Post on 16-Jul-2015
REFERENCES
• Neonatal Resuscitation Textbook- 6th edition
• Neonatal Resuscitation Textbook- 5th edition
• 2010 American heart association guideline for cardiopulmonary resuscitation and emergency cardiovascular care.
• www.aao.org/nrp
• www.healthstream.com/hcl/aap
Need
• Birth asphyxia accounts for about 23% of the approximately 4 million neonatal death occur each year world wide.
Lancet. 2010;375:1969-1987
Neonatal Resuscitation
• Majority (90%) – no resuscitation
• 10% - some assistance
• <1% - extensive resuscitation
Neonatal Resuscitation Program
• NRP was originally designed in mid 1970
• By AAP and AHA
• Updates – 2005
2010
Personnel
• Skilled personnel for every birth
• For all deliveries should be skilled in PPV & assisting CC
• Skilled personnel for complete CPR be readily available
• For anticipated high risk deliveries additional personnels be recruited
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Equipments
• Equipment list
• Optional ..
Blender, LMA, ETCO2,
CPAP
• Equipment checklist
• No longer optional
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Initial Assessment
• Term gestation
• Amniotic fluid clear
• Breathing/crying
• Good tone
• Term gestation
• Breathing/crying
• Good tone
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Assess at Birth
•Term gestation ?
• Amniotic fluid clear ?
• Breathing or crying ?
• Good muscle tone ?
• Term gestation ?
• Breathing or crying ?
• Good muscle tone ?
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Routine Care
• Provide warmth
• Clear airway
• Dry
• Assess color
• Provide warmth
• Assure open airway
• Dry
• Ongoing evaluation
(color (SPO2), activity and breathing)
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“ Emphasis on placing baby on mothers chest in skin to skin contact ”
Initial Steps
• Provide warmth
• Position
• Clear airway
(if required)
• Dry
• Stimulate
• Reposition
• Provide warmth
• Open airway
(no routine suction)
• Dry , stimulate
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Suctioning
• No routine suction
• Suction only if :
- Obvious obstruction to spontaneous breathing
- Require PPV
Initial Assessment
• Look for 3 signs
• Heart rate
• Color
• Respiration
• Look for 2 signs
• Heart rate
• Respiration (Labored,
unlabored, apnea, gasping)
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Checking Heart Rate
• Palpation of umbilical cord pulsation
• Pre-cordial auscultation
preferred to umbilical cord palpation for heart rate
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PPV Device
• Use either flow inflating, self inflating or T piece resucitator
• Same
• Emphasis on use of manometer for PPV
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PPV: If ineffective
• Take remedial measures • M...Reapply mask
• R…Reposition airway
• S….Suction
• O…Open mouth
• P….Pressure increase
• A….Alternate airway
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PPV
• Start with 100% O2 during PPV
• Use room air for term
• No evidence to give appropriate initial oxygen strategy for infants 32-37 weeks
• Initiate resuscitation using O2 concentration between 30-90% (< 32w)
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Oxygenation
• Pulse oximetryrecommended for only preterm < 32weeks with need for PPV
• Use oximeter
1. Anticipated need for
resuscitation
2. Need for PPV for more than few breaths
3. Persistent cyanosis
4. Supplementary oxygen
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Oxygenation
• No info on using pulse ox
• Attach probe to right hand or wrist (measure pre-ductal saturations)
• Attach neonatal probe before connecting it to machine
• Recording of tracing may take 1-2 m
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Oxygenation
• Use of blender for compressed air and oxygen, optional
• Start with oxygen concentration somewhere between 21-100%
• Oxygen blender is
essential
• Preterm start with O2 concentration 30-90% and then increase or decrease
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When to give 100% Oxygen
• Start with 100% O2 during PPV
• Shift to 100 % during chest compressions
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Subsequent Assessment
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Heart Rate
Respiration
Oxygenation*
* Pulse oximetry
Respiration
Heart Rate
Color
Intubation
• Indications
• Technique
• Confirmation
• Same
• Exhaled Co2 is primary method of confirmation
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Chest Compression
• Site
• Depth
• Technique
• CC: Ventilation ratio
• 2 thumb encircling hand technique preferred
• Same steps
• Provide for 45-60 sec un-interrupted
• Head end CC
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Laryngeal Mask Airway
• For near term and term infants > 2500g may be used
• No definite mention of indications
• LMA may be used for infants >2000g and ≥ 34 weeks when
1. bag and mask is ineffective
2. tracheal intubation is unsuccessful or not feasible
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Preterm Resuscitation: CPAP
• Suggested for preterm babies ( < 32 weeks) with respiratory distress
• Be considered for persistent cyanosis or labored breathing after initial steps
• Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP or ventilation as per local practice
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Preterm Resuscitation: Temp
• Polytehylene bag for
< 28 weeks
• Exothermic mattress
• Covering in plastic wrap without drying
• Pre-warming the delivery room to at least 26C
• Monitor temp closely
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Algorithm Timeline
• Assessment every 30 seconds • “First Golden Minute”
concept
• After PPV + CC assess by 45-60 sec
• After epinephrine assess HR by 1 minute
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Level of Care
• Routine care
• Observational care
• Post resuscitation care
• Routine care
• Post resuscitation care
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Therapeutic Hypothermia
• No sufficient evidence to recommend routine use of modest systemic or selective cerebral hypothermia
• Recommended for infants ≥ 36weeks with moderate to severe hypoxic ischemic encephalopathy as per protocol with provision for monitoring for side effects and long term follow up
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Glucose
• Infants who require significant resuscitation should be monitored and treated to maintain glucose in the normal range
• Glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia
• No specific target conc.
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SUMMARY• Old Guidelines become obsolete with new
evidence
• At times guidelines seem more complex and complicated
• Individualize the care and utilize the local resources
• Primum non Nocere (First Do No Harm)