La lección introduce los principios y procedimientos básicos de la reanimación neonatal, incluyendo los cambios fisiológicos que ocurren durante la transición al nacimiento, los posibles problemas que pueden surgir, y los pasos a seguir según la evaluación del recién nacido. Explica el diagrama de flujo de la reanimación que evalúa la respiración, frecuencia cardíaca y coloración del bebé, proporcionando ventilación, masaje cardíaco u otros tratamientos según sea necesario. Finalmente, enfatiza la importancia
2. Panorama y Principios de la
Reanimación
Contenido de la Lección:
•
•
•
•
Cambios fisiológicos al nacimiento
Diagrama de flujo de la Reanimación
Factores de riesgo de la Reanimación
Equipo y personal necesarios
1-2
3. ¿Qué Bebés Requieren
Reanimación?
• La mayoría de los neonatos nacen
vigorosos
• Solamente el 10% de los recién nacidos
requieren alguna asistencia
• Solo el 1% necesitan medidas mayores
de reanimación (intubación, compresiones
torácicas, y/o medicamentos) para
sobrevivir
1-3
4. Fisiología Fetal
En el feto:
• Los alvéolos están llenos de líquido
pulmonar
• In útero, el feto es dependiente de la
placenta para el intercambio gaseoso
1-4
5. Fisiología Fetal
En el feto:
• Las arteriolas
pulmonares están
contraídas.
• El flujo pulmonar
disminuido.
• El flujo sanguíneo
se divide y pasa
una parte a través
del conducto
arterioso.
Click on the image to play video
1-5
6. Pulmones y Circulación
Después del Nacimiento
• Los pulmones se
expanden con
aire
• El líquido
pulmonar se
elimina.
Click on the image to play video
1-6
7. Pulmones y Circulación
• Las arteriolas
pulmonares se
dilatan
• El flujo sanguíneo
pulmonar se
incrementa
1-7
8. Pulmones y Circulación
• Los niveles de
oxígeno en sangre
se elevan
• El conducto
arterioso se contrae
• La sangre fluye
a través de los
pulmones para
captar oxígeno
Click on the image to play video
1-8
9. Transición Normal
Los siguientes cambios importantes
ocurren en segundos después del
nacimiento:
• El líquido en los alvéolos es absorvido
• Las arterias umbilicales y la vena se
contraen provocando aumento de la
presión sanguínea.
• Los vasos pulmonares se relajan
1-9
10. Que Puede Ir Mal Durante La
Transición
• La falta de ventilación de los pulmones del
neonato provoca constricción sostenida de las
arteriolas pulmonares, evitando así que la
sangre arterial sistémica se oxigene
• La falla prolongada de una perfusión y
oxigenación adecuadas a los órganos del bebé
puede resultar en daño cerebral, daño a otros
órganos o muerte
1-10
11. Signos de Compromiso del
Recién Nacido
• Pobre tono muscular
• Depresión
respiratoria
• Bradicardia
• Presión sanguínea
baja
• Taquipnea
• Cianosis
Buen tono
con
cianosis
Mal tono
con
cianosis
1-11
12. Compromiso In Útero o
Perinatal
Apnea Primaria
• Cuando un feto ó neonato es deprivado de
oxígeno, se origina un período inicial de
intentos de respiración rápida, que es seguido
de aparición de apnea primaria y de caída de la
frecuencia cardíaca que puede mejorar con
estimulación táctil
1-12
13. Apnea Secundaria
• Si la deprivación de
oxígeno continúa,
aparece una Apnea
Secundaria, acompañada
de una caída continua de
la frecuencia cardíaca y
de la presión sanguínea.
• La Apnea Secundaria
no puede ser revertida
mediante estimulación;
debe iniciarse
ventilación asistida
QuickTime™ and a
Sorenson Video 3 decompres sor
are needed to see this picture.
Click on the image to play video
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14. Reanimación de un Neonato
con Apnea Secundaria
El inicio de presión positiva efectiva
durante la apnea secundaria
generalmente resulta en
• Mejoría rápida de la frecuencia cardíaca
1-14
15. Evaluación del Reanimador
Todos los recién
nacidos requieren de
una valoración inicial
para determinar que
reanimación van a
necesitar
1-15
16. Pasos Iniciales (Bloque A)
• Provea calor
• Posicione la cabeza
y limpie las vías
aéreas*
• Seque y estimule al
bebé para que
respire
Nacimiento
• Embarazo de término?
• Líq. Amniótico claro?
• Respira o llora?
• Buen tono muscular?
