First Response & Advanced Resuscitation · Management of meconium (cont.) If tracheal suction is...

First Response & Advanced Resuscitation Learning Modules 2 & 3

© Victorian Newborn Resuscitation Project Updated February 2014

Learning objectives: Module 2 Following completion of the theoretical & practical components of this module, the participant will be able to competently:

Set up, operate and troubleshoot the equipment used in First Response care of the newborn.Assess a newborn infant’s transition to extra-uterine life & determine the need for resuscitation.Initiate First Response interventions including face mask ventilation and external chest compressions.

Updated February 2014 © Victorian Newborn Resuscitation Project

Learning objectives: Module 3 Following completion of the theoretical & practical components of this module, the participant will be able to competently perform or assist with:

Endotracheal intubation of the newbornUsing a Pedi-Cap™ end tidal CO2 detector Insertion of a laryngeal mask airway (LMA) Establishing umbilical venous access Administration of adrenaline and volume expanders


The transition to extra-uterine lifeVery few newborn infants require “resuscitation” (ECC, drugs, intubation).Some newborns will need assistance to begin breathing at birth (∼ 7% in Australia). Most newborns will respond to simple manoeuvres to help them start breathing.“First Response” interventions are therefore most important & time critical.


Resuscitation at birthOf the 299,588 live births in Australia in 2011:

76% No intervention7% Received suctioning 9% Received oxygen therapy 6.5% Received IPPV0.8% Received intubation + IPPV0.3% Received ECC + IPPV

(AIHW, 2013: Australia’s Mothers and Babies 20111)


Preparation for resuscitation Anticipation of need

Based on risk assessmentEquipment

Checked and ready for useEnvironment

Warm and cleanSkilled personnel

Able to form a team, nominate leadership and develop a plan of action


The First Response teamAt every birth at least one member of the team should have resuscitation skills. Members of the team need to know the role, expectations and skills of the other team members. Communication and cooperation between team members are essential.


Australian & New Zealand newborn resuscitation guidelines

Section 13.1 – 13.10Neonatal Guidelines

Available for download at www.resus.org.au

Published by the AustralianResuscitation Council (ARC)& the New Zealand Resuscitation Council 2 (NZRC) in December 2010

http://www.resus.org.au/

ARC & NZRC Newborn Life Support Flow Chart

Maintain warmthAim to achieve normothermia (36.5 - 37.5oC)Avoid iatrogenic hyperthermia in all newborns.Preterm newborns: <28 weeks or <1500 grams:

Birth in a room with an ambient temperature of ≥26oC.Immediately place, while still wet and warm, into a polyethylene wrap or (food or medical grade, heat resistant), enclosed up to the neck with the head out. Dry the newborn’s head and cover with a hat or a dry, warm towel or blanket.


A: AirwayAssessment Term gestation? Breathing or crying? Good muscle tone?

ActionsPrevent heat lossEnsure open airway Stimulate


NO

YES

Stay with mother

AssessmentHR below 100/min? Gasping or apnoea?

Assessment Laboured breathing or persistent cyanosis?

NO

Routine care: Prevent heat lossOngoing evaluation

NO

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If meconium liquor is presentIf the newborn is vigorous:

Only clear the mouth, followed by the nose, if the airway appears obstructed by meconium. Endotracheal suctioning is discouraged because it does not alter outcome and may cause harm.13 (LOE 2)

If the newborn is not vigorous:Consider tracheal suctioning if a person with the expertise to perform endotracheal intubation is available. Otherwise, suction the oropharynx with a 10-12 Fgcatheter, then assess the newborn’s heart rate and breathing.


Management of meconium (cont.)

If tracheal suction is performed, it should be:Before the newborn is stimulated to breathePrompt, to minimise delay in establishing breathingBefore positive pressure ventilation is provided

“The potential benefit of removing meconium from the trachea needs to be weighed against what is likely to bean urgent need for other resuscitation manoeuvres.”

