Pediatrics new born resuscitation dr.gangadhar rao g m+91 949 3864 912

NEW BORN RESUSCITATION & MECONIUM ASPIRATION

Dr. G GANGADHAR RAO GUNTUR MEDICAL COLLEGE

FORMER PAEDIATRICIAN YASHODA HOSPITAL SEC.

Department of Pediatrics COMPOSITE HOSPITAL CRPF HYDERABAD1DR.GANGADHAR RAO G

M09493864912

2DR.GANGADHAR RAO G M09493864912

MECONIUM ASPIRATION SYNDROME

Mortality and morbidity is 28% to 40% of MAS.

INCIDENCE IS 8.8%, USUALLY POSTMATURE INFANTS, APGAR SCORE 1- 5 Min. IS LESS THAN 6


What is Meconium?

• In Greek - means "Poppy juice". • Black Green, Thick sticky odorless and acidic


Contents

• Water 72%-80%• Intestinal secretions• Epithelial cells• Swallowed Amniotic fluid• Mucopolysacchrides 80% of dry wt.• Cholesterol and Sterol precursors

• Proteins• Lipids 8% dry wt.• Bile acids and salts• Enzymes• Blood substances• Squamous cells and Vernix caseosa.



Pathogenesis

• Bile salts are blamed for. Exact cause unknown. • Inflammatory response by lung tissue.


Introduction

• Cause of Respiratory failure in newborn. • Inhalation of Meconium causes respiratory distress. • Degree of severity vary. • Meconium in Amniotic fluid 10%-20% of total deliveries.

• Mortality and morbidity in 28% to 40% of MAS.


Incidence

• Amniotic fluid stained in 16.5% (India)• MAS develop in 18.7%• MAS 1.44% in all births• No seasonal variation


Definition

• Meconium below the vocal cords.• Mild MAS < 40% Oxygen needed for < 48 hrs.• Moderate MAS > 40% Oxygen needed for > 48 hrs.• Severe MAS Ventilation > 48 hrs often with

persistent pulmonary hypertension.


Working definition

• Staining of Liquor Umbilical cord. Skin and nail.• Respiratory distress after 1 hr of birth. • Radiological features of Aspiration pneumonitis.


Causes in-utero

• Meconium staining rarely before 38wt• Levels of motilin• Maturity of myelination of gut• Lack of strong peristalsis of gut• Good sphincter tone• ‘Cap’ viscous meconium in rectum

• Foetal distress – hypoxia

• Diving reflex• Umbilical cord

compression• Gut maturation• Breech presentation• Listeriosis in foetus –

foetal diarrhoea


Risk factor • Maternal hypertension and diabetes mellitus • Maternal heavy smoking.• Chronic Respiratory and CVS disease.• Post term pregnancy.• Pre eclampsia / Eclampsia.• Oligohydramnios. • Poor biophysical profile.• Foetal distress (Abnormal Heart Rate)


Mechanism of injury

1. Mechanical Obstruction.2. Pneumothorax – “Ball Valve”.3. Pneumonitis

1. Bile salts2. Bile acids3. Release of cytokines

4. Pulmonary Vasoconstriction.5. Surfactant Inactivation.


Pathophysiology


Clinical Features• Usually full term and post term • Signs of post maturity.• Green Yellow staining of nails, skin and umbilical cord.• Afebrile, Fever or hypothermia if infected.• Resp. rate > 120/min.• Subcostal, Intercostal and sternal retraction.• Use of accessory muscles• Flaring of nostrils• Grunt• Increased Ant. Post diameter • Apnoea• Rhonchi and crepitations.


Clinical Features - Contd..CVS 1. Hypoxic myocardial damage.

2. Hypotension3. CCF

4. S2 may be single5. Murmur of tricuspid regurgitation

Abd 1. Distended (Aerophagia)

2. Liver and Spleen displaced.3. Constipation.4. Absent bowel sounds in severe cases.5. Urinary retention.

CNS: 1. Hypoxic ischemic Encephalopathy.

