new born resuscitation most important chapter of pediatrics

1. DR MAHTAB
MBBS, DNB,DCH
GMSH16 CHD
1

2. Bill keenan – Father of NRP
Professor of Pediatrics and Director of the
Neonatology Department at Saint Louis
University in St. Louis, Missouri.
2

3. Causes of Neonatal Mortality
Preterm
27%
Sepsis &
pneumonia
26%
Asphyxia
23%
Congenital
7%
Tetanus
7%
Diarrhoea
3%
Others
7%
4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–
900
3

4. Overview and Principles
WHY TO LEARN NEWBORN RESUSCITATION ?
 Birth asphyxia accounts for about 1/4th of the
4 million neonatal deaths that occur each year
worldwide.
 For many newborns resuscitation is not available
 Outcomes of these newborns can be improved with
timely and effective resuscitation.
4

5. Overview and Principles
 Approximately 90% of newborns make smooth
transition from intrauterine to extrauterine life
requiring little or no assistance
 10% of newborns need some assistance
 Only 1% require extensive resuscitation
 We must always be prepared to resuscitate, as even
some of those with no risk factors will require
resuscitation.
5

6. Newborn Resuscitation Pyramid
Assess baby’s risk for requiring resuscitation
Provide warmth
Position, clear airway if required
Dry, stimulate to breathe
Give supplemental oxygen, as required
Assist ventilation with
positive pressure
Intubate the trachea
Provide chest
compressions
Medications
Always needed
Needed less
frequently
Rarely needed

7. Overview and Principles
NEONATAL RESUSCITATION
 The sequence of resuscitation in newborns is
A-B-C as the etiology of neonatal compromise is
nearly always a breathing difficulty
 AIRWAY(position and clear)
 BREATHING (stimulate to breathe)
 CIRCULATION (assess HR and oxygenation)
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8. Equipment required
Suction Catheter
Oral mucus sucker
Radiant warmer 8

9. 9

10. 10

11. TRANSPORT
INCUBATOR
11

12. INITIAL STEPS OF RESUSCITATION
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13. Initial steps of resuscitation
Term / Preterm ?
 Term: smooth transition
 Preterm : stiff, under-developed lungs, insufficient
muscle strength, can’t maintain temperature
Breathing/Crying ?
 Watch baby’s chest
 Gasping is a series of deep, single or stacked
inspirations that occur presence of hypoxia/ischemia.
Treated as apnea.
13

14. Initial steps
Good tone ?
 Term: flexed extremities
 Preterm/sick: flaccid/limp,
extended extremities
14

15. Initial steps
 Provide warmth : Radiant
warmer, don’t cover with
towels.
 Position head and clear
airway as necessary
 Dry and stimulate the baby
to breathe, reposition
15

16. Position “ SNIFFING DOG ”
16

17. Clear airway
 Suction mouth first, then
nose
 “M” before “N”
 To prevent aspiration of
mouth contents

18. Meconium, non-vigorous baby
Insert Laryngoscope
Clear Mouth and posterior
pharynx using 12F/14F
catheter
Insert ET tube
Attach ET tube to meconium
aspirator and suction source
Apply suction and remove
slowly
Count 1-1000,2-1000,3-1000,
withdraw
Repeat if HR is < 100
18

19. Clear airway Vigorous if
1. Good tone
2. Good Cry/
Breathing
3. HR> 100/min
19

20. Dry ,Reposition, Stimulate
Stimulate :
Flicking the soles/
drying & rubbing
the back
20

21. Evaluation
 Respirations
 Heart rate: Best is
auscultation, alternatively
pulsations at base of cord is
felt. Count for 6s and “x”10
 Oxygenation by oximeter
21

22. Breathing
If Apneic or HR < 100 bpm:
 Provide positive-pressure
ventilation,spo2 monitoring.
 If breathing, and heart rate is
>100 bpm but baby is cyanotic,
give supplemental oxygen,
spo2 monitoring. If cyanosis
persists, provide positive-
pressure ventilation
 If respiratory distress is
persistent , consider CPAP and
connect oximeter
1-22

