guidlines for neonatal resussitation

1. Neonatal resuscitation
Dr pramod sarwa

2. What is neonatal resuscitation?
series of actions which are used to assist newborn
babies who have difficulty with making the
physiological ‘transition’ between the womb and ‘the
outside world’.

3. 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 cobImmersion in
cold water, sometimes alternating with immersion in hot water
Yelling, Shaking , Rubbing, Slapping, and Pinching
Nebulisation of brandy mist
Insufflation of tobacco smoke into the rectum

4. History of Neonatal Resuscitation
Assited respiration has been accepted as the
mainstay of neonatal resuscitation for about the last
40.
Formal teaching programmes have evolved over
the last 20 years.
The last 10 years have seen international
collaboration, which has resulted in careful
evaluation of the available evidence and publication
of recommendations for clinical practice.

5. The International Liaison Committee on
Resuscitation (ILCOR, 1992)
Formed in 1992 to provide a forum for liaison between
resuscitation organisations in the world AHA,europeian
,aust.
ILCOR 1997 made recommendations for Basic Life
support for the newly born. It noted that:
"the paucity of pediatric and newborn clinical
resuscitation outcome data makes scientific
justification of recommendations difficult". Discussion
of advanced life support for newborns was considered
beyond the scope of the document.”

6. ILCOR 2000-2010
ILCOR 2000 Guidelines- Identified
controversial neonatal resuscitation issues.
The Neonatal Subcommittee of ILCOR
reconvenes approximately every five years to
evaluate available evidence that may support a
change in the recommendations.
ILCOR 2005,2010 Guidelines -The literature
was researched and a consensus was reached
on those issues.

7. Poor intrapartum fetal oxygenation
Also referred as asphyxia
Common cause of death & long term disability
(mental & neurological)
Estimated to contribute to 9% of all < 5 mortality
Burden of disease assessment – 42 million
disability-adjusted life years (DALYs)

8. What is ASPHYXIA?
Asphyxia is a disturbed
physiological state due to
deprivation of oxygen supply
to the fetus / newborn.
Oxygen compromise may
be
– Acute or chronic
– Mild or severe
– Once off or repeated
episodes

9. When and why does asphyxia occur?
Asphyxia may occur
– Antenatally
– During labour / perinatal
– After delivery
• Resuscitation not
expedient
Causes of asphyxia are many (direct
/ indirect)! Eg.
– MOTHER
• Pre-eclampsia
• Obstructed labour
• Hypotension
– PLACENTA/CORD
• Cord prolapse
• Antepartum haemorrhage
– BABY
• IUGR
• Postmature
• Malpresentation/breech

11. Solutions to reduce deaths & disability
There are 3 possible intervention points.
– PRIMARY INTERVENTION – prevention of asphyxia
• Maternal health and reproductive health
• Health facility birth
• Risk factor identification (intrapartum)
• Early obstetric intervention
– Recognise and manage complications
– SECONDARY INTERVENTION – NEONATAL
RESUSCITATION
– TERTIARY PREVENTION
• Care of neonatal encephalopathy - NICU (referral services)

12. The Global Need for neonatal Resuscitation,
FIGO, Wall et al

13. What does it involve?
1. Preparation at every birth
2. Assessment of the baby’s condition at birth
3. Interventions
1. Dry / stimulate
2. Clear airway
3. Support breathing
• Ventilate (bag/mask)
• ?oxygen
1. (Advanced support)
• Chest compressions
• Intubation / ventilation
• Medications
4. Ongoing assessment
BASIC

14. Which babies need resuscitation?
Assess:
Gestation – term or preterm?
Breathing or Crying?
Good tone?
If NO then act quickly
–The first “golden minute”

15. Newborn resuscitation
Assessment
Airway, Breathing and Circulation
all assessed before and during
resuscitation:
Tone, Breathing, Heart Rate
and Oxygenation

16. Newborn resuscitation
Basic approach
Maintain normothermia

17. Newborn
life
support
algorithm

18. Assessment and airway

19. Breathing

20. Circulation

21. Supplementary Oxygen/Air
There are concerns about potential adverse
effects of 100% oxygen on breathing physiology,
cerebral circulation, and potential tissue damage
from oxygen free radicals.
There is growing evidence that air is as effective
as 100% oxygen for the resuscitation of most
infants at birth, and is associated with less
mortality and no evidence of harm.

22. Treatment Recommendation
Once adequate ventilation is established with
lung inflation/ventilation , if the heart rate
remains low, the priority should be to support
cardiac output with chest compressions and
coordinated ventilations.
Supplementary oxygen should be considered for
babies with persistent central cyanosis.

23. Tracheal Suctioning
A RCT showed that tracheal intubation and
suctioning of meconium-stained but vigorous
infants at birth offers no benefit and accordingly
is no longer indicated
No studies in Meconium-stained, depressed
infants. These should receive tracheal suctioning
immediately after birth and before stimulation,
presuming the equipment and expertise is
available.

24. Initial Breaths
The optimum pressure, inflation time, and flow
required to establish an effective FRC has not
been determined.
Average initial peak inflating pressures of 30-40
cm water used successfully to ventilate
unresponsive term infants
Ventilation rates of 30-60 breaths min−1
commonly used, but the relative efficacy of
various rates has not been investigated

25. Treatment Recommendation
Establishing effective ventilation is the primary
objective in the management of the apnoeic or
bradycardic newborn in the delivery room.
Positive-pressure ventilation alone is effective for
resuscitating almost all apnoeic or bradycardic
newborn infants
Prompt improvement in HR is the primary measure of
adequate initial ventilation; chest wall movement
should be assessed if heart rate does not improve.

