neonatL resuscitation

How to resuscitate, management in meconium aspirated baby, thin and thick meconium, ratio of ventilation and perfusion in new born, latest change in guidelines for resuscitation

1. NEONATAL RESUSCITATION m o d e r a t e d b y D r . B M C H A N D R A K U M A R p r e s e n t e d b y D r . V i j ay k h o d i f a d

2. What is neonatal resuscitation ? Assessment of the fetus at birth Identification of the babies requiring resuscitation Initial steps of resuscitation Pulmonary resuscitation Vascular Resuscitation Termination of resuscitation

3. Neonatal Resuscitation? Series of actions, used to assist newborn babies who have difficulty with making . the physiological ‘transition’ from the intrauterine to extrauterine life

4. Most newborns are vigorous at birth. Approximately 10% will require some assistance at birth to begin breathing. Less than 1% will require extensive resuscitation.

5. RESUSCITATION EQUIPMENTS General: Resuscitation bed, over head warmer (servo-controlled infrared heater), towel, stethoscope, pulse oximeter Airway Mangement: Suction device with Suction catheter ; Bulb syringe, laryngoscope with blades (size 00 and 0); ETT (size 2.5, 3.0, 3.5); EtCO2 detector; LMA (size 1)

6. Breathing support: Facemask; PPV device, O2 gas, feeding tube, Circulation support: UVC kit, iv kit, io needle, Drug and fluids: Adrenaline(1;10000/0.1mg/ml), NS, Blood

7. Assessment of the newborn at birth Cord clamping In the compromised newborn, the optimal timing of cord clamping remains unknown The more severely compromised the newborn the more likely it is that resuscitation measures need to take priority over delayed cord clamping

8. Initial Assessment: APGAR score Assesses neonatal well-being & resuscitation. 1 -min s c or e 🡆 Acido s is and Su r vival 5 -minu t e s c or e 🡆 Neurologi c ou t c ome. Each variable must be evaluated at 1 and 5 minutes.

9. Virginia Apgar

10. APGAR SCORE Sign 1 2 Color Blue Body pink , Completely ( Appearance ) Pale Extremities blue pink Heart Rate ( Pulse ) Absent < 100/min > 100/min R e fl e x Irri t abi l ity ( Grimace ) Absent Grimace Cough , sneeze Muscle Tone ( Activity ) None Some flexion of extremities Active m o v eme n t (Respiratory Effort) Absent Slow , Good , crying

11. APGAR Score 8-10 Achieved by 90% of neonates Nothing is required, except -nasal and oral suctioning -drying of the skin -maintenance of normal body temperature.

12. APGAR Score 5-7 Suffered mild asphyxia just before birth. -Respond to vigorous stimulation -Oxygen blown over the face.

13. Apgar Score 3-4 These Neonates are moderately depressed at birth. They are usually cyanotic and have poor respiratory efforts. But they usually respond to BMV, breath, and become pink.

14. Apgar Score 0-2 These neonates severely asphyxiated and require immediate r esus c i t a tion

15. Which babies need resuscitation? Newborn rapidly assessed for Term gestation? ●Crying or Breathing? Good muscle tone? If “yes,” for all 3 questions Baby does not need resuscitation and should not be separated from mother.

16. If “no,” for of any of the assessment questions  Infant should receive one or more of the following action in sequence: Initial steps in stabilization Ventilation Chest compressions Administration of epinephrine and/or volume expansion

17. (“the Golden Minute”) ≈60 sec for initial steps, reevaluating, and beginning ventilation if required. The decision to progress beyond initial steps is determined by simultaneous assessment of: ▫ Respirations (apnea, gasping, or labored or unlabored breathing) ▫ HR (whether < 100/min or > 100/min)

18. HR is assessed by intermittently auscultating the precordial pulse. When pulse detectable, umbilical pulse palpation provide rapid estimate and is more accurate than other sites.

