neonatal resuscitation newborn resuscitation

1. 1

3. Dr. Zahid Mehmood
Department of pediatrics unit 2
SZMC/H,RYK
.

4. 1- Identify the procedure
which is being shown in
the picture?
2- Enumerate 3 basic
parameters in
evaluation during
neonatal resuscitation.
3- What is APGAR score?

5. 1- Bag and Mask ventilation (1)
2-
i. breathing
ii. Heart rate
iii. Colour/crying
3-
0 1 2
A: Appearance (colour) Blue, pale Body pink, extremities
blue
Fully pink
P: Pulse (heart rate) Absent Below 100 Over 100/min
G: Grimace (response
to stimulation)
No response Facial grimace Cry
A: activity (muscle tone) Flaccid Some flexion Normal with movements
R: Respiration Absent Gasping Regular

6. 1- What step of resuscitation
is being shown in the
above diagram?
2- What is the indication for
doing this step?
3- What complications may
result if this step done
vigorously? )

7. 1- Cardiac compression along with bag &
mask ventilation. (1)
2- When heart rate is below 60/min inspite
of bag & mask ventilation, then chest
compression is started. (2)
3- ( 0.5 each)
i. Chest contusions and abrasions
ii. Rib fractures
iii. Epicardial hematoma
iv. Pulmonary hemorrhage

8.  Difference between
 Asphyxia
 hypoxia

9.  Pakistan has the world’s third highest number of
newborn deaths .
 Neonatal deaths, account for (60 %) of under-five
deaths in Pakistan.
 Three-quarters (75 %) of deaths occur in the first week
of life.
.

10. 48%
26%
18%
3%
2% 1%
1% 1% BIRTH ASPHYXIA
PREMATURITY
SEPSIS
JNN
MECONIUM ASPIRATION
NEONATAL SEIZURES
CONGENITAL
ANOMALIES
MISCELLANEOUS

11. 49%
29%
18%
2%
1%
1%
BIRTH ASPHYXIA
PREMATURITY
SEPTICEMIA
CHD
MECONIUM ASPIRATION
TETANUS NEONATORUM

12.  Basic Neonatal
Resuscitation
1. Airway support
2. Breathing/ventilation
 Advanced Neonatal
Resuscitation
1. All the steps of basic
neonatal resuscitation
2. Chest compression
3. Endotracheal intubation
4. Vascular cannulation
5. The use of drugs & fluids

17.  Identify a helper and review the emergency plan
 Prepare the area for delivery
 Wash hands
 Prepare an area for ventilation and check
equipments

20.  Is the key to a successful outcome.
 Cooperation between obstetric and pediatric staff
is important.
 Review notes
 Communicate with the parents
 Wash hands & Use sterile gloves
 Thermoneutral environment
 Check for equipment

21.  Resuscitation trolley/table
 Sterile linen
 Suction apparatus(Bulb/penguin/mechanical
sucker)
 Laryngoscope with straight blade #0, #1
 Ambu bag and face mask
 Oral airways
 Oxygen with flow meter and tubing
 Endotracheal tubes # 2.5,3.0,3.5 & 4.0

22.  Radiant warmer
 Stethoscope
 Adhesive tapes
 Syringes
 Butterfly needles
 Umbilical venous catheterization tray
 Umbilical catheter 3 and 5 fr
 Feeding tubes 5 fr.
 Disposable syringes

23.  Epinephrine 1:10,000
 Volume expanders i.e. N/saline,Albumin5%,
Ringer lactate, O-ve blood
 Sodium bicarbonate
 Dextrose water 10%
 Sterile water

31. Airway Maintenance
Stimulate Breathing

33. Open airway
 Neutral position
 Chin lift
 Jaw thrust
Clear airway
secretions, foreign body, vomits by gentle
suctioning of mouth first and then nose.

