Neonatal resuscitation program for medical students

Neonatal resuscitation

1. NEONATAL RESUSCITATION PROGRAM Varshin bal INTERN 2014 BATCH

2. if an infant is deprived of O2 , initial brief period of rapid breathing occurs . If asphyxia continues the respiratory movements cease and infant enters into a period of asphyxia known as primary apnea. If the baby in primary apnea continues asphyxiated , baby gasps for respiration , the HR continues to decrease , the BP begins to fall & infant become flaccid & enters into period of secondary apnea. First 60 s after birth is called “THE GOLDEN MINUTE ” – because by one minute newborn should start breathing on their own or should be mechanically ventilated

3. Preparation for resucutation 10% of newborns require some assistance to begin breathing Fewer than 1% need extensive resuscitative measures to survive. Every birth should be attended by at least 2 persons – 1 person skilled in neonatal resuscitation other 1 to assist. Goal is to make a “resuscitation team” with a specified leader & an identified role for each member. In case of multiple births- a separate complete team should be present for each baby.

4. In case of premature births We need an additional trained person who is skilled in ET intubation and emergency UVC. Increase temp in the room(25 to 26 C) and preheat the warmer. In significantly preterm (<29wks) we need a reclosable , food grade polyethylene bag and chemically activated warming pad ready. They are more prone for rapid heat loss. Goal is to keep axillary temp 36.5 C

5. Quick pre-resuscitation checklist WARM - preheat warmer , towels/blankets CLEAR AIRWAY- bulb syringe, 10F or 12F suction catheter attached to wall suction at 80-100mmHg AUSCULTATE – Stethoscope OXYGENATE – method to give free flow oxygen ( mask, tubing , flow- inflating bag or T-piece),gases flowing just prior to birth 5 – 10 L/min , pulse oximeter , blender set to protocol. VENTILATE – PPV devices with term & preterm masks, connected to air/O2 source , 8F feeding tube and 20 ml syringe MEDICATIONS- 1:10,000 epinephrine and normal saline, supplies for administering meds and placing emergency umbilical venous catheter. THERMOREGULATE- plastic bag or plastic wrap, chemically activated warming pad, transport incubator ready.

6. STEPS OF RESUSCITATION Intial steps in stabilization Ventilate and oxygenate-O2 administration and monitoring , PPV, advance airways Inititate chest compressions Administer epinephrine . Witholding and discontinuation of resuscitation

7. Initial steps in stabilization Warmth Positioning – baby placed on their back with neck slightly extended to maintain correct position , a rolled towel can be kept under the shoulders ( shoulder roll ) C lear airway if necessary - (M before N) Dry , stimulate and reposition

8. PPV – 1)Self inflating , 2)flow inflating / T piece resuscitator When administrating PPV for preterm provide PEEP of 5cm Initiate PPV in room air for term and FiO2 21-31% for preterm infants LMA can be used in babies with GA > 34 week if intubation is not successful . CPAP rather than routine intubation for spontaneously breathing preterm infants with respiratory distress

9. CHEST COMPRESSION Chest compression if HR<60 despite adequate ventilation Compression delivered over lower 3 rd of sternum Compression to Ventilation ratio 3:1 Two thumb and two finger technique .. Two finger techinique is no longer recommended . Use 100% O2 whenever compressions are administered . Assessment of Heart Rate is the best measure to assess progress , use of ET,CO2 and oximetry , not routinely recommended .

10. Easiest and quickest method to determine HR is to feel for a pulse at umbilical cord , where it attaches to the babies abdomen If you cannot feel the pulse , use a stethoscope to listen for heart beat If any one of these doesn’t work ask another member to quickly connect oximetry probe on cardiac leads on baby Count the number of beats in 6 seconds and multiply by 10 provides a quick estimate of HR .

11. Newborn in Meconium stained liquor Vigourous Baby - normal respiratory effort , normal muscle tone , normal HR>100bpm – only initial steps , ie Use bulb syringe or large bore suction catheter to clear secretions and any meconium from mouth and nose . Non – vigorous baby – weak/no respiratory efforts , HR<100bpm or poor muscle tone – same management as vigorous baby.

12. MEDICATIONS Epinephrine is given if HR remains below 60bpm even after 30s of effective assisted ventilation and atleast after 45-60s of chest compressions & effective ventilation. Recommended conc - 1: 10,000 Recommended route – IV (umbilical vein) and endotracheal route only if no IV access Dose- 0.1 – 0.3 ml/kg for IV . 0.5- 1 ml/kg for endotracheal route

13. Important !! Epinephrine is not indicated before adequate ventilation is established due to following reasons, Epinephrine will increase workload and oxygen consumption of heart muscle , which , in absence of O2 will cause myocardial damage. Time spent administering epi is better spent on establishing effective ventilation & oxygenation .

14. Normal saline (0.9% NaCl ) / ringer lactate is an isotonic crystalloid solution which is used to acutely treat hypovolemia. Dose- 10ml/kg IV (umbilical vein) Volume expanders should not be given in the absence of history or indirect evidence of acute blood loss. Giving large load of volume expander to a baby whose myocardial function is already compromised by hypoxia can decrease cardiac output and further compromise baby. It is advisable to give vol ex over a longer duration during resuscitation of newborns with GA < 30 weeks to avoid chance of intracranial hemorrhage.

15. Other medications Naloxone – respiratory distress with maternal h/o narcotic use within 4hr of birth ( 0.25 ml/kg of 0.4mg/ml via IV )

16. Recommendations – updated 2019 In term & late-preterm newborn(>35 weeks of gestation) receiving respiratory support at birth , initial use of 21% O2 is reasonable 100% O2 should not be used to initiate resuscitation because it is associated with excess mortality. In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth its reasonable to begin with 21% - 30% O2 with subsequent O2 titration based on pulse oximetry .

17. When to stop resuscitation ? If there is no heart rate, After 10 min of effective resuscitation process & when there is no evidence of other causes of newborn compromise discontinuation of resuscitation efforts is appropriate. Current data indicate 10 minutes of asystole , newborns are very unlikely to survive with severe disability.

18. Thank you!