NEONATAL RESUSCITATION.pptx

current protocols of neonatal resuscitation

1. Neonatal Resuscitation By: Dr. Sumera Akram F.C.P.S Pediatrics

2. AND WHOEVER SAVES A LIFE , IT IS AS THOUGH HE HAD SAVED ALL MANKIND (QURAN, 5:32 )

3. Transition from intrauterine to extrauterine life Neonatal resuscitation is assistance of neonate in making physiological transition from intra uterine life to extra uterine life lungs inflate:blood directed from heart to pulmonary vasculature: pulmonary vascular ressitance falls: systemic vascular resistance increases: PDA and foramen ovale closes in 1-2 days.

4. Burden of the problem Neonatal mortality rate of Pakistan : 49/1000 live births ( 7% of Global Neonatal Deaths) Major: No/minimal assistance 10%: assistance to begin breathing at birth 1%: extensive resuscitative measures Neonatal resuscitation: simple, inexpensive, cost effective Problem: NNR often not initiated, incorrect use of methods

5. Causes of neonatal mortality

6. Why is neonatal resuscitation important ?

7. The Golden Minute

8. What is “The golden minute” ? <30 seconds: complete initial steps Warmth Drying Clear airway if necessary Stimulate 30-60 seconds: assess 2 vital characteristics Respiration (apnea/gasping/labored/unlabored) Heart rate (<100/>100bpm )

9. Neonatal resuscitation algorithm

10. Overview of resuscitation

11. Anticipation Antipartum Risk Factors Gestational Age less than 36 weeks Gestational Age greater than 41 wks Pre- eclampsia / Eclampsia Maternal HTN Multiple gestations Fetal Anemia Polyhydramnios Oligohydramnios Fetal Hydrops Fetal Macrosomia IUGR Intrapartum risk Factors Emergency C section Forceps/Vacuum delivery Breech/Abnormal presentation Category 2/3 fetal HR tracing Maternal Magnesium therapy Placental abruptio Intrapartum bleeding Chorioamnionitis , meconium aspirate Cord prolapse

12. Skilled personel For all deliveries, at least 1 person should be present who is skilled in neonatal resuscitation and is responsible only for the infant. Additional personnel should be immediately available to assist in tasks that may be required as part of resuscitation, including intubation, medication administration, and emergency procedures, if needed.

13. Equipment for resuscitation

14. RESUSCITATION TROLLY

15. Temperature regulation a high ratio of skin surface area to body weight (in newboms as much as 75% of body heat loss may be from an uncovered head.) Brown fat very limited capacity for metabolic heat production. not capable of effective shivering ,

16. Modes of heat loss in babies A baby will lose heat by radiation to colder surfaces such as windows and walls A newborn will lose heat by conduction if placed naked on an uncovered table - never do it Immediately after birth (or a bath), a baby loses heat by evaporation A draught may cause a newborn to lose (or gain) heat through convection

17. Preventable Danger : Hypothermia

18. Steps to maintain room temperature for neonatal resuscitation Optimum room temperature shld be 23-25 C Windows and doors shld be closed to avoid heat loss by cool draught of air Vernix , dry towel Heater, warmer, incubator Avoid immediate bath

19. APGAR Score  It was originally developed in 1952 by an anesthesiologist at Columbia University,  Dr. Virginia Apgar  as way to address the need for a standardized way to evaluate infants shortly after birth.

20. How is the APGAR Scoring done ?

21. APGAR score interpretation

22. Example : apgar score

23. APGAR score

24. APGAR SCORE : IMPLICATIONS AND LIMITATIONS

25. Initial Assessment Full Term or not? Immediate cry ? Meconium clear? Vigorous / muscle tone ? YES :Do not require resuscitation Dry Skin to skin contact Covered with dry linen to maintain temperature stimulate NO :require resuscitation; follow ABCD Initial steps in stabilization(warmth, clear airway, dry, stimulate) Ventilation Chest compressions Administration of epinephrine& /or volume expansion

26. Resuscitation: initial steps 1. Dry the baby 2. Provide warmth 3. Head position “ sniffing position” 4. Clearing the airway (BULB SUCKER,PENGUIN SUCKER) Remember never do vigorous suction .always do mouth then nose 5. Tactile stimulation for breathing gently stroking the soles or rubbing the back

27. Tactile stimulation Never shake the baby

28. Correct way of tactile stimulation

29. BULB SUCKER

30. ‘M’ first then ‘N’ First mouth then nose

31. Beware !! Vigorous suction and stimulation can injure the baby

32. Assessment and reassessment Positioning, clearing airway and drying baby provides enough stimulation to initiate breathing Assess and reassess for not more than 10 seconds after every 30 seconds by looking, listening and feeling the chest movement and heart rate Increase in heart rate is the most sensitive indicator of a successful response to each step practiced

33. How to measure Heart rate? Palpation : at the umbilical, femoral, or brachial arteries auscultation : stethoscope The NRP recommends counting the heart beats heard over 6 s and multiplying by 10 to determine HR in bpm  when a stethoscope is not available , palpation of the umbilical cord provides greater accuracy. Pulse oxymetery

