neonatal resuscitation

1. Neonatal Resuscitation
CHEST COMPRESSION AND
DRUGS & FLUIDS
Presenter:
Dr Subash K.C.
Junior Resident
Moderators:
Dr. Lokraj Shah
Dr. Dipak Mishra
Dr. Arbindra Yadav
Dr. Bipesh Kumar Shah
Dr. Sagun Khanal

3. Prebirth questions..?

4. Case :
• Your team is called to attend the birth of a ‘woman at 36 weeks’
gestation who arrived complaining of decreased fetal movement and
vaginal bleeding. Fetal bradycardia is noted by obstetricians.
What next..?

5. • Resuscitation team quickly assembles in the delivery room:
Antenatal counseling
Team briefing
Equipment check

6. • An endotracheal tube, umbilical venous catheter, epinephrine, and volume
replacement are prepared because an extensive resuscitation is anticipated.
• EmLSCS is performed and the obstetrician reports bloody amniotic fluid.
• The umbilical cord is immediately clamped and cut, and a limp, pale baby is
handed to the resuscitation team.
What next..??

8. • Perform the initial steps under a radiant warmer
• However, the baby remains limp without spontaneous respirations.
What next..?

9. • Begin positive-pressure ventilation (PPV) with 21 % oxygen,
• A pulse oximeter sensor is placed on the baby's right hand.
• Baby's heart rate is 40 bpm by cardiac monitor and auscultation after 15 sec
• But the pulse oximeter does not display a reliable signal.
What next..??

10. Ventilation corrective steps

11. • Baby's chest movement present, but heart rate is 40 bpmafter 30 sec
• Chest compressions are performed with coordinated PPV using 100%
oxygen.

12. OBJECTIVES
• When to begin chest compressions
• How to administer chest compressions
• How to coordinate chest compressions with positive pressure ventilation
• When to stop chest compressions

13. OBJECTIVES
• When to give epinephrine during resuscitation
• How to administer epinephrine
• When to give a volume expander during resuscitation
• How to administer a volume expander
• What to do if the baby is not improving after giving intravenous epinephrine
and volume expander

14. • Intubation is strongly recommended if the baby's heart rate < 100
bpm and is not increasing after PPV with a face mask or laryngeal
mask

15. Endotracheal Tube Size for Babies of Various Weights and Gestational Ages
Weight Gestational age ET size
<1 kg < 28 weeks 2.5 mm ID
1-2 kg 28-34 weeks 3.0 mm ID
≥ 2 kg ≥ 34 weeks 3.5 mm ID
Laryngoscope blade size (Straight Miller)
Term No. 1
Preterm No. 0
Extremely preterm No. 00 (optional)

21. • How deeply should the tube be inserted in the trachea?
NTL + 1 cm

22. • How much time should be allowed for an intubation attempt?
 30 seconds
• How do you confirm that the endotracheal tube is in the trachea?
CO2 detector
Audible and equal breath sounds near both axillae during PPV
Symmetrical chest movement with each breath
Little or no air leak from the mouth during PPV
Decreased or absent air entry over the stomach

23. WHEN TO BEGIN CHEST COMPRESSIONS
• If the baby's heart rate < 60 bpm after at least 30 seconds of PPV that
inflates the lung
If compressions are started:
• Call for help if needed as additional personnel may be required to
prepare for vascular access and epinephrine administration
• Intubate if note done already

24. CHEST COMPRESSION
• Chest compressions are started standing at the side of
the warmer.
• One of standing at the head of the bed: provide
coordinated ventilations through an endotracheal tube
• Once intubation is completed and the tube is secure
-the compressor should move to the head of the bed
-the person operating the PPV device moves to the side

25. Where do you position your hands during chest
compressions?

26. How deeply do you compress the chest?

27. What is the compression rate?
• 90 compressions /minute
• Chest compressions are always accompanied by coordinated PPV
• 3 rapid compressions followed by 1 ventilation every 2 seconds
• 3: 1 Compression: Ventilation Rhythm
One-and-Two-and-Three-and-Breathe-and;
One-and-Two-and-Three-and-Breathe-and;
One-and-Two-and-Three-and-Breathe-and

