We normally don’t think too much about this. Very important in neonates.
Hopefully we are not called to premature resus
This is the over riding goal, and resus is aimed at this. Keep this figure in mind. All following measures aim for this goal
Bradycardia sign of asphyxia and hypoxia
That’s why bradycardia is a very bad sign
Colour of newborn poor indicator of status
Brief overview of Foetal and newborn CVS
Refer to guide
Code PinkWhat to think about when running up to Delivery Suite A summary of the Australian Resuscitation Council Guidelines For Newborn Resuscitation
Australian Resuscitation Council Guidelines http://www.resus.org.au
The transition from fetus tonewborn requires intervention by a skilled individual or team inapproximately 10% of all deliveries.
Keep warmHypothermia on admission to the neonatal unit has been shown to be associated with an increased mortality. It is essential to prevent excessive heat loss in the delivery room and throughout stabilization and transport to the neonatal unit.
Keep WarmHypothermia can increase oxygen consumption and impede effective resuscitation
Axillary Temperatures in Infants Weighing Less Than 1500 gmRanges Temperature Action NeededNormal 36.5-37.5o C ContinuePotential cold stress 36-36.5o C Cause for concernModerate hypothermia 32-36o C Danger; immediate warming of baby neededSevere hypothermia < 32o C Outlook grave; skilled care urgently needed
Keep Warm• Newborns should be dried with pre-warmed blankets or towels and placed on a pre-warmed heat source. Open bed warmers, which use radiant heat, are used in most delivery rooms. They provide warmth during resuscitation and for any subsequent invasive procedures. It is important to keep in mind that this source of heat does not protect the infant from evaporative heat loss but, instead, encourages evaporative heat losses.
Keep Warm• Continuous monitoring of temperature should occur as soon as possible after the delivery. Premature infants (< 1500 g) should be covered in plastic wrap (polyethylene) to prevent excessive heat loss. A full resuscitation, including line placement, can and should be performed with the plastic wrap in place. A woolen head cap should be used.
Keep Warm• Another common source of heat loss in the neonate undergoing resuscitation is the use of unheated non-humidified oxygen sources for the bag-valve-mask device. The inspired gases sent to the lungs are subsequently heated and humidified by the infant; this results in massive heat exchange from evaporative heat loss and insensible water loss. Whenever possible, warmed and humidified gases should be provided in the resuscitation area.
Airway management• Once in a heated environment, the infant should be positioned so as to open the airway, and the mouth and nose should be suctioned.• Should suction involve larynx and Trachea?
Easy answer is no!!• Infants have a vagal reflex response to sensory stimulation of the larynx, which may induce apnea, bradycardia, hypotension, and laryngospasm.• Suctioning the posterior oral airway or the trachea with a catheter because of extremely thick or meconium-stained fluids may cause profound central apnea, potentially profound bradycardia, and laryngospasm
Suctioning• Instillation of saline into the trachea also has been shown to stimulate the afferent sensory neurons leading to apnea, bradycardia, hypotension, and laryngospasm.• Suctioning the posterior oral airway or the trachea consequently has no place in the immediate resuscitation period.• Lung inflation has been shown to reverse the effects of vagal stimulation.
Code Pink If called to Delivery suiteHeart Rate is the critical sign. >100 is crucial
Bradycardia is Bad• Normal Newborn HR is 100-160• HR below 100 requires Positive Pressure Ventilation and Pulse Oximetry• This is irrespective of normal or abnormal Respiratory effort
Why is Bradycardia bad?• A fetus or newborn that is subjected to asphyxia initiates a "diving" reflex in an attempt to maintain perfusion and oxygen delivery to vital organs. Hypoxia and acidosis lead to pulmonary arteriolar vasoconstriction. Pulmonary vascular resistance increases, leading to decreased pulmonary blood flow and increased blood flow directly to the left atrium.
Why is Bradycardia bad?• Systemic cardiac output is redistributed, with increased flow to the heart, brain, and adrenal glands and decreased flow to the rest of the body. Early in the course of asphyxia, systemic blood pressure increases.• With ongoing hypoxia and acidosis, however, the myocardium fails and bradycardia occurs; this causes a decrease in blood pressure and tissue perfusion, leading to eventual tissue ischemia and hypoxia.
• With prolonged asphyxial insult and failure of compensatory mechanisms, cerebral blood flow falls, leading to ischemic brain injury
What about Oximetry? •Is a cyanosed Newborn normal?
