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Newborn Resuscitation Program


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NRP 2007 newborn resuscitation

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Newborn Resuscitation Program

  2. 2. Which Babies Require Resuscitation? <ul><li>Most newly born babies are delivered vigorous </li></ul><ul><li>Only about 10% of newborns require some assistance </li></ul><ul><li>Only 1% need major resuscitative measures (intubation, chest compressions, and/or medications) to survive </li></ul><ul><li> </li></ul>
  3. 3. Apnea (In Utero or Perinatal) <ul><li>Primary Apnea </li></ul><ul><li>When a fetus or a newborn first becomes deprived of oxygen, an initial period of attempted rapid breathing is followed by primary apnea and dropping heart rate. </li></ul><ul><li>Primary apnea and the dropping of the heart rate will improve with tactile stimulation </li></ul>
  4. 4. Secondary Apnea <ul><li>If oxygen deprivation continues, secondary apnea ensues, accompanied by a continued fall in heart rate and blood pressure </li></ul><ul><li>Secondary apnea cannot be reversed with just stimulation </li></ul><ul><li>Assisted ventilation must be provided </li></ul>
  5. 5. What Can Go Wrong <ul><li>Lack of ventilation of the newborn’s lungs results in sustained constriction of the pulmonary arterioles, preventing systemic arterial blood from being oxygenated </li></ul><ul><li>Prolonged lack of adequate perfusion and oxygenation to the baby’s organs can lead to brain damage, damage to other organs, or death </li></ul>
  6. 6. Neonatal Flow Algorithm
  7. 7. Preparation for Resuscitation <ul><li>Assemble equipment </li></ul><ul><li>Test equipment </li></ul>
  8. 8. Evaluating the Newborn Immediately after birth, the following questions must be asked: All newborns require initial assessment to determine whether resuscitation is required 
  9. 9. Provide Warmth <ul><li>Prevent heat loss by </li></ul><ul><li>Placing newborn under radiant warmer </li></ul><ul><li>Drying thoroughly </li></ul><ul><li>Removing wet towels </li></ul>
  10. 10. Opening the Airway <ul><li>Positioning on back or side, neck slightly extended </li></ul><ul><li> </li></ul>Open the airway by positioning the newborn in a “sniffing” position
  11. 11. Opening the Airway <ul><li>“ Sniffing” position aligns posterior pharynx, larynx, and trachea </li></ul>
  12. 12. Initial Steps <ul><li>Provide warmth </li></ul><ul><li>Position; clear airway (as necessary) </li></ul><ul><li>Dry, stimulate, reposition </li></ul>
  13. 13. Tactile Stimulation 
  14. 14. Dry, Stimulate to Breathe, Reposition
  15. 15. Potentially Hazardous Forms of Stimulation <ul><li>Slapping back or buttocks </li></ul><ul><li>Squeezing rib cage </li></ul><ul><li>Forcing thighs onto abdomen </li></ul><ul><li>Dilating anal sphincter </li></ul><ul><li>Hot or cold compresses or baths </li></ul><ul><li>Shaking </li></ul>
  16. 16. Clear Airway: No Meconium Present <ul><li>Suction mouth first, then nose </li></ul><ul><li>“ M” before “N” </li></ul>
  17. 17. Evaluation: <ul><li>Decisions and actions during newborn resuscitation are based on Respirations, Heart Rate, and Color </li></ul>Click on the image to play video 
  18. 18. Central Cyanosis and Acrocyanosis
  19. 19. Free-flow Oxygen <ul><li>Free-flow oxygen is indicated for central cyanosis </li></ul><ul><li>Free-flow oxygen cannot be given reliably by a mask attached to a self-inflating bag </li></ul>
  20. 20. Delivering Free-flow Oxygen <ul><li>Heated and humidified Oxigen, if available (if given for longer than few minutes) </li></ul><ul><li>Flow rate at approximately 5 L/min </li></ul><ul><li>Enough oxygen for newborn to become pink </li></ul>
  21. 21. Meconium Present and Newborn Vigorous <ul><li>If </li></ul><ul><li>Respiratory effort strong, and </li></ul><ul><li>Muscle tone good, and </li></ul><ul><li>Heart rate greater than 100 beats per minute (bpm) </li></ul><ul><li>Then </li></ul><ul><li>Use bulb syringe or large-bore suction catheter to clear mouth and nose </li></ul><ul><li> </li></ul>
