Transcript Neonatal resuscitation (NNR) [PPT]

Neonatal resuscitation (NNR)
Dr. Renu Singh
Burden of the problem
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Birth asphyxia
23% of the 1 million neonatal deaths in India
Long term neurological complications
Death
NNR (Neonatal resuscitation) :simple,
inexpensive, cost effective method
• Problem: NNR often not initiated, incorrect
use of methods
Successful NNR: factors
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Anticipation: call a skilled personnel
Adequate preparation
Accurate evaluation, algorithm based
Prompt initiation of support
1.Anticipation: High risk delivery
• Maternal condition
– Advanced maternal age ,DM, HT, stillbirth, fetal loss, early
neonatal death
• Fetal condition
– Prematurity, post maturity, congenital anomalies, multiple
gestations
• Ante partum complications:
APH, oligo /polyhydramnios
• Delivery complications
– Malpresentation, MSAF, instrumental delivery, antenatal
asphyxia with abnormal FHR
2. Adequate preparation
• Radiant warmer is turned on,& is heating
• Oxygen source is open with adequate flow
through the tubing
• Suction apparatus tested, functioning properly
• Laryngoscope is functional with bright light
• Resuscitation bag & mask demonstrates an
adequate seal & generation of pressure
Radiant warmer
Successful NNR: factors
1.
2.
3.
4.
Anticipation: call a skilled personnel
Adequate preparation
Accurate evaluation, algorithm based
Prompt initiation of support
Evaluation, algorithm based
• Rapid assessment of neonate clinical status
• Is the infant full term?
• Is the infant breathing or crying?
• Does the infant has good muscle tone?
• Yes: no resuscitation, routine neonatal care
• No: needs resuscitation
Approach to resuscitation
2010 AHA, AAP
• A: initial steps(provide warmth, clear airway if
necessary, dry, stimulate)
• B: breathing(ventilation)
• C: chest compressions (circulation)
• D: administration of drugs &/or volume
expansion
Resuscitation: initial steps
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Provide warmth
Head position “ sniffing position”
Clearing the airway, if necessary
Drying the baby
Tactile stimulation for breathing
AAP
Algorithm
AAP Algorithm
PPV: Positive pressure ventilation
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Form of assisted ventilation
Needed when there is no improvement in HR
Also assess chest wall movements
Should be delivered at rate of 40-60 breaths
/min, maintain HR>100 /min
• Devices: BMV, ET (endotracheal
tube),LMA(laryngeal mask airway)
Bag & mask ventilation
Endotracheal tube
• If BMV is ineffective/prolonged
• When chest compressions are performed
• Initial endotracheal suctioning of non vigorous
meconium stained newborn
Endotracheal tube
LMA(Laryngeal mask airway)
• Soft mask, fits over laryngeal inlet when
inflated, occludes the oesophageal opening
• Done when BMV is unsuccessful & tracheal
intubation is unsuccessful or not feasible
LMA(Laryngeal mask airway)
Targeted SPO2 after birth
1 minute
60-65%
2 minutes
65-70%
3 minutes
70-75%
4 minutes
75-80%
5 minutes
80-85%
10 minutes
85-90%
1. Initial steps in resuscitation
2. PPV
AAP
Algorithm
Chest compressions
• Started when HR<60 per minute despite adequate
ventilation with 100% oxygen for 30 sec
• Delivered at lower third of sternum, to depth 1/3 of
AP diameter of chest
• 2 techniques:
– 2 thumb-encircling hands technique
– Compression with 2 fingers ,second hand
supporting the back
– 3:1 ratio::[ 90 comp:30 ventilations]
1. Initial steps of resuscitation
2. PPV(ET)
3. CHEST COMPRESSIONS
AAP
Algorithm
Medications
• Rarely indicated
• Most important step to treat bradycardia is
establishing adequate ventilation
• HR remains <60bpm,despite adequate
ventilation(ET) with 100% Oxygen & chest
compressions
• Epinephrine or volume expansion or both
Epinephrine
• Route of administration: intravenous(IV),ideal
• Recommended dose: 0.01-0.03 mg/kg per
dose
• Desired concentration: 1:10,000
0.1 mg/ml
Volume expansion
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Suspected or known blood loss
Isotonic crystalloid solution ; normal saline
Blood
Dose calculation: 10 ml/kg
Asses if resuscitation is needed, keep
warm, position, clear, dry, stimulation
Give oxygen as necessary
Positive pressure ventilation
Endotracheal
intubation
Chest
compression
drugs
The golden minute
• <30 seconds: complete initial steps
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Warmth
Drying
Clear airway if necessary
Stimulate
• 30-60 seconds: assess 2 vital characteristics
• Respiration (apnea/gasping/labored/unlabored)
• Heart rate (<100/>100bpm)
• Golden Minute Project: skill based training
AAP
Algorithm
Post resuscitation care
• Needed for those who required PPV
• At risk of deterioration
– Hypo/hyperthermia ,hypoglycemia, CNS
complications(apnea, HIE), pulmonary
complications(TTN, Pneumonia), hypotension
• Need monitoring ,evaluation
• NICU may be necessary
NNR : not indicated
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Conditions with certainly early death
Extreme prematurity(GA<23 weeks)
Birth weight<400g
Anencephaly
Chromosomal abnormality: Trisomy 13
NNR: nearly always indicated
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High rate of survival
Acceptable morbidity
GA≥ 25 weeks
Those with most congenital malformations
NNR?
