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Neonatal resuscitation 2012 AG
1. Neonatal resuscitation is required for approximately 10% of newborns, with 1% needing major intervention. Preterm infants are at higher risk of requiring resuscitation. 2. Effective ventilation is the most important part of neonatal resuscitation. Bag-mask ventilation should be performed if the heart rate is less than 100 beats per minute or if the infant has apnea or gasping respiration. 3. Chest compressions are performed if the heart rate remains below 60 beats per minute after 30 seconds of effective bag-mask ventilation with 100% oxygen. Compressions are done at a 3:1 ratio with ventilations at 90 compressions per minute.
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Neonatal resuscitation 2012 AG
- 1. Neonatal Resuscitation Presented By Dr. AkshayGolwalkar Moderated By Dr. Sunil Gavhane
- 2. FACTS • 90% Don’trequire any intervention • 10% require intervention • 1 % need major resuscitation • Preterms are at high risk
- 3. How often dowe use our resuscitation skills?
- 4. Primary causes ofdeath* 18 %Other causes 09 %Malformation 29 %Perinatal hypoxia 17 %Infection 27 %Prematurity DeathsCause *Text book of Neonatal Resuscitation 6th edition
- 5. Alveoli are fluid filled Bloodvessels are constricted
- 6. After birth Fluid inthe alveoli is absorbed Alveoli • Expand • Get filled with Air 1.
- 7. 2. Pulmonary vessels dilate,causing increased blood flow to lungs
- 8. Requirements • Personnel – Atleast one trained person for all deliveries – Two persons, if high risk; or for advanced resuscitation
- 10. Bag, Mask, & Oxygen Suction Equipment Laryngoscope andETT Tube Warmer & Blankets
- 11. Resuscitation •Is the newbornterm? •Is the newborn breathing or crying? •Does the newborn have good muscle tone? •Dry & remove wet cloth •Clear airway if necessary •Wrap in prewarmed dry cloth •Breast feeds •Ongoing Evalution YE S Baby is Delivered ( Ask) Routine Care
- 13. Dry & Removewet linen
- 14. Routine Care • Vigorousterm infants with no risk factors • Babies who required but responded to initial steps, They now can stay with Mother • Skin to skin contact recommended • Clear airway, dry newborn, provide ongoing evaluation: – Breathing – Activity – Color • Transfer to New Born Nursery
- 16.
- 17. Clear Airway, ifnecessary
- 18.
- 19. Oral Suctioning Deep suctionshould be performed
- 20.
- 21. • Breathing : Regular/ Gasping / Irregular / Absent • Heart Rate : >100/m OR< 100/m OR Absent • SpO2 EVALUATE
- 23. Pulse Oximetry: Resuscitation monitor •Advantages o Not affected by acrocyanosis o Be patient and get a reading
- 25. Supplemental oxygen Free-flow oxygencannot be given reliably by a mask attached to a self-inflating bag
- 26. PPV/Bag & maskventilation
- 27. •HR below 100 •Apnoea/gasping YE S •StartPPV •Consider SpO2 monitering
- 28. Indications for Bag& Mask ventilation • Apnea or gasping respiration OR • Heart rate < 100 bpm OR • Saturation below target values despite free flow supplemental oxygen
- 29. Key point The mostimportant and effective action in neonatal resuscitation is EFFECTIVE VentilationEFFECTIVE Ventilation
- 30. Selecting equipment • Sizeof bag (200-750 ml) : To deliver a tidal volume of 6-8 ml/kg • Oxygen capability : Oxygen source, reservoir
- 31.
- 32.
- 33. Testing the self-inflatingbag • Squeeze against your palm – Pressure felt – Pressure release valve – Pressure manometer – Re-inflation
- 34.
- 35.
- 36. Self inflating bag •Advantages • Easier to use • Pressure release valve • Don’t not need a gas source to inflate
- 37. Self inflating bag •Disadvantages • Requires a reservoir to deliver 100% oxygen • Can not be used to deliver 100% free flow oxygen
- 38. Masks • Cushioned/Non-cushioned • Round/Anatomicalshaped • Size 0 or 1
- 39. The surface onwhich the baby is placed should always be warm as well as flat, firm and clean POSITION
- 40.
- 41. Positioning • Positioning theinfant & resuscitator
- 43. Forming & checkingthe seal
- 44.