  22. 22. Meconium Present and Newborn Not Vigorous <ul><li>Tracheal Suction </li></ul><ul><li>Administer oxygen, monitor heart rate </li></ul><ul><li>Insert laryngoscope, use 12F or 14F suction catheter to clear mouth </li></ul><ul><li>Insert endotracheal tube into trachea </li></ul><ul><li>Attach endotracheal tube to suction source </li></ul><ul><li>Apply suction as endotracheal tube is withdrawn </li></ul><ul><li>Repeat as necessary </li></ul>
  23. 23. Management of Meconium
  24. 24. Suctioning Meconium via Endotracheal Tube <ul><li>Suction for only 3 to 5 seconds as tube is withdrawn </li></ul><ul><li>If no meconium is recovered, proceed to resuscitation </li></ul><ul><li>If meconium is recovered, check heart rate </li></ul><ul><li>No significant bradycardia -> Reintubate, suction again if needed </li></ul><ul><li>Significant bradycardia -> Administer positive-pressure ventilation </li></ul>
  25. 25. Evaluation: Respirations, Heart Rate, Color 
  26. 26. Evaluation: Persistent Cyanosis, Apnea, or Heart Rate <100 <ul><li>For persistent apnea, begin positive-pressure ventilation/PPV promptly. </li></ul><ul><li>Continued use of tactile stimulation in an apneic newborn wastes valuable time. </li></ul>
  27. 27. Indications for Positive-Pressure Ventilation/ PPV <ul><li>Apnea/gasping </li></ul><ul><li>Heart rate less than 100 beats per minute (bpm) even if breathing </li></ul><ul><li>Persistent cyanosis despite 100% free-flow oxygen </li></ul>Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised infant 
  28. 28. Oxygen Concentration During PPV <ul><li>The Neonatal Resuscitation Program (NRP) recommends use of 100% oxygen when doing positive-pressure ventilation. </li></ul><ul><li>However, research suggests that resuscitation with less than 100% oxygen may be just as successful. </li></ul>
  29. 29. Oxygen Concentration During Positive-Pressure Ventilation <ul><li>If resuscitation is started with <100% oxygen, and there is no appreciable improvement within 90 seconds following birth, then, supplemental oxygen up to 100% should be administered. </li></ul>
  30. 30. Oxygen Concentration During Positive-Pressure Ventilation <ul><li>If oxygen is unavailable, use room air to deliver positive-pressure ventilation. </li></ul>
  31. 31. Bag and Mask: Equipment <ul><li>Mask should cover </li></ul><ul><li>Tip of Chin </li></ul><ul><li>Mouth </li></ul><ul><li>Nose </li></ul>
  32. 32. Preparation Checklist <ul><li>Select appropriate-sized mask </li></ul><ul><li>Be sure airway is clear </li></ul><ul><li>Position baby’s head </li></ul><ul><li>Position yourself at baby’s side or head </li></ul>Before beginning positive-pressure ventilation:
  33. 33. Positioning Mask on Face <ul><li>Do not jam mask down on face </li></ul><ul><li>Do not allow fingers or hands to rest on eyes </li></ul><ul><li>Do not put pressure on throat (trachea) </li></ul>
  34. 34. Face-Mask Seal An AIRTIGHT seal is essential to achieve effective Positive Pressure Ventilation To improve face-mask seal -Use light downward pressure -Gently squeeze mandible up toward mask
  35. 35. Evaluate for Signs of Effective Ventilation and improvement in the newborn <ul><li>Breathing </li></ul><ul><li>Improved heart rate </li></ul><ul><li>Color </li></ul><ul><li>Tone </li></ul><ul><li>Saturation </li></ul>
  36. 36. Frequency of Ventilation: <ul><li>40 to 60 breaths per minute </li></ul>
  37. 37. Causes and Solutions for Inadequate Chest Expansion Condition Actions Inadequate seal Reapply mask to face and lift jaw forward Blocked airway Reposition the head, suction secretions; Ventilate with the newborn’s mouth slightly open Not enough pressure Increase pressure until there is a perceptible chest movement Consider endotracheal intubation 
  38. 38. Over-inflation of Lungs <ul><li>If too much pressure is being used, the baby appears to be receiving very deep breaths. </li></ul><ul><li>Danger of causing Pneumothorax </li></ul>
  39. 39. Newborn Not Improving Heart rate less than 60 despite 30 seconds of positive-pressure ventilation
  40. 40. Continued Positive-Pressure Ventilation Orogastric tube should be inserted to relieve gastric distention