26. Treatment Recommendation
If pressure is being monitored, an initial inflation
pressure of 20 cm H2O may be effective, but a
pressure ≥30—40 cm H2O may be necessary in
some term babies.
If pressure is not being monitored, the minimal
inflation required to achieve an increase in heart
rate should be used.
There is insufficient evidence to recommend
optimal initial or subsequent inflation times.

27. Ventilation for Preterm Infants
Studies indicate that preterm lungs are more easily
injured by large-volume inflations immediately after
birth
Avoid creation of excessive chest wall movement
during ventilation of preterm infants immediately after
birth.
If positive-pressure ventilation is required, an initial
inflation pressure of 20—25 cm H2O is adequate for
most preterm infants, consider higher pressure if no
prompt improvement in heart rate or no chest
movement is obtained.

28. Treatment Recommendation
There are insufficient data to support or refute the
routine use of CPAP during or immediately after
resuscitation in the delivery room.
In preterm baby-Start resuscitation with CPAP of at
least 5–6 cm water via mask or nasal prongs to
stabilize the airway and establish functional residual
volume. It is not clear at present if delivery room
CPAP will reduce the need for subsequent surfactant
treatment or mechanical ventilation

29. Exhaled CO2 Detectors to Confirm Tracheal
Tube Placement
A positive test confirms tracheal placement of the tube,
whereas a negative test strongly suggests oesophageal
intubation.
Exhaled CO2 detection is a reliable indicator of tracheal
tube placement in infants
Identify oesophageal intubations faster than
clinical assessments
Poor or absent pulmonary blood flow may give false-
negative results may lead to unnecessary extubation.

30. Neonatal Chest Compressions
Asystole or bradycardia less than 60 that is not increasing with
airway and ventilation
Use thumbs on lower half of sternum (one finger’s width below
nipple line)
Compress 1/3 AP diameter, 100 times per minute
Compression ventilation ratio is 15.2

32. Adrenaline-Route and Dose
A paediatric study & studies in newborn animals
showed no benefit and a trend toward reduced
survival rates and worse neurological status after
administration of high-dose IV adrenaline during
resuscitation.
Animal & adult human studies show that when
given tracheally, considerably higher doses of
adrenaline than currently used are required to
show a positive effect.

33. Adrenaline-Route and Dose
Lack of human data.
Reasonable to continue to use adrenaline when
adequate ventilation and chest compressions have
failed to ↑ the HR to >60 beats/min.
Use the IV route for adrenaline.
The recommended IV dose is 0.01-.03 mg kg−1.
Do not give higher doses of intravenous adrenaline.
If the tracheal route is used, give a higher dose (0.1 mg
kg−1).The safety of these not studied.

34. Sodium Bicarbonate (SB)
Infusion
At birth babies who do not respond to initial
resuscitative efforts have acidosis
IV SB common practice for over 30 years- no
good evidence
Only 1 high quality study of 55 babies that
compared SB treatment with no treatment, did
not show any benefit nor any adverse effects.
There is insufficient evidence that SB reduces
mortality & morbidity in infants receiving
resuscitation at birth.

35. Volume Expansion
Crystalloids and Colloids
Three RCT in neonates showed that isotonic
crystalloid is as effective as albumin for the
treatment of hypotension
In consideration of cost and theoretical risks, an
isotonic crystalloid solution rather than albumin
should be the fluid of choice for volume
expansion in neonatal resuscitation.

36. Maintenance of Body Temperature
Studies showed an association between
hypothermia and increased mortality in
premature newborns.
Premature infants continue to be at risk for
hypothermia when treated according to current
recommendations (dry the infant, remove wet
linens, place the infant on a radiant warmer)

37. Hyperthermia
Babies born to febrile mothers (temp. >38 ◦C)
have an increased risk of death, perinatal
respiratory depression, neonatal seizures, and
cerebral palsy
The goal is to achieve normo-thermia and to
avoid iatrogenic hyperthermia in babies who
require resuscitation.

38. Glucose
Both low and high blood glucose may have
adverse effects
Based on available evidence, the optimal range
of blood glucose concentration to minimise brain
injury following asphyxia and resuscitation
cannot be defined.
Infants requiring resuscitation should be
monitored and treated to maintain glucose in the
normal range.

39. Induced Hypothermia
In a multicenter trial involving newborns with
suspected asphyxia, selective head cooling (34–
35°C) was associated with a non-significant reduction
in the overall number of survivors with severe
disability at 18 months but a significant benefit in the
subgroup with moderate encephalopathy.
A second large trial of asphyxiated newborns
treatment with systemic hypothermia (33.5 °C)
following moderate to severe encephalopathy was
associated with a significant (18%) decrease in death
or moderate disability at 18 months.

40. Discontinuation of resuscitation
If there is no return of heart rate after 10
minutes, evidence suggests that the newly born
is likely to suffer from severe neurological
impairment or death.
Hence, it is suggested that if there is no return of
heart rate after 10 minutes of adequate
resuscitation, it is acceptable to discontinue
resuscitation.

41. Summary
Everybody who conducts a delivery must be
able to resuscitate
Anticipate & plan
Call for help & work as a team
We should be prepared at all times
Use all available resources
Lets give our newborn a good start