Neonatal Advanced Life Support NALS

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Neonatal Advanced Life Support (NALS)

• Current Status

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History

• And he went up, and lay upon the child, and
  put his mouth upon his mouth, and his eyes upon
  his eyes, and his hands upon his hands And he
  stretched himself upon the child and the flesh
  waxed warm.
• Elisha II Kings 414.
• (The old testament)

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Mahabharat

• Sukra
• The high priest of demons had secret knowledge of
  resuscitation.

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Eighteenth Century

• If the child does not breathe immediately upon
  delivery,
• Wipe its mouth, and press your mouth to the
  childs, at the same time pinching the nose with
  your thumb and finger, inflate the lungs ,
• By which method I have saved many.
• BENJAMIN PUGH (1754)

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Neonatal Resuscitation 20th Century
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Modern Medicine

• The first quarter of an hour after birth
• is the most dangerous period of life.
• Its mortality is as great as that of any
• subsequent month
• (Handerson Y. JAMA 1928 90(8)383-386)
• Apgar Score (1953) uniformity in assessment

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Guidelines for Neonatal Resuscitation

• Before 1960 Methods based on empiric
  observation in human infants without animal
  experimentation
• 1987 AHA and AAP Structured training program
  (NRP)

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National Survey of Prevalent Traditional
Practices
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NRP in India

• NNF adopted NRP program
• 1st training of national faculty at Trivandrum
• Regular NALS courses at various venues
• Health programs
• Curriculum

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International Guidelines 2000

• ILCOR and AHA
• Consensus advisory statement 1999
• Controversies current scientific information
• Strength of evidence study design, level of
  evidence, methodology

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Classes of Recommendations
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Major Guidelines Changes

• Areas of controversies
• MSAF
• Intra-osseous infusion
• Optimal conc. Of O2
• Chest compression
• Opt. Dose of adrenaline
• Volume expanders
• Bicarbonate adm.
• Cerebral cooling
• Ethics

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Meconium Stained Amniotic Fluid

• 1. Intrapartum Suction irrespective of
  consistency
• 2. Delay drying and stimulation

• 3. ET Suction
• If respiration is absent or depressed
• Decreased muscle tone
• Heart rate lt100

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Oxygenation Ventilation

• Room air v/s 100 oxygen
• Insufficient data to change current practice
• Supp. O2 is unavailable room air (IM)
• Laryngeal mask (IM)
• Effective alternate to establish airway if bag
  mask vent. Ineffective, failed ET intubation
• Confirmation of ETT by exhaled CO2
• If clinical assessment is equivocal (IM)

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Medication, Vascular Access

• Epinephrine dose
• If the HR remains lt 60 bpm after 30 seconds of
  adequate ventilation and chest compression (1)

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Medication, Vascular Access

• Choice of fluid for volume Expansion
• Isotonic crystalloid NS, Ringer lactate
• O - negative blood if antenatal
• anticipation (2b)
• Alternative route for venous access
• Intraosseous route if venous access
• not available (2b)

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Chest Compressions

• Preferred technique
• Two thumb encircling hands (2b)
• Relative depth of compression - ¹/3 of AP
  diameter of the chest
• Sufficiently deep to generate a pulse

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Issues

• Is there a need to review current NALS protocols
  ?
• How could the coverage made more effective ?
• How to modify it for community neonatal care
  functionaries

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Review of Protocols

• Revising Publications
• Retraining of trainers and providers

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Effective Coverage

• PG curriculum
• Trainers courses
• State units
• Newborn care programs

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Community Neonatal Care

• Functionaries
• 2. Module
• 3. Training programs

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Community Neonatal Care