  41. 41. Continued Positive-Pressure Ventilation <ul><li>Gastric distention may </li></ul><ul><li>Elevate diaphragm, preventing full lung expansion </li></ul><ul><li>Cause regurgitation and aspiration </li></ul>Orogastric tube should be inserted to relieve gastric distention
  42. 42. Insertion of Orogastric Tube <ul><li>Equipment </li></ul><ul><li>8F feeding tube </li></ul><ul><li>20-mL syringe </li></ul>
  43. 43. Insertion of Orogastric Tube <ul><li>Measuring correct length </li></ul>
  44. 44. Chest Compressions: <ul><li>Compress the heart against the spine </li></ul><ul><li>Increase intrathoracic pressure </li></ul><ul><li>Circulate blood to vital organs, including the brain </li></ul>
  45. 45. Chest Compressions: 2 People Needed <ul><li>One person compresses chest </li></ul><ul><li>One person continues ventilation </li></ul>
  46. 46. Chest Compressions Technique: <ul><li>Thumb Technique (Preferred) </li></ul><ul><ul><li>Less tiring </li></ul></ul><ul><ul><li>Better control of compression depth </li></ul></ul><ul><li>2-Finger Technique </li></ul><ul><ul><li>Better for small hands </li></ul></ul><ul><ul><li>Provides access to umbilicus for medications </li></ul></ul>
  47. 47. Chest Compressions: Positioning of Thumbs or Fingers <ul><li>Run your fingers along the lower edge of the rib cage until you locate the xyphoid </li></ul><ul><li>Place your thumbs or fingers on the sternum, above the xyphoid and on a line connecting the nipples </li></ul><ul><li> </li></ul>
  48. 48. Chest Compressions: Thumb Technique <ul><li>Thumbs compress sternum </li></ul><ul><li>Fingers support back </li></ul>
  49. 49. Chest Compressions: 2-Finger Technique <ul><li>Tips of middle finger and index or ring finger of one hand compress sternum </li></ul><ul><li>Other hand supports back </li></ul>
  50. 50. Chest Compressions: Compression Pressure and Depth <ul><li>Depress sternum one third of the anterior-posterior diameter of chest </li></ul>
  51. 51. Chest Compressions: Complications <ul><li>Laceration of liver </li></ul><ul><li>Broken ribs </li></ul>
  52. 52. Chest Compressions: Coordination With Ventilation 
  53. 53. Chest Compressions: Coordination With Ventilation <ul><li>One cycle of 3 compressions and 1 breath takes 2 seconds </li></ul><ul><li>The breathing rate is 30 breaths per minute and the compression rate is 90 compressions per minute. This equals 120 “events” per minute </li></ul><ul><li> </li></ul>
  54. 54. Chest Compressions: Stopping Compressions <ul><li>After 30 seconds of compressions and ventilation, stop and check heart rate </li></ul><ul><li> </li></ul>
  55. 55. Chest Compressions: Heart Rate Remains Less than 60 bpm <ul><li>Check adequacy of ventilation </li></ul><ul><li>Consider Endotracheal Intubation if not already done </li></ul><ul><li>Insert an umbilical catheter to give epinephrine </li></ul><ul><li> </li></ul>
  56. 56. Endotracheal Intubation: to be discussed by Dr. Ronald Limchiu
  57. 57. Chest Compressions: Heart Rate Remains Less than 60 bpm <ul><li>After 30 seconds of compressions and ventilation, stop and check heart rate </li></ul><ul><li>Consider Epinephrine </li></ul><ul><li> </li></ul>
  58. 58. Administration of Medication via Umbilical Vein <ul><li>Preferred route for intravenous access </li></ul><ul><li>3.5F or 5F end-hole catheter </li></ul><ul><li>Sterile technique </li></ul>Placing catheter in umbilical vein
  59. 59. Epinephrine Indications <ul><li>30 seconds of assisted ventilation followed by </li></ul><ul><li>30 seconds of coordinated compressions and ventilation </li></ul><ul><li>_____________ </li></ul><ul><li>Total = 60 seconds  </li></ul>Epinephrine, a cardiac stimulant, is indicated when the heart rate remains below 60 beats per minute despite Note: Epinephrine is not indicated before adequate ventilation is established.
  60. 60. Medication Given: No Improvement
  61. 61. Failure to Initiate Spontaneous Respirations <ul><li>Consider </li></ul><ul><li>Brain injury (hypoxic ischemic encephalopathy) </li></ul><ul><li>Severe acidosis, congenital neuromuscular disorder </li></ul><ul><li>Sedation secondary to maternal drugs </li></ul>
  62. 62. Narcotic Antagonist: Naloxone Hydrochloride
  65. 66. Management of Meconium