34. Targeted SPO 2 after birth 1 minute 60-65% 2 minutes 65-70% 3 minutes 70-75% 4 minutes 75-80% 5 minutes 80-85% 10 minutes 85-90%

35. Limitations of HR and pulse oxy. Pulse oxymeter low peripheral perfusion, low volume state, vernix effect acrocyanosis, signal dropout, movement artefacts, arrhythmias Heart rate: Finding brachial and femoral pulse Dextrocardia,pneumothorax, diaphragmatic hernia

36. Second step : PPV- Positive pressure ventilation Needed when there is no improvement in HR (< 100/min) Two types of ventilation breaths needed: inflation breaths- 5 breaths at 30 cmH2O to open the alveoli Ventilation/rescue breaths- at 15cmH2O to continue ventilation(30 breaths /min) REMEMBER TWO- THREE- BREATH With or without supplemental oxygen( humidfied 21% at 10 l/min) Devices : BMV, ET (endotracheal tube),LMA(laryngeal mask airway)

37. Bag & mask ventilation Ambu bag is of 300ml caoacity Size 1 mask for term Size 0 mask for preterm Size 00 mask for extremely preterm

38. Operater position

39. What goes wrong ? Always reasses after first 5 inflation breaths for chest movement and consider readjusting mask, making seal and suction airway b4 jumping to the next level Mnemonic ; MR-SOPA for reassessment M:mask adjustment R:reposition airway S:suction O:open mouth chin lift jaw thurst P:pressure increase A:alternate airway(ETT,LMV)

40. Sniffing position Extension of neck with help shoulder roll:: to open the airway

41. Correct Mask position

42. Endotracheal tube Needed when: Initial endotracheal suctioning of non vigorous meconium stained newborn If BMV is ineffective/prolonged (HR less than 60) Preterm for surfactant Diaphragmatic hernia suspected ( When intubation is performed Make sure to minimize hypoxia during each attempt of intubation and limit each intubation attempt to 20 second) Pass orogastric or nasogastric tube if prolong resuscitation required.

43. Endotracheal tube: size and type

44. Laryngoscope and ambu -bag Miller laryngoscope blade preferred than macintosh blade Size 00 for VLBW, size 0 for preterm, size 1 for term 240 ml self inflation bag. ( tidal volume 5-10ml/kg )

45. Third step : Chest compressions INDICATION: Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec SITE: Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest TECHNIQUES: 2 thumb-encircling hands technique (two personel ) Compression with 2 fingers (one person) 3:1 ratio::[ 90 comp:30 ventilations) REMEMBER ONE AND TWO AND THREE AND BREATH

46. Chest compressions technique: two persons Stop chest cpmpressions if HR more than 60/min after 40-60 sec

47. Chest compression technique: one person

48. Two finger and two thumb technique

49. Third step: Drugs Rarely indicated INDICATION HR remains <60bpm,despite adequate ventilation(ET) with 100% Oxygen & chest compressions ROUTE Better and easy to pass umbilical vein cather meanwhile u are resuscitating the baby Thru ETT IV IO

50. Umbilical vein catheterization Umbilical vein catheterization may be a life-saving procedure in neonates who require vascular access and resuscitation.

51. Make sure ! After proper placement of the umbilical line, intravenous (IV) fluids and medication may be administered to critically ill neonates.  [1] In an emergency, it is best to advance the catheter only 1-2 cm beyond the point at which good blood return is obtained so as to avoid injecting hyperosmolar fluids into the portal vessels and causing liver necrosis.

52. Epinephrine/ Adrenaline Route of administration : intravenous(thru uvc ideal) and thru ETT Recommended dose : 0.1 ml/kg per dose in 1:10,000 dilution thru uvc (available in pakistan as 1:1000 packing and need to be further diluted in 9 cc of distill water to make 1:10000 dilution ) 0.5-1.0ml/kg thru ETT Can repeat after 3-5 mins upto 3 doses

53. Volume expansion Indication: Shock, Suspected or known blood loss Type of fluid : Isotonic crystalloid solution: normal saline, ringer lactate Blood; o- ve crossed matched with mother blood Dose : 10 ml/ kg 10% Dextrose: 2.5 ml/kg through UVC or peripheral vein

54. Soda bicarbonate Use of Sodium bicarbonate controversial ( after prolong resuscitation and severely depressed baby ) ABG ‘s and 1:1 dilution according to base deficit

55. Drugs which have NO role in resuscitaion Dexamethasone (can cause Metabolic derangement. Increased risk of neonatal sepsis, risk of bowel perforation, neurodevelopmental delay and intraventricular haemorrhage ) Atropine Calcium Naloxone Intracardiac adrenaline

56. Why adrenaline ? 1. Epinephrine administration has been shown to increase mean arterial pressure and carotid blood flow in asphyxiated bradycardic newborn s Adrenaline is a non-selective adrenergic agonist with potent β 1  and moderate α 1  and β 2 -receptor activity. Epinephrine is a sympathomimetic drug . Increased myocardial force of contraction (positive inotrope ) and heart rate (positive chronotrope ) occur as a result of β 1  receptor stimulation. 1. ATROPINE is generally not indicated in neonatal resuscitation, because bradycardia in the newborn is almost always related to hypoxia and not vagal stimulation. 2.  Atropine increases the heart rate and improves the atrioventricular conduction by blocking the parasympathetic influences on the heart. 3. Atropine binds to and inhibit muscarinic acetylcholine receptors, producing a wide range of anticholinergic effects.

