Reanimación Neonatal: lección 6 MEDICAMENTOS


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Curso de Reanimación neonatal, lección 6 de 9.
American Heart Association. American Academy of Pediatrics.

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  • In lesson 6 you will learn
    What medications to give during resuscitation
    When to give medications during resuscitation
    Where to give medications during resuscitation
    How to insert an umbilical venous catheter
    How to administer epinephrine
    When and how to administer fluids intravenously to expand blood volume during a resuscitation
  • If the heart rate remains below 60 bpm despite effective ventilation and chest compressions, ensure that ventilation and compressions are being given optimally and that you are using 100% oxygen.
    Epinephrine is not indicated before adequate ventilation has been established and chest compressions have been initiated for 30 seconds because
    You will waste valuable time that should be focused on establishing effective ventilation and oxygenation.
    Epinephrine will increase the workload and oxygen consumption of the heart muscle, which, in the absence of available oxygen, may cause myocardial damage.
  • To place a catheter in the umbilical vein,
    Clean the cord with antiseptic. Place a loose tie of umbilical tape around the base of the cord.
    Pre-fill a 3.5F or 5F single end-hole catheter with normal saline.
    Connect catheter to stopcock and syringe. Close the stopcock to the catheter to prevent fluid loss and air entry.
    Using sterile technique,
    Cut the cord with the scalpel below the clamp about 1 to 2 cm from the skin line. The umbilical vein will be seen as a large, thin-walled structure, usually at the 11- to 12-o’clock position.
    Insert the catheter into the umbilical vein. The course of the vein will be up toward the heart, so this is the direction you should point the catheter.
    Instructor Tip: Keep all umbilical venous catheter insertion supplies together in one sealed bag or tray.
    To prevent injury, stop compressions and alert team members when scalpel is being used.
  • Insert the catheter 2 to 4 cm (less in preterm newborns) until you get free flow of blood when you open the stopcock between the catheter and the syringe, and the syringe is gently aspirated.
    The tip of the catheter should be located only a short distance into the vein, when the blood is first able to be aspirated. If the catheter is inserted farther, there is a risk of infusing solutions into the liver and possibly causing damage.
    Inject the appropriate dose of epinephrine, followed by 0.5 to 1.0 mL of normal saline to clear the drug from the catheter.
    After resuscitation, suture the catheter in place or remove the catheter. Do not advance the catheter once the sterile field has been violated.
  • If medications are required in resuscitation, the most reliable route of administration is the intravenous route (umbilical vein is preferred). If you suspect medication may be needed, you should call for help so that additional personnel are available to establish IV access. Although the umbilical vein is the most accessible direct route, a peripheral IV may be used.
    Intratracheal epinephrine may be given while IV access is being established. Research has shown that the dose of intratracheal epinephrine should be larger (0.3 to 1.0 mL/kg) than the IV dose. Epinephrine is the ONLY drug that may be given intratracheally.
    Intraosseous access may also be used, usually in the outpatient setting.
    Instructor Tip: The 2 doses of epinephrine for IV and endotracheal (ET) use pose a great risk for medication error. Label a 3-mL syringe immediately “EPI FOR ET ONLY” or a 1-cc syringe “EPI FOR IV ONLY.” Teach students to use a 3-mL syringe for the endotracheal dose and a 1-mL syringe for the IV dose. Practice verbalizing the dosage, route, and clarifying or correcting. Consider using different color labels for IV and endotracheal doses.
  • Epinephrine should be given by the umbilical vein. The endotracheal route is often faster than placing an umbilical catheter, but is associated with unreliable absorption and may not be effective at the lower dose. If a dose of epinephrine is given via the endotracheal tube while umbilical venous access is being established, consider a higher dose (0.3 mL-1.0 mL/kg) by this route only. Do not give high doses of epinephrine intravenously.
  • As positive-pressure ventilation and chest compressions are continued, the rate should increase to more than 60 beats per minute within 30 seconds after giving epinephrine. If this does not happen, you may repeat the dose every 3 to 5 minutes. If the first dose has been given per endotracheal tube, give repeat doses via umbilical vein, if possible.
