2016 5 tips to better neonatal care
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This document provides 5 tips for better neonatal care: 1. Initial assessment of the newborn should be done within 60 seconds of birth to identify any need for ventilation or other interventions. Heart rate, appearance, muscle tone, and breathing efforts are evaluated. 2. Positive pressure ventilation may be needed if the heart rate is less than 100 beats per minute and not improving with other measures like drying, warming, and supplemental oxygen. Proper mask seal and tidal volumes are important for effective ventilation. 3. Hypothermia, hypoglycemia, and hypovolemia are common problems for newborns and should be monitored for and treated if present. This involves warming, glucose supplementation via IV if needed, and
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2016 5 tips to better neonatal care
- 1. 5 tips to better Neonatal Care 2016 Eastern Oregon EMS Conference
- 2. AKA: “I Hope I don’t F*ck this up…”
- 3. Introduction and Disclaimer • croaker260@gmail.com • • No financial disclaimers • No Conflict of interest
- 4. Just a note
- 5. Courses to Take, Repeatedly
- 7. “The Golden Minute” • Most neonatal arrests are asphyxia in nature. • First ventilation (if needed) should be administered within 60 seconds of initial assessment. • “Initial Assessment” can be done on Mom – Permitting delayed cord clamping if stable
- 8. Initial three questions • Term gestation? • Good tone? • Breathing or crying? • If “Yes” to all three, let infant stay on MOM
- 9. Evaluation, Decision, Action Cycle
- 10. What do we assess/evaluate • Appearance – Central cyanosis • Provide free flow oxygen • When pink, gradually remove oxygen • If no improvement consider PPV with 100% O2 – Acrocyanosis • Observe, monitor • Pulse • Respiration • SPO2 (?) • Tone (?)
- 11. Treatment Basics • Assessments, decisions and interventions are made on 15-30 second cycles. • Treatment decisions ARE NOT made on APGAR
- 12. Meds Intubation Chest Compressions BVM Ventilations Oxygen Drying, Warming, Positioning, Suction, Tactile Stimulation
- 13. Meds (EPI) FLUIDS Advanced Airway Chest Compressions BVM Ventilations (Room Air) Blow By Oxygen (optional) Drying, Warming, Positioning, Suction, Tactile Stimulation
- 14. 5 H’s • Heart Rate • Hypoxia • Hypothermia • Hypoglycemia • Hypovolemia
- 15. HEART RATE Treatment of the Newborn
- 16. Heart Rate is one of the best indicators of clinical status • “Assessment of heart rate remains critical during the first minute of resuscitation”… • “Use of the ECG does not replace the need for pulse oximetry to evaluate the newborn’s oxygenation”
- 17. How do we assess accurately? • Auscultate – < 25/15 seconds = Bad – < 15/15 seconds = very bad • EKG
- 18. Heart Rate • Evaluate Heart Rate • Above 100 • Evaluate other signs • Reevaluate after 30 seconds • Below 100 • PPV (Titrated 21% - 100% O2) • Reevaluate after 30 seconds • Below 60 • Continue PPV with 100% Oxygen • Initiate compressions • Reevaluate after 30 seconds
- 19. Wait..what? • Yes, initiate compressions if HR between 60- 100 and not increasing or responsive to other interventions… • 3:1 ratio • Two thumb , not two finger
- 21. Bradycardia • Possible causes – Hypoxia – Increased intracranial pressure – Hypothyroidism – Acidosis • Minimal risk if corrected quickly • Discontinue chest compressions when HR > 100 • Pharmacological – Use as last resort – Epinephrine 0.01 to 0.03 mg per kg (0.1-0.3 ml/kg) 1:10,000
- 22. HYPOXIA Treatment of the Newborn
- 23. Key Points • It is acceptable to ventilate with Room Air HOWEVER • Use 100% O2 if doing compressions • If known pre-term, it is acceptable to begin with low flow O2 and titrate.
