Dr. Muhammad Zahoor ul Haq Dr. Muhammad Zahoor ul Haq Assistant Professor of PaediatricsAssistant Professor of Paediatrics

RMC RawalpindiRMC Rawalpindi

Neonatal Neonatal ResuscitationResuscitation

Neonatal Resuscitation Neonatal Resuscitation

• Resuscitation is active Resuscitation is active intervention to establish intervention to establish normal cardio respiratory normal cardio respiratory functionfunction

• 5-10%5-10% require active require active interventionintervention

GoalGoal

• To prevent morbidity & mortality To prevent morbidity & mortality associated associated with hypoxic ischemic with hypoxic ischemic tissue tissue

(brain, heart, kidney) injury(brain, heart, kidney) injury

• Anticipate high risk situationsAnticipate high risk situations

Guideline for neonatal Guideline for neonatal resuscitation resuscitation

Integrated assessment / response Integrated assessment / response approach approach for for initial evaluation of an initial evaluation of an infant infant

- Color - Color - General appearance - General appearance - Risk factor- Risk factor

Fundamental PrinciplesFundamental Principles

- Evaluation of airway- Evaluation of airway

- Establishing effective respiration - Establishing effective respiration

- Establishing adequate circulation- Establishing adequate circulation

Immediate Care Immediate Care - Place under radiant heater - Place under radiant heater

- Dry - Dry

- Position (head down & slightly - Position (head down & slightly extended)extended)

- Clear airway - Clear airway

- Gentle tectile stimulation- Gentle tectile stimulation

Assess Assess - - Infant’s color Infant’s color

- Heart rate - Heart rate

BIRTH

Term gestation?Amniotic fluid clear?Breathing or crying?Good muscle tone?

Routine care. Provide warmth . Clear airway if needed. Dry . Assess color

Provide warmth Position; clear airway*(as necessary)Dry, stimulate, reposition

Evaluate respirations

Heart rate, and color Observational Care

Yes

Approximate

time

Breathing

HR>100

& Pnk

30

S

eco

nd

sThe Fetus and Neonatal Infant

Give supplementary

Oxygen

Provide positive –pressure ventilation

Provide positive pressure ventilation

Administer chest compression

Administer epinephrine and or volume*

Postresuscitation Care

Evaluate respirationsHeart reate, and color

Observational Care

Breathing HR>100

& Pnk

Pink

Apnea or HR <100

Breathing HR>100 but Cyanotic

Persistent Cyanosis

Effective Ventilation HR>100 & pink

HR<60

HR>60

HR<60

B

C

D

30

S

eco

nd

s3

0

Seco

nd

s

BIRTH

Term gestation?Amniotic fluid clear?Breathing or crying?Good muscle tone?

Routine care. Provide warmth . Clear airway if needed. Dry . Assess color

Provide warmth Position; clear airway*(as necessary)Dry, stimulate, reposition

Evaluate respirations

Heart rate, and color Observational Care

Yes

Approximate

time

Breathing HR>

& Pink

30

S

eco

nd

s

The Fetus and Neonatal Infant

Give supplementary

Oxygen

Provide positive –pressure ventilation

Provide positive pressure ventilation

Administer chest compression

Administer epinephrine and or volume*

Breathing HR>100 but Cyanotic Pink

Apnea or HR <100

Postresuscitation Care Persistent Cyanosis

Effective Ventilation HR>100 & pink

HR<60 HR>60

HR<60

A

B

C

D

30

S

eco

nd

s3

0

Seco

nd

s

No

Respiratory EffortRespiratory EffortStepsSteps

Follow ABCsFollow ABCsA-A- Anticepate & establish Anticepate & establish B- B- Initiate Breathing Initiate Breathing C-C- Maintain Circulation Maintain Circulation D-D- DrugsDrugs

If no respiration or heart If no respiration or heart rate below 100/minrate below 100/min

- Give positive pressure with face - Give positive pressure with face maskmask

- Endotracheal intubation - Endotracheal intubation

If heart does not improve If heart does not improve then:then:

