NEONATAL RESUSCITATION

DR. LOKANATH REDDYJUNIOR RESIDENTDEPT. OF PAEDIATRICSKASTURBA MEDICAL COLLEGEMANIPAL

Neonatal Resuscitation

History Overview and Principles of Resuscitation Initial steps of resuscitation Positive – Pressure ventilation Chest compressions Endotracheal tube intubation and LMA

insertion Medications Special considerations Resuscitation of Preterm babies Ethics and Care at the end of life

Historical aspects

For the past 40 yrs Fetal anoxia was one of the most investigated conditions affecting the newborn.

Better understanding of the effect of certain conditions on fetus like placental disease and hemorrhage.

It was then realized that obstruction to the airway immediately following birth should be the first concern in newborn resuscitation.

Historical aspects

18th Century Scottish Obstetrician Blundell first used mechanical device for tracheal intubation in living newborn

In 1920 Joseph B. DeLee introduced simple rubber catheter and glass trap to clear upper airways and stomach.

In 1953 Apgar Score was given by Varginia Apgar. She is also the first to catheterise UA in newborn

Historical aspects

1966 national guidelines for resuscitation of adults was recommended by National Academy of Sciences.

In 2000 the consensus document on advanced life support of the newborn converted the previously published advisory statements into a set of guidelines.

In 2010 revised guidelines was published.

Bill keenan – Father of NRP

 Professor of Pediatrics and Director of the Neonatology Department at Saint Louis University in St. Louis, Missouri.

Causes of Neonatal Mortality

Preterm27%

Sepsis & pneumonia

26%Asphyxia23%

Congeni-tal7%

Tetanus7%

Diar-rhoea

3%

Others7%

4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900

Overview and Principles

WHY TO LEARN NEWBORN RESUSCITATION ?

Birth asphyxia accounts for about 1/4th of the

4 million neonatal deaths that occur each year worldwide.

For many newborns resuscitation is not available

Outcomes of these newborns can be improved with timely and effective resuscitation.

Overview and Principles

Approximately 90% of newborns make smooth transition from intrauterine to extrauterine life requiring little or no assistance

10% of newborns need some assistance Only 1% require extensive resuscitation We must always be prepared to

resuscitate, as even some of those with no risk factors will require resuscitation.

Overview and Principles

ADULT vs. NEONATAL RESUSCITATION

The sequence of resuscitation in adults is C-A-B But in newborns the sequence remains A-B-C as the etiology of neonatal compromise is

nearly always a breathing difficulty

AIRWAY(position and clear) BREATHING (stimulate to breathe) CIRCULATION (assess HR and oxygenation)

Newborn Resuscitation Pyramid

Assess baby’s risk for requiring resuscitation

Provide warmthPosition, clear airway if required

Dry, stimulate to breathe

Give supplemental oxygen, as required

Assist ventilation with positive pressure

Intubate the trachea

Provide chest compressions

Medications

Always needed

Needed less frequently

Rarely needed

Overview and Principles – Changes in newborn physiology

Overview and Principles – Changes in newborn physiology

BEFORE BIRTH

Oxygen supply by placental membranes No role of lungs. Fluid filled alveoli and constricted arterioles due to low Po2 in fetal blood.

Overview and Principles – Changes in newborn physiology

Low Po2 constricted arterioles increased pulmonary vascular resistance shunting of blood from Pulmonary Artery Ductus Arteriosus Aorta.

Overview and Principles – Changes in newborn physiology

AFTER BIRTH Baby cries takes first breath air enters

alveoli alveolar fluid gets absorbed increased Po2 relaxes pulmonary arterioles decreased PVR

Overview and Principles – Changes in newborn physiology

Umbilical arteries constrict + clamp cord closure of Umbilical Arteries and Umbilical Vein increased SVR

Decreased PVR + Increased SVR functional closure of Ductus Arteriosus increased blood flow into lungs oxygenation supply to body through aorta.

