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Neonatal Resuscitation including perinatal physiology and Neonatal assessment at the time of birth

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Title: Neonatal Resuscitation including perinatal physiology and Neonatal assessment at the time of birth


1
Neonatal Resuscitation including perinatal
physiology and Neonatal assessment at the time of
birth
  • Presenter Dr. Shalini
  • Moderator Dr. Deepti
  • Dr. A.K Sethi

University College of Medical Sciences GTB
Hospital, Delhi
email anaesthesia.co.in_at_gmail.com
www.anaesthesia.co.in
2
Why learn neonatal resuscitation?
  • Birth asphyxia accounts for approximately
  • 5 million neonatal deaths yearly worldwide (
    WHO,1995).
  • For many of these newborns, appropriate
    resuscitation was unavailable.

3
Neonatal resuscitation
  • 10 neonates require some assistance at birth.
  • 1 neonates need extensive resuscitative
    measures.
  • Asphyxia accounts for 20-25 newborn deaths.

4
How does a baby receive oxygen before birth?
  • Oxygen diffuses across placental membrane from
    mothers blood to babys blood.
  • Lungs receive very little blood.
  • Alveoli are fluid filled rather than air.

5
Very little flow to lungs
6
Before birth
  • Pulm arterioles constricted
  • Umbilical arteries feeding low pressure placenta
    circulation
  • Low pressure in systemic circuit
  • High pressure in pulmonary circuit
  • Very little pulmonary blood flow

7
After birth
  • Alveoli
  • Expand
  • Get filled with air (O2)

1.
  • Fluid in the alveoli is absorbed

8
After birth
2.
Umbilical arteries and veins are clamped
Sudden increase in systemic blood pressure
9
Pulmonary vessels dilate, causing increased blood
flow to lungs
3.
10
Ductus arteriosus constricts
4.
  • Increased oxygen in blood
  • Increased pulmonary blood flow

11
Perinatal compromise results in..
  • Primary apnea occurs after failure of initial
    period of rapid attempts to breathe
  • responds to stimulation( drying,
    suctioning, tactile)
  • Secondary apnea - if oxygen deprivation continues
  • - baby not responding to tactile
    stimulation
  • - requires assisted ventilation
  • .

12
Changes due to oxygen deprivation
13
Consequences of interrupted transition
  • The compromised baby may exhibit 1 or more of the
    following clinical findings
  • Low muscle tone
  • Respiratory depression (apnea / gasping)
  • Bradycardia
  • Hypotension
  • Cyanosis

14
Apgar score
Calculated at 1 5 min after birth
15
Role of Apgar score in resuscitation
  • For resuscitation, not all elements are required
  • Resuscitation initiated before 1 min when Apgar
    is assigned
  • Initial golden minute can be lost while assigning
    Apgar score
  • Apgar score is great, but not for guiding
    resuscitation

16
Being Prepared for Resuscitation
  • Most of the time which baby to resuscitate can
    be anticipated depending on
  • ANTEPARTUM FACTORS
  • Maternal diabetes
  • PIH
  • APH
  • Maternal cardiac disease
  • Polyhydramnios
  • Oligohydramnios
  • Fetal hydrops
  • Multiple gestation
  • Fetal malformation
  • INTRAPARTUM FACTORS
  • Emergency LSCS
  • Premature labor
  • Prolonged labor
  • Significant intrapartum hemorrhage
  • Meconium stained fluid
  • Prolapsed cord
  • Persistent fetal bradycardia
  • But,resuscitation condition may come as a
    surprise also

17
Being Prepared for Resuscitation
  • Adequate preparation
  • Trained Personnel At least one
  • At least
    two when high risk anticipated
  • Equipment
  • A radiant warmer Heated and ready to use
  • All resuscitation equipment immediately available
    and in working order

18
Questions asked at the time of birth
  • Is the baby born at term ?
  • Is the baby breathing or crying ?
  • Is there good muscle tone ?
  • Is the color pink ?
  • Is the amniotic fluid clear of meconium ?
  • Now, amniotic fluid and color of baby has been
    removed from algorithm( 2010, AHA)

19
If yes to ALL the questions?
  • Routine Care
  • Nearly 90 of newborns need this
  • Provide warmth by keeping the baby over mothers
    chest or placing under radiant warmer
  • Position by slightly extending neck
  • Clear the airway as necessary