- Start chest compression - Start chest compression

- Site - Site

Lower third of sternum Lower third of sternum 3:13:1

If no improvement If no improvement

give epinephrine give epinephrine

Poor response to Poor response to Ventilation Ventilation

- Loosely fitted mask - Loosely fitted mask - Poor position of ETT- Poor position of ETT- Intraesophageal intubation - Intraesophageal intubation - Airway Obstruction - Airway Obstruction - Insufficient pressure- Insufficient pressure- Excess Air in Stomach - Excess Air in Stomach

Administration of Naloxone Administration of Naloxone HydrochlorideHydrochloride

Ind:Ind: - - Respiratory depression Respiratory depression - Mother has H/O narcotic - Mother has H/O narcotic - Drug administration - Drug administration

Dose:- Dose:- 0.1mg/kg ½, intratracheal0.1mg/kg ½, intratracheal

Emergency Volume Emergency Volume Expander Expander

- Isotonic crystalloid solution - Isotonic crystalloid solution 10-20ml/kg10-20ml/kg

- O -ve blood - O -ve blood

Sodium Bicarbonate Sodium Bicarbonate - Indication - Indication

- Documented metabolic - Documented metabolic acidosis acidosis

- Prolong resuscitation- Prolong resuscitation

- Dose- Dose - - 2meq/kg ½2meq/kg ½

Dopamine or Dobutamine Dopamine or Dobutamine Ind:Ind:

- Cardiogenic shock - Cardiogenic shock

- Dose 5-20mg/kg/min- Dose 5-20mg/kg/min

Infusion Epinephrine Infusion Epinephrine Ind:Ind:

- Unresponsive Cardiac shock - Unresponsive Cardiac shock

Dose:Dose:- 0.1-1.0mg/kg/min - 0.1-1.0mg/kg/min

Primary Apnea Primary Apnea →Asphyxia →Reduce →Asphyxia →Reduce Heart rate → apnea Heart rate → apnea

Immediate Intervention Immediate Intervention - Oxygen inhalation - Oxygen inhalation - Tectile stimulation- Tectile stimulation

Secondary Apnea Secondary Apnea - Gasping respiration - Gasping respiration - Bradycardia - Bradycardia - Hypotension - Hypotension - Finally apnea- Finally apnea

Immediate Intervention Immediate Intervention - Positive pressure ventilation - Positive pressure ventilation

Equipment RequiredEquipment Required- Resuscitation table - Resuscitation table - Sterile Linen - Sterile Linen - Suction apparatus ( Catheter 5, 6, 8)- Suction apparatus ( Catheter 5, 6, 8)- Laryngoscope with straight blade - Laryngoscope with straight blade - Ambo bag with face mask- Ambo bag with face mask- Endotracheal tube - Endotracheal tube - Gloves - Gloves

Medications Medications - Epinephrine 1:10,000- Epinephrine 1:10,000- Naloxone hydrochloride - Naloxone hydrochloride - Volume expander - Volume expander - Soda bicarbonate - Soda bicarbonate - 10% Dextrose water - 10% Dextrose water - Sterile water - Sterile water

Miscellaneous Miscellaneous - Radiant warmer- Radiant warmer- Stethoscope - Stethoscope - Adhesive tape - Adhesive tape - Syringes - Syringes - Butterfly needle - Butterfly needle - Umbilical artery - Umbilical artery - Catheterization tray- Catheterization tray

Indication for Endotracheal Indication for Endotracheal tube tube

Intubation Intubation - Ineffective bag & mask - Ineffective bag & mask

ventilation ventilation - Prolong PPV required - Prolong PPV required - Suspicion of diaphragmatic - Suspicion of diaphragmatic

hernia hernia -Preterm infant-Preterm infant-Meconium aspiration-Meconium aspiration

Stop ResuscitationStop Resuscitation

If no respiratory & cardiac If no respiratory & cardiac activity after 20 min of activity after 20 min of resuscitationresuscitation

Fixed pupilFixed pupil