Overview and Principles – Changes in newborn physiology

WHAT CAN GO WRONG ? Compromise of uterine or placental blood flow

deceleration of FHR (1st clinical sign) Weak cry inadequate ventilation to push the

alveolar fluid In utero hypoxia Meconium passage may block

the airways Fetal blood loss (abruption) Systemic

Hypotension Fetal Hypoxia/ischemia poor cardiac contractility

& fetal bradycardia Systemic Hypotension Pulmonary arterioles remain constricted PPHN

Consequences of interrupted transition

Low muscle tone Respiratory depression

(apnoea / gasping) Tachypnea Bradycardia Hypotension Cyanosis

Changes due to oxygen deprivation

Rapid breathing

Irregular Gasping

If the baby does not begin breathing immediately after being stimulated, he or she is likely In secondary apnea and will require PPV

Primary Apnea

Stimulation

Secondary Apnea

Effective Positive pressure ventilation

Myocardium is depressed

Chest compressions, medications

Changes due to oxygen deprivation

Equipment required

Suction Catheter

Oral mucus sucker

Radiant warmer

TRANSPORT INCUBATOR

INITIAL STEPS OF RESUSCITATION

Initial steps of resuscitation

Term / Preterm ? Term: smooth transition Preterm : stiff, under-developed lungs,

insufficient muscle strength, can’t maintain temperature

Breathing/Crying ? Watch baby’s chestGasping is a series of deep, single or

stacked inspirations that occur presence of hypoxia/ischemia. Treated as apnea.

Initial steps

Good tone ? Term: flexed extremities Preterm/sick: flaccid/limp,

extended extremities

Initial steps

Provide warmth : Radiant warmer, don’t cover with towels.

Position head and clear airway as necessary

Dry and stimulate the baby to breathe, reposition

Position “ SNIFFING DOG ”

Clear airway

Suction mouth first, then nose

“M” before “N” To prevent aspiration

of mouth contents

Clear airway

Vigorous if 1. Good tone2. Good Cry/

Breathing3. HR> 100/min

Meconium, non-vigorous babyInsert LaryngoscopeClear Mouth and posterior pharynx using 12F/14F catheterInsert ET tubeAttach ET tube to meconium aspirator and suction sourceApply suction and remove slowly Count 1-1000,2-1000,3-1000, withdraw Repeat if HR is < 100

Dry ,Reposition, Stimulate

Stimulate : Flicking the soles/ drying & rubbing the back

Evaluation

RespirationsHeart rate: Best is

auscultation, alternatively pulsations at base of cord is felt. Count for 6s and “x”10

Oxygenation by oximeter

Breathing

If Apneic or HR < 100 bpm:

Provide positive-pressure ventilation,spo2 monitoring.

If breathing, and heart rate is >100 bpm but baby is cyanotic, give supplemental oxygen, spo2 monitoring. If cyanosis persists, provide positive-pressure ventilation

If respiratory distress is persistent , consider CPAP and connect oximeter

Supplemental oxygen

Free flow oxygen Oxygen mask Flow inflating bag T- piece resuscitator Oxygen tubing held

close to baby’s nose

CPAP provided with Flow inflating bag T-piece resuscitator

Start with room air and increase to maintain target SpO2

Time Target Spo2

1min 60-65%

2min 65-70%

3min 70-75%

4min 75-80%

5min 80-85%

10min 85-95%

Free-flow oxygen given via oxygen tubing

MASK

Flow Inflating Bag

T-Piece Resuscitator

Positive pressure ventilation

Ventilation of the lungs is the single most and most effective step in newborn resuscitation

Indications: Gasping/apnea HR < 100/min SpO2 remains below target

values despite free flow supplemental oxygen increased to 100%.

Positive pressure ventilation

Peak inspiratory pressure (PIP) : Pressure delivered with each breath, such as the pressure at the end of a squeeze of resuscitation bag or at the end of breath with a T – piece resuscitator

Positive end – expiratory pressure (PEEP) : The gas pressure which remains in the system between breaths, such as during relaxation and before the next squeeze

Positive pressure ventilation

Continuous positive airway pressure(CPAP) : Same as PEEP, but used when the baby is breathing spontaneously and not receiving PPV. It is pressure in the system at the end of spontaneous breath when a mask is held tightly on baby’s face but the bag is not being squeezed.