20
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21
Initial Steps
  • Provide warmth
  • Position clear airway as necessary
  • Dry, stimulate and reposition
  • Give oxygen, as necessary

22
Provide warmth
  • Place under radiant warmer
  • Leave the baby uncovered under warmer
  • - to allow full visualization
  • - to permit radiant heat to reach
    the baby

23
Initial Steps
  • Provide warmth
  • Position clear airway as necessary
  • Dry, stimulate and reposition
  • Give oxygen, as necessary

24
Position by slightly extending the neck
25
Clear Airway
  • Secretions removed from airway with a towel/ bulb
    syringe
  • Copious secretions- turn face to side
  • Gentle suction- Pressure lt -100 mm Hg
  • Mouth before nose (M before N)
  • Stimulation of posterior pharynx causes vagal
    stimulation and bradycardia- STOP SUCTIONING
  • Now suctioning immediately with bulb syringe
    following birth is reserved for babies with
    obvious obstruction to spontaneous breathing or
    who require PPV (class2B)

26
Meconium present and baby vigorous
  • Vigorous Baby- Strong respiratory efforts,
  • Good muscle
    tone,
  • Heart rate gt
    100 bpm
  • 12F or 14F suction catheter or bulb syringe for
    suction of mouth or nose
  • ET suction not required

27
Meconium present and baby not vigorous
  • Insert laryngoscope
  • Clear mouth and posterior pharynx
  • Insert endotracheal tube into the trachea
  • Attach the ET to suction source
  • Apply suction as ET is slowly withdrawn
  • Repeat as necessary until no meconium or heart
    rate indicates further resuscitation
  • There is insufficient data to recommend a change
    in current practice of ET suctioning of
    non-vigrous babies with meconium staining.
    (class2B)

28
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29
Initial Steps
  • Provide warmth
  • Position clear airway as necessary
  • Dry, stimulate and reposition
  • Give oxygen, as necessary

30
Dry, stimulate to breathe and reposition
  • Use pre-warmed absorbent towels or blankets
  • Keep head in sniffing position to maintain good
    airway
  • Suction and drying provide sufficient stimulation
  • If inadequate respiration then additional tactile
    stimulation given briefly by
  • Slapping or flicking the soles of the feet
  • Gently rubbing the back, trunk or extremities
  • Overly vigorous stimulation harmful

31
Acceptable methods of stimulation
32
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33
Further Evaluation
  • Respiration-good chest movement
  • - rate depth of
    respiration
  • Heart Rate
  • Feel pulse at base of umbilical cord or
    auscultate
  • Count for 6 seconds and multiply by 10
  • gt100 bpm normal
  • Now ,heart rate and respiration are to be
    evaluated
  • Color has been deleted from algorithm
  • Heart rate is best evaluated by auscultation

34
Indications of Bag Mask Ventilation
  • After evaluation if
  • Baby is not breathing or is gasping
  • Heart rate is less than 100 bpm and /or
  • Ventilation is the Single most important most
    effective step in resuscitation of the
    compromised newly born baby
  • Along with bag mask ventilation,
  • SpO2 monitoring has been added

35
  • Targeted preductal SpO2 after birth
  • 1min 60-65
  • 2min 65-70
  • 3min 70-75
  • 4min 75-80
  • 5min 80-85
  • 10min 85-95
  • These targets are achieved by
  • initiating resuscitation with air or
  • a blended oxygen titrating the oxygen
    concentration
  • 100 oxygen
  • to achieve SpO2 in above target range.
  • Term babies ( 37 weeks)
  • In term neonates Start resuscitation with room
    air(21)
  • In preterm neonatesInitiate resuscitation using
    O2 concentration between 30-90
  • Role of CPAP has been mentioned in spontaneously
    breathing preterm baby with respiratory distress
    class IIB

36
  • Adequate bag mask ventilation is present if
  • A noticeable rise and fall of chest
  • The presence of bilateral breath sounds
  • Improvement in the color and heart rate
  • Frequency40 60 breaths per minute
  • PIP- for initial breaths 20-25 cm H 2O for
    preterm and 30-40 cm H 2O for term babies
  • PEEP likely to be beneficial for initial
    stabilization of preterm infants, if provided
    with suitable equipment(T-piece or flow inflating
    bags)
  • Continue bag mask ventilation for 30 sec to
    evaluate
  • HEART RATE
  • If HR gt 100/Min Spontaneously breathing baby
  • Stop ventilation

