How to do Neo natal Resuscitation and brief introduction

1. Dr. Shrinivas kulkarni
Proffessor and HOD
Emergency Medicine AVMC &H
Pondicherry.
5-8-2023
1

2. Resuscitate
 Latin word meaning “ arouse again”
 Definition-procedures undertaken to restore life
2

3. Introduction
 We The Anaesthesiologists/Emergency Physicians are
frequently called upon to assist or manage the care of
neonate immediately after birth during LSCS
 Most neonates require little help.
 Others require rapid intervention if serious sequelae
are to be prevented
3

4. History
4

5. Techniques Advocated and Used to
Resuscitate Newborns
1850-1950
 Squeezing the chest (Prochownich method)
 Raising and lowering the arms while an assistant
compressed the chest (Sylvester method)
 Rhythmic traction of the tongue (Laborde method)
 Tickling the chest, mouth, or throat
 Dilating the rectum by a raven’s beak or a corn cob
 Immersion in cold water, sometimes alternating with
immersion in hot water
 Yelling, Shaking , Rubbing, Slapping, and Pinching
 Electric shocks
 Nebulisation of brandy mist
 Insufflation of tobacco smoke into the rectum
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6. Whose Responsibility ?
 Joint responsibility
 Team approach
 Obsetritician,paediatrician,anaesthesiologist
 And nursing personnel.
 Forget” EGO”
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7. Role of Anaesthesiologist
 To resuscitate or help if paediatrician is not called or
called but arrives late or arrives but unable to
resuscitate
7

8. Magnitude of Problem
Asphyxia-20% of neonatal deaths
Most babies do not require resuscitation
 10% newborns require some assistance
 1% newborns require extensive resuscitative measures.
8

9. Terminology
 Newly born- baby born at the time of birth
 Newborn is first few hours after birth
 Neonate is a baby from birth up to 28 days.
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10. Regulatory Bodies
 NRP-national resucitation programme
 AAP-american acdemy of paediatrics
 AHA-american heart association
 ACOG-american college of obst.gynecologists
 ILCOR-international liason com.of resuscitation
10

11. Risk factors
Maternal-prolonged labour
- ant. Partum haemorrhage
- pregnancy induced hypertension
-fever,infection,anaemia
- hypertension
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12. Risk factors contd…
Foetal-pre-term or post-term gestation
-multiple gestation
-big babies or IUGR babies
-poly or oligo hydromnios
-reduced foetal movements
- congenital anamolies
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13. Risk factors contd…
Intra-partum-cord prolapse
-proloned labour
-precipitate labour
- forceps delivery
-maternal GA
-meconium stained liquor
-delayed and difficult extraction
13

14. Communication
 Pre-existing or pegnancy related medical conditions,
USG report,FHS monitoring
 About baby-gestational age
- no. of newborns
-reason for LSCS
-presence of meconium
-any congenital anamolies
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15. Communication contd…
 With parents- proposed plan of newborn care
- any previous experience
- answer doubts or questions
-possibility of shifting to NICU
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16. Paediatrician's attendance
 Low risk births-nurses with basic skills
 High risk births-a clinician with advanced skills
 No. of paediatricians-one per one baby
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17. ID and UD intervals
 ID-incision delivery interval-5 mins
 UD –uterine incision to extraction- 90 secs
17

18. Golden Minute
The very first minute immediately following birth is
called golden minute during which we should
complete initial steps,re-evaluate and begin
ventilation if required.
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19. Preparation
 Switch off fans and AC
 Wash with soap and water and wear gloves
 Have a tray with 2 sterile towels
 Have nursing personnel for help
 Check equipment
 Discuss with obstetrician
19

20. Equipment
 For warming- over head radiant warmer
-200 watts bulb
-exothermic mattress
-hot water bottles underneath
Suction-bulb syringe
-meconium apirator
-20 ml syringe with suction catheter
-manual foot operable suction
-electrical suction pressure <100 mm of Hg
20

21. Equipment contd.
 Ventilation-ambu bag
-masks of various sizes- round,RBS
- airways -0,00,000 sizes
-oxygen cylinder with tubes
 Intubation-laryngoscope(penlight handle)
-blade-magill,macintosh,robertshaw-oo,o,1 sizes
-oxyscope blade -preferable
-tubes-plain,pvc endotrcheal tubes
-no.s-2, 2.5, 3, 3.5, 4
-laryngeal mask no. 1
- I-gel
-coles tube
-styllets
21

22. Equipement contd…..
 Desirable-pulse oxi meter
-ETCO2
-Defibrillator
-Transport incubator
22

23. 23

24. Checklist
O2 CYLINDER-content , pressure, spanner, rinch
Laryngoscope-battery cells-functioning
Bulb-working
Suction machine-power availabality,
Manual suction
Connectors,catheters
Simple devices-bulb suc. Mec aspirator, drip set
24

