SOME ASPECTS IN SOME ASPECTS IN Neonatal ManagementNeonatal Management

BYBY::RUBANA BAABBAD MDRUBANA BAABBAD MD

CONSULTANT NEONATOLOGISTCONSULTANT NEONATOLOGIST

ContentsContents::

Resuscitation Resuscitation APGAR Score APGAR Score Management of Premature InfantManagement of Premature InfantManagement of Infant Diabetic MotherManagement of Infant Diabetic MotherPremature vs dysmaturePremature vs dysmature

Delivery Room ResuscitationDelivery Room Resuscitation

ANTICIPATION & RECOGNITION OF ANTICIPATION & RECOGNITION OF NEONATE IN DISTRESSNEONATE IN DISTRESS::

Primary ApneaPrimary Apnea: due to brief hypoxia: due to brief hypoxiaRecovers with stimulation and oxygen Recovers with stimulation and oxygen supplementsupplement..

Secondary ApneaSecondary Apnea:with prolonged hypoxia:with prolonged hypoxia . .Requires assisted ventilation and oxygenRequires assisted ventilation and oxygen..

Assume all times that it is secondary and Assume all times that it is secondary and resuscitate immediatelyresuscitate immediately . .

Goals of ResuscitationGoals of Resuscitation::

11 ) )Minimizing Immediate Heat Minimizing Immediate Heat LossLoss

22 ) )Establishing Normal Establishing Normal Respiration and Lung Respiration and Lung

ExpansionExpansion

33 ) )Increasing Arterial PO2Increasing Arterial PO2

44 ) )Supporting Adequate Cardiac Supporting Adequate Cardiac OutputOutput

STEPS FOR EFFECTIVE STEPS FOR EFFECTIVE RESUSCITATIONRESUSCITATION

Preparation:pediatric team should be Preparation:pediatric team should be presentpresent

a)identify high risk deliveries : a)identify high risk deliveries : fetal fetal distress,fetal disease or serious conditions distress,fetal disease or serious conditions

likelike meconium,prematurity,post- maturity abnormal meconium,prematurity,post- maturity abnormal fetal wt.,major anomalies,hydrops,multiple fetal wt.,major anomalies,hydrops,multiple gestation, cord prolapse,abruptio placentae.gestation, cord prolapse,abruptio placentae.

Labor &delivery conditions: like Labor &delivery conditions: like

APH.,abnormal presentation,difficult laborAPH.,abnormal presentation,difficult labor

NO PEDIATRIC TEAM NO PEDIATRIC TEAM REQUIRED:PERSONNEL FOR REQUIRED:PERSONNEL FOR

EVALUATIONEVALUATION neonatal conditionsneonatal conditions :unexpected :unexpected congenital anomalies,respiatory congenital anomalies,respiatory distress,unanticipated neonatal distress,unanticipated neonatal depression.depression.

Maternal conditions:Maternal conditions:signs of maternal infectionsigns of maternal infectionmaternal illness maternal illness e.g.DM,isoimmunization,PET,renal,e.g.DM,isoimmunization,PET,renal,endocrine, pulmonary,or cardiac endocrine, pulmonary,or cardiac diseasedisease..

NESSESARY EQUIPMENTNESSESARY EQUIPMENT1.1. Radiant warmerRadiant warmer2.2. Oxygen sourceOxygen source3.3. Self inflating bag with reservoir or anesthesia bagSelf inflating bag with reservoir or anesthesia bag4.4. Face mask with appropriate sizeFace mask with appropriate size5.5. SuctionSuction6.6. StethoscopeStethoscope7.7. Emergency box: laryngoscope, batteries ET. Emergency box: laryngoscope, batteries ET.