19. Pulse oximeter takes 1-2 min to apply, May not function during states of very poor CO or perfusion Provide continuous assessment without interruption of other resuscitation measures

20. Once PPV or supplementary O 2 administration begun, assessment consist of simultaneous evaluation of: ▫ HR, Respirations, and State of oxygenation. The most sensitive indicator of a successful r espon s e t o ea c h s t e p 🢡 ↑ i n H R .

21. Anticipation of Resuscitation Need Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation.

22. A t e v e r y deli v e r y 🢡 a t lea s t 1 pe r son required whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of PPV and chest compressions.

23. Someone else promptly available have the skills to perform a complete resuscitation, including endotracheal intubation and administration of medications. Majority of newborn who will need resuscitation can be identified before birth. If a preterm delivery(<37weeks) is expected, special preparations will be required.

24. Problems with preterm babies Immature lungs- difficult to ventilate and also more vulnerable to injury by PPV; Immature blood vessels in the brain that are prone to hemorrhage; Thi n skin & la rg e B S A 🢡 Rapid h e a t los s ; Increased susceptibility to infection; ↑ risk of hypovolemic shock related to small blood volume.

25. NEWBORN RESUSCITATION ALGORITHM

26. INITIAL STEPS To provide warmth by placing the baby under a radiant heat source, Positioning the head in a “sniffing” position to open the airway, Clearing the airway if necessary with a bulb syringe or suction catheter, Drying the baby, and Stimulating respiration .

27. The baby dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing.

28. Temperature Control VLBW (<1500 g) preterm babies are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss.

29. Additional warming techniques : Prewarming the delivery room to 26°C, Covering the baby in plastic wrapping (food or medical grade, heat-resistant plastic) Placing the baby on an exothermic mattress , Placing the baby under radiant heat .

30. Clearing the Airway When Amniotic Fluid Is Clear Deep Suctioning is avoided ▫ nasopha r y n x 🢡 b r ad y c a r dia during resuscitation. ▫ trachea in intubated babies receiving MV at NICU 🢡 deterioration of pulmonary compliance, oxygenation and ↓ CBF.

31. However, suctioning in the presence of secretions can decrease respiratory resistance. Suctioning immediately following birth should be reserved for babies who have obvious obstruction to spontaneous breathing or who require PPV.

32. When Meconium is Present Meconium-stained depressed infants are at increased risk to develop Meconium Aspiration Syndrome(MAS) Tracheal suctioning has not been associated with reduction in the incidence of MAS or mortality in these infants.

33. “Pea soup" or particulate meconium should be removed from the lung before breathing is established to improve the survival of neonates with meconium aspiration. Thin, watery meconium does not require suctioning.

34. Chest physical therapy and postural drainage done every 30 min for 2 hrs and hourly thereafter for the next 6 hrs may help remove residual meconium from the lung. All neonates born after meconium aspiration should be observed for 24 hrs because they can develop Persistent Fetal Circulation syndrome.

35. In the absence of randomized, controlled trials, there is insufficient evidence to recommend a change in the current practice of performing endotracheal suctioning of nonvigorous babies with meconium- stained amniotic fluid.

36. PULMONARY RESUSCITATION

37. Assessment of oxygen need PaO 2 uncompromised babies generally do not reach extrauterine values until ≈10 min following birth. SpO 2 may normally 70% -80% for several min u t e s f ollowing bi r th 🢡 C y anosis. Optimal management of oxygen is important because either insufficient or excessive oxygenation can be harmful

38. Supplementary Oxygen Meta-analyses comparing room air versus 100% oxygen showed increased survival when resuscitation was initiated with air. Escrig R et al found that in preterm, initiation of resuscitation with a blend of oxygen and air resulted in less hypoxemia or hyperoxemia than with either air or 100% oxygen followed by titration.

39. If the baby is bradycardic (HR<60/min) after 90 seconds of resuscitation with a lower concentration of oxygen, oxygen concentration should be increased to 100% until recovery of a normal HR.