Rate: The number of assisted breaths given per minute

Self Inflating bag

Flow Inflating Bag

T-Piece ResuscitatorDEVICES USED

Self inflating bag Flow inflating bag T- Piece resuscitator

Does not require Compressed Gas source for inflation of Bag

Requires Compressed Gas Source for inflating the bag

Requires Compressed Gas Source for inflating the bag

Functions even without a proper seal

Does not work without proper seal

Does not work without proper seal

PIP/Ti How hard & Long the bag in squeezed

Flow of incoming gas and how hard & long the bag is squeezed

Can be set exactly manually

PEEP Only if additional valve is attached

Given by adjusting flow control valve

Can be set exactly manually

CPAP/Free flow O2

Cannot be delivered

Given by adjusting flow control valve

Can be set exactly manually

Safety Features

Pop-Off ValvePressure gauge

Pressure gauge Maximum Pressure relief valve Pressure gauge

Mask

Appropriate Sizes

Mask should

Rest on Chin Cover Mouth& Nose

Suction & Position

Cup the chin in the mask and then cover the nose

Light Pressure on mask to create a seal Anterior pressure on posterior rim of mandible

Frequency of ventilation:

40 to 60 breaths per minute

Start With 21% ( higher in preterm's) oxygen and increase according to target

SaturationInitial Pressure at 20mmH2O

Ensure Effective PPV

Most Important sign is the rising of HR

Improvement in Oxygen Saturation Equal and adequate breath sounds

B/L Good Chest rise

Evaluation

Heart rateOxygenation by

oximeter

If heart rate <100 bpm

Ventilation corrective steps

Corrective steps Action

M Mask Adjustment Ensure Good seal of mask on face

R Reposition airway Sniffing Position

S Suction Mouth and nose If secretions present

O Open mouth Ventilate with baby mouth slightly open and lift the jaw forward

P Pressure increase Gradually increase the pressure every few breaths

A Airway alternative Consider ET or Laryngeal mask airway

PPV continued more than several minutes

Place an OG tube, Suction gastric contents and leave the end open.

Evaluation

If heart rate <60 bpm despite adequate ventilation for 30 seconds,

Chest compressions

Indications : HR <60/min

despite at least 30 sec of effective PPV

Strongly consider Endotracheal intubation at this point as it ensures adequate ventilation and facilitates the coordination of ventilation and chest compressions

Chest compressions

Rationale: HR<60/min despite PPV indicates very low O2 levels and significant acidosis

depressed myocardium no blood in

lungs to get oxygenated(supplied by PPV) Chest compressions + effective ventilation

(ET/PPV) oxygenation of blood recovery of myocardium to function spontaneously HR increases O2 supply to brain increases

Chest compressions

Principle: Rhythmic compressions of

sternum that Compress the heart against the

spine Increases intrathoracic pressure Circulate blood to vital organs Chest compressions

compresses heart & increased Intrathoracic pressure blood pumped into arteries

Pressure released blood enters heart from veins

Chest compressions

Positions : Chest compressions are of

little value unless the lungs are effectively ventilated

2 persons are required 1 – chest compressions

provider should have access to the chest with his hands positioned correctly

2 – Ventilation provider should be at head end to maintain effective mask-face seal or to stabilize ET tube

Chest compressions

Technique:

Thumb technique: 2 thumbs depress the sternum, hands encircle the torso and the fingers support the spine. Preferred technique

2 – Finger technique: Tips of middle & index/ring finger of one hand compresses sternum, other hand supports the back.

Chest compressions

Thumb technique is preferred as Better control of depth

of compression Can provide pressure

consistently Superior in generating

peak systolic and coronary arterial perfusion pressure.

