Neonatal resuscitation (NNR)

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Neonatal resuscitation (NNR)

• Dr. Renu Singh

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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

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Successful NNR factors

1. Anticipation call a skilled personnel
2. Adequate preparation
3. Accurate evaluation, algorithm based
4. Prompt initiation of support

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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

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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

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Radiant warmer
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Successful NNR factors

1. Anticipation call a skilled personnel
2. Adequate preparation
3. Accurate evaluation, algorithm based
4. Prompt initiation of support

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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

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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

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Resuscitation initial steps

• Provide warmth
• Head position sniffing position
• Clearing the airway, if necessary
• Drying the baby
• Tactile stimulation for breathing

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AAP Algorithm
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AAP Algorithm
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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 HRgt100 /min
• Devices BMV, ET (endotracheal tube),LMA(laryngeal
  mask airway)

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Bag mask ventilation
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Endotracheal tube

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

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Endotracheal tube
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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

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LMA(Laryngeal mask airway)
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Targeted SPO2 after birth
1 minute 60-65
2 minutes 65-70
3 minutes 70-75
4 minutes 75-80
5 minutes 80-85
10 minutes 85-90
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1. Initial steps in resuscitation
2. PPV

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AAP Algorithm
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Chest compressions

• Started when HRlt60 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
• 31 ratio 90 comp30 ventilations

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1. Initial steps of resuscitation
2. PPV(ET)
3. CHEST COMPRESSIONS

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AAP Algorithm
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Medications

• Rarely indicated
• Most important step to treat bradycardia is
  establishing adequate ventilation
• HR remains lt60bpm,despite adequate
  ventilation(ET) with 100 Oxygen chest
  compressions
• Epinephrine or volume expansion or both

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Epinephrine

• Route of administration intravenous(IV),ideal
• Recommended dose 0.01-0.03 mg/kg per dose
• Desired concentration 110,000
• 0.1
  mg/ml

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Volume expansion

• Suspected or known blood loss
• Isotonic crystalloid solution normal saline
• Blood
• Dose calculation 10 ml/kg

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The golden minute

• lt30 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 (lt100/gt100bpm)
• Golden Minute Project skill based training

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AAP Algorithm
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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

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NNR not indicated

• Conditions with certainly early death
• Extreme prematurity(GAlt23 weeks)
• Birth weightlt400g
• Anencephaly
• Chromosomal abnormality Trisomy 13

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NNR nearly always indicated

• High rate of survival
• Acceptable morbidity
• GA 25 weeks
• Those with most congenital malformations

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NNR?

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

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Discontinuing resuscitative efforts

• Newborn with no detectable heart rate, consider
  stopping NNR if the heart rate remains
  undetectable for 10 minutes

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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

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MCQ1

• For successful neonatal resuscitation following
  is/are needed except
• Anticipation
• Adequate preparation
• Skilled personnel
• Delayed initiation of support

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MCQ1

• For successful neonatal resuscitation following
  is/are needed except
• Anticipation
• Adequate preparation
• Skilled personnel
• Delayed initiation of support

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MCQ2

• Following are true in relation to initial steps
  of neonatal resuscitation except
• Provide warmth
• Tactile stimulation
• Endotracheal intubation
• Drying the baby

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MCQ2

• Following are true in relation to initial steps
  of neonatal resuscitation except
• Provide warmth
• Tactile stimulation
• Endotracheal intubation
• Drying the baby

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MCQ3

• The following is the primary measure of adequate
  ventilation
• Chest wall movement
• Improvement in heart rate
• Pink extremities
• Spo2 of 100

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MCQ3

• The following is the primary measure of adequate
  ventilation
• Chest wall movement
• Improvement in heart rate
• Pink extremities
• Spo2 of 100

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MCQ4

• Endotracheal intubation may be indicated at
  several points during neonatal resuscitation
  except
• Ineffective BMV
• During chest compressions
• Vigorous meconium stained newborn
• Non vigorous meconium stained newborn

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MCQ4

• Endotracheal intubation may be indicated at
  several points during neonatal resuscitation
  except
• Ineffective BMV
• During chest compressions
• Vigorous meconium stained newborn
• Non vigorous meconium stained newborn

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MCQ5

• The recommended compression to ventilation ratio
  in neonatal resuscitation is
• 21
• 31
• 41
• 51

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MCQ5

• The recommended compression to ventilation ratio
  in neonatal resuscitation is
• 21
• 31
• 41
• 51

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MCQ6

• The recommended dose(mg/kg per dose) and route of
  epinephrine in neonatal resuscitation
• 0.01-0.03,IV
• 0.01-0.03,IM
• 0.03-0.05,1V
• 0.05-0.1,IV

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MCQ6

• The recommended dose(mg/kg per dose) and route of
  epinephrine in neonatal resuscitation is
• 0.01-0.03,IV
• 0.01-0.03,IM
• 0.03-0.05,1V
• 0.05-0.1,IV

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MCQ7

• Recommended method/clinical indicator of
  confirming ET placement is
• Condensation in ET
• Chest movement
• Equal breath sounds on auscultation
• Exhaled C02 Detection

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MCQ7

• Recommended method/clinical indicator of
  confirming ET placement is
• Condensation in ET
• Chest movement
• Equal breath sounds on auscultation
• Exhaled C02 Detection