28. What oxygen concentration should be used with positive-pressure ventilation
during chest compressions?
• When chest compressions are started, increase the FiO2 to 100%
• Once the heart rate is greater than 60 bpm and a reliable pulse oximeter signal is
achieved, adjust the FiO2 to meet the target oxygen saturation guidelines
When to check the baby's heart rate after starting compressions?
• 60 seconds after starting coordinated chest compressions and ventilation

29. When do you stop chest compressions?
• Heart rate ≥60 bpm
If heart rate < 60 bpm after 60 sec: Access
1. Chest movement: Is the chest moving with each breath?
2. Airway: Is the airway secured with an endotracheal tube or laryngeal mask?
3. Rate: Are 3 compressions coordinated with 1 ventilation being delivered every
2 seconds?
4. Depth: Is the depth of compressions one-third of the AP diameter of the chest?
5. lnspired Oxygen: Is 100% oxygen being administered through the PPV device?

30. If the baby's heart rate remains less than 60 bpm despite 60 seconds of
effective ventilation and high-quality, coordinated chest compressions
Epinephrine administration

31. Medication requirements..?
• Most newborns requiring resuscitation will improve without emergency
medications.
• 1-3 per 1,000 term and late preterm births
• Newborns with shock from acute blood loss may also require emergency
volume expansion.

32. Medications used in NRP
Epinephrine
Volume Expanders :
 Crystalloid
 RBC

33. EPINEPHRINE
• Cardiac and vascular stimulant.
• Constriction of blood vessels outside of the heart and
increases blood flow into the coronary arteries.
• Increases the rate and strength of cardiac contractions.

34. Actions of Epinephrine
• α1-Adrenergic receptor stimulation causes peripheral vasoconstriction.
• Stimulates β1-adrenergic receptors and increases heart rate, myocardial
contractility, automaticity, and conduction velocity.
• Stimulates β2-adrenergic receptors at lower doses − Causes
bronchodilation − Causes dilation of arterioles (decreases diastolic BP)

35. • Epinephrine is not indicated before you have established ventilation that
effectively inflates the lungs.
 Concentration:
??

36. Route
• Intravenous (preferred)
• Intraosseous
• Endotracheal- Considered while vascular access is being established
Studies suggest that absorption is unreliable and the endotracheal route is less
effective.
Peripheral intravenous catheter is not recommended for emergency medication
administration in the setting of cardiovascular collapse.

37. Dose
Intravenous and Intraosseous
• 0.02 mg/kg (equal to 0.2 mL/kg)
• Range: 0.01 to 0.03 mg/kg (equal to 0.1 to 0.3 mL/kg)
Endotracheal
• 0.1 mg/kg (equal to 1 mL/kg)
• Range = 0.05 to 0.1 mg/kg (0.5 to 1 mL/kg)
• If no response, recommend intravenous or intraosseous for subsequent
doses

38. • Epinephrine is given rapidly.
• IV/ Intraosseous route: Follow the drug with a 3 ml flush of NS
• Endotracheal route: Follow the drug with several positive-pressure breaths
to distribute the drug into the lungs
• Continue chest compression with PPV

39. When to reassess HR??
After 60 seconds of epinephrine admistration
HR < 60 bpm
• Continue coordinated ventilation and
compressions
• Can repeat the epinephrine dose every 3-
5 minutes
• Consider increasing subsequent doses
HR ≥ 60 bpm
• Stop chest compression
• Continue PPV at 40-60 bpm
If the first Dose is given by the endotracheal route and there is not a satisfactory response, a
repeat dose should be given as soon as an umbilical venous catheter or intraosseous needle is
inserted

40. Volume Expander
Indicated if -
• The baby is not responding to the steps of resuscitation, and
• There are signs of shock or a history of acute blood loss
Should not be given routinely during resuscitation in the absence of
shock or a history of acute blood loss