(ARC & NZRC2, 2010, Guideline 13.4)


B: Breathing Assessment *Heart rate below100/min?Gasping or apnoeic?

NO

Actions * Positive pressure ventilation SpO2 monitoring


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Laboured breathing orPersistent cyanosis NO

ActionsEnsure open airwaySpO2 monitoringConsider CPAP

YES

AssessmentHeart rate below 100/min? Post resuscitation care

ActionsEnsure open airwayReduce face mask leaks Consider increasing pressure &/or oxygen

YES

YES* Endotracheal intubation may be considered at several stages

NO

Manual ventilation devices“A T-piece device, a self inflating bag and a flow inflating bag are all acceptable devicesto ventilate newborn infants either via a facemask or endotracheal tube”. (ARC & NZRC2, 2010)


Initial settings: T-piece device Gas flow

Set at 10 L/min (8 L/min if using cylinders) Maximum pressure relief valve

Set at 50 cm H2OPeak inspiratory pressure (PIP)

Set at 30 cm H2O (term newborn) Set at 20 - 25 cm H2O (preterm <32 weeks)

Positive end expiratory pressure (PEEP) Set at 5 - 8 cm H2O


PEEP during resuscitation With PEEP:

FRC is established and maintainedOxygenation is improved

Without PEEP:Lung aeration is not achieved as quickly Functional residual capacity (FRC) is not established

The ARC & NZRC2 (2010) recommend: If suitable equipment is available, PEEP (at least 5 cm H2O) should be used during resuscitation


Face mask leaks are commonLeaks averaging 40 to 70% around face masks are common due to poor mask placement technique.14

How you hold the face mask will determine how much leak you have and therefore how effectively you ventilate the newborn infant. The “two point top hold” is one method that has been shown to reduce face mask leak.

(Wood et al., 200814 )


Reducing leak using the “two point top hold” with a round mask

Reference: Wood, et al. (2008). Archives of Disease in Childhood, Fetal & Neonatal Edition, 93, p. F 231.


Ventilation rate and pressureVentilate at a rate of 40 - 60 inflations per minute.Peak inflating pressures required are variable and should be individualised.Be aware:

Hyperventilation (excessive PIP &/or rate) can lead to dangerously low CO2 levels (<30 mmHg). This can further depress the infant’s breathing centre & reduce cerebral blood flow. Avoid hyperventilating newborns who are unlikely to have parenchymal lung disease.


Assessing the effectiveness of positive pressure ventilation

The effectiveness of ventilation is confirmed by: 1. An increase in the heart rate above 100/min.

2. A slight rise and fall of the chest and upper abdomen with each inflation.

3. An improvement in oxygenation.


Oxygen use in resuscitationTerm newborns: Use air (21%) initially.Preterm newborns <32 weeks: Use air or blended air and oxygen (21% to ∼ 30% oxygen to start).Use air if a blender is not available. Supplemental oxygen should be used judiciously, ideally guided by pulse oximetry.

“The first priority is to ensure adequate inflation of thelungs, followed by increasing the concentration of inspired oxygen only if needed” (ARC & NZRC2, 2010, Guideline 13.4)


Why is 100% oxygen a concern?Meta-analysis of RCT’s showed increased survival rates of both term and preterm newborns who were resuscitated in air, compared with 100% oxygen. (Davis, et al., 20043)

The use of 100% oxygen delays the time to first spontaneous breath and/or cry.3,11

There is increasing evidence that even a brief period of excessive oxygenation can be harmful to the newborn during and after resuscitation.2,10


Assessment of oxygenation in the minutes after birth

In-utero, the fetal SpO2 is ∼ 50 – 60%, dropping to an intra-partum mean of 40 – 50%. The normal newborn takes 5 -10 minutes to achieve an SpO2 above 90% after birth.4,6

Visual assessment of colour is difficult and a poor means of judging oxygenation.9

A pulse oximeter can provide readings of heart rate and oxygen saturation less than 1 minute after application.4,5,6


Pulse oximetry is recommended: For all newborns requiring positive pressure ventilation or any form of respiratory support. Whenever supplemental oxygen is used.If persistent cyanosis is suspected.