25. Medications
 IV cannula 24 gauge,plaster,scissors
 Adrenaline
 10% glucose
 Sodabicrbonte
 NS,RL,Blood
 Dopamine
 Naloxone
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26. Steps of Resuscitation
 Thermal management
 Clearing airway
 Tactile stimulation
 Ventilation establishment
 Chest compressions
 Medications
26

27. Information
 Acronym “HANDS”
 H-haemorrhage
 Amniotic fluid-meconium stained
 Number of infants-twins, triplets
 Date-gestational age-prematurity
 Strip-of foetal monitoring-distress
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28. Cord Clamping
 If baby cries,cord clamping should be delayed for 1
minute or till the pulsations disappear.
 If baby does not cry, cord should be clamped
immediately and handed over for resucitation
resuscitation
28

29. Suction
 Earlier practice of suctioning as soon as head comes
out is no longer advocated.
 Routine suctioning of crying baby is not needed
 Thin meconium and baby crying-suction not needed
 Thick meconium with apnoeic baby-intatracheal
suctioning strongly advised
29

30. Primary and Sec. Apnoea
 Primary apnoea-if fetus suffers hypoxic insult, it will
lose consciousness and the medullary respiratory
centers will cease to function because of lack of 02 and
enters a period known as primary apnoea.
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31. Secondary apnoea
 If the insult continues, shuddering(whole body
Gasps at a rate of 12/min initiated by primitive
Spinal centers ) occurs. If these gasps fail,to aereate the
lungs and fadeaway , then fetus enters a period known
as secondary apnoea.
31

32. Rapid Assessment
Find out if baby is of
-term gestation
-breathing or crying
- good muscle tone
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33. How to proceed?
If answer is yes-
-Baby does not need resuscitation
-Should not be separated from mother
-Dry,cover with dry linen and place skin to skin with
mother
-Observe for activity,breathing and colour
33

34. Proceed…..
If answer is no -ABCD
Act as per following steps in sequence
1.AirwayInitial steps(place,position,dry,warmth,
clear airway and stimulate )
2 Breathing -Ventilation
3.Chest compressions
4.Drugs.
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35. Assessing Heart Rate
1.by palpating umbilical cord or precordium
2.auscultation with stehescope
3. pulse oximeter
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36. Stimuli For Baby´s Cry
 Light
 Noise
 Tactile
 Thermal stimuli
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37. Tactile Stimulus
1.rubbing over heel
2.rubbing over the back,
2or3 times
 NOTE-holding baby upside down with legs and
slapping on the back,an old method should not be
done which can lead to dangerous consequences-
intravetricular haemorrhages
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38. Temperature
 Wipe and dry, replace wet towels by dry ones
 If baby is of very low weight (<1500 gms)
Additional warming techiniques
-prewarming OT temp to 26 C
-place baby on exothermic mattress
-under radiant heat warmer
-cover with a plastic wrapping upto neck
-monitor temperature
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39. Effects Of Hypothermia
 Bradycardia
 Arrythmias
 Increasd morbidity and mortality
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40. WHO Guidelines
RANGE< TEMPERATURE ACTION NEEDED
Normal 36.5 – 37.5° c Ct.basic measures
Potential cold stress 36-36.5°c Cause for concern
Moderate hypothermia 32-36°c Danger, warming needed
Severe hypothermia <32°c Out look grave
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41. Role Of Stomach Wash
 Not routinely recommended
 Indicated in -meconium stained liquor
- severe asphyxia
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42. APGAR SCORE
 VIRGINIA APGAR-lady anaesthesiologist
 Devised in 1952
 Simple, reliable method to assess newborn
 5 criteria-score from 0-2
 Total score ranges from 0-10
 Acronym-APGAR
 First min-survival
 Fifth min-neurological outcome
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43. APGAR SCORE
criteria Score -0 Score--1 Score--2
Appearance blue Ph.blue body.pink Body n extr pink
Pulse absent <100 >100
Grimace No response Feeble cry Cry or pullaway
Activity none Some flexion Flexed arms
Respiration absent Irregular gasps Strong cry
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44. INTERPRETATION
7 and above -normal
4 and 6 -fairly low
3 and below-critically low
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45. Target O2 Saturation
Time from birth Target O2 saturation
1 min 60-70%
2 min 65-85%
3 min 70-90%
4 min 75-90%
5 min 80-90%
10 min 85 -90%
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46. Recognition of Resp. Distress
 Tachypnoea
 Grunting
 Flaring of ala nasi
 Retraction of chest ribs
 Persistant central cyanosis
46

47. PPV
 If baby-apnoeic or gasping or
HR<100/ min
 Ensure jaw support
 Keep head in sniffing position
 Commence bag mask ventilation
-Rate-40-60/min
-Inflation pressure-30-40 cm of H20
-Inflation time-0.3-0.5 secs
-PEEP-5-8 cm of h2o
47

