Neonatal resuscitation (NNR)

1. Neonatal resuscitation (NNR) Dr. Renu Singh

2. Burden of the problem • Birth asphyxia • 23% of the 1 million neonatal deaths in India • Long term neurological complications • Death • NNR (Neonatal resuscitation) :simple, inexpensive, cost effective method • Problem: NNR often not initiated, incorrect use of methods

3. Successful NNR: factors • Anticipation: call a skilled personnel • Adequate preparation • Accurate evaluation, algorithm based • Prompt initiation of support

4. 1.Anticipation: High risk delivery • Maternal condition • Advanced maternal age ,DM, HT, stillbirth, fetal loss, early neonatal death • Fetal condition • Prematurity, post maturity, congenital anomalies, multiple gestations • Ante partum complications: APH, oligo /polyhydramnios • Delivery complications • Malpresentation, MSAF, instrumental delivery, antenatal asphyxia with abnormal FHR

5. 2. Adequate preparation • Radiant warmer is turned on,& is heating • Oxygen source is open with adequate flow through the tubing • Suction apparatus tested, functioning properly • Laryngoscope is functional with bright light • Resuscitation bag & mask demonstrates an adequate seal & generation of pressure

6. Radiant warmer

11. Successful NNR: factors • Anticipation: call a skilled personnel • Adequate preparation • Accurate evaluation, algorithm based • Prompt initiation of support

12. Evaluation, algorithm based • Rapid assessment of neonate clinical status • Is the infant full term? • Is the infant breathing or crying? • Does the infant has good muscle tone? • Yes: no resuscitation, routine neonatal care • No: needs resuscitation

14. Approach to resuscitation2010 AHA, AAP • A: initial steps(provide warmth, clear airway if necessary, dry, stimulate) • B: breathing(ventilation) • C: chest compressions (circulation) • D: administration of drugs &/or volume expansion

15. Resuscitation: initial steps • Provide warmth • Head position “ sniffing position” • Clearing the airway, if necessary • Drying the baby • Tactile stimulation for breathing

17. AAP Algorithm

18. AAP Algorithm

20. PPV: Positive pressure ventilation • Form of assisted ventilation • Needed when there is no improvement in HR • Also assess chest wall movements • Should be delivered at rate of 40-60 breaths /min, maintain HR>100 /min • Devices: BMV, ET (endotracheal tube),LMA(laryngeal mask airway)

22. Bag & mask ventilation

24. Endotracheal tube • If BMV is ineffective/prolonged • When chest compressions are performed • Initial endotracheal suctioning of non vigorous meconium stained newborn

25. Endotracheal tube

27. LMA(Laryngeal mask airway) • Soft mask, fits over laryngeal inlet when inflated, occludes the oesophageal opening • Done when BMV is unsuccessful & tracheal intubation is unsuccessful or not feasible

28. LMA(Laryngeal mask airway)

29. Targeted SPO2 after birth

30. Initial steps in resuscitation PPV

31. AAP Algorithm

32. Chest compressions • Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec • Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest • 2 techniques: • 2 thumb-encircling hands technique • Compression with 2 fingers ,second hand supporting the back • 3:1 ratio::[ 90 comp:30 ventilations]

35. Initial steps of resuscitation PPV(ET) CHEST COMPRESSIONS

37. AAP Algorithm

38. Medications • Rarely indicated • Most important step to treat bradycardia is establishing adequate ventilation • HR remains <60bpm,despite adequate ventilation(ET) with 100% Oxygen & chest compressions • Epinephrine or volume expansion or both

39. Epinephrine • Route of administration: intravenous(IV),ideal • Recommended dose: 0.01-0.03 mg/kg per dose • Desired concentration: 1:10,000 0.1 mg/ml

40. Volume expansion • Suspected or known blood loss • Isotonic crystalloid solution ; normal saline • Blood • Dose calculation: 10 ml/kg

42. The golden minute • <30 seconds: complete initial steps • Warmth • Drying • Clear airway if necessary • Stimulate • 30-60 seconds: assess 2 vital characteristics • Respiration (apnea/gasping/labored/unlabored) • Heart rate (<100/>100bpm) • Golden Minute Project: skill based training

44. AAP Algorithm

45. Post resuscitation care • Needed for those who required PPV • At risk of deterioration • Hypo/hyperthermia ,hypoglycemia, CNS complications(apnea, HIE), pulmonary complications(TTN, Pneumonia), hypotension • Need monitoring ,evaluation • NICU may be necessary

46. NNR : not indicated • Conditions with certainly early death • Extreme prematurity(GA<23 weeks) • Birth weight<400g • Anencephaly • Chromosomal abnormality: Trisomy 13

47. NNR: nearly always indicated • High rate of survival • Acceptable morbidity • GA≥ 25 weeks • Those with most congenital malformations

48. NNR? • Conditions associated with uncertain prognosis • Survival borderline • Parental desires concerning initiation of resuscitation should be supported

49. Discontinuing resuscitative efforts • Newborn with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes

50. Summary • Most infants transfer from intrauterine to extra uterine life • 10% need some intervention,1% need extensive resuscitation • Anticipate the need for NNR • Adequate preparation for NNR • Evaluate the newborn as per AHA/AAP guidelines & follow the recommended protocol