Tubes,drugs:epinephrin)1:10000),NaHco3 4.2%, Tubes,drugs:epinephrin)1:10000),NaHco3 4.2%, Naloxon, albumin, and NaCL 0.9%Naloxon, albumin, and NaCL 0.9%

8.8. Umbilical catheterization trayUmbilical catheterization tray9.9. Syringes, needles, t-connectors, and stopcocksSyringes, needles, t-connectors, and stopcocks10.10. Transport incubator with batteriesTransport incubator with batteries11.11. Pulse oximetryPulse oximetry

Begin a process of Begin a process of evaluation,decision,and actionevaluation,decision,and action..

decisiondecision

actionaction

evaluationevaluation

Place on warm Place on warm tabletable

Dry &discard the Dry &discard the wet linens+extra wet linens+extra warmingwarming

PositioningPositioning Suction the mouth, Suction the mouth,

oropharynx, and oropharynx, and nares )avoid deep nares )avoid deep pharyngeal suctionpharyngeal suction

EVALUATION&ACTIONEVALUATION&ACTION

Evaluate for:Evaluate for: color: cyanosed ------oxygencolor: cyanosed ------oxygen Respiratory distress: signs?Respiratory distress: signs? Indications of bag and mask Indications of bag and mask

ventilation: apnea, HR< 100ventilation: apnea, HR< 100 RateRate, , presspress, , techniquetechnique

indication for intubation, ET size & indication for intubation, ET size & suction catheter sizes.suction catheter sizes.

TUBE SIZETUBE SIZE

Wt.of infantWt.of infant ETsizeETsize Suction Suction catheter catheter

sizesize

<<10001000 gmgm 2.52.5 5-65-6 frfr

10001000- - 20002000 gmgm

33 66

20002000 – – 30003000 gmgm

3.53.5 88

<<30003000 gmgm 44 88

CHEST COMPRESSIONSCHEST COMPRESSIONS

Indications: if after 15-30 sec of Indications: if after 15-30 sec of +ve press ventilation 100% O2 & +ve press ventilation 100% O2 & HR<60 / 60-80 bpm & not ↑HR<60 / 60-80 bpm & not ↑

Technique : 1 finger breadth Technique : 1 finger breadth below nipple line, using 2 fingers below nipple line, using 2 fingers compress 1-2 cm 90\ min ratio 3:1 compress 1-2 cm 90\ min ratio 3:1 cc to vent. cc to vent.

Medications used for Medications used for resuscitationresuscitation

Indications:Indications: Bradycardia with HR < 80 BPM Bradycardia with HR < 80 BPM

despite adequate ventilation with despite adequate ventilation with 100% O2 and chest compression for 100% O2 and chest compression for mini. Of 30 sec or HR=0mini. Of 30 sec or HR=0

EpinephrineEpinephrine Volume expandersVolume expanders Naloxone hydrochlorideNaloxone hydrochloride NaHCO3 NaHCO3

Dosage ChartDosage Chart

EpinephrineEpinephrine 0.10.1~~0.30.3 ml/kgml/kg

1:10,0001:10,000

Volume Volume expanderexpander

1010 ml/kgml/kg NS./NS./albumin,RL.albumin,RL./BLD/BLD

NaHCO3NaHCO3 2mEq/kg2mEq/kg 0.50.5 mEq/mlmEq/ml

Naloxone Naloxone Hydrochlori-Hydrochlori-dede

0.1mg/kg0.1mg/kg 1mg/ml or 1mg/ml or 0.4 mg/ml0.4 mg/ml

Special resuscitation effortsSpecial resuscitation efforts

Meconium present at delivaryMeconium present at delivary

Diaphragmatic herniaDiaphragmatic hernia

APGAR SCOREAPGAR SCORE

DEFINITION: an assessment of the DEFINITION: an assessment of the newborn’s physical condition newborn’s physical condition immediately after birth ; involve immediately after birth ; involve HR,respiratory effort,color, muscle HR,respiratory effort,color, muscle tone & reflex.tone & reflex.

Devised in 1952 by VERGINIA Devised in 1952 by VERGINIA APGAR the American anasthatologistAPGAR the American anasthatologist

The score range from 1-10The score range from 1-10 Calculated at 1&5 min. & if <7 to be Calculated at 1&5 min. & if <7 to be

repeated every 5 min.up to 20 min.repeated every 5 min.up to 20 min.

