabnormalfetalheartratepattern,maternal
administrationofanarcotic,forceps,vacuum,cordprolapse

10. Causes of Neonatal Mortality
Preterm
27%
Sepsis & pneumonia
26%
Asphyxia
23%
Congenital
7%
Tetanus
7%
Diarrhoea
3%
Others
7%
4 million neonatal deaths: When? Where? Why? Lancet2005; 365: 891–900

11. Causes of Neonatal Mortality
Asphyxia
23%
4 million neonatal deaths: When? Where? Why? Lancet2005; 365: 891–900

12. Overview and Principles
WHYTOLEARNNEWBORNRESUSCITATION?
•Birthasphyxiaaccountsforabout1/4
th
ofthe4millionneonatal
deathsthatoccureachyearworldwide.
•Formanynewbornsresuscitationisnotavailable
•Outcomesofthesenewbornscanbeimprovedwithtimelyand
effectiveresuscitation.

13. Overview and Principles
ADULT vs. NEONATAL RESUSCITATION
▪The sequence of resuscitation in adultsis C-A-B
▪But in newbornsthe sequence remains
A-B-C as the etiology of neonatal compromise is nearly always a breathing
difficulty
▪AIRWAY(position and clear)
▪BREATHING (stimulate to breathe)
▪CIRCULATION (assess HR and oxygenation)

14. Overview and Principles –Changes in
newborn physiology

15. Overview and Principles –Changes in
newborn physiology
•BEFOREBIRTH
▪Oxygensupplybyplacental
membranes
▪Noroleoflungs.Fluidfilled
alveoliandconstrictedarterioles
duetolowPo2infetalblood.

16. Overview and Principles –Changes in
newborn physiology
▪LowPo2→constricted
arterioles→ increased
pulmonaryvascularresistance
→shuntingofbloodfrom
PulmonaryArtery→Ductus
Arteriosus→Aorta.

17. Overview and Principles –Changes in
newborn physiology
AFTER BIRTH
•Baby cries →takes first breath →air enters alveoli →alveolar fluid
gets absorbed →increased Po2 →relaxes pulmonary arterioles →
decreased PVR

18. Overview and Principles –Changes in
newborn physiology
•Umbilicalarteriesconstrict+
clampcord→closureof
UmbilicalArteriesandUmbilical
Vein→increasedSVR
•DecreasedPVR+IncreasedSVR
→functionalclosureofDuctus
Arteriosus→increasedblood
flowintolungs→oxygenation
→supplytobodythroughaorta.

19. Overview and Principles –Changes in
newborn physiology
WHATCANGOWRONG?
•Compromiseofuterineorplacentalbloodflow→decelerationof
FHR(1
st
clinicalsign)
•Weakcry→inadequateventilationtopushthealveolarfluid
•Inuterohypoxia→Meconiumpassage→mayblocktheairways
•Fetalbloodloss(abruption)→SystemicHypotension
•FetalHypoxia/ischemia→poorcardiaccontractility&fetal
bradycardia→SystemicHypotension
•Pulmonaryarteriolesremainconstricted→PPHN

20. Consequences of interrupted transition
•Low muscle tone
•Respiratory depression (apnoea / gasping)
•Tachypnea
•Bradycardia
•Hypotension
•Cyanosis

21. Pathophysiology of Perinatal asphyxia
Rapid
breathing
Irregular
Gasping

22. Pathophysiology of Perinatal asphyxia

23. Pathophysiology of Perinatal asphyxia

24. Pathophysiology of Perinatal asphyxia

25. Pathophysiology of Perinatal asphyxia

26. Being Prepared
•A person skilled in neonatal resuscitation
•Radiant heat source, plastic wrap with a cap, thermal mattress and
increased room temperature
•Resuscitation equipments
Suction equipments : Mechanical suction , Meconium aspirator, Suction
catheters 10,12,14
Bag and mask equipments : Neonatal resuscitation bags , Face mask,Oxygen

27. •Intubation equipments : Laryngoscope 0,1; ET Tube 2.5-3.5,Stylet,
laryngeal masks.
•Medications : Epinephrine , Normal saline
•Pulse oximeter
•3-lead ECG
•Miscelleneous : stop watch , stethoscope, dry clothed linen , cord
clamp, syringes, feeding tube , sterile gloves

28. Equipmentsrequired
Suction Catheter
Oral mucus sucker
Radiant warmer

31. TRANSPORT
INCUBATOR

32. Apgar scores
Heartrateandrespiratoryeffortsaremostimportant

33. Diagnosis of perinatal asphyxia
-Profoundmetabolicormixedacidemia(pH<7.0)inanumbilical
arterybloodsample
-PersistenceofanAPGARscore0-3forlongerthan5minutes
-Neonatalneurologicalsequele(eg.seizures,coma,hypotonia)
-Evidenceofmultiorgandysfunction(eg,kidney,lungs,liver,heart,
intestines)
AmericanAcademyofPediatrics(AAP)andAmericanCollegeofObstetricsandGynaecology
(ACOG)

34. Newborn Resuscitation Pyramid
Assess baby’s risk for requiring resuscitation
Provide warmth
Position, clear airway if required
Dry, stimulate to breathe
Give supplemental oxygen, as required
Assist ventilation with positive
pressure
Intubate the trachea
Provide chest
compressions
Medications
Always needed
Needed less
frequently
Rarely needed

