Neonatal Resuscitation Guidelines

Dr . Mohammad AlmaghayrehDr . Mohammad Almaghayreh Princess Rahmah Teaching Hospital Princess Rahmah Teaching Hospital

What's new????

• IntroductionIntroduction• Preparation/Preparation/

AnticipationAnticipation• Initial assessmentInitial assessment• Whom to resuscitateWhom to resuscitate• Steps of resuscitationSteps of resuscitation• New additionsNew additions• ConclusionConclusion

IntroductionIntroduction

• Approximately 10% of newborn's require some assistance.• Less than 1% require extensive resuscitation measures

Because of the large total number of births, a significant number will require some degree of resuscitation

AnticipateAnticipate the riskthe risk

• Assessment of perinatal risk factors• Assemble the appropriate personnel • Organize access to supplies and check equipment• Effective teamwork and communication

Anticipation of Resuscitation Need

Risk Factors

Anticipation of Resuscitation Need

Before delivery of the baby the team should do:

• A) Antenatal counseling • B) Ask OBSTITRECIAN 4Q?1)gestational age? 2)Clear amniotic fluid? 3)How many babies? 4)Any additional risk factors?• C) Team briefing• D) Equipment check

Equipment A complete set of resuscitation equipment and drugs should always be readily available in the areas of hospitals where newborns are born or receive neonatal care1

2.2.1 Equipment checks • Facilities should maintain a clear record documenting the checking procedure for each set of resuscitation equipment and drugs1

• Each set of resuscitation equipment and drugs should be checked Before any resuscitation1

Initial Assessment?Initial Assessment? Questions to answer with yes/no

• Assess the answers to the following 3 questions:

1) Term gestation?2) Good tone?3) Breathing or crying

Yes!

Term gestation Crying or breathingGood muscle tone

• Baby does not need resuscitation

• Should not be separated from the mother.

• Dry, place skin-to-skin with the mother

• Cover with dry linen to maintain temperature

• Observe breathing, activity, and color

Term gestation?Crying or breathing?Good muscle tone?

If the answer to any of these assessment questions is “NO”

A. Initial steps of stabilizationB. Ventilate and oxygenate (HR/Breathing)C. Initiate chest compressions (HR < 60) D. Administer epinephrine and/or volume

Whom to resuscitate?Whom to resuscitate?

To proceed or not to Proceed?

• Respirations : apnea, gasping, or labored or unlabored breathing)

• Heart rate : whether > or < 100 ointermittently auscultating

the precordial pulseopalpation of the umbilical

pulse

Approximately 60 seconds (“the Golden Minute”) are allotted for completing initial steps, revaluating and beginning ventilation if required

• Most neonatal arrests are asphyxia in nature.

• First ventilation (if needed) should be administered within 60 seconds of initial assessment.

• “Initial Assessment” can be done on Mom

• Permitting delayed cord clamping if stable

O2 saturation• Once positive pressure ventilation

or supplementary oxygen administration is begun, assessment should consist of simultaneous evaluation of 3 vital characteristics:

1. heart rate2. respirations3. state of oxygenation (pulse

oximeter)

The device takes 1 to 2 minutes to apply, and it may not function during states of very poor cardiac output or perfusion

UMBILICAL CORD CLAMPING

• 25 60% of the circulating ‐volume of the feto placental unit resides in the placenta

• 20 40 mL/kg = normal ‐transfusion from placenta to neonate

Delayed cord clamping means waiting at least 30 second to stop of umbilical cord pulsation after the delivery of an infant

Definition of Delayed Cord Clamping

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Umbilical cord management

DCCDCC : less IVH, higher BP, blood volume, less need for transfusion after birth ,more iron store, and less NEC No evidence of decreased mortality or decreased incidence of severe IVH

slightly increased level of bilirubin associated with more need for phototherapy

New EntriesNew EntriesConsensus: 1)DELAYED CORD CLAMPING > 30 seconds is reasonable for both T/PT infants who do not require resuscitation at birth2)No routine use of cord milking for infants < 29 weeks of gestation outside of a research setting3)• No delay in cord clamping if placental circulation disrupted (placental abruption, bleeding placenta previa, bleeding vasa previa, or cord avulsion) 4)Insufficient evidence to recommend an approach to cord clamping for newborns who require resuscitation at birth ( Non-vigorous)

DELAYED CORD CLAMPING

• The risk of death/admission decreased by 20% for every 10-second delay in CORD CLAMPING after SPONTANEOUS RESPIRATION; this risk declined at the same rate in both BW groups.