Chest compressions

For small chests with thumbs overlapped

Chest compressions

Chest compressions

2- finger technique

Chest compressions

Chest compressions

Depth : 1/3rd of the anter0posterior diameter of chest.

Duration of downward stroke should be shorter than the duration of release

Do not lift the fingers off the chest

Chest compressions

Complications: Laceration of liver Breakage of ribs

Chest compressions

Coordination of chest compressions and

ventilation: Avoid giving compression and ventilation

simultaneously 1 breathe after every 3 compressions

Ratio is 1 : 3 or 30: 90 per minute One cycle: 2 sec, 3Compresssions + 1

ventilation 1 minute : 30 cycles or 120 events (90

compressions + 30 breaths)

Chest compressions

When to stop chest compressions?

Reassess after 45-60 sec, if HR > 60/min stop chest compressions and increase breaths to 40-60 per minute.

If HR is not improving… Insert an umbilical catheter and give

IV epinephrine

Endotracheal Intubation

Endotracheal Intubation

WHEN TO CONSIDER INTUBATION ?

Indications in resuscitation Baby is floppy, not crying, and preterm HR < 100/min, gasping/apnea HR < 100/min inspite of PPV HR < 60/min No adequate chest rise and no clinical

improvement If chest compressions are needed, intubation

provides better coordination and efficacy of PPV To administer drugs

Endotracheal Intubation

WHEN TO CONSIDER INTUBATION ?

Special conditions Meconium aspiration if baby is

depressed in which it is the first step to be done

Extreme Prematurity Surfactant administration Suspected diaphragmatic hernia

Endotracheal Intubation- Equipment and supplies

Laryngoscope with extra blades and bulbs

Straight blades Term – 1 Preterm – 0 Extremely preterm -

00

ET tube sizes

Weight GA(weeks) Tube size(mm)(internal diameter)

Below 1 kg 28 2.5

1-2 kg 28-34 3.0

2-3 kg 34-38 3.5

>3kg >38 3.5- 4.00

ET tube – Uniform diameter, uncuffed

ET tube – Vocal cord guide

Procedure… Position

Position

Position

Position

CRICOID PRESSURE

SUCTIONING

Endotracheal Intubation: Anatomic Landmarks

Procedure

Add 6 to baby’s wt.

Wt Depth of insertion

< 750g 6cm

1kg 7cm

2kg 8cm

3kg 9cm

4kg 10cm

Fixing ET tube

Confirm position

Watching the tube passing between cords Watching for chest movements Listening for breath sounds ( Axilla and stomach) Colourimeter/Capnography ( Can also be used for

PPV with mask or LMA Improvement in HR and Spo2 Vapour Condensing inside tube

Laryngeal Mask Airway

LMA

Medications - Adrenaline

Mechanism of action : Increases systemic vascular resistance Increases coronary artery perfusion pressure Improves blood flow to myocardium and

restores depleted ATPIndications : If HR remains < 60/min even after 30 sec

of effective ventilation preferably after intubation and atleast another 45-60 sec of coordinated chest compressions and effective ventilation

Medications - Adrenaline

Administration : Intravenous (recommended) EndotrachealPreparation and dosage: Adrenaline vial 1ml = 1mg (1:1000 solution) Dilute with NS to make 1:10,000 solution

(1ml = 100 mcg) IV : 0.1-0.3 ml/kg = 10-30 mcg/kg ET : 0.5 – 1 ml/kg = 50-100 mcg/kg Give rapidly – as quickly as possible Can repeat every 3-5 minutes

Medications – volume expanders

Indications: Bradycardia not improving with adrenaline Placenta previa/ AbruptionVolume Expanders: Normal saline (recommended) Ringer lactate Dosage: 10 ml/kg Route : Umbilical vein Rate: over 5-10 min , rapid infusion may

cause IVH in <30 weeks babies

Resuscitation of preterms

Additional resources , additional personnel, additional thermoregulation strategy

▪ Portable warming pad▪ Polyethylene Plastic wrap (< 29wk)▪ Prewarmed transport incubator

Use of Oxymeter, blender to target Spo2 85%- 95%

Use Lower PIP 20-25 cm of H2O during PPV

Consider giving CPAP Consider Surfactant

Post Resuscitation Care

Avoid hyperthermia, consider therapeutic hypothermia within 6 hrs for >36wks and E/O Acute perinatal HIE

Monitor for Apnea, bradycardia, BP, SPo2 &Urine output.

