Resuscitation on Asphyxiated Newborn

mts darmawan

Assess Breathing

Newborn crying?

Yes No

Provide routine care

• Chest is rising symmetrically

• Frequency >30 breaths/min.

• Not breathing/ gasping

• Breathing < 30 or > 60 breaths/ min.

Immediately start resuscitation

Provide routine care

Positioning the newborn to open the airway.

Overview

Persiapan Kelahiran Stabilisasi awal Ventilation - bag and mask :

sungkup dan bagging Kompresi dada Obat-obatan

Asphyxia - The Basics

ApneaTahapan-tahapan :

Napas cepat (takipnea) …..… HR semakin jarangApnea primer irregular gasping → HR ↓ & drop TD Apnea sekunder

Apnuprimer

Apnusekunder

Frekuensi jantung

Tekanan darah

Apnea Apnea

Asphyxia - The Basics

Mayoritas apnea primer membaik dg tindakan tepat

Sekali apnea sekunder → unresponsive utk distimulasi

Apnea harus diperlakukan sbg apnea 2nd & dianggap tjd sejak intra uterin & resusitasi tak boleh ditunda

Asphyxia

Decreased oxygen supply

in the blood

Decreased bloodsupply

Oxygen Deficit

Organ injury

End Organ

Pembersihan Cairan Paru

Napas pertama harus adekuat utk keluarkan cairan

Tekanan utk buka pertama : 2-3 x > besar dari napas normal → menangis

Problem terjadi bila : apnea Usaha napas pertama lemah coz’d by:

prematuritas depression by asphyxia, maternal drugs or anaesthesia

Persiapan Kelahiran

Antisipasi Kebutuhan Resusitasi

1. Ketahui riwayat antepartum & intrapartum

Antepartum Factors Intrapartum Factors

Age > 35 yearsMaternal diabetesPregnancy-induced hypertensionChronic hypertensionOther maternal illness(e.g. CVS, thyroid, neuro)Drug therapy(e.g. magnesium, lithiumadrenergic-blockers)No prenatal carePrevious stillbirthBleeding - 2nd/3rd trimesterHydramniosOligohydramniosMultiple gestationPost-term gestationSmall-for-dates fetus

Fetal malformations

Abnormal presentationOperative deliveryPremature Premature rupture of membranesPrecipitous labourProlonged labourIndices of fetal distressMaternal narcotics(within 4 hrs of delivery)General anaesthesiaMeconium-stained fluidProlapsed cordPlacental abruptionPlacenta previaUterine tetany

Personnel

Minimal 1 orang khusus penolong bayi yg menguasai resusitasi komplit.

Initial Stabilization

Cegah Kehilangan Panas

HangatAlas : datar, keras : cegah konveksi Keringkan tubuh & kepala, isap lendir &

cegah evaporasi Ini : merangsang timbulnya napas

Open the AirwayOpen the Airway

Supine ~ ekstensi Supine ~ ekstensi ringan ringan

Hindari overekstensi Hindari overekstensi or fleksi or fleksi →→ obs airway obs airway

Trendelenburg ~ Trendelenburg ~ boleh boleh

Handuk terlipat (Handuk terlipat (++ 2.5 2.5 cm) : di bawah cm) : di bawah pundah bila oksiput pundah bila oksiput besar besar

Open the Airway

Suction 1st : mouth and then noseIf nose 1st : may gasp & aspirate

secretions Suction : batasi 5 detik & cek HR.

bila bradycardia mungkin krn terlalu dalam

Rangsang Taktil

Bila belum bernapas juga, lakukan: Usap atau sentil telapak kaki Elus punggung dg gentel

Jangan boros waktu dg menyentil bila

10 - 15 detik tak berespon

Evaluate the Infant

1. Respirations ~ fungsi paru

Bayi merintih or apnea perlu VTPBila napas adekuat & spontan →

go to next step.

Evaluate the Infant

2. Heart Rate ~ fungsi jantung

Monitor apex jantung or dasar umbilicusBila HR < 100 bpm → VTP, bahkan sekali

pun ada usaha bernapas HR > 100 bpm → go to the next step

Evaluate heart rate.

Evaluate the Infant

3. Colour ~ oksigenasi

Sianosis sentral (+) : O2 belum cukup O2 100% 5 L/min – sungkup rapat

sampai kulit merah

Lepas bertahap : frekuensinya !

