Neonatal resuscitation Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute , puducherry India

The need Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures only 60% of asphyxiated newborns can be predicted antepartum.

The need is continuous

Initial queries ?? Term gestation? Crying or breathing?   Crying or breathing? Good muscle tone?

yes the baby does not need resuscitation should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing.

“no” 1.Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)   2.Ventilation 3.Chest compressions 4.Administration of epinephrine and/or volume expansion

The golden minute   Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required.

The goals of resuscitation to assist with the initiation and maintenance of adequate ventilation and oxygenation, adequate cardiac output and tissue perfusion, normal core temperature serum glucose

To achieve goals, be ready risk factors are identified early, neonatal problems are anticipated, equipment is available, personnel are qualified and available a care plan is formulated

Respiration equipment Oxygen supply, Assorted masks Neonatal bag and tubing to connect to an oxygen source Manometer, Endotracheal tubes (2.5-4) Tape and scissors Laryngoscope (0 and 1 sized blades) Extra bulbs and batteries CO2 detectors Stylettes for endotracheal tubes Laryngeal mask Airway (optional)

Suction equipment Bulb syringe Regulated mechanical suction Suction catheters (6F, 8F, 10F) Suction tubing Suction canister Replogle or Salem pump (10F catheter) Feeding tube (8F catheter) Syringes catheter tipped – 20 ml Meconium aspirator

Fluid equipment Intravenous catheters (22 g) Tape and sterile dressing material Dextrose 10% in water (D10W) Isotonic saline solution T-connectors Syringes, assorted (1-20 mL)

Advanced procedure ready Umbilical catheters (2.5F, 5F) Chest tube (10F catheter) Sterile procedure trays

Trained Personnel One present Two or more -- problems --- twins

Temperature control Dry and keep warm Others prewarming the delivery room to 26°C 13 covering the baby in plastic wrapping placing the baby on an exothermic mattress the baby under radiant heat prewarming the linen The goal is to achieve normothermia and avoid iatrogenic hyperthermia

Temperature range Normal 36.5-37.5o C Continue Potential cold stress 36-36.5o C concern Moderate hypothermia 32-36o C Danger Severe hypothermia < 32o C Outlook grave, skilled care urgently needed

Airway Clear liquor Meconium stained liquor

Clear liquor – suctioning routine ?? be associated with worsening of pulmonary compliance and oxygenation reduction in cerebral blood flow velocity when performed routinely (ie, in the absence of obvious nasal or oral secretions) Apnea, bradycardia, hypotension, and laryngospasm Think about routine suctioning ??

Clear liquor – suctioning routine ?? suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation (PPV)

What is routine Drying and suctioning , If no response, more vigorous stimulation, slapping the soles of the feet or rubbing the back. The back should be visualized. If there is no response to stimulation, it may be assumed the infant is in secondary apnea, and PPV should be initiated. infant's respiratory rate, heart rate, and color should be evaluated

Meconium stained liquor Historically Suction before delivery of shoulders – not proved useful routine endotracheal intubation and direct suctioning of the trachea ?? No to active crying babies !!

Mec. staining endotracheal suctioning of nonvigorous babies with meconium-stained amniotic fluid If intubation difficult and causing brady , don’t try – go back to mask ventilation

Administration of Oxygen Oxyhemoglobin saturation may normally remain in the 70% to 80% range for several minutes following birth clinical assessment of skin color is a very poor indicator of oxyhemoglobin saturation

SPO2 monitor a preductal location (ie, the right upper extremity, usually the wrist or medial surface of the palm). Term infants keep SaO2 – 90- 94% Preterm – 88-92% 8- 10 litres- oxygen Hood Monitor progress

Temperature unheated non humidified oxygen sources for the bag-valve-mask device Intubated ventilated patient – humidified warmed ventilator circuits

Positive pressure ventilation If the infant remains apneic or gasping, or if the heart rate remains <100 per minute after administering the initial steps. Assisted ventilation rates of 40 to 60 breaths per minute Heart rate , SPo2, monitor

CPAP CPAP recommend administration of continuous positive airway pressure (CPAP) to infants who are breathing spontaneously, but with difficulty, following birth, although its use has been studied only in infants born preterm

Laryngeal mask airways and PPV Laryngeal mask airways that fit over the laryngeal inlet - effective for ventilating newborns weighing more than 2000 g delivered ≥34 weeks gestation meconium-stained fluid, during chest compressions, or for administration of emergency intratracheal medications

Endotracheal Tube Placement Initial endotracheal suctioning of nonvigorous meconium-stained newborns   If bag-mask ventilation is ineffective or prolonged When chest compressions are performed For special resuscitation circumstances, such as congenital diaphragmatic hernia or extremely low birth weight

Effective ventilation Heart rate CO2 SPo2

Chest Compressions Chest compressions are indicated for a heart rate that is <60 per minute despite adequate ventilation with supplementary oxygen for 30 seconds Ventilation priority the 2 thumb–encircling hands technique the 2-finger technique,

DRUGS Drugs are rarely indicated in resuscitation of the newly born infant. Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia Atropine ???

Drugs if the heart rate remains <60 per minute despite adequate ventilation (usually with endotracheal intubation) with 100% oxygen and chest compressions, administration of epinephrine or volume expansion, or both, may be indicated. The recommended IV dose is 0.01 to 0.03 mg/kg per dose

Drugs and infusions Rarely, buffers, a narcotic antagonist, or vasopressors may be useful after resuscitation, but these are not recommended in the delivery room. An isotonic crystalloid solution – 10 ml /Kg Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia

Discontinue resuscitation In a newly born baby with no detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate remains undetectable for 10 minutes

After reading neonatal resuscitation What is shocking ?? NO APGAR score at all.

The Apgar score Evaluate the newborn baby on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. The resulting Apgar score ranges from 0 to 10. The five criteria are summarized using words chosen to form a backronym (Appearance, Pulse, Grimace, Activity, Respiration.)

SCORES Appearance - red peri. Blue total blue 0 1 2 Appearance - red peri. Blue total blue Pulse ? < 100 > 100 Grimace stim.no mild active Active tone less flexion good resist Respir. Absent weak ,gasps active cry

APGAR score Score of 10 ?? >7 ok 4 – 7 -- to act 1 min, 5 , 10, 15 minutes Score of 3 0r less persistent – neuro damage

What we do - follows ??

Prewarm clothes

Tray, oxygen weighing machine

Equipment

Bulb syringe

Gentle back massage

Ryles tube and aspiration

Inj. Vit. K , temperature monitoring with hood oxygen

Breast feeds

Thank you all