NEONATAL RESUSCITATION protocols in infants.ppt

resuscitation

1. NEONATAL
RESUSCITATION AND
EFFECTS OF PREMATURITY
PRESENTER : DR ANOOP
MODERATOR : DR DEVENDER

2. •10 % of neonates require assistance
to breathe at birth
•90% Don’t require any intervention
•10% require intervention
•1 % need major resuscitation
•Preterms are at high risk
INTRODUCTION

3. Primary causes of death*
18 %Other causes
09 %Malformation
29 %Perinatal hypoxia
17 %Infection
27 %Prematurity
DeathsCause
*Text book of Neonatal Resuscitation 6
th
edition

4. Alveoli are fluid
filled
BEFORE BIRTH
Blood vessels are
constricted

5. After birth
Fluid in the
alveoli is
absorbed
Alveoli
•Expand
•Get filled with Air
1.

6. 2.
Pulmonary vessels dilate, causing
increased blood flow to lungs

7. What can go wrong during
transition at birth ?
•Lungs do not fill with air
•The expected increase in systemic blood
pressure may fail to occur
•Pulmonary arterioles may remain constricted
.

8. How often do we need
resuscitation ?

9. Requirements

11. Bag, Mask,
& Oxygen
Suction
Equipment
Laryngoscope
and ETT Tube
Warmer &
Blankets

13. INITIAL ASSESSMENT
•Is the newborn term?
•Is the newborn
breathing or crying?
•Does the newborn
have good muscle tone?
•Dry & remove
wet cloth
•Clear airway if
necessary
•Wrap in
prewarmed dry
cloth
•Breast feeds
•Ongoing
Evalution
YES
Baby is Delivered
( Ask)
Routine Care

14. •
if the baby is not crying /breathing , we
should clamp and cut the cord
immediately and proceed to initial steps
of resuscitation ( section A )

15. SECTIONA A ( AIRWAY )
•These are the initial steps to establish airway and to
begin resuscitation of newborn
•Provide warmth by placing the baby under a radiant
warmer
•Position head to open the airway ; clear the airway
as necessary ( it may involve suctioning the trachea
to remove meconium )
•Dry the baby , discard wet linen
•Stimulate the baby to breathe , reposition the head
to maintain an open airway .

18. Positioning

19. Clear Airway

20. Clear airways
(if necessary)

21. Presence of meconium stained amniotic fluid
•Vigorous : strong
respiratory
efforts , good
muscle tone , HR >
100 bpm

22. Stimulate

23. •Evaluate newborn’s respiration and heartrate .
•Breathing :
Regular / Gasping / Irregular / Absent
•Heart Rate : >100/m OR< 100/m OR Absent
•If baby is gasping /apnea or respiration appears
laboured or persistently cyanotic or hr < 100
proceed to section B .
EVALUATION AFTER SECTION A.

24. SECTION B ( BREATHING )
•Assist the baby’s breathing by providing
positive pressure ventilation ( PPV)
•If baby is breathing , but has persistent
respiratory distress ( labored breathing )
attach a pulse oximeter ( if available ) to
consider for need for supplemental oxygen
•If the baby is preterm with labored breathing
consider CPAP by facemask

25. Pulse Oximetry
•Clinical assessment of
skin color is not
reliable
•Baby undergoing
normal transition
may take several
minutes to increase
spo2

27. Administration of supplemental oxygen
•By o2 tube , facemask , bag and mask
•If cyanosis and low spo2 persists , trial of PPV
is given .

28. PPV/Bag & mask ventilation

29. Indications for Bag & Mask
ventilation
•Apnea or gasping respiration
•Heart rate < 100 bpm
•Saturation below target values
despite free flow supplemental
oxygen

