Neonatal resusitation

1. MEKELLE UNIVERSITY
COLLEGE OF HEALTH SCIENCE
Obstetrics & Gynecology Department
Department of public health officer
Seminar on Neonatal Resuscitation
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2. Presented by
Kflom Tadesse
Moderator- Dr. Mulugeta (R3)
Date-19/04/2016 E.C
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3. Outlines
• Definition of Neonatal Resusitation
• Goals of Neonatal Resuscitation
• Thermoregulation in neonate
• Goals of Thermoregulation
• Prevention of Hypothermia
• Interventions for at risk Infants
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4. Neonatal resuscitation

5. Neonatal resuscitation
• Transition from IU life to EU (Extra uterine)life is
the most important period in neonatology
• Most infants complete the transition to extra
uterine life without difficulty and require only the
routine care; but
• 5 to 10 % require resuscitation.
• Failure to initiate and maintain effective
respiration is the most common delivery room
emergency for neonates.
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6. Goals of neonatal resuscitation
• Prevent the morbidity and mortality associated with
hypoxic-ischemic tissue injury.
• Reestablish adequate spontaneous respiration and cardiac
output.
• Improve the likelihood of preventing brain damage.
– In order to achieve this goal High-risk situations should be
anticipated by
• Pregnancy, labor, and delivery history and
• Identification of signs of fetal distress.
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7. When anticipating resuscitation
• The radiant warmer is turned on and is heating.
• The oxygen source is open with adequate flow
through the tubing.
• The suctioning apparatus is tested and is
functioning properly.
• The laryngoscope is functional with a bright light.
• Testing of resuscitation bag and mask
demonstrates an adequate seal and generation of
pressure.
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8. • The APGAR score is a practical method of
systematically assessing newborn infants
immediately after birth to help identify those
requiring resuscitation and to predict survival
in the neonatal period.
• The 1-min APGAR score may signal the need
for immediate resuscitation, and
• The 5-, 10-, 15-, and 20-min scores may
indicate the probability of successfully
resuscitating an infant.
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9. Evaluation of Newborn Infants
(The APGAR score)
SIGN 0 1 2
Color (Appearance) Blue, pale Body pink,
extremities blue
Completely pink
Heart rate(Pulse) Absent Below 100 Over 100
Response to catheter in
nostril (Grimace)
No response Grimace Cough or sneeze
Muscle tone (Activity) Limp Some flexion of
extremities
Active motion
Respiratory effort Absent Slow, irregular Good, crying
• A total score of 10 indicates an infant is in the best possible condition.
• An infant with a score of 0–3 requires immediate resuscitation.
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10. Birth
 Term gestation?
 Clear amniotic fluid?
 Breathing/crying?
 Good muscle tone?
Yes
ROUTINE CARE
 Keep warm(Skin to skin
contact)
 Clear air way if needed
 Dry neonate
 Assess color
 Medication (Vit K and
TTC eye ointment
 Initiate breast feeding
NO
A Provide warmth
Position, Clear air way
Dry, Stimulate and reposition
Evaluate RR,HR
and color
Breathing,
HR >100 ,Pink
Observational
care
Apnea
/HR<100
Breathing& HR >100
but Cyanosed Supplementary
oxygen
Pink
Persistent cyanosis
Neonatal Resuscitation flow algorism
Time frame
_____
_____
30
sec
30
sec
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11. Positive pressure ventilation*
B
Effective ventilation
HR>100 and Pink
Post resuscitation
Observation/care
HR<60
HR 60 -80 and
not responding
HR>60
C
Continue PPV*
Administer chest compression
Administer epinephrine
Volume expansion
? Sodium bicarbonate
HR<60
Persistent cyanosis
Apnea
/HR<100
D
_____
_____
30
sec
* Endotracheal intubation
Ineffective bag and mask ventilation
 If tracheal suctioning is required (MAS)
Diaphragmatic hernia is suspected
Prolonged PPV is required
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12. Neonatal resuscitation
• Rate of chest compression to ventilation is 3 to 1
• Medications are required
– When the HR remains <60/min despite 30 seconds of combined PPV and
chest compression
– During Asystole
• Epinephrine :- 0.1–0.3 mL/kg of a 1 : 10,000 solution
:- Intravenously or intratracheally
• volume expansion :- 10–20 mL/kg of an isotonic crystalloid solution
• Sodium bicarbonate :- 2 mEq/kg, 0.5 mEq/mL of a 4.2% solution
slowly (1 mEq/kg/min) if metabolic acidosis
– Make sure ventilation is adequate before giving Bicarbonate.
– may increase blood CO2 and produce respiratory acidosis complicating an
existing metabolic acidosis.
NB: Restoration of oxygenation and tissue perfusion is the main treatment of metabolic
acidosis associated with asphyxia
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13. • Severe asphyxia may also depress myocardial
function and cause cardiogenic shock despite
the recovery of heart and respiratory rates.
– poor peripheral perfusion, weak pulses,
hypotension, tachycardia, and poor urine output.
• Dopamine or dobutamine administered as a continuous
infusion (5–20 μg/kg/min) and fluids should be started
after the initial resuscitation effort to improve cardiac
output
• Epinephrine (0.1–1.0 μg/kg/min) may be indicated for
infants in severe shock who do not respond to dopamine
or dobutamine
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14. THERMOREGULATION IN THE NEONATE

