Special Deliveries…. ….. With Love and Fresh Air Monika Bhola, MD Neonatologist Rainbow Babies & Children’s Hospital

Conflict & Disclosures I have no conflict of interest However there is one disclosure…..I have a very soft spot for our respiratory department.

OBJECTIVES Briefly Discuss some salient features of Neonatal Resuscitation Highlight the differences in resuscitation of neonates vs. older children/adults Oxygen use/misuse Temperature management Births outside of a major center

Transition to Extra-uterine Life Transition from fetal life to extra-uterine life is the most complex physiologic adaptation that occurs in a human being’s life Changes occur in almost every organ system but the primary changes are in the respiratory and cardiovascular systems

Clearance of fetal lung fluid Surfactant secretion and breathing Transition of fetal to neonatal circulation Decrease in pulmonary vascular resistance and increased pulmonary blood flow Endocrine support of the tran sition

NEWBORN RESUSCITATION Approximately 10% require some assistance to begin breathing or 90% transition well Less than 1% require extensive measures to survive (chest compressions and medications)

Term –Vigorous Baby If the baby is term (>37) weeks and has good tone and respiratory effort- just dry the baby and keep the baby warm Placing baby on the mom- skin to skin- is the best way to keep this baby warm

How is Baby CPR different? It is still A-B-C Or as I like to call it A-A-A-A-A - B & C Their “arrest” is not necessarily an arrest- but apnea Do not need 100% oxygen, initially If compressions are needed – the landmarks are a little different

Oxygen at Birth In the past we felt and some still do “It can’t hurt……..”

Words of Wisdom “all substances are toxic: only the dose makes a thing not a poison.” »Paracelsus, 1524

“……the air that nature has provided for us is as good as we deserve.” »Priestley, 1775 »Compared to a candle »Lessons learnt from the past

Case Against Oxygen Ischemia and Hypoxia → cellular changes affecting antioxidant defenses as well as enzyme activities, membrane transports, mitochondrial function Hypoxia → ↓ ATP synthesis and Na/K pump alteration → cell edema and hypoxanthine accumulation → + Oxygen = toxic reactive oxygen species »Superoxide anions, hydrogen peroxide, hydroxyl radicals, nitrogen reactive species

Ischemia → promotes proinflammatory cytokines and bioactive agents → tissue vulnerability on re-perfusion

Oxygen Use In utero the fetus develops in a relatively hypoxic environment with saturations of 50-60% Sudden exposure to 100% oxygen can worsen cell and tissue injury Oxygen free radicals-antioxidants, apoptosis and re-perfusion injury

Oxygen vs RA Animal studies – severe hypoxia model Resuscitation with 100% and RA BP and blood flow restoration to brain and other markers were comparable Recent studies have shown a distinct advantage to using RA

Case for Room Air (RA)…… Meta analysis of 1082 newborns resuscitated with Room air initially and 1051 received 100% The ones in which resuscitation was initiated with RA had a reduced risk of death Saugstad et al, Neonatology, 2008

……RA A single breath of 100% oxygen in the first week of life– has resulted in decrease of minute volume Also duplicated in mice studies Delay in initiation of breathing with oxygen vs RA Hyperoxia in newborn animals – causes histological changes in brain and other organs In other animal studies- 100% oxygen in the first few days- saw evidence of pulmonary disease and cardiac failure more than a year later and lead to a shorter life span.

Baby Brains and Oxygen 70 preterm infants stabilized with either RA or 80% Oxygen exposed neonates had decreased cerebral blood flow for 2 hrs (Lundstrom et al, 1995) Similar findings by other researchers also found decreased cerebral blood flow velocity (Niijima etal)

What is the right balance? Compromised Fetus Anaerobic Metabolism → Production of Lactic acid If short → easily reversible with airway establishment If prolonged energy failure → cell membrane depolarization → cellular injury or death

Target Spo2 after birth 1min 60-65% 2min 65-70% 3min 70-75% 4min 75-80% 5min 80-85% 10min 85-95%

How Can we safely deliver oxygen Should have blenders Start resuscitation with RA for term babies Preterm babies 30-40% Don’t have blenders / home delivery/ ER/ ambulance –Self inflating bag- without reservoir will give about 40%

OXYGEN DELIVERY USING SELF INFLATING BAG FiO2 values obtained at different oxygen flow rates (range 0–10 L/min) over time during PPV at a respiration rate of 40 to 60 per minute and PIP of 25 cm H2O. Trevisamuto D etal, Pediatrics 2013;131:e