40. PPV If newborn apneic or gasping, or if the HR < 100/min a f t e r the initial s t e p s 🢡 S t art PPV. Initial Breaths and Assisted Ventilation Initial inflations following birth, either spontaneous or assisted, create FRC.

41. The primary measure of adequate initial ventilation is prompt improvement in HR. Chest wall movement should be assessed if HR does not improve.

42. An initial peak inflation pressure of 20 cm H2O is effective, but 30-40 cm H 2 O may be required in some term babies. If pressure is not being monitored, the minimal inflation required to achieve ↑ in HR should be used. Assisted ventilation @40-60 breaths/min to promptly achieve or maintain >HR 100/min.

43. C P AP Recommended in preterm newborn who are breathing spontaneously, but with difficulty. Starting infants on CPAP, ↓ the rates of intubation and MV, surfactant use, and duration of ventilation, but ↑ rate of pneumothorax.

44. PEEP versus no PEEP Although PEEP is beneficial and used routinely during MV of neonates in NICU, there have been no studies specifically examining PEEP versus no PEEP when PPV is used during establishment of an FRC following birth. PEEP is likely to be beneficial and should be used if suitable equipment is available .

45. PPV delivery devices T-piece device is preferred. PIP for term @30 cm H 2 O; Preterm @20-25 cm H 2 O; PEEP: 5-8 cm H 2 O; Max pressure relief valve: 50cm H 2 O Self inflating bag: Pressure release valve@ ≈40 cm H2O; cannot effectively deliver CPAP, PEEP or sustained inflation breaths Flow inflating (or anaesthetic) bag

46. Laryngeal Mask Airways LMA are effective for ventilating newborns weighing > 2000 g or delivered ≥ 34 weeks gestation. limited data on the use of these devices in small preterm infants(<2000g; <34 wk). LMA should be considered if facemask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible.

47. Endotracheal Tube Placement INDICATIONS: Initial endotracheal suctioning of non vigorous meconium stained newborns. If BMV is ineffective or prolonged. Newborns born without a detectable HR Expected need for continued or prolonged ventilation For special resuscitation circumstances, such as CDH and ELBW.

48. An appropriate size ETT should be inserted and the tip of the tube placed 1 to 2 cm below the vocal cords. Distance from the tip of the tube to the gums is 7, 8, 9, or 10 cm in 1-, 2-, 3-, and 4-kg infants, respectively.

49. A small gas leak should be present between the ETT and trachea when ventilation pressure is 15-25 cm H 2 O. Appropriate size of the tube 2.5 mm tube for neonates weighing < 1.5 kg, 3.0 mm tube for 1.5-2.5 kg, 3.5 mm tube for > 2.5 kg.

50. Prompt ↑ HR is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation. Exhaled CO2 detection is the recommended method of confirmation of ETT placement. Poor or absent pulmonary blood flow may give false-negative results (ie, no CO 2 detected despite ETT in the trachea).

51. Other clinical indicators of correct endotracheal tube placement are ▫ Condensation or mist in the ETT, ▫ Che s t m o v eme n t, ▫ Presence of equal breath sounds bilaterally, ▫ Improvement in skin color and SpO2.

52. Because the chest is small, breath sounds are well transmitted within the thorax. A difference in breath sounds between the two sides of chest should raise suspicion of pneumothorax, atelectasis, or a congenital anomaly of the lung.

53. Presence of loud breath sounds over the stomach suggest Tracheoesophageal Fistula. Failure to adequately ventilate the lungs at birth may make hypoxemia worse and lead to CNS damage or even death.

54. If the PaO2 > 70-80 mm Hg or SaO2 >94%, FiO 2 (if higher FiO2 is used) should be reduced untill SaO2 and PaO2 are normal for age. (normal SaO2 ≈87-95%, which is associated with a PaO2 of 55-70 mm Hg) Retinopathy of prematurity can occur in premature neonates(<34 wks gestation) with a PaO2 of ≈150 mm Hg for 2-4 hrs.