40. Maintenance of breathing/Positive
pressure ventilation

53. 1. Chest compression
2. Endotracheal intubation
3. Vascular cannulation
4. The use of drugs & fluids

54.  Chest compression is indicated
when heart rate <60/min despite of
adequate chest expansion with ventilation,
for 30 seconds.
 Ventilation breaths need to be continued
alongside chest compressions.

55. Technique
 Two thumbs technique
 Two fingers technique
 At lower third sternum (between the xiphoid and a
line drawn between nipples)
 Compression depth; approximately one third of the
anterio-posterior diameter of chest

56.  Chest compression must always be accompanied
by positive pressure ventilation.
 One ventilation after every third compression
(1:3).
 Total of 30 breaths and 90 compression per
minutes (120 events per minute)

58. Indications:
1. Ambu bagging not effective
2. Prolonged ventilation is expected
3. Suspected diaphragmatic hernia
4. Severe anatomical or functional upper airway
obstruction
5. Need for high pressure to maintain adequate
oxygenation
6. Need for bronchial or tracheal suctioning in
Meconium stained un-responsive baby
7. Instability or high probability of any of the above
occurring before or during transport.

59. Different methods are used for its calculation
 Formula 1:gestational age (weeks)/ 10
Tube size Weight (g) Gestational age
(wk)
2.5 < 1,000 < 28
3.0 1,000-2,000 28-34
3.5 2,000-3,000 34-38
3.5-4.0 >3,000 >38

60. Different methods are used for its calculation
 Formula 1: baby’s weight (in kilograms) + 6
Length of tube according to weight
Weight Depth of insertion
(in cm from upper lip)
1 7
2 8
3 9
4 10

61.  The Neonatal Resuscitation Program recommends
a 20-second limit for intubation attempts.
 For infants who were monitored with pulse
oximetry, determine their HR and Spo2 before
the intubation attempt.

64.  Umbilical vein catheterization may be a life-
saving procedure in neonates
 who require vascular access and resuscitation.
 After proper placement of the umbilical line,
 intravenous (IV) fluids
 medication may be administered to critically ill
neonates.

66.  If heart rate not improving(below 60/min)
despite
 adequate ventilation for 30 seconds
 And
 combined ventilation & chest compressions for
another 30 seconds
 then the drugs should be considered.

67.  Drug must be followed by 0.5-1.0 ml normal saline to clear
the drug from catheter.
ADRENALINE/Epinephrine:
 Preparation: 1:10,000 (100µg/ml)
 Dose: 10µg/kg, 0.1ml-0.3 ml/kg IV
 (0.5-1.0 ml/kg via Endotracheal tube)
 Route: Umbilical venous catheter or Endotracheal tube
 Rate: Rapidly

68. SODIUM BICARBONATE:
 Preparation: 4.2% (or 8.4% diluted 1:1)
 Dose: 1-2 mmol/kg (2-4ml/kg)
 Route: umbilical venous catheter
 Rate: 1mmol/kg/min
VOLUME EXPANDERS:
 Preparation:
 Normal saline
 Ringer lactate
 O negative blood, cross matched with mother’s blood if time
permits (if prenatal diagnosis has suggested low fetal blood
volume)
 Dose: 10 ml/kg
 Route: Umbilical vein
 Rate: over 5-10 min

69. DEXTROSE
 Preparation: 10%
 Dose: 250 mg/kg or 2.5 ml/kg
 Route: umbilical vein

71.  Standard algorithm of ‘ABCD’ is used but
with minimal variation.

72.  Attempts to aspirate meconium from nose & mouth
of the unborn baby , while the head is still on the
perineum is not recommended.
 If at birth, a meconium stained baby has:
Normal respiratory effort
normal muscle tone
heart rate grater than 100beats/min
Intervention:
1. Use a bulb/penguin sucker or large bore suction
catheter to clear secretions from oropharynx and
nose.
2. Do not intubate or do blind oropharyngeal suction.

