Neonatal resuscitation
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Neonatal resuscitation . Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi Medical college and research institute , puducherry India . The need .

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Neonatal resuscitation

Neonatal resuscitation

Dr. S. Parthasarathy

MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio)

Mahatma Gandhi Medical college and research institute , puducherry India


The need

The need

  • Approximately 10% of newborns require some assistance to begin breathing at birth.

  • Less than 1% require extensive resuscitative measures

  • only 60% of asphyxiated newborns can be predicted antepartum.


The need is continuous

The need is continuous


Initial queries

Initial queries ??

  • Term gestation?

  • Crying or breathing?

  • Good muscle tone?


Neonatal resuscitation

yes

  • the baby does not need resuscitation

  • should not be separated from the mother.

  • The baby should be 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.


Neonatal resuscitation

“no”

  • 1.Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)

  • 2.Ventilation

  • 3.Chest compressions

  • 4.Administration of epinephrine and/or volume expansion


The golden minute

The golden minute

  • Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required.


The goals of resuscitation

The goals of resuscitation

to assist

  • with the initiation and maintenance of adequate ventilation and oxygenation,

  • adequate cardiac output and tissue perfusion,

  • normal core temperature

  • serum glucose


To achieve goals be ready

To achieve goals, be ready

  • risk factors are identified early,

  • neonatal problems are anticipated,

  • equipment is available,

  • personnel are qualified and available

  • a care plan is formulated


Respiration equipment

Respiration equipment

  • Oxygen supply, Assorted masks

  • Neonatal bag and tubing to connect to an oxygen source

  • Manometer, Endotracheal tubes (2.5-4)

  • Tape and scissors

  • Laryngoscope (0 and 1 sized blades)

  • Extra bulbs and batteries

  • CO2 detectors

  • Stylettes for endotracheal tubes

  • Laryngeal mask Airway (optional)


Suction equipment

Suction equipment

  • Bulb syringe

  • Regulated mechanical suction

  • Suction catheters (6F, 8F, 10F)

  • Suction tubing

  • Suction canister

  • Replogle or Salem pump (10F catheter)

  • Feeding tube (8F catheter)

  • Syringes catheter tipped – 20 ml

  • Meconium aspirator


Fluid equipment

Fluid equipment

  • Intravenous catheters (22 g)

  • Tape and sterile dressing material

  • Dextrose 10% in water (D10W)

  • Isotonic saline solution

  • T-connectors

  • Syringes, assorted (1-20 mL)


Advanced procedure ready

Advanced procedure ready

  • Umbilical catheters (2.5F, 5F)

  • Chest tube (10F catheter)

  • Sterile procedure trays


Trained personnel

Trained Personnel

  • One present

  • Two or more

  • -- problems

  • --- twins


Temperature control

Temperature control

  • Dry and keep warm

  • Others

  • prewarming the delivery room to 26°C

  • 13 covering the baby in plastic wrapping

  • placing the baby on an exothermic mattress

  • the baby under radiant heat

  • prewarming the linen

  • The goal is to achieve normothermia and avoid iatrogenic hyperthermia


Temperature range

Temperature range

  • Normal 36.5-37.5o C Continue

  • Potential cold stress 36-36.5o C concern

  • Moderate hypothermia 32-36o C Danger

  • Severe hypothermia < 32o C

  • Outlook grave, skilled care urgently needed


Airway

Airway

  • Clear liquor

  • Meconium stained liquor


Clear liquor suctioning routine

Clear liquor – suctioning routine ??

  • be associated with worsening of pulmonary compliance and oxygenation

  • reduction in cerebral blood flow velocity when performed routinely (ie, in the absence of obvious nasal or oral secretions)

  • Apnea, bradycardia, hypotension, and laryngospasm

  • Think about routine suctioning ??


Clear liquor suctioning routine1

Clear liquor – suctioning routine ??

  • suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation (PPV)


What is routine

What is routine

  • Drying and suctioning ,

  • If no response,

  • more vigorous stimulation, slapping the soles of the feet or rubbing the back.

  • The back should be visualized.

  • If there is no response to stimulation,

  • it may be assumed the infant is in secondary apnea, and PPV should be initiated.

  • infant's respiratory rate, heart rate, and color should be evaluated


Meconium stained liquor

Meconium stained liquor

  • Historically

  • Suction before delivery of shoulders –

  • not proved useful

  • routine endotracheal intubation and direct suctioning of the trachea ??

  • No to active crying babies !!


