Neonatal resuscitation
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Transcript of Neonatal resuscitation
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Neonatal Resuscitation
DR. EKHLAS ALI
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Neonatal resuscitation
10% neonates require some assistance at birth.
1% neonates need extensive resuscitative measures.
Asphyxia accounts for 20-25% newborn deaths.
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How does a baby receive oxygen before birth?
Oxygen diffuses across placenta from mother’s blood to baby’s blood.
Lungs receive very little blood.
Alveoli are fluid filled rather than air.
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After birth
•Fluid in the alveoli is absorbed
Alveoli
• Expand
• Get filled with air (O2)
1.
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After birth
Umbilical arteries and veins are clamped
Sudden increase in systemic blood pressure
2.
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Pulmonary vessels dilate, causing increased blood flow to lungs
3.
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Apgar score
Calculated at 1 & 5 min after birth
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Consequences of interrupted transition
The compromised baby may exhibit 1 or more of the following clinical findings:
1. Low muscle tone
2. Respiratory depression (apnea / gasping)
3. Bradycardia
4. Cyanosis
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Antepartum Risks
Maternal diabetesChronic maternal illness Cardiovascular Thyroid Neurological Pulmonary renal
Pre eclampsiaMaternal infectionPolyhydramniosOligohydramnios
Premature rupture of membranesIUGR/pretermFetal malformationMaternal substance abuseNo antenatal carePost term gestationMultiple gestationAnaemiaAge <16 or > 35
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Intrapartum Risks
Emergency CSInstrumental deliveryAbnormal positionPremature labourPrecipitous labourChorioamnionitisProlonged rupture of membranesProlonged labour > 24 hrsProlonged 2nd stage of labour
Fetal bradycardiaNon-reassuring fetal heart rate patternGeneral anaesthesiaNarcotics administered within 4 hours of deliveryMeconium stained liquorProlapsed cordAbruptio placentaePlacenta previa
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Fetal asphyxia
Primary apnoea Apnoeic Blue Heart rate Resuscitate easily
Secondary apnoeic White, floppy Heart rate Require active resuscitation
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Equipment Needed for Resuscitation
Radiant warmer
Warm towel and blankets
Resuscitation bag and mask Self inflating bag Anaesthetic bag
Endotracheal tubes
Laryngoscope
Stethoscope
Oxygen source and tubing
Suction source and tubing
Drugs and fluids
Syringes, needles, cannulae, IV lines
+/-Umbilical lines
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Equipment Needed
Overhead radiant warmer
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Normal Delivery Procedures
Place under warmer and towel dryUse bulb syringe to clear mouth, then noseTactile stimulation if not breathing yet Auscultate heart and lungs & assess colorFree flow O2 as needed
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Steps in Resuscitation
Warmth and stimulation and assessment for the 1st 30 seconds Use warm cloth Replace when wet Rapidly assess
Tone Colour Respiratory effort
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Steps in Resuscitation - ABCDE
Airway Clear airway if required Removal of secretions if present
Suction mouth and nose DO NOT SUCTION IF AIRWAY IS CLEAR
Positioning Supine or lateral Head in neutral or slightly extended position
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Neonatal Position for Opening the Airway – ‘neutral position’
Incorrect: Neck Hyperextension
Incorrect: Neck Under Extended
Correct: Neck Slightly Extended
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Head flexed by large occiput
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Head in neutral or ‘sniffing’ position
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Acceptable methods of stimulation
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Steps in Resuscitation - ABCDE
Breathing
Assessment of respiratory effort and colour
Indications for oxygen administration Cyanosis Respiratory distress Give free flowing oxygen 5L/min
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Breathing: Indications for positive pressure ventilation
Apnoea
Gasping respiration
HR < 100 bpm
Persistent central cyanosis despite 100% O2
40-60 breaths/min
No response
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Watch for slight rise of chestRate is 40-60
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Indications of endo-tracheal Intubation
Prolonged positive-pressure ventilation (PPV) required
Bag & mask ineffective: Inadequate chest expansion
If chest compressions required: Intubation may facilitate
coordination and efficiency of ventilation
Tracheal suction required
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Steps in Resuscitation - ABCDE
Circulation
Assessment of heart rate and response to previous measures Umbilical arteries Apex beat Auscultation
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Chest Compressions
HR < 60 bpm despite adequate vent with 100% O2 for 30 seconds
2 techniques 2 thumb (preferred) 2 finger 3:1 ratio 1/3 of AP diameter
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TechniquePosition of Hands on Chest
Thumb technique
( preferred )
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TechniquePosition of Hands on Chest
Two finger technique
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Chest (cardiac) compressions
“Two-thumb” technique is usually preferred
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Steps in resuscitation - ABCDE
Drugs
Adrenaline
Volume Expanders
Naloxone
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Epinephrine Indications
HR <60 /min after PPV & CC for 30 secs
Route of administration
Intravenous
Endotracheal route (when I.V line is not secured ) Recommended
Conc. – 1:10,000 (0.1mg/ml)
Route – UVC/ IV
Dose – 0.01-0.03 mg/kg , (0.05-0.1mg/kg E.T)
Rate of admn. – as rapidly as possible
Repeat dose if no response after 60 seconds Now, intravenous route is first preferred route
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Volume ExpanderVolume Expander Indications:
Poor response to other resuscitative measures
Evidence of blood loss or suspected ( pale skin, poor perfusion, weak pulse)
Crystalloid Normal Saline Ringer Lactate or O-negative blood cross-matched with mother’s blood
Dose – 10ml/kgRoute – Umbilical veinPreparation – large syringeRate of administration – 5-10 min
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Naloxone Narcotic antagonistNaloxone Narcotic antagonist
Indications :
A history of maternal narcotic administration within the
past 4 hours
Severe respiratory depression is present after PPV has
restored a normal HR & color
Recommended
Concentration: 1.0 mg/ml
Route: Intravenous
Dose: 0.1 mg/kg
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Meconium present and baby vigorous
Vigorous Baby- Strong respiratory efforts,
Good muscle tone,
Heart rate > 100 bpm
suction catheter or bulb syringe for suction of mouth or nose
ET suction not required
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Meconium present and baby not vigorous
Insert laryngoscope
Clear mouth and posterior pharynx
Insert endotracheal tube into the trachea
Attach the ET to suction source
Apply suction as ET is slowly withdrawn
Repeat as necessary until no meconium or heart
rate indicates further resuscitation
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What to do if still no improvement?What to do if still no improvement? If no improvement seen despite all efforts
Ensure adequate ventilation, chest compressions, drug delivery
If still HR < 60/min, consider Airway malformation Lung problems Pneumothorax Diaphragmatic hernia Cong. Heart disease
If HR absent or no progress Ethical considerations of when to D/C Resuscitation
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Discontinuing Resuscitative Effort
Stop resuscitation, if HR remains undetectable for 10 - 15 min
Also take into consideration factors such as presumed etiology of the arrest, gestation of the baby, presence or absence of complications
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Guidelines for Neonatal Resuscitation
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