Ventilating ProcedureVentilating Procedure Indikasi VTP : Indikasi VTP :

– apnea or napas merintihapnea or napas merintih– HR < 100 x/minute HR < 100 x/minute

– sianosis sentarl menetap meski Osianosis sentarl menetap meski O22 100% 100%

Bag and mask the most important tool in newborn resuscitation

Ventilating Procedure

Frequency 40-60 x/minute Initial lung inflation : high pressure 30-40

cm H2O but subsequent should be 15-20 cm H2OPenilaian :

Gerakan dinding dada and Auskultasi suara paru bilateral

Ventilating Procedure

Tidak adekuat ? Evaluasi : Lihat seal sungkupreposisi kepala – extensikan sedikit - reposisi

handuk di bahu check for sekret - suction ! try ventilating with mouth slightly open - perhaps

with an oral airway ↑ pressure to 20-40 cm H2O pasang ET

Ventilating Procedure

Stlh 15-30 detik VTP → evaluasi HR Hemat waktu ~ HR :

hitung 6 detik & kali 10 = 1-minute

• Bersih dari mekonium?• Bernapas atau menangis?• Tonus otot baik• Kulit kemerahan• Cukup bulan?

• Berikan kehangatan

• Posisikan, bersihkan jalan napas*

(bila perlu)

• Keringkan, rangsang, posisikan lagi

• Berikan oksigen (bila perlu)

Nilai pernapasan, FJ, warna kulit

Perawatan rutin

Perawatan supotif

Ya

Tidak

Apnu atau FJ < 100

Bernapas

FJ < 100 & kemerahan

30

detik

L A H I R

Berikan VTP*

• Berikan VTP*

• Lakukan kompresi dada

Berikan epinefrin*

FJ < 60 FJ > 60

FJ < 60

Perawatan lanjut

Bernapas

FJ > 100 & kemerahan

30detik

30detik

Berikan VTP*

Berikan VTP* Lakukan kompresi dada

Berikan epinefrin*

The next step depends on HR

HR Action

HR > 100 x Bila napas spontan, bertahap ↓ VTP & rangsang taktil gentle

HR < 60 Kompresi dada VTP adekuat 100% O2

60 < HR < 80

(tdk naik)

Teruskan VTP Mulai kompresi dada

60 < HR < 100

(naik)

Teruskan VTP

Initiate chest compressions if HR is less than 60 or is between

60 and 80 and is NOT increasing.

Evaluate heart rate: < 80 : continue chest

compressions. > 80 stop

compressions.

Kompresi Dada

Rationale↑ sirkulasi & transport O2 Harus selalu disertai VTP O2 100 %

Kompresi Dada

Rationale

Sternum compresses the heart → ↑ intrathoracic pressure

causing blood pumped into the arteries

Release of the sternal pressure

↑ venous return to the heart

Indikasi

Kapan memulai kompresi dada :

Stlh 15-30 detik VTP dg 100% O2 - HR < 60 bpm 60 < HR < 80 & tidak naik

Kapan stop kompresi dada: HR > 80 bpm

Technique

1. Lokasi

1/3 distal sternum, di bawah garis antara 2 papilla mammae

Jangan menekan pd xiphoid → refleks vagal (Goltz refleks) → bisa fatal

Chest compressions - indication

Chest compressions should be performed if the HR < 60 beats/minute, despite adequate ventilation with 100% oxygen for 30 seconds. [ILCOR 1999 Advisory Statement],AHA- AAP 2000

Technique2. Thumb Method:

Kedua tangan melingkar tubuh bayi & menekan sternum dg 2 jempol side-by-side

Jari-jari melingkar ke punggung Pd bayi yg sangat kecil, kedua jempol bisa

superimposed (menyilang) Cara ini > efektif > disukai

Technique

2. Thumb Method:

Technique

3. Two-finger Method:

If tangan penolong terlalu kecil utk melingkar dada ~ punggung bayi

If access to the umbilicus is necessary for medications

Jari tengah & jari manis menekan sternum, tangan lain memegang punggung dr bawah

Technique

Pressure:

- depress the sternum + 1.5 cm

- release to allow the heart to fill

Rate:

Utk HR normal, kompresi- release harus 120 x/ m (2 x per detik)

