NEONATAL RESUSCITATIONPROGRAM

-Dr.Apoorva.E

• History

• Principles of Resuscitation

• Initial steps of resuscitation

• Positive – Pressure ventilation

• Endotracheal tube intubation and LMA insertion

• Chest compressions

• Medications

• Special considerations

• When to stop resuscitation

HISTORY

• Dr.William Keenan – Father of NRP

Professor of Pediatrics and Director of the Neonatology Department at Saint Louis University in St. Louis, Missouri.

• Every five years, the International Liaison Committee on Resuscitation (ILCOR) comprising representation from 13 countries worldwide reviews the available resuscitation science.

• It provides recommendations based on the available evidence at that time.

• The ILCOR guidelines were published in October 2015 and the AAP launched its 7th edition of NRP in May 2016.

PRINCIPLES OF RESUSCITATION

• Birth asphyxia accounts for about 1/4th of the neonatal deaths that occur each year worldwide.

• 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.

WHAT CAN GO WRONG ?

• Compromise of uterine or placental blood flow deceleration of FHR

• Weak cry inadequate ventilation to push the alveolar fluid

• In utero hypoxia Meconium passagemay block the airways

• Fetal blood loss (abruption) Systemic Hypotension

• Fetal Hypoxia/ischemia poor cardiac contractility & fetal bradycardia Systemic Hypotension

• Pulmonary arterioles remain constricted PPHN

CONSEQUENCES :

• Low muscle tone,apnoea / tachypnea,bradycardia,hypotension,cyanosis

• Outcomes of these newborns can be improved with timely and effective resuscitation.

NEWBORN RESUSCITATION PYRAMIDAssess baby’s need for resuscitation

Provide warmth

Position, clear airway if required

Dry, stimulate to breathe

Give supplemental oxygen, as required

PPV

Intubate the trachea

Provide chest compressions

Medications

May be needed

Needed less frequently

Rarely needed

WHAT IS NEW?

INITIAL STEPS OF RESUSCITATION

• There is increased focus throughout the 7th edition NRP on team preparation and role assignment.

• In anticipation of delivery, counselling should be done along with team briefing, role assignment and equipment check.

• Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and PPV perfectly, and whose only responsibility is care of the newborn.

• When perinatal risk factors are identified, a resuscitation team should be present and a team leader identified.

• The leader should conduct a pre-resuscitation briefing, identify interventions that may be required, and assign roles and responsibilities to the team members.

• During resuscitation, the team should demonstrate effective communication and teamwork skills to help ensure quality and patient safety.

• MSAF is a risk factor for abnormal transition and team must ensure a member with advanced airway and resuscitation skills is in attendance.

NRP’s 10 Key Behavioral Skills

• Know your environment • Anticipate and plan • Assume the leadership role • Communicate effectively • Delegate workload optimally • Allocate attention wisely • Use all available information • Use all available resources • Call for help when needed • Maintain professional behavior

• Initial assessment of the neonate and initial resuscitation steps remain unchanged.

• Emphasis on thermoregulation throughout resuscitation.• Temperature should be maintained between 36.5 and 37.5 Celsius.• For preterm infants, combination of interventions

1- Radiant warmers2- plastic wrap with a cap3- thermal mattress 4- warmed humidified gases 5- increased room temperature to 26 deg c6- Portable incubator

•Routine Care for vigorous term infants with no risk factors & babies who required but responded to initial steps , can stay with mother, Skin to skin contact recommended, clear airway, dry newborn, provide ongoing evaluation:

Breathing

Activity

Color .

• The Golden Minute (60-second) mark for completing the initial assessment, initial steps, reevaluating, and beginning ventilation (if required) is retained.

• Evaluations and decision making are based on:

a) Respiratory effort

b) Heart rate

• For assessment of heart rate,the use of a 3-lead ECG is recommended.

• Pulse oximetry to evaluate the newborn’s oxygenation.

• Indications for PPV remain unchanged,those being a heart rate less than 100 bpm or ineffective respirations.

• Initial PIP is suggested in the range of 20-25 cm H20.

• When PPV is administered to preterm infants, PEEP should be used. Recommended starting PEEP is 5 cm H20.

• Rate of PPV is 40-60 / minute.

• Rising of HR

Improvement in Oxygen Saturation

Equal and adequate breath sounds B/L

Good Chest rise

PPV

PPV EFFECTIVE OR NOT?

Self Inflating bag

Flow Inflating Bag

T-Piece Resuscitator

DEVICES USED

• After PPV started, reassess in 15 seconds.

• If no response, MR SOPA corrective measures should be incorporated.

SUPPLEMENTAL OXYGEN

• If HR is >100 but has labored breathing

Term infants start resuscitation with 21% O2,

Preterm less than 35 Weeks should be initiated with low oxygen (21% to 30%) and the oxygen titrated to achieve preductal oxygen saturation similar to that in healthy term infants.