35. General Principle of resuscitation
TABC
•Temperature : radiant warmer
•Airway : suctioning
•Breathing : tactile stimulation , positive pressure ventilation
•Circulation : stimulation , chest compression , medications

38. Initial Steps
•At birth 3questions about newborns
•Term gestation?
•Good muscle tone?
•Crying or breathing?
Ans :Yes
Does not require active resuscitation
Dry , provide warmth
Upper airway can be cleaned by wiping baby’s mouth and nose

40. Initial steps
•Ans : No
•Provide warmth : Radiant warmer , no blankets
•Positioning : placed on back with neck slightly extended
•Clear airway : presence /absence of meconium
•Suctioning , mouth first then nose
•Copious secretion:head should be turned to sidesuction catheter
Maximum time limit for suction:15sec

41. Dry stimulate and reposition
Dried adequately with prewarm linen
If poor respiratory effort -Tactile stimulation
Flicking soles and rubbing back brief

42. Clear airway
•Suction mouth first, then nose
•“M” before “N”
•To prevent aspiration of mouth contents

43. Position “ SNIFFING ”

44. Evaluation
•Respiration,heartrate
•HRbestassesed:3leadECG
•Goodbreathingandpink→observation
•Breathing,HR>100,cyanosisgiveO2
•NotbreathingwellHR<100→PositvePressureVentilation
•60seconds(“theGoldenMinute”)areallottedforcompletingthe
initialsteps,reevaluating,andbeginningventilationifrequired

45. Positive pressure ventillation
Indications
•Apneic or gasping
•HR <100 even if breathing
•Persisting central cyanosis even with 100% O2
•Non vigorous baby born via Meconium Stained Liquor
Contraindication
•Diaphragmatic hernia

46. Procedure
•Neck slightly extended
•Unobstructed view of chest and abdomen
•Appropriate sized -Facemask
•Good seal compressed using fingers
•Observe rise on chest

48. Frequency of ventilation
40 to 60 breaths per minute
Start With 21% oxygen and increase according to
target saturation
Initial Pressure at 20mm of H2O

49. Target oxygen saturation

50. •Re evaluate after30 sec
•Improvement indicated by
•HR↑,
•Spontaneous respiration,
•Good tone,
•Improving colour
Evaluation
HR > 100 if spontaneous respiration then discontinue
HR 60-100 continue bag and maskand ETT in needed
HR < 60 begin chest compression, consider ETT, ECG monitor, UVC

52. •3-leadECG-therapidandaccuratemeasurementofthenewborn’s
heartrate
•PulseoximeterprovidescontinuousassessmentoftheSpo2
•Assessmentshouldconsistofsimultaneousevaluationof3vital
characteristics:heartrate,respirations,andthestateofoxygenation
•Themostsensitiveindicatorofasuccessfulresponsetoeachstepis
↑heartrate.

53. Chest compression
•Hypoxicbaby-↓HR↓flowtovitalorgans
•Mechanicallypumpbloodtovitalorgans
•AccompaniedbyBMV
•IndicatedifHR<60evenafter30secofBMV
•Chestcompressionrhythmiccompressionofsternumthat
compressesheartagainstspine
•↑intrathoracicpressureandcirculateblood
•HR>60discontinue

54. Chest compression
Position:
•Chestcompressionsareoflittle
valueunlessthelungsare
effectivelyventilated
•2personsarerequired
1–chestcompressionsprovider
shouldhaveaccesstothechestwith
hishandspositionedcorrectly
2–Ventilationprovidershouldbeat
headendtomaintaineffective
mask-facesealortostabilizeET
tube

55. Chest compression
Technique:
•Thumbtechnique:2thumbs
depressthesternum,hands
encirclethetorsoandthefingers
supportthespine.Preferred
technique
•2–Fingertechnique:Tipsof
middle&index/ringfingerofone
handcompressessternum,other
handsupportstheback.

56. Chest compression
•Depth : 1/3
rd
of the
anteroposterior diameter of
chest.
•Duration of downward stroke
should be shorter than the
duration of release
•Do not lift the fingers off the
chest

57. Chest compression

58. Chest compression

59. Chest compression
•Rate : 1 minute 90 chest compression and 30 breaths (3:1)
•To determine blood circulation femoral pulse palpated
•Complication : broken ribs,pneumothorax, liver lacerations

60. Endotracheal intubation
•Prolongedbagandmaskisrequired
•Bagandmaskineffective
•Diaphragmaticherniasuspected

61. Procedure
•Infant head midline neck slightly extended
•Left hand hold laryngoscope
•Blade is introduced to mouth beyond base of the tongue
•Glottic opening surrounded by vocal cords on the side
•ET introduced through right side of mouth

62. Medications
Rarely needed
Through umbilical vein
Epinephrine
Volume expanders
Naloxone (not recommended 2015AHA)

63. Post-resuscitation care
•Onceeffectiveventilationand/orthecirculationhasbeen
established,theinfantshouldbetransferredtoNICU
•Intravenousglucoseinfusion
•Therapeutichypothermia

64. When to deny or stop CPR
•Lethal congenital malformation
•Fresh stillborn babies ( 0 Apgar at 1 min)
•No signs of life at 10 minutes
•Spontaneous breathing not established by 30 mins .

66. Thank You

67. MATURITYRATING
TotalScore weeks TotalScoreweeks
-10 20 20 32
-5 22 25 34
0 24 30 36
5 26 35 38
10 28 40 40
15 30 45 42
50 44
Modified Ballard Scoring System