- 45. Evaluation-Decision-Evaluation-Decision- Action cycleAction cycle Evaluation ActionDecision 30 sec30 sec
- 46. Signs of Effective Ventilation Signof response to ventilation:Sign of response to ventilation: • Improved heart rate Signs of improvement in newborn:Signs of improvement in newborn: • Improved heart rate, color, breathing, tone, and saturation
- 47. Contraindications • Diaphragmatic hernia •Non -vigorous baby born through meconium stained liquor
- 48. No improvement • Ischest rise adequate? • Is adequate oxygen being administered?
- 49. MR. SOPAMR. SOPA •M-Adjust Mask on the face •R- Reposition the head to open airway oRe-attempt to ventilate…if not effective then •S- Suction mouth then nose •O- Open mouth and lift jaw forward oRe-attempt to ventilate…if not effective then •P- Gradually increase Pressure every few breaths until visible chest rise is noted oMax Pip 40cmH2O If still not effective then… •A- Alternative Airway (ETT or LMA)
- 50. When to stop? • Heart rate above 100/min • Spontaneous breathing • Baby in Post Resuscitation care
- 51. Chest Compressions Its a2 personnel job
- 53. Indication If after 30seconds of EFFECTIVE bag and mask ventilation with 100% oxygen, Heart Rate is below 60 per minute Indications
- 54. • Pump outblood from the heart during compression and fill up blood in the heart during release • Must always be accompanied by ventilation with 100% oxygen Principle
- 55. Compress Release Heart Heart sternum Mechanismof Chest Compressions sternum
- 56. • Position – Neckslightly extended with firm support for the back – Lower 1/3rd of sternum between nipple line & sternum • Pressure required – depth – 1/3rd of the AP diameter of chest • Rate – 90/min Components
- 58. Two-finger method Techniques ofChest Compressions Thumb method
- 59.
- 60. • Easier withright hand for right handed • Index and middle or ring fingers • Other hand used to support the back • Pressure applied vertically 2 Finger Technique
- 61.
- 62. Don’t lift yourfingers/thumbs
- 63. • Advantages • Bettercontrol of depth • Less tiring • Superior generation of peak systolic & coronary perfusion pressure • Nails do not hinder performance • Disadvantages • Difficult when baby is big • Umbilicus difficult to canulate Preferred method - Thumb
- 64. Rate • 3 ChestCompressions then 1 ventilation • 90 Chest Compressions to 30 ventilations in one minute Adequacy • Palpate femoral/carotid pulse Rate and Adequacy
- 65. • Consists of3 compression & one ventilation • 120 events in 60 seconds • 1 cycles in 2 seconds • ONE- AND – TWO – AND – THREE – ANDONE- AND – TWO – AND – THREE – AND - BREATH- BREATH Cycle of events
- 66. • No pressureto be applied on ribs, Xipisternum, abdomen • Do not lift thumbs/fingers Precautions
- 67. Dangers • Broken ribs •Lacerated liver • Pneumothorax Chest Compressions
- 68. • HR 60per minute or more Stop CC, continue BMV at 40-60/min • If no improvement, check : – Effectiveness of BMV – Oxygen is 100% – Technique of CC is correct Evaluation after 30 sec of CC & BMV
- 69. When to stop chestcompressions • When heart rate is 60 per minute or more
- 70. Key points • 2personnel job • Ensure 100 % oxygen • Ensure adequate chest movement during ventilation • Co-ordinate B & M with CC at 3 : 1 • Check HR every 30 seconds • Use thumb or 2 finger technique
- 71.
- 72. Indications for intubation •Meconium suctioning in non vigorous baby • Diaphragmatic hernia • Prolonged or ineffective ventilation • Elective – VLBW – with CC
- 73.
- 74. Preparing laryngoscope • No.1 for full term • No. 0 for preterm / LBW • No. 00 for extremely preterm (optional)
- 75.
- 76. Selecting endotracheal tube TubeSize (ID mm) Weight (gm) Gest. Age (Wks) 2.5 < 1000 < 28 3.0 1000-2000 28-34 3.5 2000-3000 35-38 4.0 >3000 > 38 ID=Internal Diameter
- 77. Preparing endotracheal tube •Shorten the tube to 13 cm • Replace ET tube connector • Insert stylet (optional)
- 78. Additional items Tape :For securing the tube Suction equipment Oxygen • For free flow oxygen during intubation • For Use with the resuscitation bag Resuscitation Bag and Mask • To ventilate the infant in between intubation • To check tube placement
- 79. Positioning the infant •On a flat surface • Head in midline • Neck slightly extended • Optimal viewing of glottis
- 81.
