Transcript 4 MB - Neonatal resuscitation

Neonatal resuscitation
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab. DCA,
Dip. Software statistics PhD (physio)
Mahatma Gandhi Medical college and
research institute , puducherry India
The need
• Approximately 10% of newborns require some
assistance to begin breathing at birth.
• Less than 1% require extensive resuscitative
measures
• only 60% of asphyxiated newborns can be
predicted antepartum.
The need is continuous
Initial queries ??
• Term gestation?
• Crying or breathing?
• Good muscle tone?
yes
• the baby does not need resuscitation
• should not be separated from the mother.
• The baby should be dried, placed skin-to-skin
with the mother, and covered with dry linen
to maintain temperature.
• Observation of breathing, activity, and color
should be ongoing.
“no”
• 1.Initial steps in stabilization (provide warmth,
clear airway if necessary, dry, stimulate)
• 2.Ventilation
• 3.Chest compressions
• 4.Administration of epinephrine and/or volume
expansion
The golden minute
• Approximately 60 seconds (“the Golden
Minute”) are allotted for completing the initial
steps, reevaluating, and beginning ventilation
if required.
The goals of resuscitation
to assist
• with the initiation and maintenance of
adequate ventilation and oxygenation,
• adequate cardiac output and tissue perfusion,
• normal core temperature
• serum glucose
To achieve goals, be ready
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risk factors are identified early,
neonatal problems are anticipated,
equipment is available,
personnel are qualified and available
a care plan is formulated
Respiration equipment
• Oxygen supply, Assorted masks
• Neonatal bag and tubing to connect to an oxygen
source
• Manometer, Endotracheal tubes (2.5-4)
• Tape and scissors
• Laryngoscope (0 and 1 sized blades)
• Extra bulbs and batteries
• CO2 detectors
• Stylettes for endotracheal tubes
• Laryngeal mask Airway (optional)
Suction equipment
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Bulb syringe
Regulated mechanical suction
Suction catheters (6F, 8F, 10F)
Suction tubing
Suction canister
Replogle or Salem pump (10F catheter)
Feeding tube (8F catheter)
Syringes catheter tipped – 20 ml
Meconium aspirator
Fluid equipment
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Intravenous catheters (22 g)
Tape and sterile dressing material
Dextrose 10% in water (D10W)
Isotonic saline solution
T-connectors
Syringes, assorted (1-20 mL)
Advanced procedure ready
• Umbilical catheters (2.5F, 5F)
• Chest tube (10F catheter)
• Sterile procedure trays
Trained Personnel
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One present
Two or more
-- problems
--- twins
Temperature control
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Dry and keep warm
Others
prewarming the delivery room to 26°C
13 covering the baby in plastic wrapping
placing the baby on an exothermic mattress
the baby under radiant heat
prewarming the linen
The goal is to achieve normothermia and avoid
iatrogenic hyperthermia
Temperature range
• Normal
36.5-37.5o C
Continue
• Potential cold stress
36-36.5o C concern
• Moderate hypothermia
32-36o C
Danger
• Severe hypothermia
< 32o C
• Outlook grave, skilled care urgently needed
Airway
• Clear liquor
• Meconium stained liquor
Clear liquor – suctioning routine ??
• be associated with worsening of pulmonary
compliance and oxygenation
• reduction in cerebral blood flow velocity when
performed routinely (ie, in the absence of
obvious nasal or oral secretions)
• Apnea, bradycardia, hypotension, and
laryngospasm
• Think about routine suctioning ??
Clear liquor – suctioning routine ??
• suctioning
immediately
following
birth
(including suctioning with a bulb syringe)
should be reserved for babies who have
obvious obstruction to spontaneous breathing
or who require positive-pressure ventilation
(PPV)
What is routine
• Drying and suctioning ,
• If no response,
• more vigorous stimulation, slapping the soles of
the feet or rubbing the back.
• The back should be visualized.
• If there is no response to stimulation,
• it may be assumed the infant is in secondary
apnea, and PPV should be initiated.
• infant's respiratory rate, heart rate, and color
should be evaluated
Meconium stained liquor
• Historically
• Suction before delivery of shoulders –
• not proved useful
• routine endotracheal intubation and direct
suctioning of the trachea ??
• No to active crying babies !!
