8/6/2019 Neonatal Als 1

1/22

Neonatal Advanced LifeNeonatal Advanced Life

SupportSupport (NALS)(NALS)

Current Status

8/6/2019 Neonatal Als 1

2/22

History

History

And he went up, and lay upon the child, andput his mouth upon his mouth, and his eyes

upon his eyes, and his hands upon his hands;And he stretched himself upon the child andthe flesh waxed warm.

Elisha II Kings 4:14.

(The old testament)

8/6/2019 Neonatal Als 1

3/22

Mahabharat

Mahabharat

Sukra

The high priest of demons had secretknowledge of resuscitation.

8/6/2019 Neonatal Als 1

4/22

Eighteenth CenturyE

ighteenth CenturyIfthe child does not breathe immediately upon

delivery,

Wipe its mouth, and press your mouth to thechilds, at the same time pinching the nose

with your thumb and finger, inflate the lungs,

By whichmethodIhave savedmany.

BENJAMIN PUGH (1754)

8/6/2019 Neonatal Als 1

5/22

Neonatal ResuscitationNeonatal Resuscitation2020thth CenturyCentury

Period Suggested method

1700 1930s Immersion in c/h water

1900 1930s Laborde method,

1920 1940s Rubbing, Slapping,Pinching

1930 1960s O2 in oral cavity cath

1850s 1930s Dilatation of Rectum

1910 1950s Clearing oropharynxWith fingers

1930s 1950s 02 + 7% Co2

1950s 1970s M mask, ET,Coramine

8/6/2019 Neonatal Als 1

6/22

Modern

Medicine

Modern

Medicine

The first quarter of an hour after birth

is the most dangerous period of life.Its mortality is as great as that of any

subsequent month

(Handerson Y. JAMA 1928; 90(8):383-386)Apgar Score (1953) uniformity in

assessment

8/6/2019 Neonatal Als 1

7/22

Guidelines for NeonatalGuidelines for Neonatal

ResuscitationResuscitation Before 1960 Methods based onempiric observation in human infants

without animal experimentation

1987 AHA and AAP Structured

training program (NRP)

8/6/2019 Neonatal Als 1

8/22

National Survey of PrevalentNational Survey of Prevalent

TraditionalTraditional PracticesPracticesPractice Urban % Rural % Tribal % Total %

Slapping 51.61 53.53 59.44 53.58

Flicking 11.53 20.59 07.22 12.40

Hot Water

Immersion

19.09 07.65 13.89 15.81

C.WaterImmersion

10.40 03.53 10.00 08.99

Mouth to

mouth resp

05.48 14.71 07.22 07.62

8/6/2019 Neonatal Als 1

9/22

NRP inIndiaNRP inIndia

NNF adopted NRPprogram

1sttraining ofnational faculty atTrivandrum

Regular NALS

courses at variousvenues

Health programs

Curriculum

8/6/2019 Neonatal Als 1

10/22

International GuidelinesInternational Guidelines20002000

ILCOR and AHA

Consensus advisorystatement 1999

Controversies current scientificinformation

Strength of evidence study design, levelof evidence,methodology

8/6/2019 Neonatal Als 1

11/22

Classes of RecommendationsClasses of Recommendations

Class Interpretation

Class I Always acceptable, proven safe,

definitely usefulClass II a Acceptable, safe,useful

Class II b Acceptable, safe, useful (alternate)

Class Inter Prelim. Research stage, promisingresults but insufficient

Class III Unacceptable, no documented

benefit, may be harmful

8/6/2019 Neonatal Als 1

12/22

Major Guidelines ChangesMajor Guidelines Changes

Areas of controversies MSAF

Intra-osseous infusion

Optimal conc. Of O2 Chest compression

Opt. Dose of adrenaline

Volume expanders

Bicarbonate adm.

Cerebral cooling

Ethics

8/6/2019 Neonatal Als 1

13/22

Meconium Stained AmnioticMeconium Stained Amniotic

FluidFluid1. Intrapartum Suction

irrespective of

consistency2. Delay drying and

stimulation

3. ET Suction

If respiration is

absent ordepressed

Decreased muscletone

Heart rate

8/6/2019 Neonatal Als 1

14/22

Oxygenation & VentilationOxygenation & Ventilation

Room air v/s 100% oxygen

Insufficient data to change current practice

Supp. O2 is unavailable room air (IM)

Laryngeal mask (IM)

Effective alternate to establish airway if bag mask

vent.Ineffective, failed ET intubation

Confirmation of ETT by exhaled CO2

If clinical assessment is equivocal (IM)

8/6/2019 Neonatal Als 1

15/22

Medication, Vascular Access

Medication, Vascular Access

Epinephrine dose

If the HR remains < 60 bpm after 30seconds of adequate ventilation andchest compression (1)

8/6/2019 Neonatal Als 1

16/22

Medication, Vascular Access

Medication, Vascular Access

Choice of fluid for volume Expansion

Isotonic crystalloid NS, Ringer lactate

O - negative blood if antenatal

anticipation (2b)

Alternative route for venous access Intraosseous route if venous access

not available (2b)

8/6/2019 Neonatal Als 1

17/22

Chest CompressionsChest CompressionsPreferred technique

Two thumb encircling hands (2b)

Relative depth of compression - /3 ofAP diameter of the chest

Sufficiently deep to generate a pulse

8/6/2019 Neonatal Als 1

18/22

IssuesIssues

Is there a need toreview currentNALS

protocols ? How could the

coverage mademore effective ?

How to modify it forcommunity neonatalcare functionaries

8/6/2019 Neonatal Als 1

19/22

Review of ProtocolsReview of Protocols Revising Publications

Retraining of trainers and providers

8/6/2019 Neonatal Als 1

20/22

Effective CoverageE

ffective Coverage PG curriculum

Trainers courses

State units

Newborn care programs

8/6/2019 Neonatal Als 1

21/22

Community Neonatal CareCommunity Neonatal Care1. Functionaries

2. Module

3. Training programs

8/6/2019 Neonatal Als 1

22/22

Community Neonatal CareCommunity Neonatal Care

Modality Task NALSProtocol

Modified

Protocol

Evaluation Respiration

Heart rateColor

3

3

--

P / A--

Action Initial steps

PPVChest comp.

Medication

3

--

3