- 24. SPO2 in the Newly Born 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 85-95% Measure on the Right Arm
- 25. Primary apnea Secondary apnea Heartrate Respirations Blood pressure
- 28. Positive Pressure Ventilation • Positive Inspiratory Pressure (PIP) • Term: – Initial up to 40 cm H20 – Decrease to 20 cm H2O • Pre-Term: – 20-25 cm H20 – Adequate for most – ↑ if no prompt ↑ in HR or chest movement • Goal- Small rise in chest, and HR improvement (>100/min) • GOAL- 40-60 breaths a minute
- 29. Getting a good mask seal can be difficult • 48% demonstrated significant mask leak – – Majority were corrected with repositioning of the mask – – Some required changing the way mask was held • 25% demonstrated significant airway obstruction – – Majority corrected with repositioning the infant in the open airway position – Schmolzer et al. ADC 2011
- 31. A comment about Tidal Volume • Tidal Volumes are generally less for newborns – Small baby (<1500 grams/3.3 lbs) 4-6 ml/kg – Term Baby: 6-8 ml/kg – Adult (for comparison) 7-8 ml/kg
- 32. Pneumothorax is a real possibility
- 33. BVMs do not provide BLOW BY O2!!!!
- 34. A comment about Meconium
- 35. HYPOTHERMIA
- 36. Hypothermia • Infants cannot tolerate temperatures comfortable to adults • Hypothermia is a predictor of mortality
- 37. Key Points • Temperature of newly born non asphyxiated infants should be maintained between 36.5°C (97.7 ° F) and 37.5°C (99.5 ° F) after birth through admission and stabilization.
- 40. Brown Fat???? • Hypothermia -> Sympathetic Response • Sympathetic Response (Nor-Epi) - > Biochemical response in “Brown Fat” – Located in the Neck and between the scapula • This produces local heat, which warms blood supply passing through, therefore warming the infant… • Short term response.
- 41. Street Secrets: Newborn Hypothermia clues • Cold Feet • Red or White Extremities (shunting) • Flaccid, limp, Or weak crying • Low BG (<40 mg/dl heel stick)
- 42. Treatment Basics: • Get rid of wet towels! • Maternal warming in the stable newborn
- 44. Treatment Basics: Hypothermia in the tine-tiny • Very Low Birth weight (<1500 GM) can become cyanotic simply due to hypothermia – This can occur despite normal warming methods – Use Active Warming- Port-a-warm mattress, heat lamps, etc.
- 45. Hypothermia Treatment • Control Temperature – All newborns have difficulty with cold – Dry infant – Wrap in warm, dry blanket – Aluminum foil wrap – Well - insulated warm water containers – Do NOT use chemical hot packs • EXCEPTION: Port-A Warm mattress
- 47. HYPOGLYCEMIA
- 48. “Most babies who are critically ill, are too sick to tolerate oral feedings…” - S.T.A.B.L.E. text pg. 8
- 49. When the cord is cut… • The baby no longer receives sugar from mom • The baby begins to use brown fat for sugar and heat production • Ideally, the child should be provided a food source
- 50. What is normal glucose level for a newborn? • Ideally it is 80% of maternal glucose levels. • < 40 mg/dl within 10 minutes of birth • 50-110 mg/dl on follow up • When to check? – Within 10 minutes of birth – (Q 15-30) minutes until two consecutive readings above 50 mg/dl – Sudden change
- 51. Who is at risk? • Any baby under “stress” – Pre-birth or post birth – hypoxia • Hypothermia/shivering • Small for gestational age (SGA) , i.e. twins – 25% incidence • Exceptionally large infants (>90th percentile) • “Premature” infants (< 37 weeks) • Maternal factors – Diabetes – Beta Blockers to Tx HTN – TCA’s in 3rd trimester – Beta adrenergics (Terbutaline) to treat pre-term labor
- 52. Hypoglycemia • Assessment – Twitching/Seizures – Limpness – Lethargy – Eye rolling – High pitched or weak cry – Apnea – Irregular respirations
- 53. Hypoglycemia • Management – Assure adequate oxygenation, ventilation – IV/IO TKO • Warm fluids only – ECG – Dextrose (D10W or D12.5W) – Maintain warmth
- 54. Dextrose? • D10 – 10 GM /100 CC buritrol = 1 GM/10 cc – or – 25 GM D50 /250 bag NS • DOSE 0.2-0.5 GM/KG IV (2-5 ml/kg) – Slow IV push (5 min) – May need repeat boluses. • Document response to treatment
- 55. A comment about Hyperglycemia • The more premature the infant, the less mature their endocrine system is. Expect fluctuations.