• Initiating resuscitation of preterm newborns with high oxygen (65% or greater) is not recommended.

• If HR is >100 but has labored breathing or Sp02 cannot be maintained within target range despite 100% free-flow oxygen, consider a trial of continuous positive airway pressure (CPAP).

TARGETED PREDUCTAL SPO2 AFTER BIRTH

• 1 min 60%-65%

• 2 min 65%-70%

• 3min 70%-75%

• 4min 75%-80%

• 5min 80%-85%

• 10min 85%-95%

ADVANCED AIRWAY

• Intubation is recommended prior to chest compressions.

• If intubation is not feasible, the laryngeal mask airway should be used as an alternate advanced airway.

• Recommendations for depth of insertion are gestation-based or based on formula using nasal-tragus length (NTL) measurement.

• If heart rate is not increasing and there is no chest movement, despite MRSOPA corrective steps including intubation,

obstruction should be considered and suction can be performed either using a catheter through the ETT or a meconium aspirator.

CHEST COMPRESSIONS

• The indication for chest compressions remains unchanged, this being a heart rate less than 60 bpm in spite of 30 seconds of effective PPV.

• 100% oxygen continues to be recommended when administering chest compressions.

• The 2-thumb technique is recommended and once the airway has been secured, the team member administering compressions should switch to the head of the bed and the team member providing PPV should move to side.

• Compress 1/3rd diameter of chest.

• Do not lift the fingers off the chest.

• 90 compressions to 30 ventilations/minute

(3:1- One & two & three & breathe & One & two & three & breathe…)

• Chest compressions should be continued for 60 seconds before reassessment of heart rate.

• Electronic cardiac monitor preferred for assessment of heart rate.

MEDICATIONS 1.EPINEPHRINE• Indicated if HR remains <60 bpm after at least 30 secs of effective PPV and

another 60 seconds of chest compressions using 100% oxygen

• One dose may be given through ETT.

• If no response, give intravenous dose via emergency UVC or IO access.

• Give rapidly.

• Concentration - 1:10,000 (0.1mg/ml) .

• ETT dose - 0.5 – 1 ml/kg .

• UVC / IV dose 0.1- 0.3 ml/kg ,follow with a 1ml flush NS .

• Can repeat every 3-5 minutes.

2.OTHERS

• For treatment of hypovolemic shock, normal saline and blood are the solutions of choice and the recommended volume is 10 ml/kg.

• Ringer’s lactate is no longer recommended.

• The routine use of NaHCO3 to correct metabolic acidosis is not recommended.

• The use of naloxone to manage respiratory depression in infants born to mothers with narcotic exposure in labour is not recommended.

SPECIAL SCENARIOS

• DELAYED CORD CLAMPING :

There is a new recommendation that delayed cord clamping for 30 -60 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth.

If placental circulation is not intact, such as after a placental abruption, bleeding placenta previa, bleeding vasa previa or cord avulsion, the cord should be clamped immediately after birth.

• MECONIUM STAINED LIQUOR :

If the infant born through meconium-stained amniotic fluid is non-vigorous, the initial steps of resuscitation should be completed under the radiant warmer.

PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed.

Routine intubation for tracheal suction is not suggested.

• Pneumothorax : Percutaneous needle aspiration

• Pleural effusion : Percutaneous needle aspiration

• Congenital Diaphragmatic hernia : Intubation

• Therapeutic hypothermia for HIE : used for >/= 36wks & should meet special criteria,initiated before 6 hours after birth,in facilities with multidisciplinary care.

WHEN TO STOP RESUSCITATION ?

• An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late preterm and term infants, but decisions to continue or discontinue resuscitation efforts must be individualized.

• Where GA ( < 23wks ), B.wt ( < 400g) and / or Cong. Anomalies are associated with early death and high morbidity,resuscitation is not indicated.

Resuscitation step

Recommendations (2005)

Recommendations (2010)

Latest

First step

Assessment

Four questions• Amniotic fluid-clear or not?

Three questions• Gestation-term or not?• Breathing /Crying?• Tone- Good?

Counselling,teambriefing,equipment check

• Term/not?• Tone-good?• Breathing/crying?

Assessment (afterinitial steps )

Look for 3 signs• Hear rate• Color• Respiration

Look for 2 signs• Heart rate• Respiration( Labored,unlabored, apnea, gasping)

=

HR Palpation of umbilical cordpulsations

Auscultation of heart Auscultation + 3 -lead ECG

Resuscitation step

Recommendations (2005)

Recommendations (2010) Latest

Oxygenation Pulse oximetryrecommended for onlypreterm < 32weeks withneed for PPV

pulse oximetryfor both term and preterm =

Target saturation(pre-ductal)

Intubation

Not defined Target SpO2 ranges provided asa part of algorithm

=

Before chest compressions

TherapeuticHypothermia

No sufficient evidence

Recommended for infants ≥ =36weeks with moderate tosevere HIE

THANK YOU !