Neonatal ResuscitationNeonatal Resuscitation

4.0 CEU’S4.0 CEU’S

IntroductionIntroduction

Approximately 10 % of all newborns require Approximately 10 % of all newborns require some type of life support in the delivery some type of life support in the delivery room or nursery. In those less than 1500 room or nursery. In those less than 1500 grams the need rises to about 80%. 1% of grams the need rises to about 80%. 1% of all infants will require major resuscitative all infants will require major resuscitative measures.measures.

TransitionTransition

• The First BreathThe First Breath• Clamping of the Umbilical CordClamping of the Umbilical Cord• Pressure ChangesPressure Changes• Closure of the Ductus/Foramen ovaleClosure of the Ductus/Foramen ovale

Factors Associated with Factors Associated with Increased Risk for Increased Risk for

ResuscitationResuscitation• AntepartumAntepartum

1. Maternal Age > 351. Maternal Age > 35

2. Diabetes2. Diabetes

3. SGA3. SGA

4. Pre or Post Term4. Pre or Post Term

5. PROM5. PROM

6. Drugs6. Drugs

• IntrapartumIntrapartum

1. Breech Presentation1. Breech Presentation

2. Infection2. Infection

3. Prolonged Labor3. Prolonged Labor

4. Prolapsed Cord4. Prolapsed Cord

5. Meconium–Stained Fluids5. Meconium–Stained Fluids

6. Operative Delivery6. Operative Delivery

7. Fetal HR Abnormalities7. Fetal HR Abnormalities

Preparation for DeliveryPreparation for Delivery

• AnticipationAnticipation• Adequate Planning and PreparationAdequate Planning and Preparation• Prompt Initiation of Resuscitation StepsPrompt Initiation of Resuscitation Steps

Initial Steps of Initial Steps of ResuscitationResuscitation

1. Provide Warmth/Prevent Heat 1. Provide Warmth/Prevent Heat LossLoss

2. Position/Clear the Airway2. Position/Clear the Airway

3. Dry/Stimulate – Initiate Breathing3. Dry/Stimulate – Initiate Breathing

4. Evaluation4. Evaluation

Meconium-Stained Meconium-Stained InfantsInfants

* Vigorous* Vigorous

strong respirations, good muscle strong respirations, good muscle tone, HR>100tone, HR>100

* Not Vigorous* Not Vigorous

ThermoregulationThermoregulation

1. Always preheat the radiant warmer 1. Always preheat the radiant warmer

** Preterm babies are especially ** Preterm babies are especially vulnerable to vulnerable to

cold stress.cold stress.

2. Warm blankets to be used prior to birth.2. Warm blankets to be used prior to birth.

*** baby cannot benefit from radiant heat *** baby cannot benefit from radiant heat if covered with blankets, or team if covered with blankets, or team members block the heat with their members block the heat with their head or upper body.head or upper body.

Opening/Clearing the Opening/Clearing the AirwayAirway

• Place infant of his back or side.Place infant of his back or side.• Place in a “sniffing” positionPlace in a “sniffing” position• Suction mouth, then nose.Suction mouth, then nose.

Dry/StimulateDry/Stimulate

• Drying and removal of wet linen may Drying and removal of wet linen may be enough to initiate breathing.be enough to initiate breathing.

• Tactile Stimulation (if necessary)Tactile Stimulation (if necessary)

EvaluationEvaluation

• Respiratory EffortRespiratory Effort• Heart RateHeart Rate• ColorColor

Providing Free Flow Providing Free Flow OxygenOxygen

•Give the baby free-flow Give the baby free-flow oxygen if…oxygen if…

the newborn is breathing, the newborn is breathing, Heart rate is above 100, Heart rate is above 100, but the baby is cyanotic.but the baby is cyanotic.

****When after tactile stimulation When after tactile stimulation and administration of free and administration of free flow O2 baby remains…flow O2 baby remains…

1.1. ApneicApneic

2.2. GaspingGasping

3.3. Heart Rate < 100Heart Rate < 100

PPV is indicatedPPV is indicated

**Ventilation of the **Ventilation of the lungs is the most lungs is the most important and important and effective action of NRPeffective action of NRP

Positive Pressure Positive Pressure VentilationVentilation

• Bag and MaskBag and Mask

1. Self Inflating Bag1. Self Inflating Bag

2. Flow Inflating/Anesthesia Bag2. Flow Inflating/Anesthesia Bag

3. T-piece Resuscitator3. T-piece Resuscitator

Self Inflating BagSelf Inflating Bag

• Fills spontaneously after squeezed and Fills spontaneously after squeezed and remains inflated at all times.remains inflated at all times.

• Can deliver PPV without a compressed air Can deliver PPV without a compressed air sourcesource

• Requires an oxygen reservoir to deliver 90-Requires an oxygen reservoir to deliver 90-100% oxygen100% oxygen

• Cannot be used to deliver free-flow O2 Cannot be used to deliver free-flow O2 through the mask.through the mask.

***Pop-off valve should always be used to ***Pop-off valve should always be used to avoid delvivery of too much pressure.avoid delvivery of too much pressure.

