nnr

1. Neonatal resuscitation (NNR)
Dr. Renu Singh

2. Burden of the problem
• Birth asphyxia
• 23% of the 1 million neonatal deaths in India
• Long term neurological complications
• Death
• NNR (Neonatal resuscitation) :simple,
inexpensive, cost effective method
• Problem: NNR often not initiated, incorrect
use of methods

3. Successful NNR: factors
1. Anticipation: call a skilled personnel
2. Adequate preparation
3. Accurate evaluation, algorithm based
4. Prompt initiation of support

4. 1.Anticipation: High risk delivery
• Maternal condition
– Advanced maternal age ,DM, HT, stillbirth, fetal loss, early
neonatal death
• Fetal condition
– Prematurity, post maturity, congenital anomalies, multiple
gestations
• Ante partum complications:
APH, oligo /polyhydramnios
• Delivery complications
– Malpresentation, MSAF, instrumental delivery, antenatal
asphyxia with abnormal FHR

5. 2. Adequate preparation
• Radiant warmer is turned on,& is heating
• Oxygen source is open with adequate flow
through the tubing
• Suction apparatus tested, functioning properly
• Laryngoscope is functional with bright light
• Resuscitation bag & mask demonstrates an
adequate seal & generation of pressure

6. Radiant warmer

11. Successful NNR: factors
1. Anticipation: call a skilled personnel
2. Adequate preparation
3. Accurate evaluation, algorithm based
4. Prompt initiation of support

12. Evaluation, algorithm based
• Rapid assessment of neonate clinical status
• Is the infant full term?
• Is the infant breathing or crying?
• Does the infant has good muscle tone?
• Yes: no resuscitation, routine neonatal care
• No: needs resuscitation

14. Approach to resuscitation
2010 AHA, AAP
• A: initial steps(provide warmth, clear airway if
necessary, dry, stimulate)
• B: breathing(ventilation)
• C: chest compressions (circulation)
• D: administration of drugs &/or volume
expansion

15. Resuscitation: initial steps
• Provide warmth
• Head position “ sniffing position”
• Clearing the airway, if necessary
• Drying the baby
• Tactile stimulation for breathing

17. AAP
Algorithm

18. AAP Algorithm

20. PPV: Positive pressure ventilation
• Form of assisted ventilation
• Needed when there is no improvement in HR
• Also assess chest wall movements
• Should be delivered at rate of 40-60 breaths
/min, maintain HR>100 /min
• Devices: BMV, ET (endotracheal
tube),LMA(laryngeal mask airway)

22. Bag & mask ventilation

24. Endotracheal tube
• If BMV is ineffective/prolonged
• When chest compressions are performed
• Initial endotracheal suctioning of non vigorous
meconium stained newborn

25. Endotracheal tube

27. LMA(Laryngeal mask airway)
• Soft mask, fits over laryngeal inlet when
inflated, occludes the oesophageal opening
• Done when BMV is unsuccessful & tracheal
intubation is unsuccessful or not feasible

28. LMA(Laryngeal mask airway)

29. Targeted SPO2 after birth
1 minute 60-65%
2 minutes 65-70%
3 minutes 70-75%
4 minutes 75-80%
5 minutes 80-85%
10 minutes 85-90%

30. 1. Initial steps in resuscitation
2. PPV

31. AAP
Algorithm

32. Chest compressions
• Started when HR<60 per minute despite adequate
ventilation with 100% oxygen for 30 sec
• Delivered at lower third of sternum, to depth 1/3 of
AP diameter of chest
• 2 techniques:
– 2 thumb-encircling hands technique
– Compression with 2 fingers ,second hand
supporting the back
– 3:1 ratio::[ 90 comp:30 ventilations]

35. 1. Initial steps of resuscitation
2. PPV(ET)
3. CHEST COMPRESSIONS

37. AAP
Algorithm

38. Medications
• Rarely indicated
• Most important step to treat bradycardia is
establishing adequate ventilation
• HR remains <60bpm,despite adequate
ventilation(ET) with 100% Oxygen & chest
compressions
• Epinephrine or volume expansion or both

39. Epinephrine
• Route of administration: intravenous(IV),ideal
• Recommended dose: 0.01-0.03 mg/kg per
dose
• Desired concentration: 1:10,000
0.1 mg/ml

40. Volume expansion
• Suspected or known blood loss
• Isotonic crystalloid solution ; normal saline
• Blood
• Dose calculation: 10 ml/kg