Monitor B. Sugars, electrolytes , Hematocrit , Platelets, ABG

Maintain adequate oxygenation & support ventilation as needed

Post Resuscitation Care

Delay feeds, Start IV fluids, consider parenteral nutrition

Consider inotropes , fluid bolus Ensure adequate ventilation before

giving sodium bicarbonate(only in severe metabolic acidosis)

Special considerations

Choanal atresia – oral Airway Pierre Robin : place prone , 12F Et

through nose with tip in post pharynx Laryngeal web, cystic hygroma, Cong.

Goiter- ET/tracheostomy Pneumothorax : Percutaneous needle

aspiration Pleural effusion : Percutaneous needle

aspiration Congenital Diaphragmatic hernia

Ethical issues

Meeting and discussing with parents and documenting the conversation.

Where GA ( < 23wks ), B.wt ( < 400g) and / or Cong. Anomalies are associated with certainly early death and unacceptably high morbidity among rare survivors resuscitation is not indicated

After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life (no heart beat and no respiratory effort).

CHANGES IN 2010

Resuscitation step

Recommendations (2005)

Recommendations (2010)

Comments/LOE

Assessment

Four questions• Amniotic fluid- clear or not?

Three questions• Gestation-term or not?• Tone- Good?• Breathing /Crying?

However, trachealsuction of nonvigorousbabies with(MSAF)still to be continued

Assessment (afterinitial steps )

Look for 3 signs• Hear rate• Color• Respiration

Look for 2 signs• Heart rate• Respiration( Labored,unlabored, apnea, gasping)

HR Palpation of umbilical cordpulsation

Auscultation of heart at theprecordium is the most accurate

LOE4

Resuscitation step

Recommendations (2005)

Recommendations (2010) Comments/LOE

Oxygenation

Pulse oximetryrecommended for onlypreterm < 32weeks withneed for PPV

pulse oximetryfor both term and preterm

Target saturation(pre-ductal)

Not defined Target SpO2 ranges provided asa part of algorithm

Initial oxygenconcentration forresuscitation in caseof PPV

Term babies(≥ 37 weeks)• Start with 100% O2 duringPPV• In case non availability ofO2- start room airresuscitationPreterm babies(<32weeks) Start with oxygenconcentrationbetween 21-100%

Term babies (≥ 37 weeks) LOE-2• Start with room air (21%)•use higherconcentration by gradedincrease up to 100% toattain target saturations

Preterm(<32weeks)• Initiate resuscitation usingO2 concentration between30-90%

Initial breath strategyPositive pressureventilation (PPV)

No specific PIPrecommendation• No specificrecommendation for PEEP• Guiding of PPV looking atchest rise and improvementin heart rate

PIP- for initial breaths 20-25 cm H2O for preterm and 30-40 cm H2O for some term babies• PEEP for preterm infants, if provided with T-piece or flow inflating bags (LOE 5)

CPAP in deliveryroom

Suggested for preterm babies( < 32 weeks) with respiratorydistress

Spontaneously breathingpreterm infants with respiratorydistress may be supported withCPAP

TherapeuticHypothermia

No sufficient evidence

recommended for infants ≥36weeks with moderate tosevere HIE

Summary

Doing the simple things better is probably the most cost-effective policy.

Resuscitation can come as complete surprise So be prepared for resuscitation.

It may take several hours to learn but it should be implemented over seconds.

Practice makes one perfect.

References

Neonatal resuscitation Textbook 6th ed.

4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900

Park’s Textbook of Preventive and Social Medicine , K. park 21st Edition .