48. Assessing Effective Ventilation
 HR>100 /min
 Improvement in colour
 good muscle tone
 Resuming spontaneous ventilation
48

49. Devices for Ventilation
 No device-mouth to mouth but avoid in infectious
cases
 Bag and mask
 CPAP devices
 Laryngoscope,ET,LMA
 NICU-neonatal ventilator
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50. Ventilation Devices
50

51. Indication for LMA
 Unsuccessful bag and mask ventilation
 Unsuccessful intubation
51

52. Contraindications for LMA
 BABIES<2 KG or 34 wks
 Meconium stained liquor
 When intratracheal drugs are planned
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53. Indications for intubation
 Endotracheal suctioning of non-vigorous meconium
stained newborns
 Ineffective bag mask ventilation
 Extremely low birth weight
 When CDH is suspected
 when Intrtracheal drugs are to be given
 When prolonged ventilation is needed
53

54. Technique of Intubation
 Baby supine with head slightly extended
(Sniffing position)
 Towel roll under shoulders if necessary
 Bag and mask with 100% 02 for few mins
 Insert blade into right angle of mouth
 Push tongue to left
 Advance blade and lift
simultaneously
 Visualise epiglottis and glottis
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55. 55

56. Technique contd….
 If not seen,gentle external pressure by left little finger
is a must
 If not seen, advance or withdraw blade
 Not in-advance blade
 In too far-withdraw slowly
 Off to side-swing blade to midline
 Lifted epiglottis –withdraw blade slowly
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57. Technique contd…
 Hold tube in right hand,advance and intubate till
black mark just disappears
 Ask for cheek retraction if necessary
 Use stylet mounted tube if necessary
 Hold tube at lips,connect ambu and ventilate
 Secure tube with adhesive plaster
 Each attempt not more than 20 secs
57

58. Tip to Lip Distance
 Formula-
Distance = weight in kg +6
= ---- cms
9-10 cm at the lip for
this term infant
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59. ETT Size and Distance
weight ETT size Measurement at lip
<1000 gm 2.5 7 cms
1000-2000 gms 2.5-3 8 cms
2000-3000 gms 3-3.5 9 cms
>3000 gms 3.5-4 10 cms
59

60. Indicators of Correct ETT
Placement
 Chest expansion
 Misting of tube
 Colour improvement
 HR>100/min
 Ascultation for breath sounds
 Pulse oximeter
 ETCO2
 Chest x ray
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61. Indications for Pulse Oximetry
 When cyanosis is noticed
 When resucitation is anticipated
 When PPV is given
 When supplemental o2 is given
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62. Indications for Chest Compressions
 HR<60/ min inspite of adequate ventilation for 30 secs
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63. Techniques
 Two thumbs technique
 Two fingers technique
 Site-lower third of sternum
 Rate-90/min
 Ratio-3:1 compression to ventilation
 Deapth-1/3 of AP diameter of chest
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64. Indication for Adrenaline
HR<60/min despite ventilation and compression
Available-1ml amp(1;1000)
Route-IV ,IT, IO,IU
Dose- IV-0.01-0.03 mg/kg of 1;10,000
- IT-0.05 0.1 mg/kg(3 times IV dose)
Frequency-repeat every 5 mins
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65. Other Drugs
 10% glucose-2.5 ml/kg
- infusion at 4-6 mg/kg/min
 Fluids-indication- h/o blood loss
-isotonic saline-0.9% -10 ml/kg
- infusion at 60-80ml/kg/day
- o-ve cross matched blood
 Soda bicarb- not recommended now a days
-documented acidosis
- 4.5% conc.n, -1-2 mmol/kg
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66. Drugs contd…
 Dopamine-indicated in continued shock
-5 mic/kg/min
 Naloxone-h/o narcotics to mother in past 4 hrs
-0.1 to 0.2 mg/kg
 Defibrillation-v-tach or v-fibrillation
-1to 4 joule/kg
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67. Induced Theraputic Hypothermia
 Indication-moderate to severe ischemic
encephalopathy
 Types-whole body cooling
-selective head cooling
 Temperature-33.5 to 34.5⁰ c
 Protocol-commence within 6 hrs
-continue for 72 hrs
-rewarm slowly over 4 hrs
 Adverse effects-thrombocytopenia,sepsis
arrhythmias
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68. Witholding Resuscitation
 Extreme prematurity<400 gms or 24 wks
 Anencephaly
 Chromosomal anamoly-trisomy 13
 When birth weight and anamolies are associated with
almost certain early death.
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69. Discontinuation
 Resuscitation efforts should be stopped when there is
no detectable cardiac activity(heart rate) for 10 mins
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70. 70

71. Conclusion
Effective team work,preparation,anticipation and
planning are essential to ensure the worlds first citizen
the best possible start in life .
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72. THANK YOU
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