1

NEW BORNRESUSCITATION

DR MAHTAB MBBS, DNB,DCH

GMSH16 CHD

2

Bill keenan – Father of NRP

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

3

Causes of Neonatal MortalityPreterm

27%

Sepsis & pneu-monia26%

Asphyxia23%

Congen-ital7%

Tetanus7%

Diar-rhoea3%

Others7%

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

4

Overview and PrinciplesWHY 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 availableOutcomes of these newborns can be improved

with timely and effective resuscitation.

5

Overview and PrinciplesApproximately 90% of newborns make

smooth transition from intrauterine to extrauterine life requiring little or no assistance

10% of newborns need some assistanceOnly 1% require extensive resuscitationWe must always be prepared to resuscitate,

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

Newborn Resuscitation Pyramid

Assess baby’s risk for requiring resuscitationProvide warmth

Position, clear airway if requiredDry, 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

7

Overview and Principles NEONATAL RESUSCITATION

The sequence of resuscitation in newborns is 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)

8

Equipment required

Suction Catheter

Oral mucus sucker

Radiant warmer

9

10

11

TRANSPORT INCUBATOR

12

INITIAL STEPS OF RESUSCITATION

13

Initial steps of resuscitation

Term / Preterm ?Term: smooth transitionPreterm : 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.

14

Initial stepsGood tone ?Term: flexed extremitiesPreterm/sick: flaccid/limp,

extended extremities

15

Initial stepsProvide warmth : Radiant

warmer, don’t cover with towels.

Position head and clear airway as necessary

Dry and stimulate the baby to breathe, reposition

16

Position “ SNIFFING DOG ”

Clear airway

Suction mouth first, then nose

“M” before “N”To prevent aspiration

of mouth contents

18

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

19

Clear airwayVigorous if 1. Good tone2. Good Cry/

Breathing3. HR>

100/min

20

Dry ,Reposition, Stimulate Stimulate :

Flicking the soles/ drying & rubbing the back

21

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

1-22

1-23

24

Free-flow oxygen given via oxygen tubing

25

MASK

Flow Inflating Bag

T-Piece Resuscitator

26

Positive pressure ventilationVentilation of the lungs is the

single most and most effective step in newborn resuscitation

Indications:Gasping/apneaHR < 100/minSpO2 remains below target

values despite free flow supplemental oxygen increased to 100%.

MaskAppropriate

SizesMask should Rest on Chin Cover Mouth& Nose

28

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

30

Ensure Effective PPVMost Important sign is the rising of HRImprovement in Oxygen SaturationEqual and adequate breath sounds B/LGood Chest rise

Evaluation

Heart rateOxygenation by

oximeterIf heart rate <100 bpm

32

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

33

PPV continued more than several minutes

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

34

Evaluation

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

35

Chest compressionsIndications :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

36

Chest compressionsRationale: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

37

Chest compressionsPrinciple:Rhythmic compressions of

sternum thatCompress the heart against the

spineIncreases intrathoracic pressureCirculate blood to vital organsChest compressions

compresses heart & increased Intrathoracic pressure blood pumped into arteries

Pressure released blood enters heart from veins

38

Chest compressionsPositions :Chest compressions are of

little value unless the lungs are effectively ventilated

2 persons are required1 – 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

39

Chest compressionsTechnique: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.

40

Chest compressionsThumb technique is

preferred asBetter control of depth of

compressionCan provide pressure

consistentlySuperior in generating

peak systolic and coronary arterial perfusion pressure.

41

Chest compressions

For small chests with thumbs overlapped

42

Chest compressions

43

Chest compressions

2- finger technique

44

Chest compressions

45

Chest compressionsDepth : 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

46

Chest compressionsCoordination of chest compressions and ventilation:Avoid giving compression and ventilation

simultaneously1 breathe after every 3 compressions

Ratio is 1 : 3 or 30: 90 per minuteOne cycle: 2 sec, 3Compresssions + 1 ventilation1 minute : 30 cycles or 120 events (90

compressions + 30 breaths)

47

Chest compressionsWhen 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

48

Endotracheal Intubation

49

Endotracheal IntubationWHEN 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

50

Endotracheal IntubationWHEN 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

51

Endotracheal Intubation- Equipment and supplies

Laryngoscope with extra blades and bulbs

Straight bladesTerm – 1Preterm – 0Extremely preterm - 00

52

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

53

ET tube – Uniform diameter, uncuffed

54

ET tube – Vocal cord guide

55

Procedure… Position

56

Position

57

Position

58

Position

59

Procedure

60

Fixing ET tube

Add 6 to baby’s wt.

Wt Depth of insertion

< 750g 6cm1kg 7cm2kg 8cm3kg 9cm4kg 10cm

4-61

Confirm positionWatching the tube passing between cords Watching for chest movementsListening for breath sounds ( Axilla and stomach)Colourimeter/Capnography ( Can also be used for PPV with

mask or LMA Improvement in HR and Spo2Vapour Condensing inside tube

1-62

63

Medications - AdrenalineMechanism of action :Increases systemic vascular resistanceIncreases coronary artery perfusion pressureImproves 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

64

Medications - AdrenalineAdministration :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/kgET : 0.5 – 1 ml/kg = 50-100 mcg/kgGive rapidly – as quickly as possibleCan repeat every 3-5 minutes

65

Medications – volume expandersIndications:Bradycardia not improving with adrenalinePlacenta previa/ AbruptionVolume Expanders:Normal saline (recommended)Ringer lactateDosage: 10 ml/kgRoute : Umbilical veinRate: over 5-10 min , rapid infusion may cause

IVH in <30 weeks babies

66

Resuscitation of pretermsAdditional resources , additional personnel, additional thermoregulation strategy

Portable warming padPolyethylene Plastic wrap (< 29wk)Prewarmed transport incubator

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

Use Lower PIP 20-25 cm of H2O during PPVConsider giving CPAP Consider Surfactant

67

Post Resuscitation CareAvoid 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

68

Post Resuscitation CareDelay feeds, Start IV fluids, consider

parenteral nutritionConsider inotropes , fluid bolusEnsure adequate ventilation before giving

sodium bicarbonate(only in severe metabolic acidosis)

69