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Neonatal resuscitation part 2 by dr.saleem

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comments on face book page pediatric department sheikh zayed hospital rahim yar khan

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  • 1. Dr.Muhammad Saleem Laghari Associate Professor Department of pediatrics SZMC,RYK
  • 2.  Globally, about one quarter of all neonatal deaths are caused by birth asphyxia. Effective resuscitation at birth can prevent a large proportion of these deaths.  About 10% of all new born require some assistance to begin breathing just after delivery.  <1% of them require extensive resuscitation
  • 3. Ref: BMC Public Health 2011 11(Suppl 3):S12
  • 4.  Basic Neonatal Resuscitation 1. Airway support 2. Breathing/ventilation  Advanced Neonatal Resuscitation 1. All the steps of basic neonatal resuscitation 2. Chest compression 3. Endotracheal intubation 4. Vascular cannulation 5. The use of drugs & fluids
  • 5. Following scheme is recommended 1. Preparation 2. Safety 3. Shout for help 4. Stimulate 1. Dry & rub the back with towel and cover the newborn 2. Gentle verbal / tactile stimuli in a neonate 5. Assess for breathing (crying/movement of chest) 6. Airway 1. Open 2. Clear
  • 6. 7. Reassess for breathing 8. Breathing Inflation / ventilation / rescue breaths 7. Reassess for breathing and heart rate 8. Chest compressions Thumb/two finger technique 7. Reassess for breathing and heart rate 8. Drugs Adrenaline Sodium bicarbonate Dextrose Volume expenders 7. Reassess for breathing and heart rate 8. post-resuscitation care
  • 7.  Is the key to a successful outcome.  Cooperation between obstetric and pediatric staff is important.  Review notes  Communicate with the parents  Wash hands & Use sterile gloves  Thermoneutral environment  Check for equipment
  • 8.  Resuscitation trolley/table  Sterile linen  Suction apparatus(Bulb/penguin/mechanical sucker)  Laryngoscope with straight blade #0, #1  Ambu bag and face mask  Oral airways  Oxygen with flow meter and tubing  Endotracheal tubes # 2.5,3.0,3.5 & 4.0
  • 9.  Radiant warmer  Stethoscope  Adhesive tapes  Syringes  Butterfly needles  Umbilical venous catheterization tray  Umbilical catheter 3 and 5 fr  Feeding tubes 5 fr.  Disposable syringes
  • 10.  Epinephrine 1:10,000  Volume expanders i.e. N/saline,Albumin5%, Ringer lactate, O-ve blood  Sodium bicarbonate  Dextrose water 10%  Sterile water
  • 11. 1. Ensure your own as well as patient’s safety 2. Look for the clues as to what may have caused this emergency. 3. Wear gloves & do not perform direct mouth to mouth breathing.
  • 12. Do not hesitate to call for help especially in high risk situations.
  • 13. IN CASE OF NEWBORN: 1- Start the clock Timing to cut the cord Ascertain the duration of CPR 2- Dry the baby 3- Assess for breathing 4- Stimulate if not breathing 5- If baby starts breathing/ crying, no further help 6- if no response, then proceed further IN CASE OF NEONATE: Stimulate the baby by gentle shaking of arms or rubbing of skin or by verbal stimuli
  • 14. Assessment & reassessment is done after every 30 seconds, and take no longer than 10 seconds.  Look: Chest movements  Listen: Breath sounds & heart sounds (auscultation)  Feel: Breaths and pulse
  • 15. Open airway by  Neutral position  Chin lift  Jaw thrust Clear airway secretions, foreign body, vomits by gentle suctioning of mouth first and then nose.
  • 16.  In newborns after the airway is opened and cleared and the newborn is still not breathing, then it is necessary to aerate the lungs first with “inflation breaths” and then to continue with ‘ventilation breaths’  In case of a neonate inflation breaths are not required. Only ventilation breaths, called ‘rescue breaths’, are given.