    Instructor Tip: If first dose is given via the endotracheal tube, REMEMBER the dose given intravenously will be a DIFFERENT dose of a SMALLER volume. LABEL SYRINGES for ET or IV use and double-check dosage prior to administration.
  • If the newborn is not responding to resuscitation, recheck the effectiveness of the interventions to this point. If the baby is pale and there is evidence of blood loss, consider the possibility of volume loss.
  • If there has been placental abruption, a placenta previa, or blood loss from the umbilical cord, the baby may be in hypovolemic shock. In some cases, the baby may have lost blood into the maternal circulation and there will be signs of shock with no obvious evidence of blood loss. Newborns in shock appear pale and have a weak pulse; they may have a persistently lower heart rate. Circulatory status often will not improve in response to effective ventilation, chest compressions, and administration of epinephrine. The baby may need re-expansion of his or her intravascular volume.
  • The recommended solution for acutely treating hypovolemia is an isotonic crystalloid solution.
    Type O Rh-negative packed red blood cells, cross-matched with mother’s blood (if time permits), may be used. This sometimes may be prepared before delivery if prenatal diagnosis has suggested low fetal blood volume. If a large volume of blood loss is suspected, emergency-release type O Rh-negative packed blood may be necessary.
  • The initial dose of solution is 10 mL/kg; however, if the newborn shows minimal improvement after the first dose, you may need to give another dose of 10 mL/kg. Volume expander must be given into the vascular system. The umbilical vein is usually the most accessible vein in a newborn, although the intraosseous route can be used.
    Some clinicians are concerned that rapid administration of volume to a newborn may result in intracranial hemorrhage. A steady infusion rate over 5 to 10 minutes is reasonable.
  • The heart rate should increase, pulses should become stronger, color should improve, and blood pressure should increase.
    Volume expanders may be repeated if signs of hypovolemia persist. The same dose (10 mL/kg) should be given intravenously over 5 to 10 minutes.
  • Approximately 30 seconds each should be required for a trial of the following 4 steps of resuscitation:
    Assessment and initial steps
    Positive-pressure ventilation
    Positive-pressure ventilation and chest compressions
    Positive-pressure ventilation, chest compressions, and epinephrine
    If you are certain that effective ventilation, chest compressions, and medications are being provided, consider mechanical causes of poor response, such as an airway malformation, pneumothorax, diaphragmatic hernia, or congenital heart disease. If the heart rate is absent or no progress is made in certain conditions, such as extreme prematurity, it may be appropriate to discontinue resuscitative efforts. Be confident that optimum technique has been administered for a minimum of 10 minutes before considering such a decision (Lesson 7).
    Instructor Tip: Stay calm and work as a team under these particularly stressful conditions.
  • The laryngeal mask can be inserted with either hand; use your dominant hand.
    The mask should be deflated before insertion.
    Place the baby’s head in the “sniffing” position, just as you would for endotracheal intubation.
    When you hold the laryngeal mask, hold it like a pen. The tip of your index finger will fit at the point where the mask meets the airway tube. The top of the mask looks like the passenger compartment of the “life raft” and has an opening to the airway tube. This part will be facing upward when you hold it.
    When you insert the mask into the baby’s mouth, the top of the mask (passenger compartment of the “life raft”) faces the baby’s tongue. The back of the mask looks like the bottom of the “raft” and it has no opening. This part faces the baby’s palate during insertion.
    You can apply a small amount of water-soluble lubricant to the back of the mask to help it slide along the baby’s palate easier. For most newborns, it is not necessary because their mouths are already moist.
