Neonatal resuscitation protocol of pediatric.pptx

Nrp pediatric

1. NEONATAL RESUSCITATION PROGRAM Dr. SOHRAB DM Neonatology resident

2. Synopsis Principles of Resuscitation 10 Key Behavioral skills Initial steps of resuscitation Positive – Pressure ventilation Endotracheal tube intubation and LMA insertion Chest compressions Medications Special considerations When to stop resuscitation

3. PRINCIPLES OF RESUSCITATION - Why to learn NEWBORN RESUSCITATION Bir t h asp h yx i a a c c ou n ts - 1/ 4 th o f 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. Outcomes of these newborns can be improved with timely and effective resuscitation

4. Why do newborns require a different approach to resuscitation than adults? In adult/child cardiac arrest - It is caused by a sudden arrhythmia that prevent the heart from effectively circulating blood. As circulation to the brain decreases, At the time of arrest, the adult victim's blood oxygen and carbon dioxide ( C02) content is usually normal and the lungs remain filled with air. adult resuscitation, chest compressions maintain circulation until electrical defibrillation or medications restore the heart's function. In contrast, most newborns requiring resuscitation have a healthy heart, requires resuscitation, it is usually because respiratory failure interferes with oxygen and C02 exchange.

5. What happens during the transition from fetal to neonatal circulation? Before birth , fetal respiratory function is performed by the placenta, When the placenta is functioning normally, it transfers oxygen from the mother to the fetus and carries C0 2 away from the fetus to the mother. When placental respiration fails, the fetus receives an insufficient supply of oxygen and C02 cannot be removed. Acid increases in the fetal blood, show a decrease in activity, loss of heart rate variability, and heart rate decelerations. If the fetus is born in the early phase of respiratory failure, tactile stimulation may be sufficient to initiate spontaneous breathing, in a later phase of respiratory failure, stimulation alone will not be sufficient and the newborn will require assisted ventilation to recover.

6. If respiratory failure occurs either before or after birth, the primary problem is a lack of gas exchange. Therefore, the focus of neonatal resuscitation is effective ventilation of the baby's lungs. Before birth, the fetal lungs are filled with fluid, not air, and they do not participate in gas exchange. Blood vessels in the fetal lungs (pulmonary vessels) are tightly constricted and very little blood flows into them. After birth , a series of events culminate in a successful transition from fetal to neonatal circulation. As the baby takes deep breaths and cries, fluid is absorbed from the air sacs (alveoli) and the lungs fill with air , Air in the lungs causes the previously constricted pulmonary vessels to relax, Clamping the umbilical cord increases the baby's systemic blood pressure, decreasing the tendency for blood to bypass the baby's lungs.

7. NRP’s 10 Key Behavioral Skills  Know your environment  Anticipate and plan  Assume the leadership role  Communicate effectively  Delegate workload optimally  Allocate attention wisely  Use all available information  Use all available resources  Call for help when needed  Maintain professional behaviour

8. A neonate may not have adequate ventilation after delivery because of many problems , including asphyxia, drug-induced central nervous system (CNS) depression, CNS anomalies or injury, spinal cord injury, mechanical obstruction of the airways, congenital facial or airway deformities, immaturity, pneumonia, or congenital anomalies.

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

10. Before Delivery- Team should do  Antenatal counseling  Ask OB/GY Q? 1.Gestational age? 2.Clear amniotic fluid? 3.Any additional risk factors? 4.Discussion about umbilical cord management with obstetrician before delivery  Team briefing  Equipment check

11. The umbilical cord management plan should be established before delivery. Delayed cord clamping after birth can be performed in both preterm and term infants . Benefits to term infants include higher hemoglobin levels at birth with improved iron stores in infancy. Benefits for preterm infants include improved hemodynamic stability , decreased need for inotropic support, and decreased red blood cell transfusions. The 2020 Neonatal Resuscitation Guidelines call for at least 30-60 seconds of delayed cord clamping after birth for vigorous term and preterm infants unless contraindications are present. Umbilical cord milking should not be performed for extremely preterm infants

12. INITIAL STEPS OF RESUSCITATION There is increased focus throughout the 8 th edition NRP on team preparation and role assignment . 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.

13. 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. 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.

14. Emphasis on thermoregulation throughout resuscitation. Temperature should be maintained between 36.5 and 37.5 Celsius . For preterm infants, combination of interventions 1 - Radiant warmers 2- P lastic wrap with a cap 3- T hermal mattress 4- W armed humidified gases 5- I ncreased room temperature to 26 deg c 6 - Portable incubator

15. 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: Respiratory effort Heart rate For assessment of heart rate,the use of a 3-lead ECG is recommended. Pulse oximetry to evaluate the newborn’s oxygenation.

16. After birth Term? Tone good? Breathing/ crying?

17. INITIAL STEPS

18. Indications for PPV - those being a heart rate less than 100 bpm or ineffective respirations. Initial PIP is suggested in the range of 20 cm H20. When PPV is administered to preterm infants, PEEP should be used. Recommended starting PEEP is 5 cm H20. Rate of PPV is 40-60 / minute. Rising of HR Improvement in Oxygen Saturation Equal and adequate breath sounds B/L Good Chest rise P P V PPV EFFECTIVE OR NOT?