Technique

Cautions:

Jgn angkat jari dr dada bayi. Akibat :

- habis waktu cari kembali lokasi kompresi

→ salah area

- risiko patah iga dg risiko lanjutan pneumothorax or laserasi hati

Agar sirkulasi adekuat, kecepatan & kedalaman kompresi konsisten

Chest compression

If: HR < 60 after 30 seconds ventilation and stimulation

• Thumb technique: Place your thumbs side by side or, on a small baby, one over the other, immediately above xyphoid. The other fingers provide support needed for the back

• Pressure so that you depress the sternum to a depth of approximately1/3 of the anterior/posterior diameter of the chest. Then release.

• The downward stroke should be somewhat shorter than duration of the release.

• Your thumbs should remain in contact with the chest at all times

• 90 compressions + 30 breaths per min

”One and two and three and breath, and one and two and three and breath …”

VTP selama Kompresi Dada

1. VTP harus menyertai kompresi

2. Ratio kompresi : ventilasi = 3:1

3. Tiga kompresi diikuti 1 ‘pause’ VTP

4. Kecepatan 120 /minute – hasilkan 90 kompresi & 30 VTP / menit

5. VTP > mudah bila ET (+)

Evaluating HR CekCek HR setelah HR setelah 30 detik30 detik Selama cek, interupsi Selama cek, interupsi << 6 seconds 6 seconds Respon (+) : cek HR / 30 detik Respon (+) : cek HR / 30 detik

stopstop kompresi dadakompresi dada bila HR bila HR >> 80 80 bpm bpm VTPVTP teruskan sampai HR teruskan sampai HR > 100> 100 bpm. bpm. Bila HR < 80 bpm minimal Bila HR < 80 bpm minimal

30 detik lagi kompresi dada30 detik lagi kompresi dada

+ VTP+ VTP

Adverse effects of resuscitation with 100% O2

•Prolonges time to first breath

•Prolonges duration of positive pressure ventilation

•Increases neonatal mortality 3% in industrialised, 5% in developing countries

\

•Elevates oxidative stress (at least 4 weeks)

• Associated with acute lymphatic leukemia

Clinical data

Experimental data

• Inflammation in brain, myocardium and lungs•Increases neuronal damage?•Poorer neurological outcome

Medications

Umbilical Vein: Jalan tersering selama resuscitation Perhatian utama adl pd insersi terlalu

dalam dg risiko infus hipertonik & vasoaktif masuk hepar secara langsung

Medications

Drugs & Fluids

The only "medication" : O2 100% by VTP Bbrp memerlukan kompresi dada (10 %)Sangat sedikit (1 %) yg memerlukan

resusitasi lengkap

MedicationsEpinephrine:

Indications: HR < 80 HR = 0

Comments: iv or ET, repeated tiap 3-5 mnt k/p

Medications

Obat Lain Sebagian besar resusitasi singkat Amat jarang pemakaian atropine, calcium & Na

bicarbonate Bila arrest lama ~ metabolic acidosis, Na

bicarbonate MUNGKIN bermanfaat Bila memberi Na bikarbonat (biknat) harus VTP

efektif

Perawatan Pasca Resusitasi

Monitor ketat semua parameterMonitor ketat semua parameterCairan cukup Hati-hati kejang Hati-2 hipoglikemia

Perawatan Pasca ResusitasiCatat semua kejadian : TERTULIS. If the 5-minute APGAR < 7,

assess every 5 minutes for up to 20 minutes or until 2x scores > 8

Although the APGAR score is not used as a decision-making tool, it has been of value in assessing the progress of the resuscitation.

Larangan dalam Rekam Medik

Tipp exDihapusDitempel dengan kertas baru

Dicoret, sehinga tulisan lama masih bisa Dicoret, sehinga tulisan lama masih bisa dibaca dengan jelasdibaca dengan jelas

Bubuhkan tanda tangan atau parafBubuhkan tanda tangan atau paraf

Kesalahan Tulis dlm Status

Conclusion

Hal-hal penting :

Skill skill skill skill skill !!! Only by working through a simulated

resuscitation can doing written guidelines into effective action

(Hanya dengan MENGERJAKAN dengan simulasi, dapat mengerjakan pedoman dengan BENAR)

Terima Kasih