41. Volume expansion recommendations:
• Solution: Normal saline (NS) or ‘O’ Negative blood
• Route: Intravenous or intraosseous
• Preparation: 30 to 60 mL syringe (labeled NS or O Negative blood)
• Dose: 10 mL/kg
• Rate: Over 5 to 10 minutes

42. Questions to Ask When Heart Rote Is Not lmproving With
Compressions, Ventilation, Epinephrine, and Volume
Expansion
• Is the chest moving with each breath?
• Is the airway secured with an endotracheal tube oral laryngeal mask?
• Are 3 compressions coordinated with 1 ventilation being delivered every 2
seconds?
• Is the depth of compressions one-third of the AP diameter of the chest?
• Is 100% oxygen being administered through the PPV device?
• Was the correct dose of epinephrine given intravenously?
• Is the umbilical venous catheter or intraosseous needle in place or has it been
dislodged?
• Is a pneumothorax present?

43. When to stop chest compression?
• When HR ≥ 60 bpm
• If HR < 60 bpm
A reasonable time frame for considering cessation of resuscitation efforts
is around 20 minutes after birth
However, the decision to continue or discontinue should be individualized
based on patient and contextual factors.

44. Change NRP 7th Edition NRP 8th Edition
Epinephrine
intravenous/intraosseous (IV/IO)
flush volume increased.
Flush IV/IO epinephrine with 0.5
to 1 mL normal saline
Flush IV/IO epinephrine with 3 mL
normal saline (applies to all weights
and gestational ages)
Epinephrine IV/IO and
endotracheal doses have been
simplified for educational
efficiency. The dosage range is
unchanged. The simplified doses
(IV/IO and ET) do not represent an
endorsement of any particular
dose within the recommended
dosing range. Additional research
is needed.
Range for IV or IO dose =
0.01 - 0.03 mg/kg
(equal to 0.1 - 0.3 mL/kg)
Range for endotracheal dose =
0.05 - 0.1 mg/kg
(equal to 0.5 – 1 mL/kg)
The suggested initial IV or IO dose =
0.02 mg/kg (equal to 0.2 mL/kg)
The suggested endotracheal dose
(while establishing vascular access) =
0.1 mg/kg (equal to 1 mL/kg)

45. Review Questions..
Q. A newborn is apneic at birth. The baby does not improve with the
initial steps, and positive-pressure ventilation is started. After 30
seconds, the heart rate has increased from 40 beats per minute (bpm)
to 80 bpm. Chest compressions (should)/(should not) be started.
Positive-pressure ventilation (should)/(should not) continue.

46. Q. A newborn is apneic at birth. The baby does not improve with the
initial steps or positive-pressure ventilation. An endotracheal tube is
inserted properly, the chest moves with ventilation, bilateral breath
sounds are present, and ventilation has continued for another 30
seconds. The heart rate remains 40 beats per minute. Chest
compressions (should)/(should not) be started. Positive-pressure
ventilation (should)/(should not) continue

47. Q. The correct depth of chest compressions is approximately…………
Q. The ratio of chest compressions to ventilation is
(3 compressions to 1 ventilation)/(1 compression to 3 ventilations)
Q. You should briefly stop compressions to check the baby's heart rate
response after (30 seconds)/(60 seconds) of chest compressions with
coordinated ventilations.

48. Q. Ventilation that moves the chest has been performed through an
endotracheal tube for 30 seconds, followed by coordinated chest
compressions and 100% oxygen for an additional 60 seconds. Epinephrine is
indicated if the baby's HR < 60 / 80 bpm.
Q. The preferred route for epinephrine is (intravenous)/(endotracheal)

49. Q. The recommended concentration of epinephrine for newborns is
(0.1 mg/mL)/(1 mg/mL).
Q. The suggested initial intravenous dose of epinephrine is
(0.02 mg/kg)/(0.1 mg/kg).

50. Q. If the baby's heart rate remains less than 60 beats per minute, you
can repeat the dose of epinephrine every (3 to 5 minutes)/(8 to 10
minutes).
Q. If an emergency volume expander is indicated, the initial dose is
(1 mL/kg)/(10 mL/kg).