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

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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  1. Special considerationsResuscitation of premature babiesEthics and Care at End of Life

  2. Special considerations • Situations that may complicate resuscitation and cause ongoing problem • Post-resuscitation management • Resuscitation outside hospital or beyond time of birth

  3. Difficult situations • Not able to ventilate adequately • Cyanosis despite adequate ventilation • Bradycardia despite adequate ventilation • No spontaneous breathing despite adequate ventilation

  4. 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

  5. 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 prematurity High inflation pressure • Congenital pneumonia

  6. Cyanosis/Bradycardia despite adequate ventilation • Cyanotic heart disease • Congenital heart block Ensure adequate ventilation

  7. 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)

  8. 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

  9. 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

  10. Post-resuscitation care • Temperature control • Close monitoring of vital signs • Laboratory studies

  11. Post-resuscitation care • Look for complications • Pulmonary hypertension • Pneumonia/other lung complications • Metabolic acidosis • Hypotension • Seizures • Apnea • Hypoglycemia • Feeding problem

  12. 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)

  13. 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

  14. 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

  15. Keeping a premature baby warm • Increase temperature of the delivery room • Pre-heat the radiant warmer • Pre- warmed transport incubator

  16. 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

  17. 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

  18. 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%

  19. Oxygen in a premature baby ! Resuscitation efforts not to be delayed while waiting for pulse oximeter to display a strong signal

  20. 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

  21. CPAP

  22. 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

  23. Ventilation in a premature baby • Prophylactic surfactant as per your practice ! Baby should be fully resuscitated before surfactant is given

  24. 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

  25. 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

  26. 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)

  27. 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

  28. 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

  29. 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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