Transcript Neonatal Resuscitation Anywhere/Anytime

Emergency Care of the
Newborn
Tina M. Slusher, MD
Associate Professor of Pediatrics
University of Minnesota
[email protected]
Neonatal Mortality WHO Data 2005
Danny Dorling
Center for Global Pediatrics
The 3 leading recognized causes of
neonatal death world wide are:
A. Prematurity, infection,
congenital anomalies
B. Prematurity, infection,
asphyxia
C. Diarrheal diseases,
asphyxia, prematurity
D. Prematurity, infection,
neonatal tetanus
44%
36%
15%
5%
A.
B.
C.
D.
World
Preterm 28%
Infections 26%
Asphyxia 23%
Congenital
anomalies 8%
Tetanus 7%
Other 7%
Diarrheal 3%
USA
Preterm 23%
Congenital
anomalies 22%
Sepsis 4%
Asphyxia/Hypoxia 3%
Daily Risk of Neonatal Death
Lawn et al. Lancet, 2005.
Center for Global Pediatrics

Newborn resuscitation*/
Respiratory distress

Delayed umbilical clamping*

Umbilical cord antisepsis*

Postnatal
Interventions
Hypothermia prevention* &
management/Kangaroo Care*
Hypoglycemia prevention and
management*

Vit K prophylaxis*

Breastfeeding*

Hepatitis B vaccination*

Sepsis (Pneumonia*)


Hyperbilirubemia screening*


Traditional birth attendant
(TBA)/CHW training*
*Community Based interventions
Zulfiqar et al; Pediatrics
2005;115;519-617