• Conditions associated with uncertain
prognosis
• Survival borderline
• Parental desires concerning initiation of
resuscitation should be supported
Discontinuing resuscitative efforts
• Newborn with no detectable heart rate,
consider stopping NNR if the heart rate
remains undetectable for 10 minutes
Summary
• Most infants transfer from intrauterine to
extra uterine life
• 10% need some intervention,1% need
extensive resuscitation
• Anticipate the need for NNR
• Adequate preparation for NNR
• Evaluate the newborn as per AHA/AAP
guidelines & follow the recommended
protocol
MCQ1
For successful neonatal resuscitation following
is/are needed except:
1. Anticipation
2. Adequate preparation
3. Skilled personnel
4. Delayed initiation of support
MCQ1
• For successful neonatal resuscitation
following is/are needed except:
1. Anticipation
2. Adequate preparation
3. Skilled personnel
4. Delayed initiation of support
MCQ2
• Following are true in relation to initial steps of
neonatal resuscitation except
1. Provide warmth
2. Tactile stimulation
3. Endotracheal intubation
4. Drying the baby
MCQ2
• Following are true in relation to initial steps of
neonatal resuscitation except
1. Provide warmth
2. Tactile stimulation
3. Endotracheal intubation
4. Drying the baby
MCQ3
• The following is the primary measure of
adequate ventilation
1. Chest wall movement
2. Improvement in heart rate
3. Pink extremities
4. Spo2 of 100%
MCQ3
• The following is the primary measure of
adequate ventilation
1. Chest wall movement
2. Improvement in heart rate
3. Pink extremities
4. Spo2 of 100%
MCQ4
Endotracheal intubation may be indicated at
several points during neonatal resuscitation
except
1. Ineffective BMV
2. During chest compressions
3. Vigorous meconium stained newborn
4. Non vigorous meconium stained newborn
MCQ4
• Endotracheal intubation may be indicated at
several points during neonatal resuscitation
except
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4.
Ineffective BMV
During chest compressions
Vigorous meconium stained newborn
Non vigorous meconium stained newborn
MCQ5
• The recommended compression to ventilation
ratio in neonatal resuscitation is
1. 2:1
2. 3:1
3. 4:1
4. 5:1
MCQ5
• The recommended compression to ventilation
ratio in neonatal resuscitation is
1. 2:1
2. 3:1
3. 4:1
4. 5:1
MCQ6
• The recommended dose(mg/kg per dose) and
route of epinephrine in neonatal resuscitation
1. 0.01-0.03,IV
2. 0.01-0.03,IM
3. 0.03-0.05,1V
4. 0.05-0.1,IV
MCQ6
• The recommended dose(mg/kg per dose) and
route of epinephrine in neonatal resuscitation
is
1. 0.01-0.03,IV
2. 0.01-0.03,IM
3. 0.03-0.05,1V
4. 0.05-0.1,IV
MCQ7
• Recommended method/clinical indicator of
confirming ET placement is
1. Condensation in ET
2. Chest movement
3. Equal breath sounds on auscultation
4. Exhaled C02 Detection
MCQ7
• Recommended method/clinical indicator of
confirming ET placement is
1. Condensation in ET
2. Chest movement
3. Equal breath sounds on auscultation
4. Exhaled C02 Detection