Critical Concepts NICU
Transcript of Critical Concepts NICU
Critical ConceptsNICU
Brian M. Barkemeyer, MD
LSUHSC Division of Neonatology
2011-12
At birth
• 100% of infants need someone present dedicated to the infant and capable of initial steps in neonatal resuscitation
• 10% of infants require some level of resuscitation at birth
• 1% of infants require major resuscitation
“Golden hour”
• At no other time in one’s life will necessary critical concepts in resuscitation have a potential lifelong impact– Appropriate interventions (or the lack thereof) can
make the difference between life or death, or normal life vs. life of disability
Preparation
• NRP - Neonatal Resuscitation Program– Evidence-based, standardized program jointly
sponsored by American Academy of Pediatrics and American Heart Association
• Proper equipment
• Knowledge– In most cases, the need for neonatal
resuscitation is predictable
– But not always!
Risk Factors Predictive ofNeed for Neonatal Resuscitation
• Maternal illness– Hypertension– Diabetes– Infection
• Prematurity• Post-maturity• Multiple gestation• Maternal bleeding• Maternal drug abuse• No prenatal care
• Fetal distress• Abnormal fetal position• Abnormal labor• Fetal anomalies• Macrosomia• IUGR• Placental abnormalities• Meconium-stained
amniotic fluid
Transition toExtrauterine Life
• Fluid-filled alveoli to air-filled alveoli
• Circulatory changes– Decreased pulmonary vascular resistance resulting
in increased pulmonary blood flow and cessation of flow through foramen ovale and ductus arteriosus
– Cessation of flow to placenta resulting in increased systemic vascular resistance
Lack of Appropriate Resuscitation
• Interrupts normal transition to extrauterine life
• Hypoxia
• Respiratory and metabolic acidosis
• Ischemia
• Potential for death or long term adverse outcome
Three Basic Questions
• Term infant?
• Breathing/crying at birth?
• Normal tone at birth?
• If the answer to these three questions is yes, infant doesn’t need resuscitation, but does deserve initial steps
Initial Steps
• Drying
• Warming
• Stimulation
• Positioning
• Clear airway
• Necessary for all newborns!
Warming
• Appropriate room temperature• Rapid drying to avoid evaporative heat loss• Remove wet towels• Mother – skin to skin• Radiant heat warmer• Blankets, cap
• Premature infants and IUGR infants at highest risk for hypothermia
Establishment of the Airway
• Suction mouth then nose (“M before N”)
• Shoulder roll to aid in positioning
• Head positioned in slight extension, or “sniffing position”– Not too extended
– Not too flexed
ABC’s
• Airway– Suction secretions, assess for anomalies
• Breathing– Stimulate respiratory effort
• Tactile
• Bag-mask positive pressure ventilation (PPV)
• Circulation– Assess heart rate
• Chest compressions if PPV ineffective at restoring heart rate
Skills to Learn
• Neonatal assessment
• Use of bulb suction
• Administration of positive pressure ventilation by bag-mask
• Intubation and assistance with intubation
• Chest compressions
Assessment/Reassessment:Sequential steps in resuscitation
• Initial steps [30 seconds]
• PPV [30 seconds]
• Chest compressions [30 seconds]
• Medications [30 seconds]
Neonatal Assessment
• Respirations– Normal rate and depth, good chest movement
• Heart rate– Normal > 100
– Count for 6 seconds, multiply x 10
• Color– Pink lips and trunk
– Acrocyanosis vs. central cyanosis
Indications for PPV
• If after initial steps in resuscitation [30 sec], assessment reveals– Apnea
– Gasping respirations
– Heart rate < 100
Indications for Chest Compressions
• If after initial steps in resuscitation [30 sec] and effective PPV [30 sec], assessment reveals– Heart rate < 60
Indications for Epinephrine
• Heart rate persists < 60 after– Initial steps [30 seconds]
– PPV [30 seconds]
– Chest compressions [30 seconds]
• Dosage given IV (UVC preferred), or endotracheal (higher dose given)
Indications for Volume Administration
• History of blood loss at delivery suggesting hypovolemia
AND
• Infant appears to be in shock (pallor, poor perfusion, failure to respond appropriately to resuscitation efforts)
• IV, 10-20 mL/kg, Normal saline, Ringer’s lactate, or O-blood
Meconium-stained Amniotic Fluid
• 15% of deliveries; at risk for meconium aspiration syndrome
• Suctioning of upper airway and trachea in infants who are not vigorous may help prevent meconium aspiration syndrome– Vigorous defined by
• Heart rate > 100
• Normal respiratory effort
• Normal tone
Positive Pressure Ventilation
• Appropriate size mask and bag• Self-inflating vs. flow-inflating bag• Forming a good seal with mask• Achieve adequate chest rise• 40-60 breaths per minute
• When done appropriately, PPV should result in improvement in heart rate and color
Ineffective PPV
• Reposition mask on face
• Reposition head
• Suction upper airway
• Ventilate with mouth open
• Increase ventilatory pressure
• Replace bag
• Endotracheal intubation
Self-inflating bag
Flow-inflating bag
Chest Compressions
• Should be coordinated with PPV
• 2 thumb method preferred
• Compression of sternum 1/3 depth of AP diameter of chest
• 120 events per minute (compressions and respirations combined)
• “One and two and three and breathe”
Chest Compressions
Endotracheal Intubation
• ET tube size similar to size of patient’s little finger
• < 28 wks, < 1000 g = 2.5 ETT
• 28-34 wks, 1000-2000 g = 3.0 ETT
• 34-38 wks, 2000-3000 g = 3.5 ETT
• 38-42 wks, > 3000 g = 4.0 ETT
• Insertion depth– “Tip to lip” measurement = weight in kg plus 6
• 2 kg patient should have ETT secure at 8 cm mark at lip
Endotracheal Intubation
Unique Aspects of Endotracheal Intubation in Infants
• Narrowest part of airway is subglottic area
• Uncuffed ET tubes typically utilized
• Increased airway resistance associated with more narrow airway diameter
• Relative lack of structural support for neonatal airway
Unique Anatomic Challenges
• Choanal atresia– Endotracheal intubation may be required
• Pierre-Robin sequence– Prone positioning
– NG tube into posterior pharynx
• Congenital diaphragmatic hernia– Endotracheal intubation
– Gastric decompression
Key Points
• Appropriate resuscitation requires a rapid series of assessments, interventions, and reassessments
• All infants deserve basic steps of resuscitation– Drying, warming, positioning, clear airway
• Prompt initiation of respiratory support with positive pressure ventilation by bag-mask is the key to successful resuscitation of most infants