Neonatal Vit A
supplementation*
Topical Emollient therapy*
Prevention & treatment of
ophthalmia neonatorum*
Percentage of Neonatal Resuscitation
Doable at most hospitals/clinics in the
developing world
A.
B.
C.
D.
<50%
>90%
<70%
>70%
39%
22%
23%
17%
A.
B.
C.
D.
Appropriate
neonatal
resuscitation is
easily
adjusted to
the resources
available!!!!!
95% of
resuscitation as
taught by NRCP
guidelines is
“doable” at
most hospitals &
many clinics in
the developing
world!!!
Basic Resuscitation Equipment
• Warm delivery room (w/out draft - w/ fans
off)
• Two pieces of cloth used to dry and wrap
newborn to prevent heat loss
• Mucous extractor or DeLee Aspirator
• Positive Pressure Bag (“Ambu” bag) and mask
or device to give positive pressure
ventilation (mouth-to-mouth may be
appropriate in some situations)
What is most important in neonatal
resuscitation
A.
B.
C.
D.
E.
Oxygen
Ventilation
Epinephrine
Sodium Bicarbonate
20%
Meconium aspirator
A.
50%
30%
B.
0%
1%
C.
D.
E.
Neonatal Resuscitation
• Birth asphyxia is characterized by absent
or depressed breathing at birth.
• Proper ventilation of the newborn is the
most important aspect of resuscitation.
20-30 seconds
ONLY!!
Is my baby breathing?
Is my baby breathing well?
IF no to either
Definitely okay
to start with room
air !!! IF oxygen
available can give
if infant stays cyanotic
Only after 30 seconds of
PPV with a HR < 60
Mostly NRP/ PALS*
CAN NEWBORN INFANTS BE RESUSCITATED WITH ROOM AIR?
Pilot Study
Based on some of these animal data, we performed a pilot study resuscitating 42 newborn infants with room air
and 42 infants with 100% oxygen.
Saugstad
Emphasize Time
• Remember first block warm, dry,
position, suction, stimulate should be
accomplished in NO MORE than 2030 seconds
• By 30 seconds you should be positive
pressure ventilating any infant who is
not breathing or not breathing well
Suction Mouth First then Nose, Stimulate Appropriately
• HR is the 1° sign of improved ventilation
during neonatal resuscitation
• In community based resuscitation focus on
ventilation—most “resusciatatable” infants
resuscitated with ventilation NOT chest
compressions and drugs
• Some programs teaching family members to
do mouth to mouth secondary to concerns
about infections in places where positive
pressure bags not an option
Respiratory Distress
• Keep oxygen flow in preemie low- aim for pink
infant or O2 sats 87-95% (minimize risk of eye
damage & limit oxygen toxicity).
• In term infants at risk for pulmonary
hypertension keep oxygen high.
• Respiratory distress > 1st hr of life always
think sepsis/pneumonia & Rx accordingly.
• Apnea of prematurity is treated w/ aminophylline.
Dilute IV form w/ clean water and give po/ngt if
solution not available. (Caffeine OK too)
• Aminophylline
– Load 5-6 mg/kg IV or po
– Maintenance 1-2 mg/kg/dose q 6-8-12h IV/po
• Continuous Positive Airway Pressure (CPAP) may be
useful in mild-moderate respiratory distress or
apnea without a ventilator
Depth of tube
In water determines
CPAP delivered
Delayed umbilical clamping
• May increase newborn infants iron
stores and reduce incidence of iron
deficiency anaemia in infancyimportant public health importance.
• (BMJ 1996;312:136-137, Grajeda et
al Am J Clin Nutr. 1997;65:425-431)
Maintenance of Body Temperature
Hypothermia occurs when body temp
(axillary) drops below 36.5C (97.7F).
Neonatal cold injuries are common worldwide.
• Ethiopian hospital - 67% of LBW and
high-risk infants admitted to NICU
from outside were cold.
• India - mortality rate of hypothermic
infants was twice that of infants
without hypothermia.
• Cold infants are more
difficult to resuscitate.
• Hypothermia clearly 
morbidity/ mortality in
newborns.
• Skin-to-skin contact
immediately upon delivery &
in nursery greatly  risk of
hypothermia or cold injury.
• **Exception is asphyxiated
infant---data NOT
complete so can not yet
recommend cooling but
absolutely should NOT
overheat asphyxiated
infants!!
Hypoglycemia
• Defined as <40-45 mg/dL
• IF possible confirm strips w/ blood glucose
• Major cause of morbidity especially in groups
such as premies, SGA, and IDM
• Most cost effective strategy for preventing
hypoglycemia is early frequent breast feeding
(cup & spoon or NGT if not able to feed
@breast)
Hypoglycemia cont.
• IF breast feeding not possible 
glucose can be treated in mild group
w/ 5% glucose by mouth 4-8cc/kg
• IF glucose <25mg/dL treat w/IV
D10W 2-4cc/kg (not D25 or D50)
• Exclusive is KEY!
• Especially if mother is HIV+
Sepsis
• Sepsis is major cause of death worldwide in neonates
• Think about early & cover broadly until
able to rule-out
• REMEMBER-Any deviation from
normal can be sepsis temperature,
WBC, lethargy, glucose, vomiting,
diarrhoea, any feeding intolerance,
respiratory distress beyond 1st hour,
etc, etc,
Sepsis continued
• Amp/Gent reasonable choices
• Consider cloxacillin if staph likely in
your nursery.
• Cefotaxime good choice for resistant
gram neg organisms or meningitis if
available
• DO NOT use Ceftriaxone in
Neonates!
Hyperbilirubemia
• May be largest “unrecognized” or silent
cause of neonatal morbidity/mortality in
the developing world
• Need to think about it, look for it, and
when severe treat it---all huge challenges
in most of the developing world.
Traditional birth attendant
(TBA)/CHW training
• Most babies in developing world (60-80%+)
still born at home~half without access to
skilled care)
• Trained TBA’s do a better job of taking
care of newborns than untrained TBA’s!
• Continued training important as it is for all
of us
Thanks
The End
9/18/08
Reference list
included-bulk from
Bhutta et al, Pediatric
2005:115;519-617)