73.  If at birth, a meconium stained baby has:
depressed respiration
depressed muscle tone
heart rate <100 beats/min
Intervention:
1. immediate Endotracheal intubation and
direct suctioning of trachea is done without
stimulation.

74. Results from:
 Positive pressure ventilation
 Lung malformation
 If the chest is not expanding adequately despite
proper positioning of airways , ambu-bagging, giving
adequate pressure, placing Guedel airways and there
is no improvement in heart rate, then this condition
must be considered.
 Removing obstruction of lung airways by external
chest drainage of air through placement of needle or
chest drain in pleural space.

75. In neonate it may results from:
 Hydrops fetalis
 Chylothorax
Manage by chest drain insertion.

76.  If Chest is not expanding adequately despite
proper positioning of airways, ambu-baging,
giving adequate pressure, placing Guedel airways
and there is no improvement in heart rate.
 Think CDH and confirm on examination.
 Resuscitation with a bag and mask
contraindicated.
 Should have immediate endotracheal intubation
and place a large orogastric catheter.

77.  Babies are nasal breathers.
 Should be considered where after proper
airway opening and clearing maneuvers, good
expansion of the chest cannot be obtained by
ambu-baging.
Intervention:
 Inserting a plastic oral airway will allow air
to pass through mouth.

78.  Developmental malformation of palate and
oropharynx.
 Small mandible results in critical narrowing
of pharyngeal airway.
 Tongue, posteriorly placed, falls back into
pharynx and obstructs it just above larynx.
 Maintain airway by positioning or use of
plastic oral airway.

79.  Get hypothermic earlier than term babies.
 Fragile lungs and thus inability to breath
effectively.
 Maintain body temperature during
resuscitation and use lower pressures for
chest expansion.

80.  Naloxone is no longer recommended as part of
initial resuscitation in a delivery room.
 Giving a narcotic antagonist is not the correct
first therapy for a baby who is not breathing.
 The first corrective action is positive pressure
ventilation.
Indications:
1. Continued respiratory depression after PPV has
restored a normal HR.
2. A history of maternal narcotic administration
during labour within 4 hours.

81.  Naloxone : DOSE : 0.1 mg/kg I/V bolus.
 Caution: Do Not give Naloxone to the
newborn whose mother is suspected of being
addicted to narcotics.

83.  Effective spontaneous breathing has been
established as evidenced by:
 Increasing heart rate
 Spontaneous breathing
 Senior staff and parents must be consulted
before stopping positive pressure ventilation in
cases of:
 Signs of established biological death
 The existence of DNR is established
 If there is no detectable heart rate for >10 min despite
adequate measures

84. Breathing
problems
• Breathing is faster than 60 or less than
30 breaths in a minute.
• Breathing is shallow or irregular, with or
without pauses.
• These is a noise with each breath
(grunting)
• There is in drawing of the chest with
breathing, flaring of the nostrils.
•Tongue and lips or skin color is blue.
Feeding
difficulties
or not
sucking
•Unable to suck or sucks poorly
•Cannot be awakened to suck or does not
stay awake to suck long enough to empty
the breast.
•Sucks but does not seem satisfied.

85. Feels cold • body (abdomen or back) feels cold
or cooler than that of a well person.
• Axillary temperature below 36oC.
Fever •Body (abdomen or back) feels hot
compared to that of a well person.
•Axillary temperature above 37oC.
Red, swollen
eyelids and pus
discharge from
the eyes.
Redness
swelling, pus or
foul odor around
the cord or
umbilicus

86. Convulsions
/ fits
•Fits are more than a tremor or jittery
movements of normal babies. (fits
should be differentiated from tremor or
jitteriness. Tremors or jitteriness are
coarse repetitive movements that
generally occur secondary to
spontaneously and continue even after
holding the baby.
Jaundice /
yellow skin
•Yellow skin or eye color which begins in
the first 24 hours or after 2 weeks if
serious
•Yellow skin color that appears when the
baby has any other danger sign is serious.