Neonatal Outcome Following Cord Clamping After Onset of Spontaneous Respiration (PEDIATRIC 2014)

Physiology of thermal regulation in neonates

Convection EvaporationRadiation

ConductionPhotograph: "HumanNewborn" by Ernest F - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:HumanNewborn.JPG#/media/File:HumanNewborn.JPG

Temperature

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Temperature categories(World Health Organization)

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Temperature regulation•Admission temperature strong predictor of mortality at all gestational ages.Hypothermia increases risk of:1)Intraventricular haemorrhage2)Respiratory Distress3)Hypoglycaemia 4)late-onset sepsis

predictor of outcomes as well as a quality indicator

Strategies to Provide Warmth

For all newborns– Environmental Temperature at least 25°C

(77°F)– Warm Blankets for Drying– Hats (wool or plastic) For newborns requiring resuscitation– Radiant Warmer– Warm, humidified gases For premature– Polyethylene Occlusive wrapping– Heated (Na Acetate) Mattresses

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Consensus1)Maintain temperature between 36.5-37.5°C2)Plastic wrap, radiant warmer, thermal mattress, warm humidified gases and increased room temperature3)Hyperthermia (>38.0°C) should be avoided4)Rapid or slow cooling both acceptable

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Maintaining normothermia in resource-limited settings

1)Clean food-grade plastic bag up to the level of the neck and swaddle them after drying 2)Kangaroo mother care

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Maternal hyperthermia in labour is associated with increased mortality, neonatal seizures and encephalopathy

"Intrapartum fever and chorioamnionitis as risks for encephalopathy in term newborns: A case-control study." Developmental Medicine and Child Neurology 50(1): 19-24. Blume, H. K., C. I. Li, et al. (2008).

A comment about Meconium

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• Deterioration of pulmonary compliance, oxygenation and cerebral blood flow velocity accompany tracheal suction

Non vigorous baby: Routine intubation for tracheal suction not suggested

Meconium-stained amniotic fluid is a perinatal risk factor that requires the presence of one resuscitation team member with full resuscitation skills, including endotracheal intubation

Meconium Stained Amniotic Fluid

Initial steps (warm, dry & stim) may be performed first

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Assessment of Heart Rate•Increasing heart rate is most sensitive indicator of a successful response to each intervention•Underestimation of the newborn’s heart rate by auscultation, palpation and pulse oximetry•3-lead ECG displayed a reliable heart rate faster than pulse oximetry

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Consensus

During resuscitation of T/PT newborn's, use 3-lead ECG for the rapid and accurate measurement of the newborn’s heart rate.

Initial HR assessed by auscultation– PPV begins, consider ECG monitor– When/if chest compressions begin, ECG is preferred method of

determining HR.

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Administration of oxygen in Preterm•Resuscitation of PT newborn's (<35) with high oxygen (65%) showed no improvement in survival to hospital discharge

Resuscitate preterm < 35 weeks with low oxygen (21-30%) and titrate to achieve preductal oxygen saturation target.

• Adjust the oxygen concentration as needed to achieve the oxygen saturation target by pulse oximetry• If the newborn has labored breathing or oxygen saturation cannot be maintained with the target range despite 100% free flow oxygen, consider a trial of CPAP

Focus Intently on Achieving Effective Ventilation

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Positive Pressure Ventilation/PEEP•PEEP :supplementary oxygen required to achieve target oxygen saturation may be slightly less when using PEEP.