19. 40 to 60 breaths per minute Start With 21% ( higher in preterm's) oxygen and increase according to target Saturation Initial Pressure at 20mmH2O

20. Self Inflating bag Flow Inflating Bag T-Piece Resuscitator DE V IC E S USED

21. After PPV started, reassess in 15 seconds . If no response, MR SOPA corrective measures should be incorporated.

22. Corrective steps Action M Mask Adjustment Ensure Good seal of mask on face R Reposition airway Sniffing Position S Suction Mouth and nose If secretions present O Open mouth Ventilate with baby mouth slightly open and lift the jaw forward P Pressure increase Gradually increase the pressure every few breaths A Airway alternative Consider ET or Laryngeal mask airway

23. SUPPLEMENTAL OXYGEN 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. 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 ).

24. TARGETED PREDUCTAL SPO2 AFTER BIRTH 1 min 2 min 3min 4min 5min 1 min 60 % - 65% 65%-70% 70 % - 75% 75 % - 80% 80%-85% 85 % - 95%

25. 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.

26. CHEST COMPRESSIONS 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. 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.

27. Compress 1/3 rd diameter of chest. Do not lift the fingers off the chest. 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.

28. MEDICATIONS 1.E P INEPHRINE

29. 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. 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.

30. WHEN TO STOP RESUSCITATION ? An Apgar score of at 20 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.

31. Special situations There are situations where resuscitation may not improve the baby or resuscitation may need to be modified. Some of such situations are mentioned here. Preterm delivery 1.Preterm infants <32 weeks , should be covered with a plastic sheet without drying, Initial oxygen concentration during PPV is between 21 and 30% Labored breathing warrants delivery room CPAP It is preferable to provide peak end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP) during PPV using T-piece resuscitator

32. 2. Baby is not improving with resuscitation 1. Congenital diaphragmatic hernia (CDH) or other lung malformation (antenatal diagnosis) - Intubate immediately after birth and insert orogastric tube for draining the stomach 2. Lung hypoplasia (presence to oligohydramnios)- PPV with high pressures to move the chest and this in turn predisposes for pneumothorax 3.Severe primary pulmonary hypertension of the newborn (PPHN)

33. Congenital diaphragmatic hernia (CDH)

34. 3 .Chest is not moving despite providing EtPPV Obstruction in the airway possibly due to thick secretion or aspirated meconium Attach the tracheal aspirator to the ET tube and remove the ET tube with suctioning. Do not move to next step until chest movement is seen with PPV 4, Persistent bradycardia after ensuring effective PPV ; Severe asphyxia ; Congenital heart block No change in the resuscitation sequence. Suspect heart block if there is maternal history of lupus

35. 5.Airway malformation is suspected difficult to provide effective PPV and difficult to intubate ; Retrognathia—Robin sequence ; Mass in the lower jaw— cystic hygroma Robin sequence : Put the baby in prone and insert nasopharyngeal airway through the nose using 2.5 size ET tube to be placed beyond the tongue. If not improving, then tracheostomy may be required. If severe obstruction suspected antenatally, then multidisciplinary meeting for ex-utero intrapartum therapy (EXIT) and tracheostomy Choanal atresia bilateral - Airway malformation suspected if baby improves with crying but becomes cyanosed when mouth is closed -Oral airway can be inserted to maintain the airway

36. Robin sequence

37. Choanal atresia bilateral

38. 6.Gastrointestinal (GI) malformations Gastroschisis and omphalocele ; Gastroschisis and omphalocele, umbilical cord should be clamped as far away as possible. Place the baby and the exposed bowel in a sterile clean plastic bag and position the baby and bowel on the right side. Insert orogastric tube for continuous gastric drainage. Handle the bowel gently ; If baby requires PPV in babies with gastroschisis, then intubation is preferred over bag and mask

39. 7.Neural tube defect Meningomyelocele is prone for rupture ; Baby to be placed in prone or lateral position. ; If baby needs resuscitation, prepare a donut using towel and placed at the level of the lesion to avoid the pressure effect on the lesion due to the body weight. Use non-latex plastic wrap over the lesion. Baby not improving or suddenly worsens ; Pneumothorax ; Pleural effusion Intercostal drain (ICD)

40. Post resuscitation Care Surfactant in at-risk newborns Dose/ route/ timing/ techniques Indications for therapeutic hypothermia ?mild HIE/ ?36 weeks’ gestation Adjunctive therapies to therapeutic hypothermia Optimal management of blood glucose Optimal rewarming strategy

41. Take Home Message 1. Newborn resuscitation requires anticipation & preparation by providers who train individually & as teams 2. Most newly born infants do not require immediate cord clamping or resuscitation & can be evaluated & monitored during skin to skin contact after birth 3. Inflation & Ventilation of the lungs are the priority in newly born infants who require support after birth 4. A rise in heart rate is a important indicator in effective ventilation & response to resuscitative interventions.

42. 5. Pulse oximetry is used to guide oxygen therapy & meet oxygen saturation goals 6. Chest compressions are provided if there is poor heart rate response to ventilation after appropriate ventilation corrective steps, which include endotracheal intubation 7. The heart rate response to chest compressions and medications should be monitored electrocardiographically 8. If the response to chest compressions is poor, it may be reasonable to provide epinephrine , preferably by IV route 9. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require Volume expansion 10. If all these steps of effective resuscitation are completed and there is no response to heart rate by 20mins, redirection of care should be discussed with team & family

43. T H A N K Y O U !