Apgar scoring systemApgar scoring system

signsign 00 11 22

HRHR absentabsent < <100100 bpmbpm < <100bpm100bpm

Resp.effortResp.effort absentabsent Slow/ Slow/ irregularirregular

Good cryingGood crying

Muscle toneMuscle tone limplimp Some Some flexion of flexion of

the the extremitiesextremities

Active Active motionmotion

Reflex Reflex irritabilityirritability

No No responseresponse

grimacegrimace Cough/ Cough/ sneezesneeze

colorcolor Blue/paleBlue/pale Pink Pink body,blue body,blue

extremitiesextremities

All pinkAll pink

Definition of dysmaturityDefinition of dysmaturity

1. Characteristic of faulty embryologic 1. Characteristic of faulty embryologic development, often leading to structural development, often leading to structural and/or functional abnormalities.and/or functional abnormalities.

2. 2. Relating to or characteristic of an infant Relating to or characteristic of an infant whose birth weight is inappropriately low whose birth weight is inappropriately low for its gestational agefor its gestational age

Premature vs. DysmaturePremature vs. Dysmature

< 20wks.&< 37 weeks< 20wks.&< 37 weeks Incomplete organ Incomplete organ

system developmentsystem development thin shiny thin shiny

skin,extended arms skin,extended arms and legs,little and legs,little subcutanous fat,spase subcutanous fat,spase hair few palmar and hair few palmar and sole creases,poorly sole creases,poorly developed ear developed ear cartilage ,genitalia cartilage ,genitalia boys few rugae boys few rugae undescended testicles- undescended testicles- girls gaping labia girls gaping labia prominent clitorisprominent clitoris

postmaturity postmaturity syndrome:syndrome:  a   a syndrome due to syndrome due to placental insufficiency placental insufficiency that causes chronic that causes chronic stress and hypoxia, stress and hypoxia, seen in fetuses and seen in fetuses and neonates in postterm neonates in postterm pregnancies, pregnancies, characterized by characterized by decreased decreased subcutaneous fat, skin subcutaneous fat, skin desquamation, and desquamation, and long fingernails, often long fingernails, often with yellow meconium with yellow meconium staining of the nails, staining of the nails, skin, and vernix.skin, and vernix.

The Premature infantThe Premature infant

The premature infant is quickly The premature infant is quickly transferred from the warm fluid transferred from the warm fluid medium of the liquor amnii with its medium of the liquor amnii with its practically constant temperature practically constant temperature to the variable circumstances of to the variable circumstances of an extrauterine life; he/she loses an extrauterine life; he/she loses the preparatory transition-time of the preparatory transition-time of the third trimester of intrauterine the third trimester of intrauterine existence .existence .

Problems of prematurityProblems of prematurity ThermoregulationThermoregulation Respiratory distress Respiratory distress ApneaApnea SepsisSepsis poor sucking& swallowing reflexpoor sucking& swallowing reflex NeurologicNeurologic CvsCvs HematologicHematologic NutritionalNutritional GastrointestinalGastrointestinal MetabolicMetabolic RenalRenal Immunologic Immunologic opthalmologicopthalmologic

Management of premature Management of premature infantsinfants Thermal regulationThermal regulation O2 therapy & assissted ventilationO2 therapy & assissted ventilation PDAPDA Fluid& electrolite managementFluid& electrolite management NutritionNutrition HyperbilirubinemiaHyperbilirubinemia InfectionInfection immunizationimmunization

Management of infants of Management of infants of diabetic mothersdiabetic mothers Evaluation: before delivery : size, Evaluation: before delivery : size,

pulmonary maturity, obvious pulmonary maturity, obvious anomaliesanomalies

After delivery: After delivery: ApgaApgar score, physical r score, physical examination for major congenital examination for major congenital anomaliesanomalies

In the nursery: continuous evaluation In the nursery: continuous evaluation repeat the examination, monitor blood repeat the examination, monitor blood glucose, hematocrit, calcium & glucose, hematocrit, calcium & bilirubin levels.bilirubin levels.