Neonatal/Pediatric Cardiopulmonary Care

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Neonatal/Pediatric Cardiopulmonary Care

• Resuscitation

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When To Resuscitate

• Need usually related
• Combination of
• Can occur in

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Causes of Fetal Asphyxia

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Apnea
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Effect of Asphyxia on Lungs

• Initial adaption to extra-uterine life requires 2
  steps

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Effect of Asphyxia on Lungs
Asphyxia
Blood flow continues through d.a.
f.o. (by-passing lungs)
Apneic or ineffective respirations
Negative pressure not generated to open Alveo li
to push fluid out
Pulmonary hypertension
Pulmonary vasoconstriction
PaO2 ?, PaCO2 ?, ? pH
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Effect of Asphyxia on Lungs

• If asphyxia severe with lactic acidosis
• ?
• Ventilation alone will not change
• acid-base imbalance
• ?

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Effect of Asphyxia on Lungs

• In severe cases - might be beneficial to give
  HCO3- to

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Effect of Asphyxia on Lungs

• NOTE
• Adequate ventilation must be maintained when
  bicarb given!!!
• Why??

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Effect of Asphyxia on Lungs
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Preparation For Resuscitation

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Basics of Neonatal Resuscitation
3 steps

• A -
• B -
• C -

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Resuscitation Cycle
Evaluation
Decision
Action
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Steps in Resuscitation

• 1st step

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Mechanisms of Heat Loss

• Radiation
• Loss to
• Conduction
• Loss to
• Evaporation
• Loss when
• Convection
• Loss to

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Causes of Heat Loss

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ColdStress
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Steps in Resuscitation
Next Step Open airway

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Steps in Resuscitation
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Evaluate Respiratory Effort
Evaluate
respirations
None or
Spontaneous
gasping
Evaluate
PPV with
heart rate
100 O2
Below 100
15 - 30 sec.
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Evaluate Heart Rate
Evaluate
heart rate
Above 100
Evaluate
color
Blue
Pink or
peripheral cyanosis
Provide oxygen
Observe and
monitor
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Indications for PPV

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Positive Pressure Ventilation

• Flow-inflating bag
• Self-inflating bag
• Pressure gauge
• Oxygen flow 5-8 lpm
• Pop-off at 30-40 cmH2O

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PPV Technique

• Slightly extend neck
• Mask held with thumb forefinger
• Bag squeezed with fingertips
• Initial rate -
• Done for 15-30 sec., then re-evaluate
• May require -

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Re-evaluate Heart Rate
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Chest Compressions

• 2 fingers or thumbs
• Lower 1/3 of sternum
• Sternum depressed
  1/2-3/4 inches
• 31 compression-to-ventilation ratio
• Continue for 30 sec., stop for 6 sec. to
  re-evaluate HR
• DCd when HR gt 80, then re-evaluate RR

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Indications for Intubation

• Bag/mask ventilation is difficult or ineffective
• Prolonged PPV is required
• Thick meconium is present in amniotic fluid
• Suspicion of diaphragmatic hernia

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ETT Sizes
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Laryngoscope Blades

• Size 1 for
• Size 0 for

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Intubation Technique

• Same as adult
• Limit attempts to -
• Provide blow-by oxygen at -
• ETT tip midway between carina clavicles
• Cut ETT to leave -

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Medications - Uses

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Medications - Routes

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Instillation Into ETT
N A V E L O2
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Medications - Indications

• HR lt 80 despite PPV and chest compressions for at
  least 30 sec.
• HR is 0

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Epinephrine

• Powerful sympathomimetic
• 1st drug given
• IV or ETT, delivered rapidly
• Repeated q3-5 until HR -

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Volume Expanders

• Given if hypovolemic
• ? BP
• Pallor with adequate oxygenation
• HR gt 100 with weak pulses
• Failure to respond to resuscitation
• Whole blood, 5 albumin, plasma expanders, NS
• IV, may be repeated as needed

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Sodium Bicarbonate

• Prolonged arrest not responding
• Alkaline to buffer metabolic acidosis
• Only given when ventilation is adequate
• IV

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Narcan (naloxone)

• Reversal of narcotic depression
• Demerol (meperidine)
• Morphine sulfate
• Fentanyl (Sublimaze)
• IV, IM, sub-q, ETT
• Given rapidly

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Dopamine

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APGAR Scoring

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APGAR Scoring
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Serum Glucose
Sources

• Nutritional needs of fetus supplied by Mom
  regulated by placenta
• Fetus prepares for postnatal life by ? energy
  stores developing enzyme-dependant processes
  for usage of stored energy

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Serum Glucose
Energy Storage

• Glycogen
• Triglycerides (brown fat)

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Serum Glucose
Post-delivery

• At 2 hours -
• By 3 days -

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Serum Glucose
Hypoglycemia

• Term -
• Preterm -

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Hypoglycemia - Signs

• Tremors
• Irritability
• ?or?Moro reflex
• Apnea/tachypnea
• Cyanosis
• Seizures

• Lethargy
• Hypothermia
• Weak/high-pitched cry
• Poor feeding
• Vomiting
• CV failure

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Hypoglycemia
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Hypoglycemia - Causes

• Hyperinsulinism
• Prematurity
• IUGR
• Starvation
• Sepsis
• Shock
• Asphyxia

• Hypothermia
• Glucogen Storage Disease
• Galactosemia
• Adrenal insufficiency
• Polycythemia
• Congenital heart defects
• Iatrogenic causes

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Hyperinsulinism

• Fetus of diabetic Mom
• Rh incompatibility
• Insulin-producing tumors
• Maternal tocolytic therapy (ritodrine,
  terbutaline)

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Glucose Measurement

• Glucose Test Strip Dextrostik
• One Touch
• Lab sample (blood glucose)

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Hypoglycemia Treatment

• Early feeding (oral)
• D10W
• 200 mg/kg bolus over 1-3 minutes
• Cont IV, 4-8 mg/kg/min. until feedings started
• Treat cause

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Umbilical Blood Sampling

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Umbilical Vein Catheter (UVC)

• Usually placed in -
• Drug administration during -

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Umbilical Artery Catheter (UAC)
Indications

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Umbilical Artery Catheter (UAC)
Placement

• 5 Fr. catheter (gt1250 g), 3.5 Fr. catheter (lt1250
  g)
• Sterile procedure
• Heparinized-filled catheter
• Tip L3-4 for low catheter, T8 for high catheter
  (in aorta below renal a., above bifurcation of
  femoral a.)

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UAC
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Umbilical Artery Catheter
Complications

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Umbilical Artery Catheter
Sampling Technique