37
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38
Indications of chest compressions
  • Heart rate less than 60 bpm despite 30 sec of
    effective positive pressure ventilation with 100
    oxygen
  • Start chest compressions while continuing
    assisted ventilation
  • Coordinate compression with ventilation
  • One cycle of event consists of 3 compression plus
    1 ventilation
  • 120 events per 60 sec i.e ( 90 compression 30
    breath)
  • At least 1/3rd of anteroposterior diameter of the
    chest
  • Compression of chest followed by release taken as
    ONE COMPRESSION
  • Higher ratio(152) should be considered if arrest
    is of cardiac origin class IIB
  • Reevaluate after 30 sec, if heart ratelt 60bpm
    proceed to next step

39
Technique Position of Hands on Chest
  • Thumb technique ( preferred )

40
Technique Position of Hands on Chest
Two finger technique
41
When to Stop chest Compressions?
  • After approx. 30 sec of CC PPV
  • Count Heart Rate
  • If gt60 - Stop Chest compressions, continue PPV
  • Continue PPV at 40 - 60 BPM
  • Till Heart rate gt100
  • Baby breathing spontaneously

42
Indications of endotracheal Intubation
  • Prolonged PPV required
  • Bag mask ineffective Inadequate chest
    expansion
  • If chest compressions required Intubation may
    facilitate coordination and efficiency of
    ventilation
  • Tracheal suction required e.g. MSAF
  • Diaphragmatic Hernia
  • Role of LMA has been mentioned
  • Effective for ventilating newborns with
    weightgt2000g or gt34wks gestation classIIB
  • Limited data in preterm newborns
  • LMA use should be considered if face mask
    ventilation or intubation unsuccessful classIB

43
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44
Medications used during resuscitation
  • If HR lt 60/Min, despite continued PPV Chest
    compressions
  • Medications used are
  • Epinephrine
  • Volume expanders
  • Naloxone

45
Epinephrine
  • Indications
  • HR lt60 /min after PPV CC for 30 secs
  • Route of administration
  • Intravenous
  • Endotracheal route (when I.V line is not secured
    )
  • Recommended
  • Conc. 110,000 (0.1mg/ml)
  • Route ET/ IV
  • Dose 0.01-0.03 mg/kg , (0.05-0.1mg/kg E.T)
  • Rate of admn. as rapidly as possible
  • Now, intravenous route is first preferred route

46
Volume Expander
  • Indications
  • Poor response to other resuscitative measures
  • Evidence of blood loss or suspected ( pale skin,
    poor perfusion, weak pulse)
  • Crystalloid
  • Normal Saline
  • Ringer Lactate or
  • O-negative blood cross-matched with mothers
    blood
  • Dose 10ml/kg
  • Route Umbilical vein
  • Preparation large syringe
  • Rate of administration 5-10 min
  • In premature babies Rapid boluses may induce ICH

47
Naloxone
  • Indications
  • A history of maternal narcotic administration
    within the past 4 hours
  • Severe respiratory depression is present after
    PPV has restored a normal HR color
  • Recommended
  • Concentration 1.0 mg/ml
  • Route Intravenous
  • Dose 0.1 mg/kg
  • Administration of naloxone as a part of initial
    resuscitative effort is not recommended in
    newborn with respiratory depression

48
What to do if still no improvement?
  • If no improvement seen despite all efforts
  • Ensure adequate ventilation, chest compressions,
    drug delivery
  • If still HR lt 60/min, consider
  • Airway malformation
  • Lung problems
  • Pneumothorax
  • Diaphragmatic hernia
  • Cong. Heart disease
  • If HR absent or no progress
  • Ethical considerations of when to D/C
    Resuscitation

49
Premature babies concerns
  • Premature babies are physiologically
    anatomically immature, at risk of complications
    as
  • May be surfactant deficient,prone to injury from
    PPV
  • Immature brain capillaries, poor respiratory
    drive
  • Weak muscles, not able to breathe
  • More prone to hypothermia
  • More likely to be infected
  • Small blood volume, prone to hypovolemia
  • Immature tissues, prone to oxygen toxicity