Mec. staining
• endotracheal suctioning of nonvigorous
babies with meconium-stained amniotic fluid
• If intubation difficult and causing brady , don’t
try – go back to mask ventilation
Administration of Oxygen
• Oxyhemoglobin saturation may normally
remain in the 70% to 80% range for several
minutes following birth
• clinical assessment of skin color is a very poor
indicator of oxyhemoglobin saturation
SPO2 monitor
• a preductal location (ie, the right upper
extremity, usually the wrist or medial surface
of the palm).
• Term infants keep SaO2 – 90- 94%
• Preterm – 88-92%
• 8- 10 litres- oxygen Hood
• Monitor progress
Temperature
• unheated non humidified oxygen sources for
the bag-valve-mask device
• Intubated ventilated patient – humidified
warmed ventilator circuits
Positive pressure ventilation
• If the infant remains apneic or gasping,
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• if the heart rate remains <100 per minute
after administering the initial steps.
• Assisted ventilation rates of 40 to 60 breaths
per minute
• Heart rate , SPo2, monitor
CPAP
• CPAP
• recommend administration of continuous
positive airway pressure (CPAP) to infants who
are breathing spontaneously,
• but with difficulty, following birth, although
its use has been studied only in infants born
preterm
Laryngeal mask airways and PPV
• Laryngeal mask airways that fit over the laryngeal
inlet - effective for ventilating newborns
• weighing more than 2000 g
• delivered ≥34 weeks gestation
• meconium-stained fluid,
• during chest compressions,
• or for administration of emergency intratracheal
medications
Endotracheal Tube Placement
• Initial endotracheal suctioning of nonvigorous
meconium-stained newborns
• If bag-mask ventilation is ineffective or prolonged
• When chest compressions are performed
• For special resuscitation circumstances, such as
congenital diaphragmatic hernia or extremely low
birth weight
Effective ventilation
• Heart rate
• CO2
• SPo2
Chest Compressions
• Chest compressions are indicated for a heart
rate that is <60 per minute despite adequate
ventilation with supplementary oxygen for 30
seconds
• Ventilation priority
• the 2 thumb–encircling hands technique
• the 2-finger technique,
DRUGS
• Drugs are rarely indicated in resuscitation of
the newly born infant.
• Bradycardia in the newborn infant is usually
the result of inadequate lung inflation or
profound hypoxemia
• Atropine ???
Drugs
if the heart rate remains <60 per minute
despite adequate ventilation (usually with
endotracheal intubation) with 100% oxygen
and chest compressions, administration of
epinephrine or volume expansion, or both,
may be indicated.
• The recommended IV dose is 0.01 to 0.03
mg/kg per dose
Drugs and infusions
• Rarely, buffers, a narcotic antagonist, or
vasopressors may be useful after resuscitation,
but these are not recommended in the delivery
room.
• An isotonic crystalloid solution – 10 ml /Kg
• Intravenous glucose infusion should be
considered as soon as practical after
resuscitation, with the goal of avoiding
hypoglycemia
Discontinue resuscitation
• In a newly born baby with no detectable heart
rate, it is appropriate to consider stopping
resuscitation if the heart rate remains
undetectable for 10 minutes
After reading neonatal resuscitation
• What is shocking ??
• NO APGAR score at all.
The Apgar score
• Evaluate the newborn baby on five simple
criteria on a scale from zero to two,
• then summing up the five values thus
obtained.
• The resulting Apgar score ranges from 0 to 10.
• The five criteria are summarized using words
chosen to form a backronym
• (Appearance, Pulse, Grimace, Activity, Respiration.)
SCORES
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Appearance - red
Pulse
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Grimace stim.no
Active
tone less
Respir.
Absent
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2
peri. Blue total blue
< 100
> 100
mild
active
flexion good resist
weak ,gasps active cry
APGAR score
• Score of 10 ??
• >7 ok
• 4 – 7 -- to act
• 1 min, 5 , 10, 15 minutes
• Score of 3 0r less persistent – neuro damage
What we do - follows ??
Prewarm clothes
Tray, oxygen weighing machine
Equipment
Bulb syringe
Gentle back massage
Ryles tube and aspiration
Inj. Vit. K , temperature monitoring
with hood oxygen
Breast feeds
Thank you all