Reversal of right to left shunting• Clamping of the umbilical cord removes the low-resistance placental vascular circuit and thereby raises total systemic vascular resistance, with a resultant increase in left ventricular and aortic pressures. The increased systemic vascular resistance, combined with the decreased pulmonary vascular resistance, reverses the shunt through the ductus arteriosus (from right-to-left shunting to left-to- right shunting) until the ductus closes completely.• All of these events result in closure of the other fetal shunts. With the decrease in right atrial pressure and the increase in left atrial pressure, the 1-way "flap-valve" foramen ovale is pushed closed against the atrial septum. This functional closure at birth is followed by anatomic closure, which usually occurs at several months of age.
• Functional closure of the ductus arteriosus generally occurs within 72 hours of life, with anatomic closure by age 1-2 weeks.• Functional postnatal circulation generally is established within 60 seconds; however, completion of the transformation can take up to 6 weeks.
How to correct Bradycardia• PPV using Neopuff• 5cm PEEP (Positive End Expiratory Pressure)• 30cm PIP (Peak Inspiratory pressure)• Settings should already be made on resus trolley
PPV• Ventilatory rates of 40-60 breaths/min should be provided initially, with proportionally fewer assisted breaths provided if the infants spontaneous respiratory efforts increase.
Chest Compressions• Pressure should be applied to the lower portion of the sternum, depressing it to a depth of about one third of the anterior-posterior diameter. The chest should fully re-expand during relaxation. One ventilation should be interposed after every 3 chest compressions.• An overall rate of 120 compression/ventilation events per minute is recommended; with the 3:1 compression-to-ventilation ratio, this equates to 90 compressions and 30 breaths each minute.
Chest Compressions• Evaluate heart rate and color every 30 seconds. Infants who fail to respond may not be receiving effective ventilatory support; thus, constantly evaluating ventilation is imperative. Chest compressions should be discontinued when the heart rate is 60 beats/min or higher.
Intubation• If things still not going well then intubation required
Intubation Blade size 0 or 1 should be chosen in accordance with the size of the infant. Premature infants may be more easily intubated with a size 0 blade, and term infants require a size 1 blade. Endotracheal tube should be chosen in accordance with the weight of the infant .• Table 3. Endotracheal Tube Size and Measurement at Lip According to Infant Weight• Infant Weight Endotracheal Tube Size Endotracheal Tube Measurement at Lip• < 1000 g 2.5 7 cm• 1000-2000 g 2.5-3 8 cm• 2000-3000 g 3-3.5 9 cm• > 3000 g 3.5-4 10 cm
Intubation• Another way of estimating correct placement of the ET tube is to take the weight of the infant in kilograms and add 6 to yield the number of centimeters at which the tube should be secured at the lip.
Intubation• Assessment for equal bilateral breath sounds with maintenance of oxygenation.• An increase in the heart rate within 5-15 seconds is an excellent indicator of adequate ventilation and appropriate ET tube placement.
Intravenous Access• Needed for Volume expansion• Administration of Adrenaline
Intravenous Access• Peripheral Venous access• Umbilical Vein Catheterisation• Intraosseous access generally not recommended (Too small intramedullary space and fragile bones)
Intravenous Access• Umbilical vein catheterization may be a life- saving procedure in neonates who require vascular access and resuscitation.• The umbilical vein remains patent and viable for cannulation until approximately 1 week after birth
Umbilical Vein Catheterisation• Advance the catheter only 1-2 cm beyond the point at which good blood return is obtained. This is approximately 4-5 cm in a full-term neonate.
Umbilical Vein Catheterisation• Secure the catheter with a suture through the cord, marker tape, and a tape bridge.• The position of the catheter must be confirmed radiographically. A properly placed umbilical vein catheter appears to travel cephalad until it passes through the ductus venosus
Adrenaline• The recommended dose is 0.01-0.03 mg/kg (0.1-0.3 mL of the 1:10,000 solution), preferably administered intravenously (IV). Higher IV doses are not recommended
Adrenaline• If you are too overwhelmed and can’t think• Easy tip to remember is that average newborn in size will need 1ml of 1:10,000 Adrenaline
Adrenaline• If vascular access cannot be obtained, Adrenaline may be given via the ET tube• The dose should be increased to 3 times the IV dose. Followed with infusion of 0.5-1 mL of saline to ensure that the drug is delivered to the lung, where it is absorbed and delivered to the heart.
Volume Expansion• Suspected Blood loss• Pale poor perfusion or weak pulse• Not responded to other resuscitative measures 10ml/kg IV push over few minutes
Anything else?• “DEFG” Don’t ever forget Glucose If glucose low, administer 5ml/kg 10% Dextrose and recheck
What Next?•Get as much help as possible locally•NETS retrieval to NICU