- 56. HYPOVOLEMIA Treatment of the Newborn
- 57. Key points to remember • Premature and SGA infants may need more fluid requirments because of increased fluid loss through thinner skin.
- 58. Tips for IV access • 24 gauges for most infants • IO’s only work for full term – Consider Umbilical Lines (medic/RN Only) • Locations – Scalp – Hands – Feet – A/C • Use own finger as a tourniquet • Remember: Blood return will be slow
- 59. Shallow angle of insertion [Photograph found in Royal Children's Hospital Melbourne, Melbourne, Australia]. (n.d.). Retrieved February 22, 2016, from http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/
- 60. Scott-Warren, V., & Morley, R. (2015). Paediatric vascular access. BJA Education Bja Educ, 15(4), 199-206. Retrieved February 22, 2016, from http://bjaed.oxfordjournals.org/content/early/2015/06/03/bjaceaccp.mku050
- 62. Umbilical Lines (UVC) • May be the best option for an unstable premature infant. • Size: – Under 1.5 kg: 3.5 French – 1.5 + kg: 5 French • IV Caths? – 18 Gauge – Do not advance past abd wall
- 65. Fluids • Rarely needed – Refractory bradycardia and arrest – Severe Maternal Blood loss pre-birth • 10 cc / kg • “Volume expansion should be considered when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the infant’s heart rate has not responded adequately to other resuscitative measures.” (Class IIb, LOE C)
- 67. Comments about Narcan and the Newly Born
- 68. Non Viable? • Fundus below the umbilicus • Eyes Fused • Maternal Report
- 69. Final Thoughts
- 70. The 4 “Ts” Recalled “THROMBIN” Check labs if suspicious.
Editor's Notes
- S.T.A.B.L.E. is the most widely distributed and implemented neonatal education program to focus exclusively on the post-resuscitation/pre-transport stabilization care of sick infants. Based on a mnemonic to optimize learning, retention and recall of information, S.T.A.B.L.E. stands for the six assessment and care modules in the program: Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support. A seventh module, Quality Improvement stresses the professional responsibility of improving and evaluating care provided to sick infants. First introduced in 1996 in the US and Canada, S.T.A.B.L.E. has grown internationally to include instructor training and courses in more than 45 countries.Currently, there are more than 3,800 registered instructors worldwide and more than 411,000 neonatal healthcare providers have completed a S.T.A.B.L.E. Learner course. Sugar and Safe Care Temperature Airway Blood Pressure Lab Work Emotional Support
- The Golden Minute (60-second) mark for completing the initial steps, reevaluating, and beginning ventilation (if required) is retained to emphasize the importance of avoiding unnecessary delay in initiation of ventilation, the most important step for successful resuscitation of the newly born who has not responded to the initial steps. Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitation measures, such as cardiac compressions and medications. Although most newly born infants successfully transition from intrauterine to extrauterine life without special help, because of the large total number of births, a significant number will require some degree of resuscitation. 3 2 Newly born infants who do not require resuscitation can be generally identified upon delivery by rapidly assessing the answers to the following 3 questions: Term gestation? Good tone? Breathing or crying? If the answer to all 3 questions is “yes,” the newly born infant may stay with the mother for routine care. Routine care means the infant is dried, placed skin to skin with the mother, and covered with dry linen to maintain a normal temperature. Observation of breathing, activity, and color must be ongoing. If the answer to any of these assessment questions is “no,” the infant should be moved to a radiant warmer to receive 1 or more of the following 4 actions in sequence:
- HR is a good indicator of improvement or deterioration Assessment of heart rate remains critical during the first minute of resuscitation and the use of a 3-lead ECG may be reasonable, because providers may not assess heart rate accurately by auscultation or palpation, and pulse oximetry may underestimate heart rate. Use of the ECG does not replace the need for pulse oximetry to evaluate the newborn’s oxygenation
