Post on 22-Jul-2015
transcript
Neonatal Resuscitation
DR. EKHLAS ALI
Neonatal resuscitation
10% neonates require some assistance at birth.
1% neonates need extensive resuscitative measures.
Asphyxia accounts for 20-25% newborn deaths.
How does a baby receive oxygen before birth?
Oxygen diffuses across placenta from mother’s blood to baby’s blood.
Lungs receive very little blood.
Alveoli are fluid filled rather than air.
After birth
•Fluid in the alveoli is absorbed
Alveoli
• Expand
• Get filled with air (O2)
1.
After birth
Umbilical arteries and veins are clamped
Sudden increase in systemic blood pressure
2.
Pulmonary vessels dilate, causing increased blood flow to lungs
3.
Apgar score
Calculated at 1 & 5 min after birth
Consequences of interrupted transition
The compromised baby may exhibit 1 or more of the following clinical findings:
1. Low muscle tone
2. Respiratory depression (apnea / gasping)
3. Bradycardia
4. Cyanosis
Antepartum Risks
Maternal diabetesChronic maternal illness Cardiovascular Thyroid Neurological Pulmonary renal
Pre eclampsiaMaternal infectionPolyhydramniosOligohydramnios
Premature rupture of membranesIUGR/pretermFetal malformationMaternal substance abuseNo antenatal carePost term gestationMultiple gestationAnaemiaAge <16 or > 35
Intrapartum Risks
Emergency CSInstrumental deliveryAbnormal positionPremature labourPrecipitous labourChorioamnionitisProlonged rupture of membranesProlonged labour > 24 hrsProlonged 2nd stage of labour
Fetal bradycardiaNon-reassuring fetal heart rate patternGeneral anaesthesiaNarcotics administered within 4 hours of deliveryMeconium stained liquorProlapsed cordAbruptio placentaePlacenta previa
Fetal asphyxia
Primary apnoea Apnoeic Blue Heart rate Resuscitate easily
Secondary apnoeic White, floppy Heart rate Require active resuscitation
Equipment Needed for Resuscitation
Radiant warmer
Warm towel and blankets
Resuscitation bag and mask Self inflating bag Anaesthetic bag
Endotracheal tubes
Laryngoscope
Stethoscope
Oxygen source and tubing
Suction source and tubing
Drugs and fluids
Syringes, needles, cannulae, IV lines
+/-Umbilical lines
Equipment Needed
Overhead radiant warmer
Normal Delivery Procedures
Place under warmer and towel dryUse bulb syringe to clear mouth, then noseTactile stimulation if not breathing yet Auscultate heart and lungs & assess colorFree flow O2 as needed
Steps in Resuscitation
Warmth and stimulation and assessment for the 1st 30 seconds Use warm cloth Replace when wet Rapidly assess
Tone Colour Respiratory effort
Steps in Resuscitation - ABCDE
Airway Clear airway if required Removal of secretions if present
Suction mouth and nose DO NOT SUCTION IF AIRWAY IS CLEAR
Positioning Supine or lateral Head in neutral or slightly extended position
Neonatal Position for Opening the Airway – ‘neutral position’
Incorrect: Neck Hyperextension
Incorrect: Neck Under Extended
Correct: Neck Slightly Extended
Head flexed by large occiput
Head in neutral or ‘sniffing’ position
Acceptable methods of stimulation
Steps in Resuscitation - ABCDE
Breathing
Assessment of respiratory effort and colour
Indications for oxygen administration Cyanosis Respiratory distress Give free flowing oxygen 5L/min
Breathing: Indications for positive pressure ventilation
Apnoea
Gasping respiration
HR < 100 bpm
Persistent central cyanosis despite 100% O2
40-60 breaths/min
No response
Watch for slight rise of chestRate is 40-60
Indications of endo-tracheal Intubation
Prolonged positive-pressure ventilation (PPV) required
Bag & mask ineffective: Inadequate chest expansion
If chest compressions required: Intubation may facilitate
coordination and efficiency of ventilation
Tracheal suction required
Steps in Resuscitation - ABCDE
Circulation
Assessment of heart rate and response to previous measures Umbilical arteries Apex beat Auscultation
Chest Compressions
HR < 60 bpm despite adequate vent with 100% O2 for 30 seconds
2 techniques 2 thumb (preferred) 2 finger 3:1 ratio 1/3 of AP diameter
TechniquePosition of Hands on Chest
Thumb technique
( preferred )
TechniquePosition of Hands on Chest
Two finger technique
Chest (cardiac) compressions
“Two-thumb” technique is usually preferred
Steps in resuscitation - ABCDE
Drugs
Adrenaline
Volume Expanders
Naloxone
Epinephrine Indications
HR <60 /min after PPV & CC for 30 secs
Route of administration
Intravenous
Endotracheal route (when I.V line is not secured ) Recommended
Conc. – 1:10,000 (0.1mg/ml)
Route – UVC/ IV
Dose – 0.01-0.03 mg/kg , (0.05-0.1mg/kg E.T)
Rate of admn. – as rapidly as possible
Repeat dose if no response after 60 seconds Now, intravenous route is first preferred route
Volume ExpanderVolume Expander Indications:
Poor response to other resuscitative measures
Evidence of blood loss or suspected ( pale skin, poor perfusion, weak pulse)
Crystalloid Normal Saline Ringer Lactate or O-negative blood cross-matched with mother’s blood
Dose – 10ml/kgRoute – Umbilical veinPreparation – large syringeRate of administration – 5-10 min
Naloxone Narcotic antagonistNaloxone Narcotic antagonist
Indications :
A history of maternal narcotic administration within the
past 4 hours
Severe respiratory depression is present after PPV has
restored a normal HR & color
Recommended
Concentration: 1.0 mg/ml
Route: Intravenous
Dose: 0.1 mg/kg
Meconium present and baby vigorous
Vigorous Baby- Strong respiratory efforts,
Good muscle tone,
Heart rate > 100 bpm
suction catheter or bulb syringe for suction of mouth or nose
ET suction not required
Meconium present and baby not vigorous
Insert laryngoscope
Clear mouth and posterior pharynx
Insert endotracheal tube into the trachea
Attach the ET to suction source
Apply suction as ET is slowly withdrawn
Repeat as necessary until no meconium or heart
rate indicates further resuscitation
What to do if still no improvement?What to do if still no improvement? If no improvement seen despite all efforts
Ensure adequate ventilation, chest compressions, drug delivery
If still HR < 60/min, consider Airway malformation Lung problems Pneumothorax Diaphragmatic hernia Cong. Heart disease
If HR absent or no progress Ethical considerations of when to D/C Resuscitation
Discontinuing Resuscitative Effort
Stop resuscitation, if HR remains undetectable for 10 - 15 min
Also take into consideration factors such as presumed etiology of the arrest, gestation of the baby, presence or absence of complications
Guidelines for Neonatal Resuscitation