Mec staining

Mec. staining

  • endotracheal suctioning of nonvigorous babies with meconium-stained amniotic fluid

  • If intubation difficult and causing brady , don’t try – go back to mask ventilation


Administration of oxygen

Administration of Oxygen

  • Oxyhemoglobin saturation may normally remain in the 70% to 80% range for several minutes following birth

  • clinical assessment of skin color is a very poor indicator of oxyhemoglobin saturation


Spo2 monitor

SPO2 monitor

  • a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm).

  • Term infants keep SaO2 – 90- 94%

  • Preterm – 88-92%

  • 8- 10 litres- oxygen Hood

  • Monitor progress


Temperature

Temperature

  • unheated non humidified oxygen sources for the bag-valve-mask device

  • Intubated ventilated patient – humidified warmed ventilator circuits


Positive pressure ventilation

Positive pressure ventilation

  • If the infant remains apneic or gasping,

  • or

  • if the heart rate remains <100 per minute after administering the initial steps.

  • Assisted ventilation rates of 40 to 60 breaths per minute

  • Heart rate , SPo2, monitor


Neonatal resuscitation

CPAP

  • CPAP

  • recommend administration of continuous positive airway pressure (CPAP) to infants who are breathing spontaneously,

  • but with difficulty, following birth, although its use has been studied only in infants born preterm


Laryngeal mask airways and ppv

Laryngeal mask airways and PPV

  • Laryngeal mask airways that fit over the laryngeal inlet - effective for ventilating newborns

  • weighing more than 2000 g

  • delivered ≥34 weeks gestation

  • meconium-stained fluid,

  • during chest compressions,

  • or for administration of emergency intratracheal medications


Endotracheal tube placement

Endotracheal Tube Placement

  • Initial endotracheal suctioning of nonvigorousmeconium-stained newborns

  • If bag-mask ventilation is ineffective or prolonged

  • When chest compressions are performed

  • For special resuscitation circumstances, such as congenital diaphragmatic hernia or extremely low birth weight


Effective ventilation

Effective ventilation

  • Heart rate

  • CO2

  • SPo2


Chest compressions

Chest Compressions

  • Chest compressions are indicated for a heart rate that is <60 per minute despite adequate ventilation with supplementary oxygen for 30 seconds

  • Ventilation priority

  • the 2 thumb–encircling hands technique

  • the 2-finger technique,


Drugs

DRUGS

  • Drugs are rarely indicated in resuscitation of the newly born infant.

  • Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia

  • Atropine ???


Drugs1

Drugs

if the heart rate remains <60 per minute despite adequate ventilation (usually with endotracheal intubation) with 100% oxygen and chest compressions, administration of epinephrine or volume expansion, or both, may be indicated.

  • The recommended IV dose is 0.01 to 0.03 mg/kg per dose


Drugs and infusions

Drugs and infusions

  • Rarely, buffers, a narcotic antagonist, or vasopressors may be useful after resuscitation, but these are not recommended in the delivery room.

  • An isotonic crystalloid solution – 10 ml /Kg

  • Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia


Discontinue resuscitation

Discontinue resuscitation

  • In a newly born baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate remains undetectable for 10 minutes


After reading neonatal resuscitation

After reading neonatal resuscitation

  • What is shocking ??

  • NO APGAR score at all.


The apgar score

The Apgar score

  • Evaluate the newborn baby on five simple criteria on a scale from zero to two,

  • then summing up the five values thus obtained.

  • The resulting Apgar score ranges from 0 to 10.

  • The five criteria are summarized using words chosen to form a backronym

  • (Appearance, Pulse, Grimace, Activity, Respiration.)


Scores

SCORES

0 1 2

  • Appearance - red peri. Blue total blue

  • Pulse ? < 100 > 100

  • Grimace stim.no mild active

  • Active tone less flexion good resist

  • Respir. Absent weak ,gasps active cry


Apgar score

APGAR score

  • Score of 10 ??

  • >7 ok

  • 4 – 7 -- to act

  • 1 min, 5 , 10, 15 minutes

  • Score of 3 0r less persistent – neuro damage


Neonatal resuscitation

What we do - follows ??


Prewarm clothes

Prewarm clothes


Tray oxygen weighing machine

Tray, oxygen weighing machine


Equipment

Equipment


Bulb syringe

Bulb syringe


Gentle back massage

Gentle back massage


Ryles tube and aspiration

Ryles tube and aspiration


Inj vit k temperature monitoring with hood oxygen

Inj. Vit. K , temperature monitoring with hood oxygen


Breast feeds

Breast feeds


Thank you all

Thank you all


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