  • 17.  Ventilation / rescue breaths are given at the rate 30/min.  Effective ventilation:  Good chest movement  Improvement of heart rate within 20-30 seconds
  • 18.  Chest compression is indicated when heart rate <60/min despite of adequate chest expansion with ventilation, for 30 seconds.  Ventilation / rescue breaths need to be continued alongside chest compressions.
  • 19. Technique  Two thumbs technique  Two fingers technique  At lower third sternum (between the xiphoid and a line draw between nipples)  Compression depth; approximately one third of the anterio-posterior diameter of chest
  • 20.  Duration of downward stroke of compression should be shorter than duration of release.  Don’t lift your thumbs or fingers off the chest between two compressions.  Chest compression must always be accompanied by positive pressure ventilation.  One ventilation interposed after every third compression (1:3).  Total of 30 breaths and 90 compression per minutes (120 events per minute)  One and two and three and breath and ……..
  • 21.  If heart rate not improving(below 60/min) despite adequate ventilation and chest compressions for 30 seconds then drugs should be considered.
  • 22.  Drug must be followed by 0.5-1.0 ml normal saline to clear the drug from catheter. ADRENALINE:  Preparation: 1:10,000 (1g/10,000ml, 100mg/l or 100µg/ml)  Dose: 10µg/kg, 0.1ml-0.3 ml/kg (0.5-1.0 ml/kg via endotracheal tube)  Route: Umbilical venous catheter or endotracheal tube  Rate: Rapidly
  • 23. SODIUM BICARBONATE:  Preparation: 4.2% (or 8.4% diluted 1:1)  Dose: 1-2 mmol/kg (2-4ml/kg)  Route: umbilical venous catheter  Rate: 1mmol/kg/min VOLUME EXPANDERS:  Preparation:  Normal saline  Ringer lactate  O negative blood, cross matched with mother’s blood if time permits (if prenatal diagnosis has suggested low fetal blood volume)  Dose: 10 ml/kg  Route: Umbilical vein  Rate: over 5-10 min
  • 24. DEXTROSE  Preparation: 10%  Dose: 250 mg/kg or 2.5 ml/kg  Route: umbilical vein
  • 25.  Reassess after every 30 seconds, and take no longer than 10 seconds.
  • 26. 1. Ambu bagging not effective 2. Prolonged ventilation is expected 3. Suspected diaphragmatic hernia 4. Severe anatomical or functional upper airway obstruction 5. Need for high pressure to maintain adequate oxygenation 6. Need for bronchial or tracheal suctioning in meconium stained un-responsive baby 7. Instability or high probability of any of the above occurring before or during transport.
  • 27. Different methods are used for its calculation  Formula 1:gestational age (weeks)/ 10  Formula 2: Tube size Weight (g) Gestational age (wk) 2.5 < 1,000 < 28 3.0 1,000-2,000 28-34 3.5 2,000-3,000 34-38 3.5-4.0 >3,000 >38
  • 28. Different methods are used for its calculation  Formula 1: baby’s weight (in kilograms) + 6  Formula 2: Length of tube according to weight Weight Depth of insertion (in cm from upper lip) 1 7 2 8 3 9 4 10
  • 29. 1. The conditions suitable for a neonate should be maintained during the transfer. 2. Transferring team must be able to deal with any problems arising during transportation. 3. The receiving hospital should be informed before departure.
