NEONATAL RESUSCITATION

Dr.(COL) C.G.WILSON PROFESSOR& H.O.D(PAED) Dr. K.SATYANARAYANA CONSULTANT(PAED) KAMINENI HOSPITALS

PREPARATION FOR NEONATAL RESUSCITATION

Dr. K.SATYANARAYANA M.D; CONSULTANT(PAED)

NEONATAL RESUSCITATION
After delivery most of the babies fall into one of the 4 groups. 1. Fit and healthy (90-95%) 2. Primary apnoea (5-6%) Apnoeic and blue Inadequate breathing HR : 80 100 3. Terminal apnoea (0.2 0.5%) pale, limp apnoeic HR < 60 4. Dead but resuscitable ( < 0.1%)

Which baby requires resuscitation ? No respiratory effort at all

Feeble and Inadequate effort

Vigorous cyanosed respiratory effort but

Apnoeic due to primary muscle and CNS disorder * Anticipation and preparation are key factors in the management of resuscitation.

Identification of the high risk neonate:

1. PiH
2. DM 3. Oligohydramnios / Polyhydramnios

4. Multiple pregnancy
5. Rh incompatability 6. Postdated pregnancy 7. APH 8. Abnormal presentations 9. Maternal infections and disorders 10. Meconium stained liquor 11. Prolonged labour 12. Cord prolapse / shoulder dystocia

FACTORS OTHER THAN B.A. REQUIRING RESUSCIATION

1. PT

2. Maternal hypocapnia
3. Maternal drugs depressing CNS 4. Sepsis (GBS) 5. Anemia 6. Primary muscle and CNS disorder 7. Congential malformations of the airway and CNS

PRIMARY APNOEA Shallow respiration

HR & BP
Tone HR & BP Flaccid

Responds to stimulation
and O2 inhalation

SECONDARY APNOEA Requires resuscitation

Primary apnoea and secondary apnoea may occur even in utero. Apnoea at birth assume it as secondary apnoea only. Secondary apnoea and brain damage.

Asphyxia is defined as combn of hypoxemia, hypercapnia and metabolic acidosis.

Hypoxemia & acidosis

Constriction of arterioles in lungs

Constriction of the
arterioles of other organs (brain&heart spared)

PBF, Perfusion

Organ damage

Oxygenation of tissues

PREPARATION FOR RESUSCIATATION

Personnel: 1 person skilled in resuscitation should attend every delivery 2 persons depressed newborn

1 person Intubation & ventilation

2nd person Monitor HR & chest compressions Multiple pregnancy Separate team for each infant

NEONATAL RESUSCITATION SUPPLIES AND EQUIPMENT Suction equipment:

Bulb syringe Mechanical slow suction (100mm Hg) with tubing Suction catheters, 5F or 6F, 8F and 10F or 12F

Meconium aspiration device

Bag-and-mask equipment:
Neonatal resuscitation bag with a pressurerelease valve and / or pressure manometer and reservoir (the bag must be capable of delivering 90% to 100% oxygen)
Face masks, newborn and premature sizes (masks with cushioned rim preferred)

Oxygen with flow meter (flow rate up to 10L/min and tubing (including portable oxygen cylinders)

Intubation equipment:
Laryngoscope with straight blades, No. 0 (preterm) and No.1 (term) Extra bulbs and batteries for laryngoscope Endotracheal tubes: 2.5, 3.5, and 4.0mm ID Styllet (optional) Scissors Tape for securing tracheal tube Laryngeal mask airway (optional)

Umbilical vessel catheterization:

Sterile gloves

Scalpel or scissors
Providone iodine solution Alcohol sponges Umbilical tape Umbilical catheters: 3.5F, 5F Three-way stopcock Flushing solution

Miscellaneous:
Gloves and appropriate personal protection Radiant warmer or other heat source Firm, padded resuscitation surface Clock (timer optional) Warmed linens (at least two per delivery) Stethoscope

Tape, or inch

Miscellaneous:
Cardiac monitor and electrodes (optional) and/or pulse oximeter with probe. Oropharyngeal airways Syringes 1, 2, 5, 10, 20 and 50mL

Needles- 18, 21 & 25 gauge or puncture device for needle less system.

Medications:
Administration of drugs is rarely indicated in resuscitation of the NB infant. However, in rare cases the following medications are used: Epinephrine 1:10,000 (0.1mg/mL) Dilute 1ml of 1:1000 solution and keep ready (0.5ml. + 4.5ml NS) Isotonic crystalloid (normal saline or Ringers lactate) for volume expansion. (Albumin is no longer recommended). 0ve red cells may be used.