  • Reanimación Neonatal: lección 6 MEDICAMENTOS

    1. 1. Lección 6: MEDICAMENTOS
    2. 2. Medicamentos para la Reanimación Neonatal Contenido de la Lección: • Indicaciones de los medicamentos • Indicaciones para colocación de catéter venoso umbilical • Como insertar un catéter venoso umbilical • Como administrar la adrenalina • Como y cuando suministrar expansores de volumen 6-2
    3. 3. Adrenalina: Indicaciones La adrenalina, un estimulante cardíaco, esta indicado cuando la frecuencia cardíaca permanece por debajo de 60 latidos por minuto a pesar de • 30 segundos de ventilación asistida seguida de • 30 segundos de masaje cardíaco coordinado con ventilación _____________ Total = 60 segundos  Nota: La adrenalina no está indicada antes de que se establezca una adecuada ventilación. 6-3
    4. 4. Medicamentos. Administración Vía Vena Umbilical Colocando un catéter en la vena umbilical • Vía preferida para acceso venoso • Catéter 3.5F ó 5F con hoyo en la punta • Técnica estéril 6-4
    5. 5. Medicamentos. Administración Vía Vena Umbilical • Inserte un catéter de 2 a 4 cms • Observe que fluya libremente la sangre cuando aspire • Use menos profundidad en pretérminos • La inserción en el hígado puede causar daño 6-5
    6. 6. Administración de Medicamentos: Vías Alternas • Tubo endotraqueal • Intraósea 6-6
    7. 7. Administración de Adrenalina  6-7
    8. 8. Adrenalina: Efectos, Repetición de Dosis • Incrementa la fuerza y la frecuencia de las contracciones cardíacas • Causa vasoconstricción periférica • Dosis repetidas deben administrarse vía umbilical, si es posible • Repita la dosis por vía umbilical, si la primera fué vía endotraqueal 6-8
    9. 9. Adrenalina: Pobre Respuesta (Frecuencia Cardíaca < 60 lpm) Compruebe efectividad de • Ventilación • Masaje Cardíaco • Intubación endotraqueal • Suministro de adrenalina Considere la posibilidad de Hipovolemia 6-9
    10. 10. Pobre Respuesta a la Reanimación: Hipovolemia Indicaciones para expansores de volumen • El bebé no responde a la reanimación y … • Parece estar en estado de choque (color pálido, pulsos débiles, frecuencia cardíaca baja persistente, ninguna mejoría del estado circulatorio a pesar de los esfuerzos de reanimación) • Puede haber antecedentes de alguna condición asociada a pérdida de sangre fetal (ej, sangrado vaginal abundante, placenta previa, transfusión feto-feto, etc)  6-10
    11. 11. Expansores de Volumen Sanguíneo Recomendado: • Solución salina Aceptable: • Lactato de Ringer • Sangre O Rh negativo 6-11
    12. 12. Expansión del Volumen Sanguíneo : Dosis y Administración Solución recomendada= Salina normal Solución aceptable= Lactato de Ringer o Sangre O Rh-negativo Dosis recomendada = 10 mL/kg Vía recomendada= Vena umbilical Preparación recomendada = Volumen requerido en una jeringa grande Velocidad de administración recomendada = Entre 5 a 10 minutos  6-12
    13. 13. Respuesta Esperada: Expansores de Volumen Signos esperados de expansión de volumen • Incremento de la frecuencia cardíaca • Pulsos mas fuertes • Disminución de la palidez • Aumento de la presión sanguínea Seguimiento si la hipovolemia persiste • Repita expansores de volumen (dosis 10 mL/kg) 6-13
    14. 14. Medicación Administrada: Sin Mejoría Verificar efectividad de: Ventilación Masaje cardíaco Intubación endotraqueal Administración de adrenalina r Considear la posibilidad de Hipovolemia FC <60 ó cianosis persistente o falla en la ventilación Considerar condiciones como: • Malformaciónes de vías aéreas Neumotórax Hernia diafragmática Cardiopatía congénita Ó FC Ausente Considerar supender la reanimación 6-14
    15. 15. Fin de la Lección 6 6-15
    16. 16. Inserción del Catéter en la Vena Umbilical 6-5A
    17. 17. Inserción del Catéter en la Vena Umbilical 6-5B