41. Asses if resuscitation is needed, keep
warm, position, clear, dry, stimulation
Give oxygen as necessary
Positive pressure ventilation
Endotracheal
intubation
Chest
compression
drugs

42. The golden minute
• <30 seconds: complete initial steps
• Warmth
• Drying
• Clear airway if necessary
• Stimulate
• 30-60 seconds: assess 2 vital characteristics
• Respiration (apnea/gasping/labored/unlabored)
• Heart rate (<100/>100bpm)
• Golden Minute Project: skill based training

44. AAP
Algorithm

45. Post resuscitation care
• Needed for those who required PPV
• At risk of deterioration
– Hypo/hyperthermia ,hypoglycemia, CNS
complications(apnea, HIE), pulmonary
complications(TTN, Pneumonia), hypotension
• Need monitoring ,evaluation
• NICU may be necessary

46. NNR : not indicated
• Conditions with certainly early death
• Extreme prematurity(GA<23 weeks)
• Birth weight<400g
• Anencephaly
• Chromosomal abnormality: Trisomy 13

47. NNR: nearly always indicated
• High rate of survival
• Acceptable morbidity
• GA≥ 25 weeks
• Those with most congenital malformations

48. NNR?
• Conditions associated with uncertain
prognosis
• Survival borderline
• Parental desires concerning initiation of
resuscitation should be supported

49. Discontinuing resuscitative efforts
• Newborn with no detectable heart rate,
consider stopping NNR if the heart rate
remains undetectable for 10 minutes

50. Summary
• Most infants transfer from intrauterine to
extra uterine life
• 10% need some intervention,1% need
extensive resuscitation
• Anticipate the need for NNR
• Adequate preparation for NNR
• Evaluate the newborn as per AHA/AAP
guidelines & follow the recommended
protocol

51. MCQ1
For successful neonatal resuscitation following
is/are needed except:
1. Anticipation
2. Adequate preparation
3. Skilled personnel
4. Delayed initiation of support

52. MCQ1
• For successful neonatal resuscitation
following is/are needed except:
1. Anticipation
2. Adequate preparation
3. Skilled personnel
4. Delayed initiation of support

53. MCQ2
• Following are true in relation to initial steps of
neonatal resuscitation except
1. Provide warmth
2. Tactile stimulation
3. Endotracheal intubation
4. Drying the baby

54. MCQ2
• Following are true in relation to initial steps of
neonatal resuscitation except
1. Provide warmth
2. Tactile stimulation
3. Endotracheal intubation
4. Drying the baby

55. MCQ3
• The following is the primary measure of
adequate ventilation
1. Chest wall movement
2. Improvement in heart rate
3. Pink extremities
4. Spo2 of 100%

56. MCQ3
• The following is the primary measure of
adequate ventilation
1. Chest wall movement
2. Improvement in heart rate
3. Pink extremities
4. Spo2 of 100%

57. MCQ4
Endotracheal intubation may be indicated at
several points during neonatal resuscitation
except
1. Ineffective BMV
2. During chest compressions
3. Vigorous meconium stained newborn
4. Non vigorous meconium stained newborn

58. MCQ4
• Endotracheal intubation may be indicated at
several points during neonatal resuscitation
except
1. Ineffective BMV
2. During chest compressions
3. Vigorous meconium stained newborn
4. Non vigorous meconium stained newborn

59. MCQ5
• The recommended compression to ventilation
ratio in neonatal resuscitation is
1. 2:1
2. 3:1
3. 4:1
4. 5:1

60. MCQ5
• The recommended compression to ventilation
ratio in neonatal resuscitation is
1. 2:1
2. 3:1
3. 4:1
4. 5:1

61. MCQ6
• The recommended dose(mg/kg per dose) and
route of epinephrine in neonatal resuscitation
1. 0.01-0.03,IV
2. 0.01-0.03,IM
3. 0.03-0.05,1V
4. 0.05-0.1,IV

62. MCQ6
• The recommended dose(mg/kg per dose) and
route of epinephrine in neonatal resuscitation
is
1. 0.01-0.03,IV
2. 0.01-0.03,IM
3. 0.03-0.05,1V
4. 0.05-0.1,IV

63. MCQ7
• Recommended method/clinical indicator of
confirming ET placement is
1. Condensation in ET
2. Chest movement
3. Equal breath sounds on auscultation
4. Exhaled C02 Detection

64. MCQ7
• Recommended method/clinical indicator of
confirming ET placement is
1. Condensation in ET
2. Chest movement
3. Equal breath sounds on auscultation
4. Exhaled C02 Detection