Sodium bicarbonate dilute 7.5% solution 1:1 with DW to get approximate concentration
Naloxone hydrochloride 0.4mg/mL 1-mL ampoules; or 1.0 mg/mL 2-mL ampoules

NEONATAL RESUSCITATION PROTOCOL

STEPS OF RESUSCITATION

Dr(col) C.G.WILSON
PROFESSOR& H.O.D(PAED)

STEPS OF RESUSCITATION
ON YOUR MARCH.GET SET

PREVENTION OF HEAT LOSS PROVIDE WARMTH AIRWAY CLEARING & CLEANING INITIATION OF BREATHING EVALUATION

PREVENTION OF HEAT LOSS & PROVIDE WARMTH

DRYING PREWARMED TOWEL REMOVE WET TOWEL RADIANT WARMER EUTHERMIC ATMOSPHERE

AIRWAY MANAGEMENT
EXCESSIVE SECRETIONS & M S A F BEFORE DRYING

POSITION - ON BACK FLAT

HEAD SLIGHT EXTENSION & ONESIDE TOWEL - SHOULDER BLADE

AIRWAY CLEARING

BULB SYRINGE

De Lee MUCUS SUCKER

MECHANICAL 100mm Hg

INITIATION OF BREATHING TACTILE STIMULATION

HARMFUL ACTIONS
1.

CONSEQUENCES
BRUISING # PNEUMO RUPUTURE OF LIVER, SPLEEN HYPO / HYPER THERM BURNS

SLAPPING BACK

2. SQUEEZING RIB CAGE 3. FORCING THIGHS ONTO ABDOMEN

4.

HOT / COLD COMPRESS

INTER-RELATIONSHIP -

RESP, HR, COLOUR

AT BIRTH 60 90 SEC RARELY

- SOME -CYANOSIS - PINK / ACROCYANOSIS - RESP REGULAR FREE HR 100 MT FLOW CENTRAL CYANO OXYGEN - HIGH CONCN O2 (80%) - GRADUAL WEANING TILL PINK AT ROOM AIR

INITIAL

FREE FLOW OXYGEN

OXYGEN HEATED, HUMIDIFIED 5L / mt NEARER TO NOSE 1/2 INCH-80% 1 INCH-60% 2INCH-40%

EVALUATION
NO BREATHING/GASP AFTER 2 TACTILES STIMLNS CHECK: RESP EFFORT

HR
COLOUR

BREATHING (N) HR > 100 / mt PINK COLOUR

IF NOT - PROTOCOL

SUPPORTIVE CARE

PROTOCOL
GASP / NO BREATHING & HR < 100
30 SEC BAG & MASK WITH OXYGEN CHECK HR FOR 6 SEC X 10 HR < 60 APNOEA CHEST COMPRESSION & BMV 30 SEC (100%) HR 60 - 100 APNOEA (N) BREATHING HR 100 & PINK FREE FLOW OXYGEN

BMV 30 SEC

HR 100 & HR < 60

PINK

PINK AT ROOM AIR

DRUGS & INTUB OROGASTRIC TUBE FOR BMV > 2 Mts

BAG & MASK VENTILATION

BAG

VALVE ASSEMBLY

SELF INFLATING / AMBU BAG

AIR INLET OXYGEN INLET

VALVE ASSEMBLY
PATIENT OUTLET

FACE MASK
CUSHIONED RIM 0, 1, 2 SIZES ROUND / CONICAL

CHECK EQUIPMENT
-BAG BLOCK OUTLET & SQUEEZE --PR RELEASE VALVE
RELEASE HEAR AIR

CLEAN 2% GLUTARALDEHYDE 20-40 --WASH WITH DISTD WATER

PROCEDURE B M V
POSITION TEST MOUTH SEAL 2 -3 SQ. CHEST RISE INITIAL HIGHER PR 30 -40 CM H20 40 PER MT ( 30 60)

CHEST COMPRESSION 90 / mt (ONE SQ. AFTER 3 COMPRESSIONS) AFTER 30 SEC, EVALUATE HR, BR, COLOUR CONTRA DIA HERNA M S A F WITH RESP DEPRESSION (INTRA PARTUM SUCTIONING PRIOR TO BMV)

CHEST COMPRESSION
RHYTHMIC COMPRESSION STERNUM THAT:
INCREASE INTRATHORACIC PR CIRCULATE BLOOD TO VITAL ORGANS HEART FILLED WHEN PR RELEASED

OF

COMPRESS HEART AGAINST SPINE

METHOD
Two finger technique of chest compression In the two fingers technique the index and the third finger of the hand is used Two thumbs encircling hands

LOCATION & DEPTH

RATE OF COMPRESSION
COMPRESSION / RELEASE ACTION 90 / Mt VENTLN 30 / mt RATIO 3 : 1

HALF SECOND FOR EACH EVENT IN 2 SECONDS 3 COMPR & 1 SQ

IN 60 SECONDS 90 COMPR & 30 SQ

EVALUATE AFTER 30 SEC

HR 6 SEC X 10

-CAROTID, BRACHIAL, FEMORALS FELT

PRECAUTIONS:
DO NOT REMOVE FINGER / THUMB IN BETWEEN FEEL THE PULSES FOR EFFECTIVENESS DO NOT SQUEEZE CHEST