Downloaded 255 times
More Related Content
Similar to Neonatal resuscitation
Neonatal resuscitation
- 1. NEONATAL RESUSCITATION Presented by:Dr.Himanshu Dave Secondary DNB (1st year) DEPARTMENT OF PEDIATRICS NRCH
- 2. Topics to behighlighted • History • Principles of Resuscitation • Initial steps of resuscitation • Positive – Pressure ventilation • Endotracheal tube intubation and LMA insertion • Chest compressions • Medications • Special considerations • When to stop resuscitation
- 3. HISTORY • Dr.William Keenan– Father of NRP • Every five years, the International Liaison Committee on Resuscitation (ILCOR) comprising representation from 13 countries worldwide reviews the available resuscitation science.
- 4. • It providesrecommendations based on the available evidence at that time. • The ILCOR guidelines were published in October 2015 and the AAP launched its 7th edition of NRP in May 2016.
- 5. PRINCIPLES OF RESUSCITATION •Birth asphyxia accounts for about 1/4th of the neonatal deaths that occur each year worldwide. • 90% of newborns make smooth transition from intrauterine to extra uterine life requiring little or no assistance. • 10% of newborns need some assistance. • Only 1% require extensive resuscitation.
- 6. WHAT CAN GOWRONG ? Compromise of uterine or placental blood flow Deceleration of FHS Weak cry Inadequate ventilation to push the alveolar fluid
- 7. In utero hypoxia Meconiumpassage May block the airways
- 8. Pulmonary arterioles remainconstricted PPHN (Persistent Pulmonary Hypertension of New Born)
- 9. CONSEQUENCES • Low muscletone , apnoea or tachypnea , bradycardia or hypotension and cyanosis. • Outcomes of these newborns can be improved with timely and effective resuscitation.
- 11. INITIAL PREPARATIONS • Thereis increased focus throughout the 7th edition NRP on team preparation and role assignment. • Team briefing • Role assignment • Equipment check.
- 12. Initial preparations cont… •Every birth should be attended by at least 1 person whose only responsibility is care of the newborn. • Meconium stained amniotic fluid- ensure a member with advanced airway and resuscitation skills is in attendance.
- 13.
- 14. INITIAL ASSESSMENT • Ask4 questions to the obstetrician: 1) Gestational age? 2) MSAF? 3) Single or multiple gestation? 4) Risk factors in mother?
- 15. INITIAL STEPS • Initialassessment after birth :Tone ? and breathing/crying? • Warmth and position airway • Suction if necessary • Dry and stimulate • Repositioning
- 16. Initial Steps cont… •In stable infants, delayed cord clamping should be performed for at least 30 seconds • Temperature should be maintained between 36.5 and 37.5 Celsius • Focus on thermoregulation throughout resuscitation
- 17. ROUTINE CARE • Vigorousterm babies with no risk factors & who required but responded to initial steps: – Skin to skin contact and can stay with mother – Clear airway – Dry newborn – Provide ongoing evaluation: Breathing , Activity and Colour .
- 18. Role of supplementaloxygen in NRP • Starting resuscitation gas for term infant should be 21% • In infants <35 weeks, starting gas should be 21-30% and should be increased as per requirement. • Continue to achieve target saturations using preductal saturation monitor.
- 19. TARGETED PREDUCTAL SPO2AFTER BIRTH • 1 min 60%-65% • 2 min 65%-70% • 3min 70%-75% • 4min 75%-80% • 5min 80%-85% • 10min 85%-95%
- 20. The Golden Minute •The Golden Minute (60-second) mark is for completing the initial assessment, initial steps, re-evaluating, and beginning ventilation if required . • Evaluations and decision making are based on: a) Respiratory effort b) Heart rate
- 21. Evaluation • For assessmentof heart rate, the use of a 3- lead ECG is recommended. • Pulse oximetry to evaluate the newborn’s oxygenation
- 22. Positive Pressure Ventilation(PPV) • Indications for PPV : - Heart rate less than 100 bpm or - Ineffective respirations. • Initial PIP (Peak Inspiratory Pressure) is suggested in the range of 20-25 cm H20. • When PPV is administered to preterm infants, PEEP(Positive End Expiratory Pressure) should be used. Recommended starting PEEP is 5 cm H20.
- 23. PPV cont…. • Rateof PPV is 40-60 / minute. (Breathe ,2,3..) • Rising of HR • Improvement in Oxygen Saturation PPV • Equal and adequate breath sounds Effective • B/L Good Chest rise If
- 24. PPV cont… • AfterPPV started, reassess in 15 seconds. • If no response; MR SOPA corrective measures should be incorporated.