- 82.
- 83. Lip reference mark:(6 + weight in kilos) cm 9-10 cm at the lip for this term infant
- 84. Tube in Rt.Main bronchus • Breath sounds only on right chest • No air heard entering stomach • No gastric distention Action Withdraw the tube, recheck
- 85. Tube in esophagus •No breath sounds heard • Air heard entering stomach • Gastric distention may be seen • No mist in tube Action Remove the tube, oxygenate the infant with a bag and mask, reintroduce ET tube
- 86. Complications of intubation •Hypoxia • Bradycardia • Apnea • Pneumothorax • Soft tissue injury • Infection
- 87. Minimizing hypoxia during intubation •Providing free-flow oxygen (Assistant’s responsibility) • Limiting each intubation attempt to 20 seconds
- 88.
- 90.
- 91. No drugs forme!No drugs for me!
- 92. MEDICATIONS • Epinephrine • Volumeexpansion
- 93. Neonatal Resuscitation No roleof • Atropine • Calcium • Dexamethasone • Dextrose • Intra cardiac adrenaline • Naloxone
- 94. Epinephrine • Formulation 1:1000 •Dilution 1:10000 (Ten times) 0.2 ml in 1.8 ml • Load 1 ml (in 1ml syringe) • Dose 0.1-0.3 ml/kg • Route IV (preferable) • Rate Rapid bolus
- 95. Epinephrine Follow up: ifHR < 60 or 0 • Repeat epinephrine q 3-5 minutes • Ensure: effective ventilation effective chest compressions endotracheal intubation (if not done already) • Consider using volume expander
- 96. What is expectedresponse • After 30 seconds of administration and continued PPV and CC – HR should increase to > 60 bpm • If no response repeat the dose every 3-5 minutes • Repeat doses should preferably be give IV
- 97. “If the babyappears to be in shock and is not responding to resuscitation, administration of a volume expander may be indicated” ! Shock - HypovolemiaShock - Hypovolemia
- 98. Signs of Hypovolemia •Pallor persisting beyond oxygenation • Weak pulses • Low blood pressure • Lack of response to resuscitation Hypovolemia is a common but often unrecognized cause of need for resuscitation
- 99. Volume Expansion • Indicatedwhen there is no response to resuscitation and there is evidence of blood loss or hypovolemia • Repeated doses may be necessary if there is minimal response after the first dose • Umbilical vein remains preferred route but intraosseous acceptable
- 100. Medication Administration via UmbilicalVein • Preferred route for intravenous access • 3.5F or 5F end-hole catheter • Sterile technique Placing catheter inPlacing catheter in umbilical veinumbilical vein
- 102. Volume Expanders • Normalsaline • Ringer’s lactate • Whole blood (O Neg cross matched with mother’s blood)
- 103. Normal saline Indications • Evidenceor suspicion of acute blood loss with signs of hypovolemia and/or baby responding poorly to resuscitation
- 104. • Dose –10ml/kg • Route – Umbilical vein • Preparation – large syringe • Rate of administration – 5-10 minutes In premature babies: Rapid boluses may induce ICH Normal saline
- 105. Volume expanders • Effect: Volume expansion, correction of metabolic acidosis • Expectation : Better BP & pulses, less pallor • Follow up : If signs of hypoperfusion persist, repeat volume expander, consider sodium bicarbonate or dopamine
- 107.
Editor's Notes
- #31 This is a critically important skill and the single most important step in the resuscitation of the compromised newborn. The success of resuscitation may be dependent on the effectiveness of this procedure.
- #104 To place a catheter in the umbilical vein, Clean the cord with antiseptic. Place a loose tie of umbilical tape around the base of the cord. Pre-fill a 3.5F or 5F single end-hole catheter with normal saline. Connect catheter to stopcock and syringe. Close the stopcock to the catheter to prevent fluid loss and air entry. Using sterile technique, Cut the cord with the scalpel below the clamp about 1 to 2 cm from the skin line. The umbilical vein will be seen as a large, thin-walled structure, usually at the 11- to 12-o’clock position. Insert the catheter into the umbilical vein. The course of the vein will be up toward the heart, so this is the direction you should point the catheter. Instructor Tip: Keep all umbilical venous catheter insertion supplies together in one sealed bag or tray. To prevent injury, stop compressions and alert team members when scalpel is being used.