5 cm H2O PEEP when PPV is administered to preterm new-born's

PPV delivered effectively with a flow-inflating bag, self-inflating bag or T-piece resuscitator

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• Use of respiratory mechanics monitors have been reported to prevent excessive pressures and tidal volumes• Exhaled CO2 monitors may help assess that actual gas exchange is occurring during face-mask PPV attempts.

Effectiveness, particularly in changing important outcomes, has not been established

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• CPAP decreases rate of intubation, duration of MV with potential benefit of reduction of death and/or BPD without significant increase in air leak or severe IVH.

spontaneously breathing PT infants with respiratory distress may be supported with CPAP initially rather than routine intubation for administering PPV

Chest Compressions1) Intubation is strongly recommended prior

to beginning chest compressions2) • If intubation is not successful or not

feasible, a laryngeal mask may be used3) • Chest compressions = two-thumb

technique4) • Once the endotracheal tube or laryngeal

mask is secured, the compressor administers chest compressions from the head of the newborn

5) • Chest compressions continue for 60 seconds prior to checking a heart rate

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LMA recommended during resuscitation > 34 weeks when tracheal intubation is unsuccessful or is not feasible

LMA(Laryngeal mask airway)

• Fits over laryngeal inletThe laryngeal mask airway can be used in resuscitation of the

newborn if facemask ventilation is unsuccessful if tracheal intubation is unsuccessful or not feasible. • –The LMA may be considered as an alternative to a

facemask for positive pressure ventilation among newborns weighing more than 2000 g or delivered≥34 weeks gestation

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Endotracheal Intubation

Endotracheal Intubation• Depth of the endotracheal tube,

determined by using the• “Initial Endotracheal Tube Insertion

Depth” table, or by measuring the nasal-tragus length (NTL)

• No more weight + 6

NTL = distance fromthe base of the nasal septum to the tip ofthe tragus on eitherside

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100% Oxygen whenever chest compressions are provided

Supplementary oxygen concentration should be weaned as soon as the HR recovers

Chest compression

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TH may be considered and offered under clearly defined protocols similar to those used in published clinical trials and in facilities with the capabilities for multidisciplinary care and longitudinal follow-up

Induced Therapeutic Hypothermia (Induced Therapeutic Hypothermia (Resource Limited settingResource Limited setting))

Post resuscitation care

Post resuscitation care

Bundles of interventionsimproving the outcome of preterm infants

• Maintain normal temperature– Without drying, cover in food-grade plastic wrap or bag

and use a hat and thermal mattress or other adjunct• Use a 3-lead cardiac monitor (chest or limb leads) for

rapid and reliable continuous HR• Initiate ventilation with low supplemental oxygen (21-

30%)• If PPV, use a device with PEEP• Consider CPAP immediately after birth as an alternative

to routine intubation and surfactant administration.

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Withholding Resuscitation New EntriesNew Entries

< 25 weeks, consider accuracy of gestational age assignment, presence/absence of chorioamnionitis and the level of care

Useful data for antenatal counselling provides outcome figures for infants alive at the onset of labor, not only forthose born alive or admitted to a neonatal intensive care unit

What has not changedVeni, Venti, Vici

• Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn.”

Slapping, shaking, spanking, or holding the newborn upside down are potentially dangerous and should not be used. During all handling, care should be taken to ensure that the infant’s head and neck are supported in a neutral position, especially if muscle tone is low If the infant does not breathe, assisted ventilation should be started [

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Comments about Narcan and the Newly Born

There is insufficient evidence to evaluate safety and efficacy of administering naloxone to a newborn with respiratory depression due to maternal opiate exposure. Animal studies and case reports cite complications from naloxone, including pulmonary edema, cardiac arrest, and seizures.

SODIUM BICARBONATE

• Sodium bicarbonate should not be routinely given to babies with metabolic acidosis.

• There is currently no evidence to support this routine practice.

“New and revised treatment recommendations do not imply that clinical care that involves the use of previously published guidelines is either unsafe or ineffective

Any Questions???Any Questions???THANK YOU