57. Discontinuing resuscitative efforts consider stopping NNR if the heart rate remains undetectable for 20 minutes

58. FINAL STEP: Post resuscitation care Proper documentation Parental counselling Shifting of baby to NICU under thermoneutral environment Need monitoring ,evaluation of BSR and Vitals

59. Infection care of newborn 23% Reduction in neonatal mortality when 7.1% chlorhexidine digluconate was used on the first day of life, as demonstrated by the clinical trials conducted in South Asia. Recent research has shown that when hospitalization is not possible a safe, effective and simpler antibiotic treatment can be provided in lower-level facilities. To start with : inj cefotaxime (50 mg/kg BD) inj amikacin (15 mg/kg OD) inj ampicillin And inj gentacin for meconium stained

60. Kangroo technique 40% reduction in mortality of low birthweight infants (less than 2000g) who receive KMC compared to conventional neonatal care ( conde-agudelo and diaz rossello . 2016)

61. Benefit of KMC

62. Special cases Preterm Meconium stained Birth asphyxia Pneumothorax Pleural effusion Diaphargmatic hernia Choanal atresia Airway malformation or obstruction Maternal drugs

63. Resuscitation of preterms Additional resources,additional personel Additional thermoregulation (portable warming pad, polyethylene plastic wrap (29 wk) , Prewarmed transport incubator. Use of oxymeter,blender to target spo2 85%-95 %( avoid high and prolonged oxygenation) Use lower pip 20-25cm of H2O during PPV / High PEEP 5-8 cm of H2O Consider giving CPAP Consider surfactant

64.  Premature infants (< 1500 g) should be covered in plastic wrap (polyethylene) to prevent excessive heat loss. 

65. Meconium stained baby More frequently in infants who are postmature and small for gestational age.   Risk factors : Maternal HT Maternal DM Maternal heavy cigarette smoking Maternal chronic respiratory or CV Dx Post term pregnancy Pre- eclampsia / eclampsia Oligohydramnios IUGR Poor biophysical profile Abnormal fetal HR pattern

66. Mechanism of injury 1.Mechanical Obstruction of the Airway 2. Pneumonitis  3.Pulmonary vasoconstriction / persistent pulmonary hypertension  4. Surfactant inactivation

67. Diagnosis of meconium stained neonate CLINICALLY: Evidence of postmaturity : peeling skin, long fingernails The vernix , umbilical cord, and nails may be meconium -stained, depending upon how long the infant has been exposed in utero . ( nails will become stained after 6 hours and vernix after 12 to 14 hours of exposure) The chest typically appears barrel-shaped, with an increased anterior-posterior diameter caused by overinflation . Auscultation : rales and rhonchi immediately after birth.

68. Radiologically Emphysema and hyperinflation Patchy asymmetric bilaterally homogeneous areas of opacification due to atelectasis similar to respiratory distress syndrome (RDS).  Coarse interstitial infiltrates + pneumothorax 2D Echocardiogram for evaluation of PPH.

69. Management : Meconium stained baby

70. How to do suction in mecomium stained baby Direct laryngoscopy with suction of the mouth and hypopharynx under direct visualization, followed by intubation and then suction directly to the ET tube as it slowly withdrawn.The process is repeated until either ‘‘little additional meconium is recovered, or until the baby’s heart rate indicates that resuscitation must proceed without delay’’.

71. Bubble CPAP

72. Birth asphyxia- hypoxic ischemic encephalopathy WHO defines : “failure to initiate and sustain breathing at birth” and based on APGAR score as an APGAR score <7 at 1 minute. Criteria outlined by ACOG &AAP: Prolonged merabolic or mixed acidemia (pH<7 in cord blood sample) Persistence of APGAR score of <3 at 5min or more Clinical neurological manifestation as seizures, hypotonia , coma or HIE in immediate neonatal period. Evidence of multi organ dysfunction in immediate neonatal period

73. Birth asphysxia - hypoxic ischemic encephalopathy : management in NICU

74. Other Special consideration Choanal atresia -oral airway Pierre robin : place prone, ET thru nose with tip in posterior pharynx Laryngeal web,cystic hygroma,cong goite r: ET/ tracheostomy Pneumothorax :percut needle aspiration Pleural effusion : per cut needle aspiration Cong diaphragmatic hernia : consider ETT

75. Pearls of neonatal resuscitation Top 10 Take-Home Messages for Neonatal Life Support Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. The heart rate response to chest compressions and medications should be monitored electrocardiographically. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family.

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