resuscitation of a newborn

Resuscitation In Newborns

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Dr. Kalpana MallaMD Pediatrics

Manipal Teaching Hospital

Approximately 10% of newborns require some assistance to begin breathing at birth.

Approximately 1% require extensive resuscitative measures.

APNEA

• Primary – deprivation of oxygen → rapid breathing → resp stop →HR↓ → apnea

*** will re- establish breathing with oxygen and stimulation

• Secondary –If asphyxia continues →deep gasping resp → HR ↓ & BP ↓ →last gasp →apnea

*** unresponsive to oxygen and stimulation →PPV must be started

• Always assume infant has secondary Apnea & commence Resuscitation

Resuscitation Assignments

• Team Leader- Airway

• Second Rescuer- Pulse Check (HR) Chest Compression• Third Rescuer- Medications Equipment

Core Knowledge and Skills

• Airways - Establish Clear Airway• Breathing- Ventilation & Oxygenation• Circulation- Adequate Cardiac Output• Drugs • Environment - Reduce Heat Loss

Steps in Resuscitation - ABCDE

• Airway – open & clear airway – Suction mouth and then nose , trachea if needed – No more than 5cms & no longer than 5 secs – Mechanical suction - vacuum does not exceed 100 mmHg (5litres) – Airway tube / ET tube

• If nose cleared first the infant may gasp and aspirate secretions in the pharynx

Airway

DO NOT SUCTION IF AIRWAY IS CLEAR– Positioning

• Supine or lateral • Head in neutral or slightly extended

position - Avoid overextension or flexion

CLEARING THE AIRWAY OF MECONIUM

Current recommendations No longer advise routine intrapartum oropharyngeal and

nasopharyngeal suctioning for infants born to mothers with meconium staining of

amniotic fluid

Suction

• Suction - Bulb syringe DeLee mucus trap Suction catheters (6F, 8F, 10F)

Feeding tube with syringe Meconium aspirator

Steps in Resuscitation - ABCDE

• Breathing -Initiate breathing - Tactile stimulation - PPV – bag & mask – bag & ET tube• Assessment of respiratory effort and color

Tactile Stimulation

• Drying• Suctioning• Slapping or flicking the soles of the feet• Rubbing the back gently

• Do not waste time continuing tactile stimulation if there is no response after 10 - 15 seconds.

Harmful actions

• Slapping back• Squeezing rib cage• Forcing thigh onto abdomen• Dilating anal sphincter• Using hot or cold compression or bath• Blowing cold air onto face• Burning placenta

Use of oxygen duringneonatal resuscitation

• Indications for oxygen administration – Cyanosis – Respiratory distress - Give free flowing oxygen 5L/min

• Use – 100% supplemental oxygen• If oxygen unavailable - use room air to deliver

positive-pressure ventilation

Steps in Resuscitation - ABCDE

Indications for PPV / Bag-Valve-Mask Ventilation

• Apnoeic • Gasping respiration • HR < 100 bpm • Persistent central cyanosis despite 100% O2 • 40-60 breaths/min • No response

Bag-Valve-Mask Ventilation

• Neutral Position of Head• Tight Mask Seal• Avoid Pressure on Trachea•Assisted rate= 40 to 60 bpm

Bag-Valve-Mask Ventilation

• Signs of Adequate Ventilation: - Bilateral Chest Expansion - Bilateral Breath Sounds - Adequate Heart Rate & Color

Bag and mask

Ventilate for 30 seconds:

Rate: 40-60 /minPressure: Visible rise and fall of chest

Continue ventilation Initiate chest compression

Consider intubation

HR > 100 bpm:Check for spontaneous

respirations

HR < 60 HR >100

Bag and mask the most important tool in newborn resuscitation

ENDOTRACHEAL TUBE PLACEMENT

• ET intubation - indicated at several points during neonatal resuscitation:

1. Tracheal suctioning for meconium 2. Bag-mask ventilation is ineffective / prolonged3.When chest compressions are performed4.When ET administration of medications is required5.Congenital diaphragmatic hernia or extremely low

birth weight (<1000 g)

Place a pillow under the head and neck but NOT under the shoulders

This allows a straight line of

vision from the mouth to the vocal cords

The laryngoscope is

introduced into the right hand side of the mouth (it is held by the left hand

• The tongue is swept to the left and the tip of the blade is advanced until a fold of skin / cartilage is visualised at twelve o’ clock

• This is the epiglottis, and this sits over the glottis (the opening of the larynx) during swallowing

• The tip of the blade is advanced to the base of the epiglottis, known as the vallecula, and the entire laryngoscope is lifted upwards and outwards