- Yes, initiate compressions if HR between 60-100 and not increasing or responsive to other interventions… 3:1 ratio Two thumb , not two finger Indications: Pulse oximetry (with probe attached to right upper extremity; usually wrist or arm), should be used to assess any need for supplementary oxygen. Dosage: Term babies: Begin resuscitation with air O2 administration should be guided by SpO2 (pulse ox on upper right extremity; ie, wrist or palm)
- Compress to depth of 1/3 AP diameter of chest Compress the lower 1/3 of the sternum Use 2-thumb technique rather than 2-finger technique 3:1 compressions to ventilation ratio for asphyxial arrest Coordinate compressions and ventilations to avoid simultaneous delivery Avoid frequent interruptions in compressions
- Epinephrine remains the primary vasopressor for neonatal resuscitation complicated by asystole or prolonged bradycardia not responsive to adequate ventilation and chest compressions. Epinephrine increases coronary perfusion pressure primarily through peripheral vasoconstriction. Current guidelines recommend intravenous epinephrine administration (0.01-0.03 mg/kg). Endotracheal epinephrine administration results in unpredictable absorption. High-dose intravenous epinephrine poses additional risks and does not result in better long-term survival. Vasopressin has been considered an alternative to epinephrine in adults, but there is insufficient evidence to recommend its use in newborn infants. Future research will focus on the best sequence for epinephrine administration and chest compressions. Clin Perinatol. 2012 Dec;39(4):843-55. doi: 10.1016/j.clp.2012.09.005. Medications in neonatal resuscitation: epinephrine and the search for better alternative strategies. Weiner GM1, Niermeyer S.
- Resuscitation of preterm newborns of less than 35 weeks of gestation should be initiated with low oxygen (21% to 30%) and the oxygen titrated to achieve preductal oxygen saturation approximating the range achieved in healthy term infants. There are insufficient data about the safety and the method of application of sustained inflation of greater than 5 seconds’ duration for the transitioning newborn. A laryngeal mask may be considered as an alternative to tracheal intubation if face-mask ventilation is unsuccessful, and a laryngeal mask is recommended during resuscitation of newborns 34 weeks or more of gestation when tracheal intubation is unsuccessful or not feasible. Spontaneously breathing preterm infants with respiratory distress may be supported with continuous Key Words: cardiopulmonary resuscitation neonatal Part 13: Neonatal Resuscitation 1 positive airway pressure initially rather than with routine intubation for administering PPV.
- Administration of Oxygen to Preterm Newborns 2015 (Updated): Resuscitation of preterm newborns of less than 35 weeks of gestation should be initiated with low oxygen (21% to 30%), and the oxygen concentration should be titrated to achieve a preductal oxygen saturation approximating the interquartile range measured in healthy term infants after vaginal birth at sea level. Initiating resuscitation of preterm newborns with high oxygen (65% or greater) is not recommended. This recommendation reflects a preference for not exposing preterm newborns to additional oxygen without data demonstrating a proven benefit for important outcomes. 2010 (Old): It is reasonable to initiate resuscitation with air (21% oxygen at sea level). Supplementary oxygen may be administered and titrated to achieve a preductal oxygen saturation approximating the interquartile range measured in healthy term infants after vaginal birth at sea level. Most data were from term infants not during resuscitation, with a single study of preterm infants during resuscitation. Why: Data are now available from a meta-analysis of 7 randomized studies demonstrating no benefit in survival to hospital discharge, prevention of bronchopulmonary dysplasia, intraventricular hemorrhage, or retinopathy of prematurity when preterm newborns (less than 35 weeks of gestation) were resuscitated with high (65% or greater) compared with low (21% to 30%) oxygen concentration.