Place the oximeter onto the right hand or wrist (pre-ductal saturation measurements).

(ARC & NZRC2, 2010, Guideline 13.3 and Guideline 13.4)


Target saturations for newborns during the first minutes after birth


Time after birth in minutes Targeted pre-ductal SpO2 after birth during resuscitation

1 minute 60 – 70%2 minutes 65 – 85% 3 minutes 70 – 90% 4 minutes 75 – 90% 5 minutes 80 – 90% 10 minutes 85 – 90%

ARC & NZRC2, 2010, Guideline 13.4

Centile charts with the ARC’s targeted pre-ductal SpO2 after birth

Time after birth in minutes

Targeted pre-ductal SpO2 after birth during resuscitation

1 minute 60 – 70%

2 minutes 65 – 85%

3 minutes 70 – 90%

4 minutes 75 – 90%

5 minutes 80 – 90%

10 minutes 85 – 90%

Adapted from Dawson4 et al., 2010 and the ARC & NZRC2, 2010

N.B The relationship between PaO2 and SpO2 is not linear

Adapted from: Sola, Chow & Rogido, 2005, An Pediatr 62(3): 266-281

P

SpO2 ≥ 95%

=

? PaO2

In air FiO2 > 0.21

If the heart rate is not improving with positive pressure ventilation

Check the ventilation techniqueIs there a face mask leak?Is the airway patent?

Increase the peak inflating pressureIncrease the PIP in 5 cm increments: 30→ 35→ 40→ 45→ 50+ cm H2O if necessary

Increase the oxygen according to SpO2Increase to 100% if the heart rate is <60/min


C:CirculationAssessment Heart rate below 60/min?

* Endotracheal intubation should be considered

+ Ensure the O2 has been increased to 100% if the heart rate is <60/min

Actions *Chest compressions at 90/minute3 compressions to each breath100% oxygen+

Consider intubation or LMA


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YES

Assessment Heart rate below 60/min?

YES

YES

Techniques for ECC in newborns

Hand encircling, two thumb technique (preferred technique)

Two finger technique


Advanced resuscitation Advanced resuscitation interventions are indicated if first response interventions do not result in a rapid improvement in:

Heart rate, breathing, SpO2 & muscle toneSuch interventions include:

Intubation & use of an end-tidal CO2 detectorEstablishing umbilical venous or intraosseous access Administration of adrenaline Administration of volume expanders


Consider endotracheal intubation at any time, if expertise is available

Weight (kg)

ETT size(mm ID)

< 1 kg 2.5

1 – 2 kg 3.0

2 – 3 kg 3.5

> 3 kg 3.5 /4.0


Endotracheal size internal diameter (ID) can be calculated as gestation age in weeks divided by 10

Depth of insertion of oral ETTCorrected gestation (Weeks)

Actual weight(kg)

ETT mark at the lip (cm)

23 – 24 0.5 – 0.6 5.525 – 26 0.7 – 0.8 6.027 – 29 0.9 – 1.0 6.530 – 32 1.1 – 1.4 7.033 – 34 1.5 – 1.8 7.535 – 37 1.9 – 2.4 8.038 – 40 2.5 – 3.1 8.541 - 43 3.2 – 4.2 9.0


Weight (kg)

ETT size(mm ID)*

< 1 kg 2.5

1 – 2 kg 3.0

2 – 3 kg 3.5

> 3 kg 3.5 /4.0

*GA divided by 10

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Verify ETT position with an exhaled CO2 detector (e.g. Pedi-Cap™)

Give 6 positive pressure inflations, then interpret

INSPIRATION

EXPIRATION

“GOLD IS GOOD”Updated February 2014

© Victorian Newborn Resuscitation Project

Caution when using a Pedi-Cap™

Despite being correctly placed in the trachea, there are circumstances in which the Pedi-Cap™

may not change colour. This may occur when: • Insufficient inflations are delivered• Insufficient tidal volume is delivered• There is very low or absent pulmonary blood flow• If contaminated with adrenaline or surfactant• If exposed to high humidityDo not re-intubate unnecessarily.