Evaluación
• Provea calor
• Posicione la cabeza y
las vías aéreas
• Seque, estimule, reposicione
*Considere intubación de la traquea en este punto (para
neonatos deprimidos con líquido amniótico meconial)
1-16
17. Evaluación
Después de los pasos iniciales, las acciones
posteriores están basadas en la evaluación de
•
•
•
Respiraciones
Frecuencia cardíaca
Coloración
• Evalúe respiración,
frecuencia cardíaca y
coloración
Tienes aproximadamente 30 segundos para
obtener respuesta de un paso antes de
decidir ir al siguiente
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18. Respiración (Bloque B)
Si está apnéico o la FC es
< 100 lpm:
• Provea ventilación con
presión positiva*
• Si esta respirando y la FC
es >100 lpm pero el bebé
está cianótico, ofrezca
oxígeno suplementario. Si la
cianosis persiste, administre
ventilación con PPI
Evalúe respiración,
frecuencia cardíaca
y coloración
Respira, FC >100 pero cianótico
Apnea ó
FC < 100
• Provea oxígeno
suplementario
Cianosis persistente
Suministre
Ventilación con
Presión Positiva
*La intubación endotraqueal debe ser considerada en varios
pasos
1-18
19. Circulación (Bloque C)
Si la frecuencia cardíaca es <60 lpm a pesar de
una adecuada ventilación por 30 segundos,
• Dé masaje cardíaco mientras continúa la
ventilación con PPI*
• Después evalúe nuevamente. Si la FC es <60 lpm,
proceda con el Bloque D
•Provea Ventilación con Presión Positiva*
•Administre Masaje Cardíaco*
*Considere la intubación de la tráquea en este punto
1-19
20. Medicamentos (Bloque D)
Si la frecuencia cardíaca es <60 lpm a pesar
de una adecuada ventilación y masaje cardíaco
• Administre adrenalina mientras continúa con ventilación
asistida y compresiones torácicas*
30 seg
• Provea Ventilación con Presión Positiva*
• Administre Masaje Cardíaco*
FC <60
Evaluación
• Administre Adrenalina*
*Considere la intubación de la tráquea en este punto
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21. Puntos Importantes en el
Diagrama de Flujo de la
Reanimación Neonatal
• La acción más importante y efectiva en la
reanimación neonatal es ventilar los pulmones del
bebé
• La ventilación con presión positiva efectiva en la
apnea secundaria generalmente da como
resultado una rápida mejoría de la frecuencia
cardíaca
• Si la frecuencia cardíaca no se incrementa, puede
suceder que la ventilación es inadecuada y/o el
masaje cardíaco o que sea necesario administrar
adrenalina
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22. Puntos Importantes en el
Diagrama de Flujo de la
Reanimación Neonatal
•
•
•
FC <60 lpm → Se requieren pasos adicionales
FC >60 lpm → El masaje cardíaco puede detenerse
FC >100 lpm y respiración espontánea → la
ventilación con PPI puede suspenderse
• Asterisco (*): la intubación endotraqueal debe ser
considerada en varios pasos
• Límite de Tiempo: si no hay mejoría en 30 segundos
pase al siguiente paso
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23. Preparación para Reanimación:
Personal y Equipo
• Cada nacimiento debe ser atendido cuando menos por
una persona cuya única responsabilidad es el bebé y
que sea capaz de iniciar la reanimación. Esa persona o
alguien más qué esté disponible inmediatamente deben
tener las destrezas necesarias para llevar a cabo una
reanimación completa
• Cuando de prevé que se requerirá una reanimación,
debe estar presente personal adicional antes de que
ocurra el nacimiento
• Prepare el equipo necesario
– Encienda el calentador radiante
– Cheque el equipo de reanimación
1-23
24. Preparación para la
Reanimación: Factores de
Riesgo
• En la mayoría de los casos, la
reanimación neonatal puede ser
anticipada si se identifican los factores
de riesgo anteparto e intraparto
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26. ¿Porqué los Prematuros
Tienen un Mayor Riesgo?
•
•
•
•
•
•
Posible deficiencia de surfactante
Menor control respiratorio
Pérdida rápida de calor, pobre control de temperatura
Posible infección
Susceptible de hemorragia cerebral
Susceptible de hipovolemia secundario a pérdida de
sangre
• Músculos débiles que dificultan una respiración
espontánea
• Los tejidos inmaduros pueden ser dañados por
oxígeno excesivo
1-26
In Lesson 1 you will learn the
Changes in physiology that occur when a baby is born
Sequence of steps to follow during resuscitation
Risk factors that can help predict which babies will require resuscitation
Equipment and personnel needed to resuscitate a newborn
Which babies require resuscitation?
Most newly born babies are vigorous.
About 10% of newborns require some assistance to begin breathing at birth.
Only about 1% need extensive resuscitation measures (intubation, chest compressions, and/or medications) to survive.
