1. Neonatal/Pediatric Cardiopulmonary Care Resuscitation

2. 2 When To Resuscitate n Need usually related n Combination of n Can occur in

3. 3 Causes of Fetal Asphyxia n n n n

4. 4 Apnea

5. 5 Effect of Asphyxia on Lungs n Initial adaption to extra- uterine life requires 2 steps: – –

6. 6 Effect of Asphyxia on Lungs Asphyxia Apneic or ineffective respirations Negative pressure not generated to open Alveo li to push fluid out PaO 2 , PaCO 2 ,  pH  pH Pulmonaryvasoconstriction Pulmonaryhypertension Blood flow continues through d.a. & f.o. (by-passing lungs)

7. 7 Effect of Asphyxia on Lungs If asphyxia severe with lactic acidosis  Ventilation alone will not change acid-base imbalance 

8. 8 Effect of Asphyxia on Lungs n In severe cases - might be beneficial to give HCO 3 - to –

9. 9 Effect of Asphyxia on Lungs n NOTE: Adequate ventilation must be maintained when bicarb given!!! Why??

10. 10 Effect of Asphyxia on Lungs

11. 11 Preparation For Resuscitation n n n

12. 12 Basics of Neonatal Resuscitation n A - n B - n C - 3 steps:

13. 13 Resuscitation Cycle Evaluation Decision Action

14. 14 Steps in Resuscitation 1st step =

15. 15 Mechanisms of Heat Loss n Radiation –Loss to n Conduction –Loss to n Evaporation –Loss when n Convection –Loss to

16. 16 Causes of Heat Loss n n n

17. 17 Cold Stress

18. 18 Steps in Resuscitation n n Next Step = Open airway

19. 19 Steps in Resuscitation

20. 20 Evaluate Respiratory Effort Evaluate heart rate PPV with 100% O2 None or gasping Spontaneous Below 100 15 - 30 sec. Evaluate respirations

21. 21 Evaluate Heart Rate Above 100 Evaluate color Provide oxygen Observe and monitor Pink or peripheral cyanosis Blue Evaluate heart rate

22. 22 Indications for PPV n n n n

23. 23 Positive Pressure Ventilation n Flow-inflating bag n Self-inflating bag n Pressure gauge n Oxygen flow 5-8 lpm n Pop-off at 30-40 cmH 2 O

24. 24 PPV Technique n Slightly extend neck n Mask held with thumb & forefinger n Bag squeezed with fingertips n Initial rate - n Done for 15-30 sec., then re-evaluate n May require -

25. 25 Re-evaluate Heart Rate

26. 26 Chest Compressions n 2 fingers or thumbs n Lower 1/3 of sternum n Sternum depressed 1/2-3/4 inches n 3:1 compression-to-ventilation ratio n Continue for 30 sec., stop for 6 sec. to re-evaluate HR n DC’d when HR > 80, then re-evaluate RR

27. 27 Indications for Intubation n Bag/mask ventilation is difficult or ineffective n Prolonged PPV is required n Thick meconium is present in amniotic fluid n Suspicion of diaphragmatic hernia

28. 28 ETT Sizes

29. 29 Laryngoscope Blades n Size 1 for n Size 0 for n

30. 30 Intubation Technique n Same as adult n Limit attempts to - n Provide blow-by oxygen at - n ETT tip midway between carina & clavicles n Cut ETT to leave -

31. 31 Medications - Uses n n n

32. 32 Medications - Routes n n n n

33. 33 Instillation Into ETT NAVEL NNAAVVEELLO2O2NNAAVVEELLO2O2

34. 34 Medications - Indications n HR < 80 despite PPV and chest compressions for at least 30 sec. n HR is 0

35. 35 Epinephrine n Powerful sympathomimetic – – – n 1st drug given n IV or ETT, delivered rapidly n Repeated q3-5’ until HR -

36. 36 Volume Expanders n Given if hypovolemic –  BP –Pallor with adequate oxygenation –HR > 100 with weak pulses –Failure to respond to resuscitation n Whole blood, 5% albumin, plasma expanders, NS n IV, may be repeated as needed

37. 37 Sodium Bicarbonate n Prolonged arrest & not responding n Alkaline to buffer metabolic acidosis n Only given when ventilation is adequate n IV

38. 38 Narcan (naloxone) n Reversal of narcotic depression –Demerol (meperidine) –Morphine sulfate –Fentanyl (Sublimaze) n IV, IM, sub-q, ETT n Given rapidly

39. 39 Dopamine n n n n n n

40. 40 APGAR Scoring n n n n

41. 41 APGAR Scoring

42. 42 Serum Glucose n Nutritional needs of fetus supplied by Mom & regulated by placenta n Fetus prepares for postnatal life by  energy stores & developing enzyme- dependant processes for usage of stored energy Sources

43. 43 Serum Glucose n Glycogen – – n Triglycerides (brown fat) – – Energy Storage

44. 44 Serum Glucose At 2 hours - By 3 days - Post-delivery

45. 45 Serum Glucose Term - Preterm - Hypoglycemia

46. 46 Hypoglycemia - Signs n Tremors n Irritability n  or  Moro reflex n Apnea/tachypnea n Cyanosis n Seizures n Lethargy n Hypothermia n Weak/high-pitched cry n Poor feeding n Vomiting n CV failure

47. 47 Hypoglycemia

48. 48 Hypoglycemia - Causes n Hyperinsulinism n Prematurity n IUGR n Starvation n Sepsis n Shock n Asphyxia n Hypothermia n Glucogen Storage Disease n Galactosemia n Adrenal insufficiency n Polycythemia n Congenital heart defects n Iatrogenic causes

49. 49 Hyperinsulinism n Fetus of diabetic Mom n Rh incompatibility n Insulin-producing tumors n Maternal tocolytic therapy (ritodrine, terbutaline)

50. 50 Glucose Measurement n Glucose Test Strip “Dextrostik” n “One Touch” n Lab sample (blood glucose)

51. 51 Hypoglycemia Treatment n Early feeding (oral) n D 10 W –200 mg/kg bolus over 1-3 minutes –Con’t IV, 4-8 mg/kg/min. until feedings started n Treat cause

52. 52 Umbilical Blood Sampling n n

53. 53 Umbilical Vein Catheter (UVC) n Usually placed in - n Drug administration during -

54. 54 Umbilical Artery Catheter (UAC) n n n Indications

55. 55 Umbilical Artery Catheter (UAC) n 5 Fr. catheter (>1250 g), 3.5 Fr. catheter (<1250 g) n Sterile procedure n Heparinized-filled catheter n Tip L3-4 for low catheter, T8 for high catheter (in aorta below renal a., above bifurcation of femoral a.) Placement

56. 56 UAC

57. 57 Umbilical Artery Catheter n n n n n Complications

58. 58 Umbilical Artery Catheter n n n n Sampling Technique