- Targeted Preductal SpO2 after Birth 1 min 60-65% 2 min 65-70% 3 min 70-75% 4 min 75-80% 5 min80-85%10 min 85-95% Notes: Assess simultaneously, HR, RR and SpO2
- Initial Parameters Rate: 40 - 60 breaths/min (to achieve/maintain HR > 100) (Assess chest wall movement if HR does not improve) PIP: 20 - 40 cm H2O (Individualize to achieve ↑ HR and/or chest movement) If monitored, 20 cm H2O may be effective If not monitored, use minimum inflation required to achieve ↑ HR. Preterm infants PIP: 20 to 25 cm H2O Adequate for most ↑ if no prompt ↑ in HR or chest movement Avoid excessive chest wall movement. Monitor PIP if possible PEEP or CPAP may be beneficial
- https://www.youtube.com/watch?v=rls9R8iFuck
- Unless it is a flow inflating bag, which in the field in the U.S..not, they are suffocating the infant unless they have taken over actively assisting respirations. A self inflating BVM does not provide any (or minimal) free flow O2 and the valve takes in excess of 20 cmH2O of pressure to open if one has a very tight seal. Even cupping your hand with O2 tubing between your fingers and placed lightly over the child's face would be much safer.
- Meconium staining: Routine intrapartum suctioning no longer advised Vigorous infant (HR > 100, strong respiratory effort, good muscle tone) - do not perform ET suctioning Not vigorous - perform ET suctioning immediately after birth New guidelines will say not to even suction even if there is meconium, rather ETT based on vigor and other indicators. “Suctioning Nonvigorous Infants Through Meconium-Stained Amniotic Fluid 2015 (Updated): If an infant born through meconiumstained amniotic fluid presents with poor muscle tone and inadequate breathing efforts, the initial steps of resuscitation should be completed under the radiant warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed. Routine intubation for tracheal suction in this setting is not suggested, because there is insufficient evidence to continue recommending this practice. However, a team that includes someone skilled in intubation of the newborn should still be present in the delivery room. 2010 (Old): There was insufficient evidence to recommend a change in the current practice of performing endotracheal suctioning of nonvigorous infants with meconium-stained amniotic fluid. Why: Review of the evidence suggests that resuscitation should follow the same principles for infants with meconium-stained fluid as for those with clear fluid; that is, if poor muscle tone and inadequate breathing effort are present, the initial steps of resuscitation (warming and maintaining temperature, positioning the infant, clearing the airway of secretions if needed, drying, and stimulating the infant) should be completed under an overbed warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed. Experts placed greater value on harm avoidance (ie, delays in providing bagmask ventilation, potential harm of the procedure) over the unknown benefit of the intervention of routine tracheal intubation and suctioning. Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each individual infant. This may include intubation and suction if the airway is obstructed. “
- Temperature of newly born nonasphyxiated infants should be maintained between 36.5°C and 37.5°C after birth through admission and stabilization. A variety of strategies (radiant warmers, plastic wrap with a cap, thermal mattress, warmed humidified gases, and increased room temperature plus cap plus thermal mattress) may be reasonable to prevent hypothermia in preterm infants. Hyperthermia (temperature greater than 38°C) should be avoided because it introduces potential associated risks. In resource-limited settings, simple measures to prevent hypothermia in the first hours of life (use of plastic wraps, skinto-skin contact, and even placing the infant after drying in a clean food-grade plastic bag up to the neck) may reduce mortality. Below 35o C (95o F) Increased surface to volume ratio Can be an indicator of sepsis Can lead to: metabolic acidosis pulmonary hypertension hypoxemia
- A variety of strategies (radiant warmers, plastic wrap with a cap, thermal mattress, warmed humidified gases, and increased room temperature plus cap plus thermal mattress) may be reasonable to prevent hypothermia in preterm infants. In resource-limited settings, simple measures to prevent hypothermia in the first hours of life (use of plastic wraps, skin to-skin contact, and even placing the infant after drying in a clean food-grade plastic bag up to the neck) may reduce mortality. Hyperthermia (temperature greater than 38°C/ 100.4° F ) should be avoided because it introduces potential associated risks.