55. Administration of Surfactant Its use resulted in significant improvement in the outcome of preterms. The incidences of pulmonary gas leaks, HMD deaths, BPD, and pulmonary interstitial emphysema are lower after surfactant use. Administered as liquid (Survanta@4mL/kg; [email protected]/kg into trachea at birth).

56. VASCULAR RESUSCITATION

57. CARDIAC MASSAGE indicated when HR < 60/min despite adequate PPV with O2 for 30 seconds. Rescuers should ensure that assisted ventilation is being delivered optimally before starting chest compressions because ▫ ventilation is the most effective action and ▫ chest compressions are likely to compete with effective ventilation,

58. Compressions should be delivered on the lower third of the sternum to a depth of ≈1/3 rd of the AP diameter of the chest. Two techniques: ▫ compression with 2 thumbs with fingers encircling the chest & supporting the back ▫ compression with 2 fingers with a second hand supporting the back.

59. The 2 thumb–encircling hands technique may generate higher peak systolic and coronary perfusion pressure than the 2- finger technique, So recommended in newborns

60. Compressions and ventilations should be coordinated to avoid simultaneous delivery. The chest should be permitted to reexpand fully during relaxation, but the rescuer’s thumbs should not leave the chest. compressions to ventilations ratio 3:1 (i.e. ≈120 events/min to maximize ventilation at 90 compressions and 30 breaths

61. Thus each event will be allotted ≈1/2sec, with exhalation occurring during the first compression after each ventilation. A 3:1 compression to ventilation ratio is used where ventilation compromise is the primary cause, but rescuers should consider using higher ratios (eg, 15:2) if the arrest is believed to be of cardiac origin.

62. Respirations, HR and oxygenation should be reassessed periodically, and coordinated chest compressions and ventilations should continue until the spontaneous HR ≥60/min. Avoid frequent interruptions of compressions, as they will compromise artificial maintenance of systemic perfusion and maintenance of coronary blood flow.

63. If the neonate's condition does not improve rapidly with ventilation and tactile stimulation, an umbilical artery catheter should be inserted. Most preterm neonates weighing < 1250 gram at birth and 1-3% of term neonates require an umbilical artery catheter during resuscitation.

64. Umbilical venous catheter (UVC) Most rapidly accessible intravascular route ▫ to administer drugs (Adrenaline); ▫ for fluid administration to expand blood volume, ▫ to measure blood gase, pH and arterial BP, Provide continued vascular access until an alternative route is established

65. RESUSCITATION DRUGS Bradycardia is usually the result of inadequate lung inflation or profound hypoxemia, and establishing adequate ventilation is the most important step. if the HR remains < 60/min despite one minute of adequate ventilation and chest compressions with100% O 2, adrenaline or volume expansion or both are indicated

66. IV is the preferred route: UVC is preferable to intraosseous Recommended IV dose is 0.01-0.03 mg/kg/dose; rapid bolus followed by 1ml of 0.9% NS flush

67. Intratracheal dose is higher(0.05 to 0.1 mg/kg); 1:10,000 (0.1 mg/mL); may be considered while IV access is being obtained; Follow with PPV – Flush not recommended Can be repeated every 5 minutes, if HR remains < 60/min.

68. Volume Expansion Detection of Hypovolemia measuring the arterial BP and by physical examination (i.e. pale skin color, have poor capillary refill time, poor skin perfusion, extremities are cold, and pulses (radial and posterior tibial) are weak or absent, and temperature).

69. CVP measurements are helpful in detecting hypovolemia and in determining the adequacy of fluid replacement. Normal CVP in neonates is 2-8 cm H 2 O. If CVP < 2 cm H2O, hypovolemia suspected.

70. Treatment of Hypovolemia The key is intravascular volume expansion. Best be done with blood and crystalloids If hypovolemia is suspected at birth, Rh- negative type O PRBCs should be available in delivery room before neonate is born.

