detailed discussion of resuscitation of neonates as per latest NRP protocol

1. Neonatal Resuscitation – What is New?
Towards “INTACT SURVIVAL”
Presented by –
Dr Gururaja R
MD, DNB
Pediatriciain

3. Neonatal care in India
• Birth asphyxia is an
important cause of
mortality
• FAILURE TO BREATH AT
BIRTH
• Birth Asphyxia
• APGAR <3

4. Birth asphyxia
• Progressive hypoxia
• Acidosis
• Hypo perfusion
• Hypercapnia
• Multiorgan dysfunction
• Death
• HIE
• Long term neurological
sequelae
• CEREBRAL PALSY

5. Neonatal Resuscitation Program (NRP)
• Broad consensus on
evidence based
resuscitation
• Based on AHA and AAP
guidelines
• Whole world follow this
protocol
• Latest published in 2015
• Revision 2017

7. Why this topic?
• 16-20% of neonatal
deaths
• 5-10% deliveries require
Resuscitation
• Intact survival

8. Why do newborns require a different
approach to resuscitation than adults?
• Adult cardiac arrest
• Complication of existing
heart disease
• Most newborns have a
HEALTHY HEART
• Newborns require
resuscitation due to
problem in respiration
leading to inadequate gas
exchange

12. Fetal circulation – Changes in Newborn
Physiology

15. Lung inflation
• Lungs do not take part
in respiration
• Placenta
• Fetal alveoli filled with
fluid
• Fluid removal starts
after onset of labour
• May be delayed in LSCS

18. Changes at birth
• LUNGS start functioning
• Absence of placenta
• Systemic circulation

20. Fetal response to intrauterine hypoxia
• Fetus deprived of
oxygen ---
• Tachycardia
• Tachypnoea
• PRIMARY APNOEA

22. Secondary apnoea
• Primary apnoea identified early ----
• Just tactile stimulation revives the
newborn
• As asphyxia deepens
• Bradycardia, hypotension
• Flaccid baby
• DIFFICULT TO DIFFERENTIATE B/W
PRIMARY AND SECONDARY APNOEA
CLINICALLY
• Practically, WHAT WE SEE DURING
DELIVERY IS SECONDARY APNOEA

23. Secondary Apnoea
• Requires PPV
• All infant born with
apnoea are considered
to have secondary
apnoea
• Start resuscitation

25. If infant fails breathe after birth
• BIRTH ASPHYXIA(ALL THESE
TAKES PLACE IN LESS THEAN 5
MINUTES)
• Cyanosis
• Pulmonary vasoconstriction
• Metabolic acidosis
• Diving – in – reflex
• Myocardial depression
• Brain hypoxia
• Death
• If survives -----
NEUROLOGICAL DEFICIT

26. WE CAN MAKE DIFFERENCE
• THIS CAN BE
PREVENTED
• ENSURE CONTINUOUS
OXYGEN SUPPLY TO
BRAIN
• BUT ---HOW?
• NRP

28. We need to be prepared for
resucitation
• Anticipation
• Maternal risk factors –
antepartum and
intrapartum
• COMPLETE SURPRISE
• Each delivery as
emergency?
• Skilled staff

30. Equipment required

31. Equipment required

32. Equipment required

33. Apgar scores – does it really help in
NRP?

34. Apgar scores – does it really help in
NRP?
• Can not waste time
• Not used to guide
resuscitation
• Useful in assessing the
response to
resuscitation and
prognosis

36. Evaluation
• Respiration
• Heart rate(checked for
0nly 6 seconds – then
multiply by 10)
• Colour
• LOW HEART RATE-
most important

37. Three questions
• TERM OR NOT?
• BREATHING ?
• MUSCLE TONE?

38. Routine care – if anwers all 3 questions
is “YES”
• Warmth
• Clear airway
• Dry
• Hand over to mother

39. Three questions
• TERM OR NOT?
• BREATHING ?
• MUSCLE TONE?

40. Initial steps --- if anwers all 3 questions
is “NO”
• Warmth
• Clear airways
• positioning
• Dry
• STIMULATE
• 30 seconds

41. • If the baby has labored
breathing-------------------
• CPAP

42. RAM- cannula----HFHNC

45. Warmth
• Receive in prewarmed
linen
• Placed under heat
source
• RADIANT WARMER

50. New recommendation 2017
• Routine endotracheal
intubation not
recommended
• In non vigorous babies
• Use PPV
• Insufficient evidence
and studies

54. Positive pressure ventilation

71. Start chest compressions

108. IV Access

113. Latest concepts of NRP
• Room air oxygen
• Induced therapeutic
hypothermia
• Delayed cord clamping
• Intratracheal suction
may not be required in
Meconium aspiration ?

116. Thank you