15. Goal of Thermoregulation
Maintain correct body temperature range in order to:
– Maximize metabolic efficiency
– Reduce oxygen use
– Protect enzyme function
– Reduce calorie expenditure
Why newborns are more exposed to excessive heat loss?
• Skin is thin & blood vessels are close to the surface
• Have little subcutaneous fat to serve as barrier to heat loss
• Term Infants have 3x the surface to body mass of an adult
• Preterm infants and SGA infants have 4x the surface mass to body
mass of an adult
• Preterm infants are especially susceptible to heat loss due to
– poor tone,
– Decreased fat and
– thinner skin than term infants
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16. Neutral Thermal Temperature
A neutral thermal temperature is the body temperature at
which an individual's oxygen use and energy expenditure
are minimized.
– Minimal metabolic rate
– Minimal oxygen consumption
Classification of hypothermia is based on core temperature
– NORMAL – 36.5 to 37.5˚C
– Cold Stress 36.0 to 36.4˚C
• Cause for concern
– Moderate hypothermia 32 –35.9˚C
• Danger, warm infant
– Severe hypothermia – below 32˚C
• Outlook grave, skilled care urgently needed
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17. Risk Factors for Hypothermia
• Cardiac / respiratory problems
• Large open areas in the skin
• Sedated Infants
• Drug exposure
• Premature
• SGA
• Neuro Endocrine problems

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Risk factors for Preterm Infants
• Less brown fat and glycogen stores
• Decreased ability to maintain flexion
• Increased body surface area compared to
weight
 More surface area means more skin
 More skin means more radiant heat and
more insensible water loss.
Production of Heat
 Metabolic Processes
 Voluntary Muscle Activity
 Peripheral Vasoconstriction
 Nonshivering Thermogenesis

19. Non shivering Thermo genesis
• Brown fat is an energy source for infants
• It can be found: Near Kidneys and adrenals, Neck,
mediastinum, scapular and the axilla areas.
• Can not be replaced once used
When the air temperature around the baby is cool, thermo
receptors in the skin are stimulated.
 Non-shivering thermogenesis is initiated and brown fat is burned for
energy to keep the body temperature stable.
 This is the infant’s initial response.
 Conversion of brown fat uses oxygen and glucose,
therefore, the cold stressed infant will become hypoxic and
hypoglycemic. Blood gas and glucose levels are affected.
 Growth is affected as calories are used to stay warm
rather than grow
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20. Signs and Symptoms of
Hypothermia in Infants
Vasoconstriction
• Peripheral vasoconstriction occurs in an effort
to limit heat loss via blood vessels close to the
skin surface.
– Pallor and cool skin may be noted, due to poor
peripheral perfusion
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21. Increased Respiratory Rate
• Pulmonary vasoconstriction occurs secondary to
metabolic acidosis.
– Increasing Respiratory Distress
Related to decreased surfactant
production, hypoxia, & acidosis
Restlessness
• Restlessness may be a type of behavioral
thermoregulation used to generate heat through muscle
movement.
• The first sign may be an alteration in sleep patterns.
• Restlessness also indicates a change in
mental status as cerebral blood flow
diminishes, due to vasoconstriction 21