30. Key point
The most important and effective
action in neonatal resuscitation is
EFFECTIVE Ventilation

31. Self inflating bag

32. Masks
•Cushioned/Non-cushioned
•Round/Anatomical shaped
•Size 0 or 1

33. The surface on which the baby
is placed should always be warm
as well as flat, firm and clean
POSITION

34. Correct position of mask

35. Positioning
•Positioning the infant & resuscitator

36. Forming & checking the seal

37. Ventilation rate and pressure

38. Evaluation-Decision-Evaluation-Decision-
Action cycleAction cycle
Evaluation
Action Decision
30 sec30 sec

39. Signs of Effective Ventilation
Sign of response to ventilation:Sign of response to ventilation:
•Improved heart rate
Signs of improvement in newborn:Signs of improvement in newborn:
•Improved heart rate, color, breathing, tone,
and saturation

40. Contraindications
•Diaphragmatic hernia
•Non -vigorous baby born through meconium stained
liquor

41. No improvement
•Is chest rise adequate?
•Is adequate oxygen being
administered?

42. MR. SOPA MR. SOPA
•M- Adjust Mask on the face
•R- Reposition the head to open airway
oRe-attempt to ventilate…if not effective then
•S- Suction mouth then nose
•O- Open mouth and lift jaw forward
oRe-attempt to ventilate…if not effective then
•P- Gradually increase Pressure every few breaths until
visible chest rise is noted
oMax Pip 40cmH2O If still not effective then…
•A- Alternative Airway (ETT or LMA)

43. When to stop ?
•Heart rate above 100/min
•Spontaneous breathing

44. EVALUATION OF SECTION B
•After 30 seconds of PPV , CPAP /or
supplemental oxygen evaluate the newborn
again to ensure that ventilation is adequate
before moving to next step .
•With proper ventilation , in almost all cases
the HR would rise above 100 bpm .
•If HR is below 60 ,you should you should
proceed to section C

45. SECTION C ( CIRCULATION )
•Support circulation by starting chest
compressions
•While continuing PPV .
•At this stage ,it is strongly
recommended to to do endotracheal
intubation , it gives more coordination
between chest compressions and PPV .

46. Chest Compressions
Its a 2 personnel job

47. Indication
If after 30 seconds of EFFECTIVE bag and mask ventilation
with 100% oxygen,

Heart Rate is below 60 per minute
Indications

48. •Compress the heart b/w sternum and spine
•Increase intrathoracic pressure
•Pump blood into circulation
•Must always be accompanied by ventilation with 100% oxygen
Principle

49. •Position
•Neck slightly extended with firm support for the
back
•Site of compression
•Lower 1/3
rd
of sternum in the midline
•Pressure required – depth
•1/3
rd
of the AP diameter of chest
•Rate
•90/min
Components

50. Site of compressions

51. Two-finger method
Techniques of Chest
Compressions
Thumb method

52. Rate
•3 Chest Compressions then 1 ventilation
•90 Chest Compressions to 30 ventilations in one minute
Adequacy
•Palpate femoral/carotid pulse
Rate and Adequacy

53. coordination of chest compresssions and
ventilation

54. •HR 60 per minute or more Stop CC,
continue BMV at 40-60/min
•If no improvement, check :
•Effectiveness of BMV
•Oxygen is 100%
•Technique of CC is correct
•Coordination of CC & BMV
Evaluation after 30 sec of
CC & BMV

55. When to stop
chest compressions
•When heart rate is 60 per minute or more

56. Key points
•2 personnel job
•Ensure 100 % oxygen
•Ensure adequate chest movement during ventilation
•Co-ordinate B & M with CC at 3 : 1
•Check HR every 30 seconds
•Use thumb or 2 finger technique

57. Intubation

58. Indications for intubation
•Meconium suctioning in non
vigorous baby
•Diaphragmatic hernia
•Prolonged or ineffective ventilation
•Elective
• VLBW
•with CC

59. Intubation equipment

60. Preparing laryngoscope
•No. 1 for full term
•No. 0 for preterm / LBW
•No. 00 for extremely preterm (optional)

61. 3.5
3.0
2.5
Stylet
>2000 gm
1000-2000 gm
<1000 gm

62. Selecting endotracheal tube
Tube Size
(ID mm)
Weight
(gm)
Gest. Age
(Wks)
2.5 < 1000 < 28
3.0 1000-2000 28-34
3.5 2000-3000 35-38
4.0 >3000 > 38
ID=Internal Diameter