- 27. Indication of CPAP •If HR is >100 but has laboured breathing or Sp02 cannot be maintained within target range despite 100% free-flow oxygen: - consider a trial of Continuous Positive Airway Pressure (CPAP)
- 28. ADVANCED AIRWAY Intubation isrecommended prior to chest compressions. If intubation is not feasible, the laryngeal mask airway should be used as an alternate advanced airway. Recommendations for depth of insertion are gestation-based or based on formula using nasal-tragus length (NTL) measurement.
- 29.
- 31. CHEST COMPRESSIONS • Theindication for chest compressions: - Heart rate less than 60 bpm in spite of 30 seconds of effective PPV. • 100% oxygen to be given when administering chest compressions.
- 32. Chest compressions cont… •The 2-thumb technique is recommended (Two finger technique is now obsolete).
- 33. Chest compression cont… •Compress 1/3rd diameter of chest. • Do not lift the fingers off the chest. • 90 compressions to 30 ventilations/minute (3:1- One & two & three & breathe & One & two & three & breathe…)
- 34. Chest Compression Cont… •Chest compressions should be continued for 60 seconds before reassessment of heart rate. • Electronic cardiac monitor preferred for assessment of heart rate.
- 35. Technique of chestcompressions with PPV
- 36. MEDICATIONS 1.EPINEPHRINE • Indicated if: HR remains <60 bpm after at least 30 sec of effective PPV and another 60 seconds of chest compressions using 100% oxygen . • One dose may be given through ETT. • If no response, give intravenous dose via emergency UVC or IO access.
- 37. MEDICATIONS cont… • Concentration- 1:10,000 (0.1mg/ml) . • ETT dose - 0.5 – 1 ml/kg . • UVC / IV dose 0.1- 0.3 ml/kg ,follow with a 1ml flush NS . • Can repeat every 3-5 minutes.
- 38. MEDICATIONS cont… 2.OTHERS • Forhypovolemic shock: Normal saline and blood are the solutions of choice and the recommended volume is 10 ml/kg. • Ringer’s lactate is no longer recommended.
- 39. • The routineuse of NaHCO3 to correct metabolic acidosis is not recommended. • The use of naloxone to manage respiratory depression in infants born to mothers with narcotic exposure in labour is not recommended.
- 40. SPECIAL SCENARIOS • DELAYEDCORD CLAMPING : Recommendation that delayed cord clamping for 30 -60 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth. If placental circulation is not intact (placental abruption or bleeding due to any cause): The cord should be clamped immediately after birth.
- 41. SPECIAL SCENARIOS • MECONIUMSTAINED LIQUOR : If the infant born through meconium-stained amniotic fluid is non vigorous, 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 is not suggested.
- 42. SPECIAL SCENARIOS • Pneumothorax: Percutaneous needle aspiration • Pleural effusion : Percutaneous needle aspiration • Congenital Diaphragmatic hernia : Intubation • Therapeutic hypothermia for HIE : For >/= 36wks with severe birth asphyxia, initiated within 6 hours after birth, in facilities with multidisciplinary care.
- 43. WHEN TO STOPRESUSCITATION ? * An APGAR score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants, but decisions to continue or discontinue resuscitation efforts must be individualized. * Where GA ( < 23wks ), B.wt ( < 400g) and / or Congenital anomalies are associated with early death and high morbidity, resuscitation is not indicated.
- 44.
Editor's Notes
- #16 Initial assessment and initial resuscitation steps remain unchanged.
- #17 Thermoregulation is emphasized and a combination of interventions is recommended for temperature control in the preterm infant. The aim for all infants is to maintain normothermia with temperature in the range of 36. to 37.5.
- #19 In the stable infant who does not require resuscitation, delayed cord clamping is recommended for at least 30 seconds. There is insufficient evidence to recommend an approach to the infant requiring resuscitation so the recommendation remains that in that situation, the cord should be clamped and resuscitation commenced. Starting resuscitation gas for term infants is 21% oxygen. Following review of the ILCOR worksheet and recommendation in regard to preterm infants, in those infants born less than 35 weeks gestation, the starting oxygen concentration should be in low (21-30%) rather than high range. There is insufficient evidence to make a clear recommendation within this range and choice of starting concentration of oxygen should be as per local guidelines. Oxygen saturations should continue to be measured using a preductal saturation probe and oxygen should be titrated to meet target guidelines.