50
What additional resources do you need?
  • Additional resources during resuscitation of
    preterm baby
  • Additional trained personnel (at least 2)
  • Additional means of maintaining temperature (at
    greater risk of hypothermia)
  • Room temperature 26 0C
  • Plastic wraping classI
  • Exothermic mattresses class IIB
  • Oxygen blender (to titrate oxygen conc.)
  • Pulse oximetry
  • Role of CPAP has been mentioned in preterm babies
    only

51
Postresuscitation care
  • Babies who require resuscitation are at risk for
    deterioration after vital signs have returned to
    normal, therefore postresuscitation care is
    important
  • Earlier in 2005 guidelines three levels of
    post-resuscitation care were discussed, but now
    only two levels have been mentioned
  • Routine care
  • Post-resuscitation care

52
  • Post-resuscitation care
  • After resuscitation, infant should be maintained
    in, or transferred to place where close
    monitoring anticipatory care can be provided.
  • Glucose
  • No specific target glucose concentration defined
    at present
  • Intravenous glucose infusion should be
    considered as soon as after resuscitation with
    the goal to avoid hypoglycemia

53
  • Induced therapeutic hypothermia
  • Induced hypothermia (33.5-34.50 C) had
    significantly lower mortality in babies with
    documented Hypoxic ischemic encephalopathy
    lesser neurodevelopmental disability.
  • Commencement of hypothermia within 6 hrs
    following birth, continuation for 72hrs, slow
    rewarming over at least 4 hrs.

54
Withholding Resuscitation
  • Clinicians should not hesitate to withdraw
    support when functional survival is highly
    unlikely
  • Resuscitation is not indicated
  • Gestation, birth weight, or congenital anomalies
    are associated with almost certain early death
  • Prematurity (gestational age lt23 weeks or birth
    weight lt400 g),
  • Anencephaly
  • Chromosomal abnormalities

55
Discontinuing Resuscitative Effort
  • Stop resuscitation, if HR remains undetectable
    for 10 min
  • Also take into consideration factors such as
    presumed etiology of the arrest, gestation of the
    baby, presence or absence of complications