71. Crystalloid and blood should be titrated in 10 mL/kg and given slowly over 10 minutes. At times, >50% of the blood volume (85 mL/kg in term; and 100 mL/kg in preterm) must be replaced, especially when the placenta is transected or abrupted. In most cases, <10-20 mL/kg of volume restores mean arterial pressure to normal.

72. Care should be taken to avoid giving volume expanders rapidly, because rapid infusions of large volumes have been associated with hypertension and IVH. Hypertension may disrupt the intracerebral vessels and cause intracranial hemorrhage if cerebrovascular autoregulation is absent.

73. Postresuscitation Care Babies who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Once adequate ventilation and circulation have been established, the infant should be maintained in, or transferred to an environment where close monitoring and anticipatory care can be provided.

74. Monitoring required may include: Oxygen saturation(SpO2) Heart rate and ECG Respiratory rate and pattern Blood glucose measurement Blood gas analysis Fluid balance and nutrition Blood pressure Temperature Neurological

75. Role of Glucose Newborns with lower blood glucose levels are at ↑ risk for brain injury so maintain BGL >2.5 mmol/L. If the blood glucose concentration is low, bolus of glucose (0.5 to 1.0 mL/kg of 10% dextrose) and constant infusion of 5-7 mg/kg/min intravenously is given .

76. Induced Therapeutic Hypothermia Infants born ≥36 weeks gestation with evolving moderate to severe hypoxic- ischemic encephalopathy should be offered therapeutic hypothermia (33.5-34.5⁰C). The treatment according to the studied protocols include commencement within 6 hrs following birth, continuation for 72 hrs, and slow rewarming over at least 4 hours.

77. Guidelines for Withholding and Discontinuing Resuscitation It is based on the physician's experience and desires of the parents. In making the decision, the physician must consider the probability of neurologic damage and chances of a productive, useful life are poor, consideration should be given to discontinuing all resuscitative efforts.

78. Withholding Resuscitation It may be considered reasonable, when there have been conditions with poor outcome (i.e. gestation, birth weight, or congenital anomalies are associated with almost certain early death or unacceptably high morbidity is likely among the rare survivors) and opportunity for parental agreement, (eg <23 wk gestation; BW<400g; trisomy 13)

79. conditions with ↑rate of survival, acceptable morbidity (with ≥ 25 wks gestation and with most congenital malformations, resuscitation is always indicated. Conditions with borderline survival, high morbidity rate and uncertain prognosis, parental desires concerning initiation of resuscitation should be supported.

80. Discontinuing Resuscitative Efforts In a newly born baby with no detectable HR, resuscitation are discontinued if the HR remains undetectable for 10 min. resuscitation efforts beyond 10 min with no HR should be considered if presumed etiology of the arrest, gestation of the baby, and the parental desire.

81. LET S GIV E O U R NEWBORN A GOO D START! Than k s……..

82. Risk factors for neonatal resuscitation Maternal PROM (> 18 hours) Bleeding in 2 nd or 3 rd trimester PIH Substance abuse Drug Diabetes mellitus Chronic illness Maternal pyrexia Maternal infection Chorioamnionitis Heavy sedation Previous fetal or neonatal death Fetal Multiple gestation gestation (< 35 wks; >41 wks) Large for dates IUGR Alloimmune haemolytic disease Polyhydramnios and oligohydramnios Reduced fetal movement before onset of labour Congenital abnormalities which may effect breathing, cardiovascular function or other aspects of perinatal transition Intrauterine infection Hydrops fetalis Intrapartum Non reassuring FHR patterns on CTG Abnormal presentation Prolapsed cord Prolonged labour APH(e.g. abruption, placenta praevia, vasa praevia) Meconium in the amniotic fluid Narcotic administration to mother within 4 hours of birth Forceps birth Vacuum-assisted (ventouse) birth Maternal GA