Instructor Tip: Practice resuscitation skills frequently, especially if skills are not used often. This may be done with “mock codes.”
In the fetus, oxygen is transferred across the placenta, and the lungs contain no air.
The alveoli (potential air sacs) of the fetus are filled with fluid that has been produced within the lungs.
Blood flow through the fetal lung is markedly diminished compared with that required after birth, as the pulmonary arterioles are constricted and blood flow is diverted across the ductus arteriosus.
At birth, as the newborn takes the first few breaths, several changes occur, whereby the lungs take over the lifelong function of respiration.
Following birth, the lungs expand as they are filled with air. The fetal lung fluid gradually leaves the alveoli.
At the same time as the lungs are expanding and the fetal lung fluid is clearing, the arterioles in the lungs begin to open, allowing a considerable increase in the amount of blood flowing through the lungs.
As blood levels of oxygen rise, the ductus arteriosus begins to constrict.
Blood previously diverted through the ductus arteriosus flows through the lungs, where it picks up oxygen for transport to tissues throughout the body. The ductus remains constricted, and the normal extrauterine circulatory pattern is established.
Normally, there are 3 major changes that take place within seconds
after birth.
Alveolar fluid is absorbed into lung tissue and replaced by air.
Umbilical arteries and veins are clamped, removing the low resistance placental circuit and increasing systemic blood pressure.
Blood vessels in lung tissue relax, increasing pulmonary blood flow.
A baby may encounter difficulty before labor, during labor, or after birth. Some of the problems that may disrupt normal transition are
The baby may not breathe sufficiently to force fluid from the alveoli, or foreign material such as meconium may prevent air from entering the alveoli.
Excessive blood loss may occur, or there may be inadequate cardiac contractility or bradycardia from hypoxia and ischemia.
Lack of oxygen or ventilation of the newborn’s lungs results in sustained constriction of the pulmonary arterioles, preventing arterial blood from becoming oxygenated. Prolonged lack of adequate perfusion and oxygenation to the baby’s organs can lead to brain damage, damage to other organs, or death.
The compromised baby may exhibit one or more of the following clinical findings:
Poor muscle tone
Depression of respiratory drive due to insufficient oxygen reaching the brain
Bradycardia
Low blood pressure
Tachypnea (rapid respirations)
Cyanosis (blue color)
Other conditions, such as infection, hypoglycemia, or depressant drugs given to the mother before birth, may also cause these symptoms.
When babies are deprived of oxygen (in utero or after delivery), they undergo a well-defined sequence of events that starts with cessation of respiration.
Primary apnea follows the sequence noted on this slide. An important point is that, during primary apnea, the newborn responds to stimulation.
Instructor Tip: Initiate resuscitation immediately. Resuscitation may be inappropriately delayed if the health care provider does not recognize the need for neonatal resuscitation. Any delay in transferring a compromised newborn to the resuscitation team is unacceptable practice.
If oxygen deprivation continues, deep gasping respirations develop, the heart rate continues to decrease, and the blood pressure decreases.
An important point is that, during secondary apnea, stimulation will not restart the baby’s breathing. Assisted ventilation must be provided to reverse the process triggered by oxygen deprivation. If a baby doesn’t begin to breathe immediately after being stimulated, he or she is likely in secondary apnea and will require positive-pressure ventilation.
Instructor Tip: Quickly achieve and maintain oxygenation in full-term and post-term newborns after perinatal hypoxia-ischemia because they are especially prone to persistent pulmonary hypertension.
Most babies in secondary apnea will respond to effective ventilation with a rapid improvement in heart rate. The longer a baby has been in secondary apnea, the longer it will take for spontaneous breathing to resume. If heart rate does not improve rapidly with effective ventilation, myocardial function may be compromised and chest compressions and/or medications may be required.
The flow diagram begins with the birth of the baby. Each resuscitation step is shown in a block. Below each block is a decision point to help decide whether proceeding to the next step is needed.
At the time of birth, you should ask yourself 4 questions about the newborn. These questions are shown in the Assessment block.
Term gestation?
Amniotic fluid clear?
Breathing or crying?
Good muscle tone?
If any answer is “no,” you should continue to the next steps.
These are the initial steps you take to establish an airway and begin resuscitating a newborn. An asterisk (*) indicates intubation may be considered or required (eg, in a depressed newborn with meconium).
After initial steps, evaluate the newborn often, about every 30 seconds.
If the newborn is not breathing (has apnea) or has a heart rate less than 100 beats per minute (bpm), proceed to Block B.
Instructor Tip: Respirations and color are naturally assessed during the initial steps because you are handling the baby and assessing progress through the first moments of transition.