23. 1-23

24. 24

25. MASK
Flow Inflating Bag
T-Piece Resuscitator
25

26. Positive pressure ventilation
 Ventilation of the lungs is the
single most and most effective
step in newborn resuscitation
Indications:
 Gasping/apnea
 HR < 100/min
 SpO2 remains below target values
despite free flow supplemental
oxygen increased to 100%.
26

27. Mask
Appropriate Sizes
 Mask should
Rest on Chin
Cover Mouth
& Nose

28. Suction & Position
Cup the chin
in the mask
and then cover
the nose
Light Pressure
on mask to
create a seal
Anterior
pressure on
posterior rim of
mandible 28

29. Frequency of ventilation:
40 to 60 breaths per minute
Start With 21% ( higher in preterm's) oxygen and
increase according to target Saturation
Initial Pressure at 20mmH2O

30. Ensure Effective PPV
 Most Important sign is the rising of HR
 Improvement in Oxygen Saturation
 Equal and adequate breath sounds B/L
 Good Chest rise
30

31. Evaluation
 Heart rate
 Oxygenation by
oximeter
If heart rate <100 bpm

32. Ventilation corrective steps
Corrective steps Action
M Mask Adjustment Ensure Good seal of mask
on face
R Reposition airway Sniffing Position
S Suction Mouth and nose If secretions present
O Open mouth Ventilate with baby
mouth slightly open and
lift the jaw forward
P Pressure increase Gradually increase the
pressure every few
breaths
A Airway alternative Consider ET or Laryngeal
mask airway
32

33. PPV continued more than several
minutes
 Place an OG tube, Suction gastric contents and leave
the end open.
33

34. Evaluation
If heart rate <60 bpm
despite adequate
ventilation for 30
seconds,
34

35. Chest compressions
Indications :
 HR <60/min despite
at least 30 sec of
effective PPV
Strongly consider Endotracheal intubation at this point
as it ensures adequate ventilation and facilitates the
coordination of ventilation and chest compressions 35

36. Chest compressions
Rationale:
 HR<60/min despite PPV indicates
very low O2 levels and significant acidosis 
depressed myocardium  no blood in lungs to get
oxygenated(supplied by PPV)
 Chest compressions + effective ventilation (ET/PPV)
 oxygenation of blood  recovery of myocardium to
function spontaneously  HR increases  O2 supply
to brain increases
36

37. Chest compressions
Principle:
 Rhythmic compressions of sternum
that
 Compress the heart against the spine
 Increases intrathoracic pressure
 Circulate blood to vital organs
 Chest compressions  compresses
heart & increased Intrathoracic
pressure  blood pumped into
arteries
 Pressure released  blood enters
heart from veins
37

38. Chest compressions
Positions :
 Chest compressions are of
little value unless the lungs
are effectively ventilated
 2 persons are required
 1 – chest compressions
provider should have access
to the chest with his hands
positioned correctly
 2 – Ventilation provider
should be at head end to
maintain effective mask-face
seal or to stabilize ET tube
38

39. Chest compressions
Technique:
 Thumb technique: 2 thumbs
depress the sternum, hands
encircle the torso and the
fingers support the spine.
Preferred technique
 2 – Finger technique: Tips of
middle & index/ring finger of
one hand compresses sternum,
other hand supports the back.
39

40. Chest compressions
 Thumb technique is
preferred as
 Better control of depth of
compression
 Can provide pressure
consistently
 Superior in generating peak
systolic and coronary arterial
perfusion pressure.
40

41. Chest compressions
For small chests with
thumbs overlapped 41

42. Chest compressions
42

43. Chest compressions
2- finger
technique
43

44. Chest compressions
44

45. Chest compressions
 Depth : 1/3rd of the
anter0posterior
diameter of chest.
 Duration of
downward stroke
should be shorter
than the duration of
release
 Do not lift the fingers
off the chest
45

46. Chest compressions
Coordination of chest compressions and
ventilation:
 Avoid giving compression and ventilation simultaneously
 1 breathe after every 3 compressions
 Ratio is 1 : 3 or 30: 90 per minute
 One cycle: 2 sec, 3Compresssions + 1 ventilation
 1 minute : 30 cycles or 120 events (90 compressions + 30
breaths)
46

