Special considerations resuscitation of premature babies ethics and care at end of life
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Special considerations Resuscitation of premature babies Ethics and Care at End of Life. Special considerations. Situations that may complicate resuscitation and cause ongoing problem Post-resuscitation management Resuscitation outside hospital or beyond time of birth. Difficult situations.

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Special considerations Resuscitation of premature babies Ethics and Care at End of Life

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Special considerationsResuscitation of premature babiesEthics and Care at End of Life


Special considerations

  • Situations that may complicate resuscitation and cause ongoing problem

  • Post-resuscitation management

  • Resuscitation outside hospital or beyond time of birth


Difficult situations

  • Not able to ventilate adequately

  • Cyanosis despite adequate ventilation

  • Bradycardia despite adequate ventilation

  • No spontaneous breathing despite adequate ventilation


Not able to ventilate

  • Mechanical blockage of airways

    • Meconium or mucus in pharynx or trachea

      Tracheal suction

    • Choanal atresia

      Pass small-caliber suction catheter, oral airway

    • Pharyngeal malformation (Robin syndrome)

      Prone, nasopharyngeal airway

    • Other rare conditions (laryngeal web)

      Emergency tracheostomy


Not able to ventilate

  • Impaired lung functions

    • Pneumothorax

      Diminished air entry, transillumination, X-ray, drain

    • Congenital pleural effusion

      Hydrops, Drain

    • Congenital diaphragmatic hernia

      Intubate, orogastric tube

    • Pulmonary hypoplasia

    • Extreme prematurityHigh inflation pressure

    • Congenital pneumonia


Cyanosis/Bradycardia despite adequate ventilation

  • Cyanotic heart disease

  • Congenital heart block

Ensure adequate ventilation


No spontaneous breathing despite adequate ventilation

  • Brain injury (HIE, severe acidosis, congenital neuromuscular disorder)

  • Sedation due to drugs given to mother (narcotic drugs, magnesium sulfate, general anesthesia, non-narcotic analgesics)


Naloxone

  • Indications

    • Continued respiratory depression after PPV has restored a normal heart rate and color

      AND

    • History of maternal narcotic administration within past 4 hours


Naloxone

  • Recommended concentration = 1.0 mg/ml

  • Route: IV preferred; IM acceptable but delayed onset of action; ET not recommended

  • Dose: 0.1 mg/kg

  • May require repeated administration


Post-resuscitation care

  • Temperature control

  • Close monitoring of vital signs

  • Laboratory studies


Post-resuscitation care

  • Look for complications

    • Pulmonary hypertension

    • Pneumonia/other lung complications

    • Metabolic acidosis

    • Hypotension

    • Seizures

    • Apnea

    • Hypoglycemia

    • Feeding problem


Resuscitation outside hospital or beyond time of birth

  • Same principles (Restore adequate ventilation)

  • Alternative heat source (Skin-to-skin contact)

  • Clear airway (Bulb syringe, wipe with a cloth)

  • Ventilation (Mouth-to-mouth-and-nose)

  • Vascular access (Peripheral vein cannulation/intraosseus needle)


Resuscitation and Prematurity

  • Thin skin, large surface area and ↓ fat

  • Oxygen toxicity

  • Weak muscles - difficulty in breathing

  • Immature nervous system –less respiratory drive

  • Immature lung

  • Fragile brain capillaries

  • Small blood volume


Additional Resources Needed

  • Additional trained personnel

  • Additional means of maintaining temperature

    • Re closable, food grade polyethylene bag

    • Portable warming pad

    • Transport incubator

  • Additional means to control oxygenation

    (in a hospital in which babies at <32 weeks gestation are born electively)

    • Compressed air source

    • Oxygen blender

    • Pulse oximeter


Keeping a premature baby warm

  • Increase temperature of the delivery room

  • Pre-heat the radiant warmer

  • Pre- warmed transport incubator


Keeping a premature baby warm

  • If baby is born at less than 28 weeks gestation, consider placing him below the neck in a re closable polyethylene bag without first drying the skin

  • Avoid overheating


Oxygen in a premature baby

  • Connect a blender to compressed oxygen and air sources and to PPV device

  • Start somewhere between room air and 100% oxygen

  • Attach a pulse oximeter to baby’s foot or hand

  • Heart rate displayed by pulse oximeter should agree with heart rate that you palpate or hear


Oxygen in a premature baby

  • Adjust oxygen concentration to achieve an oxygen saturation that gradually increases to 90%

  • Accept 70% to 80% if-heart rate is increasing and oxygen saturation is increasing

  • If saturation is less than 85% and not increasing, increase oxygen concentration

  • Decrease oxygen concentration of saturation rises above 95%


Oxygen in a premature baby

!

Resuscitation efforts not to be delayed while waiting for pulse oximeter to display a strong signal


Ventilation in a premature baby

  • Consider giving CPAP if the baby Is breathing spontaneously and has a heart rate above 100 bpm but has

    • Labored breathing or

    • Is cyanotic or

    • Has low oxygen saturation

  • By using flow-inflating bag or T-piece resuscitator


CPAP


Ventilation in a premature baby

  • Use lowest inflation pressure necessary to achieve adequate response

  • Initial inflation pressure of 20-25 cm H2O

  • May need higher pressure if no improvement in heart rate and no chest rise


Ventilation in a premature baby

  • Prophylactic surfactant as per your practice

!

Baby should be fully resuscitated before surfactant is given


How to decrease chances of brain injury in a premature baby?

  • Gentle handling

  • No head-down position

  • Avoid excessive positive pressure or CPAP

  • Adjust ventilation and oxygen concentration gradually and appropriately (use pulse oximeter and blood gas)

  • Do not give rapid infusion of fluids

  • Avoid infusion of hypertonic solutions


Post-resuscitation management of a premature baby

  • Monitor blood sugar

  • Monitor for apnea and bradycardia

  • Give and adjust ventilation and oxygen concentration gradually and appropriately

  • Give feeding slowly and cautiously

  • Increase suspicion of infection


Ethics and neonatal resuscitation

  • Primary role in determining goals of care with parents

  • Informed consent based on complete and reliable information (may not be available before or immediately after delivery)


Not to initiate resuscitation

  • Confirmed gestational age of less than 23 weeks or birth weight less than 400 gm

  • Anencephaly

  • Confirmed trisomy 13 or 18

  • If parents wish: confirmed gestational age of 24-25 weeks

Based on your survival rates and local policy


Counseling parents before a high risk birth

  • Obstetrician and neonatologist perspectives may be different

  • Short and long term outcome of babies of different gestation in your hospital

  • Discuss resuscitation and level of care to be given to baby

  • Documentation


When to stop resuscitation?

  • No heart rate after 10 minutes of complete and adequate resuscitation

  • No evidence of other causes of compromise


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