  • 30. 1. Monitor vital signs, glucose 2. Monitor events & complications 3. Care of endotracheal tube & vascular lines 4. Skin to skin contact with mother where possible 5. Reassess the baby as required 6. Keep record 7. Communicate with parents
  • 31. Neonatal Life Support Preparation, Safety, Shout for help, Stimulate Assess breathing Not breathingStarts crying No need of Resuscitation, Give to mother Airway open & clear Airway open & cleared ..... Reassess, baby not crying 5 Inflation / Rescue breaths Reassess breathing
  • 32. Reassess breathing No chest movementGood chest movement Ventilation/Rescue breaths Repeat 5 inflation/rescue breath Check chest movement Good chest movement Reassess HR Reassess (every 30 sec) Regular breathing, good HR Stop ventilation/Rescue breaths Reassess, check airway No chest movement Consider ETT, Guedel airway Good HR Slow HR Chest compression Reassess breathing No good chest movement Consider other possibilities
  • 33. Chest compressions Ventilation / Rescue breaths Stop ventilation/rescue breaths Reassess (after 30sec) Reassess (every 30 sec) Regular breathing, good HR Continue CC, ventilation / rescue breaths Consider drugs Reassess (every 30 sec) Good HR Slow HR Slow heart rate Abandon resuscitation after 10 minutes of undetectable HR
  • 34.  Effective spontaneous breathing has been established as evidenced by:  Increasing heart rate  Spontaneous breathing  Senior staff and parents must be consulted before stopping positive pressure ventilation in cases of:  Signs of established biological death  The existence of DNR is established  If there is no detectable heart rate for >10 min despite adequate measures
  • 35.  Standard algorithm of ‘ABCD’ is used but with minimal variation.
  • 36.  Attempts to aspirate meconium from nose & mouth of the unborn baby , while the head is still on the perineum is not recommended.  If at birth, a meconium stained baby has: Normal respiratory effort normal muscle tone heart rate grater than 100beats/min Intervention: 1. Use a bulb/penguin sucker or large bore suction catheter to clear secretions from oropharynx and nose. 2. Do not intubate or do blind oropharyngeal suction.
  • 37.  If at birth, a meconium stained baby has: depressed respiration depressed muscle tone heart rate <100 beats/min Intervention: 1. immediate endotracheal intubation and direct suctioning of trachea is done without stimulation. 2.
  • 38. Results from: Positive pressure ventilation Lung malformation  If the chest is not expanding adequately despite proper positioning of airways , ambu-bagging, giving adequate pressure, placing Guedel airways and there is no improvement in heart rate, then this condition must be considered.  Removing obstruction of lung airways by external chest drainage of air through placement of needle or chest drain in pleural space.
  • 39.  In neonate it may results from: Hydrops fetalis Chylothorax  Manage by chest drain insertion.
  • 40.  If Chest is not expanding adequately despite proper positioning of airways, ambu-baging, giving adequate pressure, placing Guedel airways and there is no improvement in heart rate.  Think CDH and confirm on examination.  Resuscitation with a bag and mask contraindicated.  Should have immediate endotracheal intubation and place a large orogastric catheter.
  • 41.  Babies are nasal breathers.  Should be considered where after proper airway opening and clearing maneuvers, good expansion of the chest cannot be obtained by ambu-baging. Intervention:  Inserting a plastic oral airway will allow air to pass through mouth.
  • 42.  Developmental malformation of palate and oropharynx.  Small mandible results in critical narrowing of pharyngeal airway.  Tongue, posteriorly placed, falls back into pharynx and obstructs it just above larynx.  Maintain airway by positioning or use of plastic oral airway.
  • 43.  Get hypothermic earlier than term babies.  Fragile lungs and thus inability to breath effectively.  Maintain body temperature during resuscitation and use lower pressures for chest expansion.
  • 44.  Naloxone is no longer recommended as part of initial resuscitation in a delivery room.  Giving a narcotic antagonist is not the correct first therapy for a baby who is not breathing.  The first corrective action is positive pressure ventilation. Indications: 1. Continued respiratory depression after PPV has restored a normal HR. 2. A history of maternal narcotic administration during labour within 4 hours.
  • 45.  Naloxone : DOSE : 0.1 mg/kg I/V bolus.  Caution: Do Not give Naloxone to the newborn whose mother is suspected of being addicted to narcotics.