63. Preparing endotracheal tube
•Shorten the tube to 13 cm
•Replace ET tube connector
•Insert stylet (optional)

64. Additional items
Tape : For securing the tube
Suction equipment
Oxygen
•For free flow oxygen during intubation
•For Use with the resuscitation bag
Resuscitation Bag and Mask
•To ventilate the infant in between intubation
•To check tube placement

65. Positioning the infant
•On a flat surface
•Head in midline
•Neck slightly extended
•Optimal viewing of glottis

67. Intubation view

68. EVALUATION OF SECTION C
•After 30 sec of chest compression and
PPV , evaluate the newborn again
•If the HR is still below 60 bpm , proceed
to section D

69. SECTION D ( DRUG )
•Insert and umbulical catheter
•Administer epinephrine as you continue
PPV and chest compressions.

70. MEDICATIONS
•Epinephrine
•Volume expansion

71. Medication Administration via
Umbilical Vein
•Preferred route for
intravenous access
•3.5F or 5F end-hole
catheter
•Sterile technique
Placing catheter in Placing catheter in
umbilical veinumbilical vein

72. Neonatal Resuscitation
No role of
•Atropine
•Calcium
•Dexamethasone
•Dextrose
•Intra cardiac adrenaline
•Naloxone

73. Epinephrine
•Available as 1:1000 concentration
•Dilute 1 ml with 9 ml of water
( 1:10,000)
•Dose : 0.1 – 0.3 ml/kg ( 0.01-0.03 mg
/kg )

74. Epinephrine
Follow up: if HR < 60 or 0
• Repeat epinephrine q 3-5 minutes
• Ensure:
effective ventilation
effective chest compressions
endotracheal intubation
(if not done already)
• Consider using volume expander

75. What is expected response
•After 30 seconds of administration and
continued PPV and CC
–HR should increase to > 60 bpm
•If no response repeat the dose every 3-5
minutes
•Repeat doses should preferably be give IV

76. “If the baby appears to be in shock
and is not responding to
resuscitation, administration of a
volume expander may be
indicated”
!
Shock - Hypovolemia

77. Signs of Hypovolemia
•Pallor persisting beyond oxygenation
•Weak pulses
•Low blood pressure
•Lack of response to resuscitation
Hypovolemia is a common but often unrecognized cause
of need for resuscitation

78. Volume Expansion
•Indicated when there is no response
to resuscitation and there is
evidence of blood loss or
hypovolemia
•Repeated doses may be necessary if
there is minimal response after the
first dose
•Umbilical vein remains preferred
route but intraosseous acceptable

79. Volume Expanders
•Normal saline
•Ringer’s lactate
•Whole blood (O Neg cross
matched with mother’s blood)

80. Normal saline
Indications
•Evidence or suspicion of acute blood loss with signs of
hypovolemia and/or baby responding poorly to
resuscitation

81. •Dose – 10ml/kg
•Route – Umbilical vein
•Preparation – large syringe
•Rate of administration – 5-10 minutes
In premature babies: Rapid boluses may induce ICH
Normal saline

82. Volume expanders
•Effect : Volume expansion, correction of metabolic
acidosis
•Expectation : Better BP & pulses, less pallor
•Follow up : If signs of hypoperfusion persist, repeat
volume expander

83. EVALUATION OF SECTION D
•If the heart rate remains 60 bpm ,
actions of section C and sectionD are
continued and repeated .
•When HR rises above 60 bpm , chest
compression is stopped , PPV is
continued until HR is above 100 bpm
and the baby is breathing well .

84. •Evaluation occurs after initiation of each
action and is based on following two sign
•Respiration
•Heart rate
•The process of evaluation , decision and
action is repeated frequently throughout
resuscitation

85. •After giving effective ventilation , chest compression and
medications and still there is no improvement consider
mechanical causes of poor response
•Airway malformation , pneumothorax, diaphragmatic
hernia , congenital heart disease
•If heart rate is absent /no progress is being made in certain
conditions like extreme prematurity , it may be
appropriate to discontinue resuscitative efforts
•Optimum techniques should be administered for a
minimum of 10 minutes before considering such decisions .

86. !! THANK YOU !!