• This flips the epiglottis upwards and exposes the glottis below

• An opening is seen with two white vocal cords forming a triangle on each side

• The tip of the ET tube is advanced through the vocal cords and once the cuff has passed through, one stops advancing The tube is secured at this level and the cuff inflated

ET tube sizes

GA Weight ET tubes Size• <28weeks <1Kg 2.5cm• 28-34 1-2Kg 3 cm• 34-38 2-3Kg 3-3.5 cm• >38 >3 Kg 3.5- 4cm

Steps in Resuscitation - ABCDE

• Circulation • Assessment of heart rate• Umbilical arteries pulsation• Chest Compressions

Steps in Resuscitation - ABCDE

Indication for Chest Compressions1. HR < 60 bpm despite adequate vent with 100%

O2 for 30 seconds

2. Heart Rate 60 to 80 but not Increasing (±) - controversial

2 techniques

• 2 thumb (preferred) • 2 finger • 3:1 ratio • 1/3 of AP diameter

Chest compression

1.Thumb technique: - Place thumbs side by side or one

over the other above xyphoid - other fingers provide support for the back

- Depress the sternum to a depth of 1/3 of the anterior/posterior diameter of the chest

- Your thumbs should remain in contact with the chest at all times

- Rate - 3:1

Drugs needed forNewborn Resuscitation

Steps in resuscitation - ABCDE

Drugs • Adrenaline • Volume Expanders • Naloxone ±• Sodium bicarbonate (0.5 mEq/mL)

Drugs

1.Adrenaline • HR < 60 /min after 30 seconds of adequate

ventilation and chest compressions • Give via ETT, UVC, IV • Repeat dose if no response after 60 seconds• IV or ET dose - 0.1 to 0.3 mL/kg of 1:10,000

(0.01 to 0.03 mg/kg) repeated every 3 to 5 /min

• ET: 0.3 to 1.0 mL/kg of 1:10,000

• No different dose for premature infants

Steps in resuscitation - ABCDE• Volume expanders • Not given routinely • Useful in hypovolemia

– Suspected where there is a pale tachycardic infant

• Normal saline - 10mL/kg over 5-10 min• Route - UVC, IV • Blood or packed red cells - If haemorrhagic

shock is suspected

Drugs

• Naloxone • Inadequate spontaneous respiratory effort • Mothers who received narcotics within 4 hrs

of delivery • Dose - 0.1mg/kg of a 0.4 mg/mL solution • Route - ETT, IV, UVC, IM, SC

Steps in resuscitation- ABCDE

• Environment – Turn on radiant warmer – Warm blankets/cap/plastic wrap for

preterms – Shut doors and windows – Heat Lamps

Equipments : Prepare for birth

• Two clean towels for thermal protection

• Warm delivery room > 25oC

• A radiant heater / warmer

• Clean delivery kit for cord care, gloves

• an additional set of equipment in reserve for multiple births or in case of failure of the first set

Equipments - Oxygen supply

- Bag and mask, face mask, oral airway (Guedel

airway)

- Intubation – Laryngoscope (0 and 1 sized blades) ET tubes, (2.5-4)

Scissors ,gloves Extra bulbs and batteries Stethoscope

Fluids

- IV catheters (22 g)

- Tape and sterile dressing material

- D10W

- Isotonic saline solution

- T-connectors

- Syringes (1-20 mL)

Rapid assessment - 5 characteristics

• Full-term gestation?

• Amniotic fluid clear of meconium ?

• Breathing or crying?

• Good muscle tone?

• Color pink?

If the answer to any of these assessment is "no"

• Initial steps in stabilization ( warmth, position, clear airway, dry, stimulate)

• Ventilation

• Chest compressions

• Administration of epinephrine and/or volume expansion

Resuscitation Priorities

- Drying, Warming, Positioning - Suctioning, Stimulation - BVM Vent - Oxygen - Chest Compressions -Intubation -Medications

• BIRTH ↓

Clear of meconium?Breathing or crying?Good muscle tone? YES Routine careColour pink? -WarmthTerm gestation? -Clear airway -Dry the baby NO• Provide warmth• Position and clear airway*-suction• Dry, stimulate, reposition• Give oxygen

• Evaluate:- Breathing Supportive care HR>100 pink

Apnoea or HR <100Provide positive pressure ventilation* by ambu bag

→Breathing HR >100 pink ↓ Ongoing care

IF• HR<60• Provide positive pressure ventilation*• Administer chest compression ↓• HR<60• Administer Epinephrine***ET may be considered at several steps

Discontinuing resuscitation efforts

• 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)

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