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 • 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.
Initial queries ?? • Term gestation? • Crying or breathing? • Good muscle tone?
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.
“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 • Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required.
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 • risk factors are identified early, • neonatal problems are anticipated, • equipment is available, • personnel are qualified and available • a care plan is formulated
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 • 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 • 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 • Umbilical catheters (2.5F, 5F) • Chest tube (10F catheter) • Sterile procedure trays
Trained Personnel • One present • Two or more • -- problems • --- twins
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 • 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 • Clear liquor • Meconium stained liquor
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 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 • 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 • 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 • 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 • 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 • 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 • unheated non humidified oxygen sources for the bag-valve-mask device • Intubated ventilated patient – humidified warmed ventilator circuits
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
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 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 • 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 • Heart rate • CO2 • SPo2
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 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 ???
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 • 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 • 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 • What is shocking ?? • NO APGAR score at all.
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 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 • Score of 10 ?? • >7 ok • 4 – 7 -- to act • 1 min, 5 , 10, 15 minutes • Score of 3 0r less persistent – neuro damage