Flow-Inflating BagFlow-Inflating Bag

• Also known as an anesthesia bagAlso known as an anesthesia bag• Fills only when oxygen from a compressed Fills only when oxygen from a compressed

source flows through it.source flows through it.• Depends on a compressed gas source.Depends on a compressed gas source.• Uses a flow-control valve to regulate pressureUses a flow-control valve to regulate pressure

(pressure manometer is required to avoid (pressure manometer is required to avoid excess pressures)excess pressures)

• Looks like a deflated balloon when not in useLooks like a deflated balloon when not in use• Can be used to administer free-flow O2Can be used to administer free-flow O2

T-Piece ResuscitatorT-Piece Resuscitator

• Requires a gas sourceRequires a gas source• Must have a tight face-mask seal to inflate the Must have a tight face-mask seal to inflate the

lungslungs• Pressures are set manually with adjustable controlsPressures are set manually with adjustable controls• Operator sets maximum circuit pressure, PiP, and Operator sets maximum circuit pressure, PiP, and

peeppeep• PiP must be adjusted to achieve correct chest PiP must be adjusted to achieve correct chest

movementmovement• Can be used to delivery free-flow O2Can be used to delivery free-flow O2

**Postive Pressure is provided by occluding and **Postive Pressure is provided by occluding and releaseing the hole in the peep cap.releaseing the hole in the peep cap.

Bag and Mask Bag and Mask PerformancePerformance

* Face Masks* Face Masks 1. size/shape1. size/shape

2. seal/correct position2. seal/correct position

* Rate* Rate

* Pressures* Pressures

* NG/OGT placement* NG/OGT placement

Supplemental OxygenSupplemental Oxygen

•TermTerm•PretermPreterm•Heart Rate <100Heart Rate <100

Chest CompressionsChest Compressions

• Indicated when Heart Rate is less Indicated when Heart Rate is less than 60 despite 30 seconds PPV.than 60 despite 30 seconds PPV.

• Two acceptable techniquesTwo acceptable techniques a. two fingera. two finger b. thumbb. thumb• Correct positioningCorrect positioning• Rate/Depth/CoordinationRate/Depth/Coordination• ComplicationsComplications

Endotracheal IntubationEndotracheal Intubation

•IndicationsIndications 1. Suctioning the trachea1. Suctioning the trachea

2. When Bag & Mask is ineffective2. When Bag & Mask is ineffective

3. Facilitate coordination with CC3. Facilitate coordination with CC

4. Administer Epinephrine4. Administer Epinephrine

Endotracheal IntubationEndotracheal Intubation

•EquipmentEquipment 1. Laryngoscope1. Laryngoscope

2. Endotracheal Tubes2. Endotracheal Tubes

3. Stylette3. Stylette

4. Suction4. Suction

5. Ambu bag5. Ambu bag

6. Oxygen6. Oxygen

Endotracheal IntubationEndotracheal Intubation

•Steps of IntubationSteps of Intubation 1. Position the Head1. Position the Head

2. Inserting Laryngoscope2. Inserting Laryngoscope

3. Landmarks3. Landmarks

4. Suction/insertion of 4. Suction/insertion of tubetube

Endotracheal IntubationEndotracheal Intubation

* Correct Placement* Correct Placement 1. Vital Signs1. Vital Signs

2. Breath Sounds2. Breath Sounds

3. Vapor3. Vapor

4. Chest Movement4. Chest Movement

5. CO2 detectors5. CO2 detectors

6. Lip to Tip6. Lip to Tip

7. CXR7. CXR

* Securing the Tube* Securing the Tube

Endotracheal IntubationEndotracheal Intubation

•ComplicationsComplications 1. Hypoxia1. Hypoxia

2. Bradycardia/Apnea2. Bradycardia/Apnea

3. Pneumothorax3. Pneumothorax

4. 4. Contusions/LacerationsContusions/Lacerations

5. Perforations5. Perforations

6. Infections 6. Infections

Laryngeal MaskLaryngeal Mask

• What is it?What is it?• How does it How does it

work?work?• Indications for it?Indications for it?• LimitationsLimitations• ComplicationsComplications

MedicationsMedications

• NaloxoneNaloxone

• EpinephrineEpinephrine

• Volume ExpandersVolume Expanders

• Sodium BicarbonateSodium Bicarbonate

Premature InfantsPremature Infants

• Additional RisksAdditional Risks• Additional EquipmentAdditional Equipment• Use of OxygenUse of Oxygen• Brain InjuryBrain Injury• ThermoregulationThermoregulation

Post Resuscitation CarePost Resuscitation Care

• Routine CareRoutine Care• Observational CareObservational Care• Post-resuscitative CarePost-resuscitative Care

Routine careRoutine care

Observational CareObservational Care

Intensive CareIntensive Care

Ethics/Compassionate Care Ethics/Compassionate Care at the End of Lifeat the End of Life

• Ethical PrincipalsEthical Principals

1. Autonomy1. Autonomy

2. Benefits2. Benefits

3. Nonmalefience3. Nonmalefience

4. Justice4. Justice

* Parents Role* Parents Role

* Law* Law

Support at DeathSupport at Death

Be clear and honestBe clear and honest

What “not” to sayWhat “not” to say

Provide humane and Provide humane and compassionate carecompassionate care

Follow-upFollow-up

Care of the StaffCare of the Staff