If the newborn is not breathing adequately (has apnea or is gasping), has a heart rate of <100 beats per minute (bpm), or appears blue (cyanotic), you proceed to block B.
If the baby is apneic or has a heart rate of <100 bpm, give positive-pressure ventilation. If the baby is breathing and has a heart rate of >100 bpm but has central cyanosis, you should give supplemental oxygen. If central cyanosis persists after giving oxygen, you should then proceed to positive-pressure ventilation.
If, after 30 seconds of adequate positive-pressure ventilation, the heart rate is less than 60 bpm, chest compressions and epinephrine may be needed for sufficient cardiac output so that blood can reach the lungs to pick up oxygen.
Support circulation by starting chest compressions while continuing ventilation. After 30 seconds of chest compressions, evaluate the newborn again. If the heart rate is still less than 60 beats per minute, proceed to Block D.
If the heart rate remains less than 60 beats per minute, the actions in Blocks C and D are continued and repeated. This is indicated by the curved arrow.
Studies have shown that the most important aspect of neonatal resuscitation is effective ventilation. Once effective ventilation is established and the baby does not respond, it can be assumed that blood and tissue oxygen levels have become extremely low and that the baby is in secondary apnea. Chest compressions and epinephrine will be needed for sufficient cardiac output so that blood can reach the lungs to pick up oxygen.
To follow the resuscitation flow diagram, it is important to remember the following heart rates and time sequences.
Instructor Tip: The flow diagram may look complex at first, but the Neonatal Resuscitation Program (NRP) takes you through each step. Practice helps ensure rapid, simultaneous assessment of the newborn and timely interventions.
Every birth should be attended by at least 1 person whose only responsibility is the baby and who is capable of initiating resuscitation. Either that person or someone else who is immediately available should be able to perform a complete resuscitation. It is not sufficient to have someone “on call” (either at home or in a remote area of the hospital) for neonatal resuscitation in the delivery room. If the delivery is anticipated to be high risk and thus may require more advanced neonatal resuscitation, or if the resuscitation will be of a baby less than approximately 32 weeks’ gestation, additional equipment and personnel are necessary in the delivery room. (See Lesson 8.) All personnel should observe appropriate body fluid precautions during resuscitation as defined by hospital policy.
Instructor Tip: You should ask yourself these questions: Is every birth in this setting attended by a person who can initiate resuscitation? What is the protocol for assembling team members for an anticipated high-risk birth? Is equipment set up the same in every room so that no one has to search for items?
In many cases, delivery of a depressed newborn can be anticipated on the basis of the antepartum and intrapartum history.
Premature babies have anatomical and physiologic characteristics that are quite different from babies born at term. These and other unique characteristics present special challenges during resuscitation of premature babies. These and other aspects of prematurity should alert you to seek extra help when anticipating a preterm birth. (See Lesson 8.)
Newborns who have required resuscitation are at risk for deterioration after their vital signs have returned to normal. Following are 3 levels of post-resuscitation care:
Routine Care
Vigorous newborns with no risk factors and clear amniotic fluid.
Instructor Tip: Put a vigorous baby directly on mother’s chest (after checking with the mother that this is okay), dry, and cover with dry linen.
Observational Care
Newborns who have prenatal or intrapartum risk factors who are still at risk for developing problems associated with perinatal complications and should be evaluated frequently during the immediate postpartum period.
Instructor Tip: Initial assessment occurs under the radiant warmer where baby receives the initial steps; transfer to the nursery for monitoring may be necessary. Example: meconium-stained fluid, initial depressed breathing or activity, or cyanosis requiring brief free-flow oxygen.
Post-resuscitation Care
Babies who require positive-pressure ventilation or more extensive resuscitation and who may require ongoing support should generally be managed in an environment where ongoing evaluation and monitoring are available.
Newborns who have required resuscitation are at risk for deterioration after their vital signs have returned to normal. Following are 3 levels of post-resuscitation care:
Routine Care
Vigorous newborns with no risk factors and clear amniotic fluid.
Instructor Tip: Put a vigorous baby directly on mother’s chest (after checking with the mother that this is okay), dry, and cover with dry linen.
Observational Care
Newborns who have prenatal or intrapartum risk factors who are still at risk for developing problems associated with perinatal complications and should be evaluated frequently during the immediate postpartum period.
Instructor Tip: Initial assessment occurs under the radiant warmer where baby receives the initial steps; transfer to the nursery for monitoring may be necessary. Example: meconium-stained fluid, initial depressed breathing or activity, or cyanosis requiring brief free-flow oxygen.
Post-resuscitation Care
Babies who require positive-pressure ventilation or more extensive resuscitation and who may require ongoing support should generally be managed in an environment where ongoing evaluation and monitoring are available.