Airway Proper equipment for Neonates Correct Size Face mask- Term and Preterm Self inflating Bags-240 ml Anesthesia bag Manometer

T-piece/ Neopuff

ET tubes- 2.5, 3.0, uncuffed LMA – Size 1 Miller Laryngoscope blades-Size 1 & 0

Chest Compressions Lack of gas exchange with simultaneous hypoxia and carbon dioxide elevation- most common reason that newborns fail to transition successfully If there is significant hypoxemia and acidosis- the myocardium could be depressed

Airway…. (again!) It is ABSOLUTELY essential to establish EFFECTIVE ventilation for 30 secs–prior to chest compressions Corrective measures should be tried if unable to get effective ventilation M-R-S-O-P-A

MRSOPA- (Corrective Measures) MMask Seal RReposition of head SSuction OOpen Mouth PPressure Increase AAlternate Airway

Temperature Management

Thermo Neutral Zone in Humans Unclothed resting adult—23-28 ⁰ C (73 ⁰ F) Unclothed full term neonate—32-35 ⁰ C (90 ⁰ F) Unclothed 1 Kg preterm neonate– 35 ⁰ C (95 ⁰ F)

Heat Loss In New Borns

Temperature and Resuscitation WHO recommends that the DR temperature should be about 72 ⁰ F or mid 70’s If preterm delivery is expected then the temperature should be around ⁰ F Other modes of keeping the baby warm –Radiant Warmer –Warm blankets –Warm gel packs –Baby hats –Thermal plastic wrap

Picture of Basic Equipment

Infant PortableThermal Packs

Warm Blankets

Consequences of Hypothermia in Preterm Infants ºC Every 1º drop in baby’s temperature increases mortality risk by 28% !!!!!

Other sobering data…. Hypothermia is associated with increase in morbidity Respiratory Distress Metabolic derangements Intra Ventricular Hemorrhage Infection Increased hospital length of stay

Hyperthermia Elevated temperature increases the risk of death or impairment – almost 4 fold increased risk This is worse if there has already been a brain injury A rise of just 1.5ºC above normal can cause significant impairment

Not Too Hot Not Too Cold

Special Considerations

Viability Less than 23 weeks- survival chances are very poor Survival has improved over the years NRP recommends offering resuscitation if 23 weeks and >400gms

Survival Gestation al age 23 weeks 24 weeks 25 weeks 26 weeks 27 weeks Survival50-60%70- 80% % % >90%

Special Considerations in Preterm Infants Greater risk for injury Lung-Protective strategy should start right at birth- GENTLE VENTILATION PPV is the cornerstone of respiratory support Very crucial to establish FRC- PEEP Need to deliver adequate Tidal Volume- PIP

Post Resuscitation Temperature Sugar- Never give new borns > D10W IV fluids IV access Normal D.stick-35-40

Emergency IV acess If unable to start PIV- may place emergency Umbilical vein catheter Place an umbilical tie Clean with Betadine Place a sterile catheter (5Fr) in the vein (largest vessel) till you get blood return (2- 3 cms in preterm infants and about 5 cms in term Avoid Intraosseous in preterm infants.

Neonatal Encephalopathy These babies should be transferred to a tertiary care center ASAP Therapeutic cooling –significantly decreases mortality and neuro-developmental impairment Therapeutic hypothermia should be instituted in a controlled environment and within 6 hrs Prevent hyperthermia Aim at keeping temperature at low end of normal

Abdominal Anomalies Gastroschisis- omphalocele Place sterile wrap soaked in saline around anomalie Prevent excessive insensible water loss Place in sterile bowel bag Place a replogle to decompress the bowel Start IV- Fluids and Antibiotics

Airway Anomalies Pierre Robin or severe micrognathia and if in respiratory distress:- Place in supine position If respiratory distress continues- may need a stable airway Intubation LMA Nasopharyngeal ET tube

Congenital Diaphragmatic Hernia If in distress will need intubation Avoid using bag and mask PPV- will worsen Consider this diagnosis if you have a newborn with a scaphoid abdomen Decompress the bowel Intubate

“Useful Accessory” Placenta

Love & Fresh Air What was that all about?

Warmth- gentle ventilation = Love RA or OWL (Oxygen with Love) = Fresh Air