- The Warm Chain” – Passive Warm Delivery Area Immediate Drying (ASAP) Skin to Skin Breast Feeding Postponing Bathing and weighing Dry bedding/clothes (Often overlooked) Mom/Baby together Warm transport
- Hypothermia increases Cardiovascular Stress and O2 Demand This causes Hypoxia , respiratory failure, and even neurological damage
- Brown adipose tissue (BAT), also known as brown fat, is one of two types of fat humans and other mammals have - the other type is known as white or yellow fat. Human newborns and hibernating mammals have high levels of brown fat. Brown fat's main function is to generate body heat. However, scientists are just starting to understand what brown fat does, and stress that there is a great deal about it that we do not yet know. White adipocytes (white fat cells) have a single lipid droplet, brown adipocytes contain many small lipid droplets, as well as a very high number of iron-containing mitochondria. Brown fat gets its dark red to tan color from its high iron content. Brown fat has more capillaries than white fat, because of its higher oxygen consumption. Brown fat also has many unmyelinated nerves, providing sympathetic stimulation to the fat cells. Brown adipose tissue (BAT), also known as brown fat, is one of two types of fat humans and other mammals have - the other type is known as white or yellow fat. Human newborns and hibernating mammals have high levels of brown fat. Brown fat's main function is to generate body heat. However, scientists are just starting to understand what brown fat does, and stress that there is a great deal about it that we do not yet know. White adipocytes (white fat cells) have a single lipid droplet, brown adipocytes contain many small lipid droplets, as well as a very high number of iron-containing mitochondria. Brown fat gets its dark red to tan color from its high iron content. Brown fat has more capillaries than white fat, because of its higher oxygen consumption. Brown fat also has many unmyelinated nerves, providing sympathetic stimulation to the fat cells.
- Three main factors that negatively affect the infants ability to maintain a normal glucose psot birth: Poor glycogen stores: Hyperinsulinemia (too much insulin): Diabetic Mother Increased glucose Utilization
- http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/ Shallow angle of insertion [Photograph found in Royal Children's Hospital Melbourne, Melbourne, Australia]. (n.d.). Retrieved February 22, 2016, from http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/
- Scott-Warren, V., & Morley, R. (2015). Paediatric vascular access. BJA Education Bja Educ, 15(4), 199-206. Retrieved February 22, 2016, from http://bjaed.oxfordjournals.org/content/early/2015/06/03/bjaceaccp.mku050
- “…To conclude, trans-illumination of the palm can be a simple, yet effective technique to facilitate difficult peripheral intravenous cannulation in pediatric patients, thus avoiding the need and preventing the inherent risks of alternative techniques for intervenus access .“ Shrestha, G. S., Acharya, B., & Tamang, S. (2015). Transillumination of palm for peripheral intravenous cannulation in an infant with difficult venous access. J. Soc. Anesth. Nep. Journal of Society of Anesthesiologists of Nepal, 2(1), 31. Retrieved February 22, 2016.
- This topic was last reviewed in 2010.3 Dosing recommendations remain unchanged from 2010. 7,8 Volume expansion should be considered when blood loss is known or suspected (pale skin, poor perfusion, weak pulse) and the infant’s heart rate has not responded adequately to other resuscitative measures.216 (Class IIb, LOE C) LAST UPDATED: OCT 2010 An isotonic crystalloid solution or blood may be useful for volume expansion in the delivery room. (Class IIb, LOE C) LAST UPDATED: OCT 2010 The recommended dose is 10 mL/kg, which may need to be repeated. When resuscitating premature infants, care should be taken to avoid giving volume expanders rapidly, because rapid infusions of large volumes have been associated with IVH.(Class IIb, LOE C)
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