Neonatal Resuscitation Program

NRP- 2010 guidelines

1. NEONATAL RESUSCITATION PROGRAM Dr Anagha Anand

2. Neonatal Resuscitation is intervention after a baby is born to help it breathe and to help its heart beat . Of the 25 million infants born every year in India, 3-5% experience asphyxia at birth Neonatal resuscitation skills are essential for all health care providers who are involved in the delivery of newborns

3. The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have updated the resuscitation guidelines that are being propagated world wide through the NEONATAL RESUSCITATION PROGRAM (NRP)

4. Anticipation A radiant heat source ready for use All resuscitation equipments immediately available & in working order At least 1 person skilled in neonatal resuscitation Preparing for Resuscitation

5. Neonatal Resuscitation Supplies & Equipments -Suction Equipment Mechanical suction Suction catheters 10,12, or 14 F Meconium aspirator -Bag and Mask Equipment Neonatal resuscitation bags ( self limiting) Face- masks ( for both term & preterm babies) Oxygen with flow meter and tubing -Intubation Equipment Laryngoscope with straight blades no.0 (preterm)& no.1 (term) Extra bulbs & batteries ( for laryngoscope) Endotracheal tubes ( int diameter 2.5, 3, 3.5 & 4)

6. Medications Epinephrine Normal saline or Ringer Lactate Naloxone hydrochloride Miscellaneous Linen, shoulder roll, gauze Radiant warmer Stethoscope Syringes 1,2,5,10,20,50 ml Feeding tube 6 F Umbilical catheters 3.5, 5 F Three way stopcocks Gloves

7. Based primarily on 3 signs Respiration Heart rate Color Evaluation

8. Performed at 1min & again at 5 min after birth. But resuscitation must be initiated bfr 1 min score is assigned Not used to guide resuscitation But can reflect how well the baby is responding to resuscitative efforts Should be obtained every 5 min for upto 20 min, if the score is < 7

9. Term / Preterm ? Term: smooth transition Preterm : stiff, under-developed lungs, insufficient muscle strength, can’t maintain temperature Breathing/Crying ? Watch baby’s chest Gasping is a series of deep, single or stacked inspirations that occur presence of hypoxia/ischemia . Treated as apnea. Steps of Resuscitation

10. Good tone ? Term: flexed extremities Preterm/sick: flaccid/limp , extended extremities Steps of Resuscitation

11. Provide warmth : Radiant warmer, don’t cover with blankets or towels . Position head and clear airway if necessary Placed on her back or side with neck slightly extended. Brings post pharynx, larynx & trachea in line Place a rolled blanket or towel under the shoulders, elevating them 3/4 th or 1 inch off the mattress.

12. Suction mouth first, then nose “M” before “N” To prevent aspiration of mouth contents If copious secretions present → head should be turned to one side Never insert catheter too deep in mouth or nose for suction → stimulation of post pharynx → vagal response → bradycardia or apnea Max time limit – 15 sec Steps of Resuscitation

13. Management of infant born through MSL

14. For non-vigorous babies initial steps are modified as: Place under radiant warmer. Postpone drying & suctioning to prevent stimulation Remove residual meconium in the mouth & post pharynx by suctioning under direct vision using laryngoscope Intubate & suction out meconium from the lower airway

15. Dry, Stimulate and Reposition Stimulate : Flicking the soles/ drying & rubbing the back Steps of Resuscitation

16. Respirations Heart rate: Best is auscultation, alternatively pulsations at base of cord is felt. Count for 6s and “x”10 Color- look at tongue, mucous membranes & trunk Evaluation

17. Evaluation If baby has good breathing, HR>100/min, no cyanosis →no additional intervention If baby has laboured breathing or persistent cyanosis -preterm babies → CPAP -term babies→ supplemental oxygen If baby is apneic, has gasping breathing or HR < 100/min → PPV is needed

18. PPV – using a self-inflating bag & face mask Positive pressure ventilation

19. Indications: Gasping/apnea HR < 100/min Persistent central cyanosis despite administration of 100% free flow oxygen Contraindications: Diaphragmatic hernia Non vigorous babies born through MSL, B & M ventilation carried out only after tracheal suctioning PPV

20. Appropriate Sizes Mask should Rest on Chin Cover Mouth & Nose PPV

21. When n/l rise of chest is observed start ventilating. Ventilation should be carried out at a rate of 40-60 breaths per min, following a ‘squeeze, two, three’ sequence

22. PPV may cause abd distension as gas escapes into the stomach via oesophagus . ↓ Presses on diaphragm & compromises the ventilation So orogastric tube should be inserted & left open to decompress the abdomen PPV continued more than several minutes

23. Rhythmic compression of the sternum →compress heart against spine → ↑se intrathoracic pressure → circulate blood to the vital organs Always accompanied by BMV so that only oxygenated blood is circulated Chest compressions

24. Indications : HR <60/min even after 30 sec of effective PPV Once HR>60/min CC should be discontinued. Chest Compressions

25. Thumb technique: 2 thumbs depress the sternum, hands encircle the torso and the fingers support the spine. Preferred technique 2 – Finger technique: Tips of middle & index/ring finger of one hand compresses sternum, other hand supports the back. Methods

26. A positive breath should follow every third chest compression In 1 min 90 compressions & 30 breaths are administered To determine the efficiency of CC, the carotid or femoral pulsations should be checked periodically Rate

27. After 30 sec HR is checked: HR<60 → CC should continue along with B & M ventilation. In addition medications have to be given HR>60 → CC should be discontinued. BMV should be continued until the HR > 100/min & the infant is breathing spontaneously Evaluation

28. Endotracheal Intubation

29. When tracheal suction is required ( non vigorous babies born through MSL) When prolonged BMV is required When BMV is ineffective When diaphragmatic hernia is suspected Indications

30. Laryngoscope with extra blades and bulbs Straight blades Term – 1 Preterm – 0 Endotracheal Intubation

31. ET tube – Vocal cord guide

32. Infant’s head should be in midline & neck slightly hyper extended. Laryngoscope is held in left hand b/w thumb & the first three fingers, with the blade pointing away from oneself Stand at the head end, the blade is introduced in the mouth & advanced to just beyond the base of tongue Procedure

33. Position

34. Position Once the glottis & vocal cords are visualized, he ET is introduced from the right side of the mouth Its tip is inserted into the glottis until the vocal cord guide is at level of the glottis

35. Epinephrine (1:1000) Indication :HR< 60/min after 30 sec of effective PPV & CC. Effects: Inotropic, chronotropic , peripheral vasoconstrictor Dose: 0.1-0.3ml/kg Route: i.v , through umbilical vein, directly into tracheobronchial tree through ET Medications

36. NS, RL Indication: Acute bleeding with hypovolemia Effects: increase intravascular volume, improves perfusion Dose: 10ml/kg Route: umbilical vein Medications

37. Naloxone (0.4mg/ml) Indication: Respiratory depression with maternal history of narcotic use within 4 hr of birth Effects: Narcotic antagonist Dose: 0.25ml/kg(0.1mg/kg) Route: i.v preferred, delayed onset of action with i.m use, administer only after restoring ventilation Medications

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