22. Lethargy
• If thermo-instability goes unrecognized, the infant
will become more lethargic, as cerebral blood flow
continues to diminish and hypoxemia and
hypoglycemia become more pronounced.
Metabolic Disturbances
• Metabolic acidosis
• Hypoxemia
• Hypoglycemia
• progress due to continued metabolism of brown fat,
release of fatty acids and anaerobic metabolism
(lactic acid)
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23. Cardiac
• As central blood volume increases, initially the heart rate and
blood pressure increase
Arrhythmias
• May result from depressed myocardial contractility and
irritability caused by hypothermia
Poor Feeding/Weight Loss
• Poor weight gain occurs when:
– calories consumed
– brown fat stores are used to make body heat.
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24. Consequences of Hypothermia
• Hypoxemia from  Oxygen consumption
• Hypoglycemia from  glucose metabolism
• Respiratory & metabolic acidosis secondary to anaerobic
metabolism
• Inhibition of surfactant production related to  acidosis
•  pulmonary blood flow related to pulmonary vasoconstriction
in response to  body temperature
•  pulmonary vascular resistance compromises the delivery of
oxygen at the cell level
•  risk of developing Persistent Pulmonary hypertension(PPHN)
in the near term, term or post term infant
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25. Physiologic consequences of cold stress
Cold stress
Metabolism Oxygen consumption
Brown adipose tissue
metabolism
Release of FAs
use of glucose
use of Glycogen stores
Hypoglycemia
Respiratory rate
Hypoxia
Anaerobic metabolism
Lactic acidosis
PH
Metabolic
acidosis
Pulmonary vasoconstriction
Further hyopxia
Surfactant production
Respiratory distress
Failure to gain weight
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26. Prevention of Hypothermia
• Hypothermia can be prevented by maintaining
a neutral thermal environment and reducing
heat loss.
• A neonate is in a neutral thermal environment
when the axillary temperature remains at
36.5° - 37.5° (97.7° - 99.2° F) with minimal
oxygen and calorie consumption
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27. Prevention of Hypothermia
• Mechanisms of Heat loss
1. Evaporation
• Loss of heat when water evaporates from the skin and respiratory tract
Highest immediately after birth and with bathing
can be prevented by:
– Keeping the neonate and his/her environment dry.
– Drying the baby immediately after delivery.
– Placing preterm or SGA infant in occlusive wrap/bag at delivery
– Delay bath until temperature is stable
2. Convection
• Heat loss to surrounding moving air
• CONVECTIVE HEAT LOSS can be prevented by:
– Providing warm ambient air temperature
• Placing infants less than 1500 grams in incubators
• Keeping portholes of the incubator closed
• Warming all inspired oxygen
• On open warmers keeping sides up and covering infant if possible
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3. Radiation:- Heat loss to surrounding colder solid objects(not in
direct contact) independent of air temperature
RADIANT HEAT LOSS can be prevented by:
Avoiding placement of incubators, warming tables and bassinets
near cold windows, walls, air conditioners, etc..
Placing a knit hat on the infant’s head
 environmental temperature
4. Conduction:- Heat loss to cold solid objects in direct contact
Can be prevented by:
Placing a warm diaper or blanket between the neonate and cold
surfaces
Placing infant on pre-warmed table at time of delivery
Warming all objects that come in contact with the neonate
Admitting infant to a pre-warmed room
Skin to skin contact (Kangaroo mother care)

29. Interventions for at Risk Infants
• Pre-warmed radiant warmer bed
• Pre-warmed incubator
• Do not leave a warmer bed or incubator in the manual
mode
• Heated water pad
• Heat lamp
• Warm and humidify inspired gases
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30. Rewarming the Hypothermic Infant
• Always be prepared to intervene
• Rewarm slowly (0.5˚C per hour)
• Monitor closely (vital signs every 15 – 30min)
– Core temp
– Skin temp will be higher than axillary
– Blood pressure
• Rewarming may lead to vasodilation - hypotension
– Heart rate and rhythm
• Bradycardia & arrhythmias common with hypothermia
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31. References
• UpToDate 21.6
• Wiliam gynecology 26th edition
• Medstar ObsGyn 2015 E.C
• William gynecology 4th edition
• Obstetrics Simplified-El-mowafi
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