56
Changes in 2010 guidelines (AHA)
Resuscitation step Recommendations (2005, AHA/ACC) Recommendations (2010, AHA/ACC)
1) Assessment for need of resuscitation Four questions Gestation-term or not? Amniotic fluid- clear or not? Tone- Good? Breathing /Crying? Three questions Gestation-term or not? Tone- Good? Breathing /Crying?
2) Routine care(Given if answer to all three question is YES) Provide warmth Clear airway Dry Assess color Provide warmth Assure open airway Dry Ongoing evaluation(color, activity and breathing)
3) Initial steps Provide warmth Position Clear airway(if required) Dry, stimulate, reposition Provide warmth Open airway( no routine suction) Dry , stimulate
57
4) Assessment (after initial steps and ongoing) Look for 3 signs Hear rate Color Respiration Look for 2 signs Heart rate Respiration( Labored, unlabored, apnea, gasping) Auscultation of heart at the precordium is the most accurate
5) Positive pressure ventilation (PPV) 5.1) Indication for PPV 5.2) Assessment of effectiveness of resuscitation steps once PPV is started Indications are(any 1 out of 3) Heart rate lt 100/min Apnea or gasping Persistent central cyanosis despite free flow oxygen Heart rate Color Respiration Indications (1 out of 2) Heart rate lt 100/min Apnea or gasping Heart rate Pulse oximetry Respiration
58
5) Oxygenation 5.1) Assessment of oxygenation 5.2) Target saturation (pre-ductal) Based on color Pulse oximetry recommended for only preterm lt 32weeks with need for PPV Not defined Based on pulse oximetry for both term and preterm Target SpO2 ranges provided as a part of algorithm 1min- 60-65 2 min- 65-70 3min- 70-75 4min- 75-80 5min- 80-85 10min- 85-95 (same for both term and pre-term)
59
6) Initial oxygen concentration for resuscitation in case of PPV Term babies( 37 weeks) Start with 100 O2 during PPV However if room air resuscitation is started supplemental O2 up to 100 should be given if no improvement within 90 seconds following birth In case non availability of O2- start room air resuscitation Preterm babies(lt32weeks) Start with oxygen concentration somewhere between 21-100 No specific concentration recommended Advocates use of blender for graded increment or decrement of O2 Pulse oximetry for targeting SPO2-85-95 Term babies ( 37 weeks) Start with room air(21) No improvement in heart rate or oxygenation as assessed by pulse oximetry- use higher concentration by graded increase up to 100 to attain target saturations Use blender for graded increased in delivered oxygen concentrations Preterm(lt32weeks) Initiate resuscitation using O2 concentration between 30-90 Titrate O2 concentration to attain SPO2 values recommended at different time points Uses blended air oxygen mixture judiciously guided by pulse oximetry
60
7) Peripartum suctioning for neonates born through meconium stained amniotic fluid No routine oropharyngeal and nasopharyngeal suction Tracheal suction only in non-vigorous babies born through meconium stained amniotic fluid (MSAF) Intrapartum suctioning for MSAF not advised No routine oropharyngeal and nasopharyngeal suction required Tracheal suction of non vigorous babies with MSAF still to be continued though evidence for the same is conflicting Intrapartum suctioning for infants with MSAF , after delivery of head before delivery of shoulder not advised
61
8) Initial breath strategy Positive pressure ventilation (PPV) No specific recommendation for short or long inflation time No specific PIP recommendation No specific recommendation for PEEP Guiding of PPV looking at chest rise and improvement in heart rate No specific recommendation for short or long inflation time as evidence is conflicting PIP- for initial breaths 20-25 cm H2O for preterm and 30-40 cm H2O for term babies PEEP likely to be beneficial for initial stabilization of preterm infants, if provided with suitable equipment(T-piece or flow inflating bags)
62
9) CPAP in delivery room Suggested for preterm babies ( lt 32 weeks) with respiratory Distress Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP or ventilation as per local practice(Class IIB LOE B) CPAP is now mentioned in the algorithm for persistent cyanosis or labored breathing after initial Steps.
10) Airway management 10.1) Confirmation of endotracheal tube placement 10.2) Laryngeal mask airway Exhaled CO2 detection is recommended except in cardiac asystole where direct laryngoscopy may have to be done For near term and term infants gt2500g may be used with no definite mention of indications Same LMA may be used for infantsgt2000g and 34 weeks in case bag and mask is ineffective and tracheal intubation is unsuccessful or not feasible(LOE 2)
63
11) Upper airway interface Mask- rounded cushioned of appropriate size Other alternative is anatomical shaped mask Evidence for anatomical shaped or rounded mask to maintain seal is conflicting PPV by nasal prongs superior to facial masks for providing PPV
12) Method of PPV No Change
13) Chest compression No Change
64
14) Drugs 14.1) Naloxone Naloxone considered in case of infants born to mothers with history of opiod exposure within 4 hours of delivery and there is persistent respiratory depression even after restoration of heartrate and color by effective PPV Naloxone is not recommended as part of initial resuscitation in babies with respiratory depression. Focus needs to be on effective ventilation
15) Supportive care 15.1)Therapeutic Hypothermia 15.2)Delayed cord clamping No sufficient evidence for recommended routine use Avoid hyperthermia in such cases Not recommended Therapeutic hypothermia recommended for infants 36weeks with moderate to severe hypoxic ischemic encephalopathy with provision for monitoring for side effects and long term follow up For uncomplicated births both term and preterm not requiring resuscitation delay cord clamping by at least 1 minute
65
16) Changes in ongoing care After birth 3 types of care mentioned routine care, observational care and post resuscitation care Post resuscitation two types of ongoing care mentioned routine care and post resuscitation care
17) Withholding Resuscitation No change
18) Discontinuing care Insufficient evidence to make new recommendations
19) Educational program to teach resuscitation No mention of such a section AHA/AAP NRP should adopt simulation, briefing-debriefing techniques in designing an educational program for acquisition and maintenance of skills necessary for effective neonatal resuscitation.
66
2005
2010
67
References
  • Textbook of neonatal resuscitation,5 th
    edtn2006 APP and AHA.
  • Neonatal Resuscitation 2010 AHA Guidelines for
    cardiopulmonary Resuscitation and Emergency
    Cardiovascular Care.

68
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