Laryngeal mask airway (LMA)Consider if:

Face mask ventilation is unsuccessful Tracheal intubation is unsuccessful or not feasibleTerm or near term infant

Size 1 LMA suitable for infants ≥ 34 weeks, 2 - 5 kg


D:Drugs

* Endotracheal intubation should be performed

+ Ensure the O2 has been increased to 100% if the heart rate is <60/min

Assessment +Heart rate below 60/min?

Actions * Venous accessAdrenaline IV: 0.1- 0.3 mL/kg of 1:10,000 solution (10-30 mcg/kg)Consider volume expansion


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YES

Remember to document all interventions & the newborn’s response

Medications: AdrenalineAdrenaline should be given intravenously

If no UV/IO access & HR < 60/min despite effective IPPV & ECC, administer a higher dose via the ETT.Presentation; 1:10,000 (0.1mg/mL).


IV 0.1 to 0.3mL/kgCan be repeated

10 to 30micrograms/kg

Approximate dose in a 3.5 kg term infant = 1mL

ETT 0.5 to 1mL/kgCan be repeated

50 to 100 micrograms/kg

Approximate dose in a 3.5 kg term infant = 3.5mL


Medications: Volume expandersIntravascular fluids should be considered:

If fetal blood loss is suspected and/orThe newborn appears to be in shock (pale, poor perfusion, weak pulses) The newborn has not responded to other resuscitation measures (especially if the HR is not improving)

Normal saline should be used initially.2

Follow with O negative red blood cells in the setting of massive blood loss (or suspected concealed blood loss).Dose: 10 mL/kg, IV over several mins. Can be repeated.


Post resuscitation careContinually reassess SpO2 and respiratory effort. Adjust ventilation pressures & rate accordingly.Do not extubate the infant, even if breathing spontaneously, until consultation with a tertiary centre neonatologist or a NETS Consultant. Assess circulation: Heart rate, capillary refill time, and blood pressure (if equipment available).Maintain normothermia: 36.5 – 37.50C. Maintain BSL ≥ 2.6 mmol/L.


Post resuscitation care (cont.) Therapeutic hypothermia (Whole body cooling)

Cooling should be considered in newborn infants ≥ 35 weeks with evolving moderate to severe hypoxic ischaemic encephalopathy to reduce brain injury.Consult with NETS or a tertiary centre neonatologist as soon as possible after initial resuscitation to discuss if the newborn meets the criteria for cooling.All newborns who are cooled must be transferred to a tertiary neonatal intensive care unit for ongoing care.


For more information on: Intubation Use of a Pedi-Cap™ end tidal CO2 detectorUse of a laryngeal mask airway (LMA) Intravenous, umbilical and intraosseous access Medications Discontinuation &/or withdrawal of resuscitation Resuscitation in special circumstancesPost resuscitation care

See the “Learning Resources” section of the NeoResus web site at http://www.neoresus.org.au/pages/edu.php


http://www.neoresus.org.au/pages/edu.php

References1. Australian Institute of Health and Welfare (2013). Australia’s mothers and

babies, 2011. Retrieved January 24, 2014 from http://www.aihw.gov.au/publication-detail/?id=60129545702

2. Australian & New Zealand Resuscitation Councils. (2010). Section 13: Neonatal Guidelines. Retrieved February 14, 2011 from: http://www.resus.org.au

3. Davis, P.G., Tan, A., O’Donnell, C.P. & Schulze, A. (2004). Resuscitation of newborn infants with 100% oxygen or air: A systematic review and meta analysis. The Lancet: 364:1329-1333.