47. Chest compressions
When to stop chest compressions?
 Reassess after 45-60 sec, if HR > 60/min stop chest
compressions and increase breaths to 40-60 per
minute.
If HR is not improving…
 Insert an umbilical catheter and give IV epinephrine
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48. Endotracheal Intubation
48

49. Endotracheal Intubation
 WHEN TO CONSIDER INTUBATION ?
Indications in resuscitation
 Baby is floppy, not crying, and preterm
 HR < 100/min, gasping/apnea
 HR < 100/min inspite of PPV
 HR < 60/min
 No adequate chest rise and no clinical improvement
 If chest compressions are needed, intubation provides
better coordination and efficacy of PPV
 To administer drugs
49

50. Endotracheal Intubation
WHEN TO CONSIDER INTUBATION ?
Special conditions
 Meconium aspiration if baby is depressed in which it is
the first step to be done
 Extreme Prematurity
 Surfactant administration
 Suspected diaphragmatic hernia
50

51. Endotracheal Intubation-
Equipment and supplies
 Laryngoscope with extra
blades and bulbs
 Straight blades
 Term – 1
 Preterm – 0
 Extremely preterm - 00
51

52. ET tube sizes
Weight GA(weeks) Tube size(mm)
(internal diameter)
Below 1 kg 28 2.5
1-2 kg 28-34 3.0
2-3 kg 34-38 3.5
>3kg >38 3.5- 4.00
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53. ET tube – Uniform diameter, uncuffed
53

54. ET tube – Vocal cord guide
54

55. Procedure… Position
55

56. Position
56

57. Position
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58. Position
58

59. Procedure
59

60. 60

61. Fixing ET tube
 Add 6 to baby’s wt.
Wt Depth of
insertion
< 750g 6cm
1kg 7cm
2kg 8cm
3kg 9cm
4kg 10cm
4-61

62. Confirm position
 Watching the tube passing between cords
 Watching for chest movements
 Listening for breath sounds ( Axilla and stomach)
 Colourimeter/Capnography ( Can also be used for PPV with
mask or LMA
 Improvement in HR and Spo2
 Vapour Condensing inside tube
1-62

63. Medications - Adrenaline
Mechanism of action :
 Increases systemic vascular resistance
 Increases coronary artery perfusion pressure
 Improves blood flow to myocardium and restores
depleted ATP
Indications :
 If HR remains < 60/min even after 30 sec of effective
ventilation preferably after intubation and atleast
another 45-60 sec of coordinated chest compressions
and effective ventilation
63

64. Medications - Adrenaline
Administration :
 Intravenous (recommended)
 Endotracheal
Preparation and dosage:
 Adrenaline vial 1ml = 1mg (1:1000 solution)
 Dilute with NS to make 1:10,000 solution (1ml = 100 mcg)
 IV : 0.1-0.3 ml/kg = 10-30 mcg/kg
 ET : 0.5 – 1 ml/kg = 50-100 mcg/kg
 Give rapidly – as quickly as possible
 Can repeat every 3-5 minutes
64

65. Medications – volume expanders
Indications:
 Bradycardia not improving with adrenaline
 Placenta previa/ Abruption
Volume Expanders:
 Normal saline (recommended)
 Ringer lactate
 Dosage: 10 ml/kg
 Route : Umbilical vein
 Rate: over 5-10 min , rapid infusion may cause IVH in
<30 weeks babies
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66. Resuscitation of preterms
 Additional resources , additional personnel,
additional thermoregulation strategy
 Portable warming pad
 Polyethylene Plastic wrap (< 29wk)
 Prewarmed transport incubator
 Use of Oxymeter, blender to target Spo2 85%- 95%
 Use Lower PIP 20-25 cm of H2O during PPV
 Consider giving CPAP
 Consider Surfactant
66

67. Post Resuscitation Care
 Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks and E/O Acute
perinatal HIE
 Monitor for Apnea, bradycardia, BP, SPo2 &Urine
output.
 Monitor B. Sugars, electrolytes , Hematocrit , Platelets,
ABG
 Maintain adequate oxygenation & support ventilation
as needed
67

68. Post Resuscitation Care
 Delay feeds, Start IV fluids, consider parenteral
nutrition
 Consider inotropes , fluid bolus
 Ensure adequate ventilation before giving sodium
bicarbonate(only in severe metabolic acidosis)
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