4. Dawson, J.A., Kamlin, O.F., Vento, M., Wong., Cole, T.J., Donath, S.M., Davis, P.G., & Morley, C.J. (2010). Defining the reference range for oxygen saturation for infants after birth. Pediatrics, 126 (5):e1340-e1347.


http://www.aihw.gov.au/publication-detail/?id=60129545702

http://www.resus.org.au/

References5. Dawson, J.A., Kamlin, O.F., Wong, C., Te Pas, A.B., O’Donnell, C.P.,

Donath, S., Davis, P.G., & Morley, C.J. (2008). Oxygen saturations and heart rate during delivery room resuscitation of infants < 30 weeks’ gestation with air or 100% oxygen. Archives of Disease in Childhood, Fetal & Neonatal Edition, 94: F87-F91.

6. Dawson, J.A., O’Donnell, C.P., Kamlin, C.O., & Morley, C.J. (2007). Pulse oximetry for monitoring infants in the delivery room: a review. Archives of Disease in Childhood, Fetal & Neonatal Edition, 2: F4-F7.

7. Escrig, R., Arruza, L., Izquierdo, I., Villar, G., Saenz, P., Gimeno, A., Moro, M., & Vento, M. (2008). Achievement of targeted oxygen saturation values in extremely low gestational age neonates resuscitated with low or high oxygen concentrations: A prospective, randomized trial. Pediatrics, 121(5), 875-881.


References 8. Hooper, S., Lewis, R. & Yagi, N. (2009). Establishing lung volume & a

functional residual capacity in preterm rabbit pups (Video). Monash University Department of Physiology & the SPring-8 Synchrotron, Japan.

9. O’Donnell, C.P., Kamlin, C.O. Davis, P.G., Carlin, J.B., & Morley, C.J. (2007). Clinical assessment of infant colour at delivery. Archives of Disease in Childhood, Fetal Neonatal Edition, 92: F465-F467.

10. Perlman, J., Wyllie, J., Kattwinkel, J., Atkins, D., Chameides, L., Goldsmith, J.P., Guinsburg, R., Hazinski, M.F., Morley, C., Richmond, S., Simon, W.M., Singhal, N., Szyld, E., Tamura, M., & Velaphi, S. (2010). Special Report Neonatal Resuscitation: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Pediatrics, 126 (5): e1319-e1344.


References 11. Tan, A., Schulze, A., O’Donnell, C., & Davis, P. (2005) Air versus oxygen

for resuscitation of infants at birth (Review). Cochrane Database of Systematic Reviews, 2005, Issue 2.

12. Wang, C., Anderson, C., Leone, T., Rich, W., Govindaswami, B., & Finer, N. (2008). Resuscitation of preterm infants using room air or 100% oxygen. Pediatrics, 121 (6): 1083-1089.

13. Wiswell, T.E., et al. (2000). Delivery room management of the apparently vigorous meconium stained neonate: results of the multicentre, international collaborative trial. Pediatrics, 105 (1): 1-7.

14. Wood, F.E., Morley, C.J., Dawson, J.A., Kamlin, C.O., Owen, L.S., Donath, S., & Davis, P.G. (2008). Improved techniques reduce face mask leak during simulated neonatal resuscitation. Study 2. Archives of Disease in Childhood: Fetal & Neonatal Edition, 93: F 230-F234.


Disclaimer This teaching program has been developed by the Newborn Emergency Transport Service (NETS) Victoria as an educational program around neonatal care with the assistance of a grant from the Department of Health Victoria.

Whilst appreciable care has been taken in the preparation of this material, NETS shall not be held responsible for any act or omission which may result in injury or death to any baby as a result of reliance on this material.


CopyrightThis presentation was developed by Rosemarie Boland on behalf of the Victorian Newborn Resuscitation Project (2014). The material is copyright NeoResus. This presentation may be downloaded for personal use but remains the intellectual property of NeoResus and as such, may not be reproduced or used for another training program without the written permission of the Victorian Newborn Resuscitation Project Executive.

Please contact us at [email protected]


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