2. Signs of birth asphyxia.17DR.GANGADHAR RAO G

M09493864912


Complications• Pneumothorax• Pneumomediastenum • Pneumopericardium• Pneumoperitonium• Subcutaneous Emphysema• Broncho pulmonary Dysplasia • Persistent Pulmonary Hypertension• Pulmonary damage• Cerebral damage (Hypoxic)• Secondary Bacterial Infection• Renal Failure• Complication of intubation and ventilation



Diagnosis

• Meconium stained amniotic fluid (MSAF)• Presence of meconium in trachea.• Radiological features. Always suspect MAS in MSAF.


Investigations• Hb % normal • White cell count R• Thrombocytopenia with PPH• Disseminated Intravascular coagulation• PaCO2 Low – Normal - Raised• Metabolic acidemia• Culture for sepsis• Parameters of renal failure• Urine analysis – Normal except in renal failure• Color is Greenish brown due to Meconium pigment• ECG -Normal• ECHO – Reduced cardiac contractility



Radiology

Use: Determine the extent of intrathoracic pathology

• Identify areas of atelectasis and air block syndromes.

• Assure appropriate positioning of endotracheal tube and umbilical artery catheter.


Radiology - Contd..• Patchy infiltrates.• Increased anterioposterior diameter.• Atelectasis.• Flattening of diaphragm.• Retrosternal lucency.• Small pleural effusions in about 33% cases.• Pneumothorax and/or pneomediastinum in 25% cases.• Diffuse chemical pneumonitis • Cardiomegaly to be detected due to underlying perinatal

asphyxia



Management• Minimal handling • Routine care – Thermal environment, hydration, oxygen.• Suction of oropharynx every 30 min• Chest Physiotherapy• Correction of Acidosis• Monitor BP and Renal functions• Blood gas monitoring.• Ventilation IPPV 60-80 / min, CPPV – unusual.• IV tolazoline for PPHT• Antibiotic if infection suspected.



Prevention

• Optimum Antenatal care• Risk factors for MAS• Monitoring of foetal heart for foetal distress• Foetal scalp blood pH where possible• Expediate delivery if foetal distress• Avoid post maturity (more than 42 wt.)• Presence of two skilled persons in resuscitation for every

delivery in labour room



Prevention contd.

Intrapartum MSAF present: • Aspirate oropharynx first then nasopharynx after

the birth of head.• Assess the newborn after birth.


Classification

Vigorous Newborn:• Strong spontaneous Resp. Effort• Good muscle tone• Heart rate > 100/min• Monitor for MAS

Non Vigorous Newborn: Airway suction Direct laryngoscopy and suction









NEW BORN RESUSCITATION Intubate

• Suction through Intubation tube.• Continue tracheal aspiration with meconium

aspiration till “little or no meconium is aspirated or heart rate indicates resuscitation”.

• Aspirate Gastric meconium

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Do’s

1. Oropharyngeal suction at perineum in all MSAF babies.2. Intrapartum fetal heart rate monitoring in all MSAF

babies.3. Anticipate passage of meconium or MAS during birth of

all IUGR babies in the labor room. 4. Skillful resuscitation and assistance are key points in

management.5. Do intubate neonates born through MSAF who are

depressed (non vigorous babies) at birth irrespective of consistency of meconium.



Dont’s

• Do not go by the consistency of meconium in management for intubation.• Do not apply cricoid pressure, chest compression or occlude airway by fingers to prevent initiation of respiration in MSAF babies.• Do not ignore the general condition of baby during

intubation.

Thank you 52DR.GANGADHAR RAO G M09493864912

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Thank you

Dr. G GANGADHAR RAO

STUDENT OF GUNTUR MEDICAL COLLEGEFORMER PAEDIATRICIAN YASHODA HOSPITAL SEC.

Department of Pediatrics COMPOSITE HOSPITAL CRPF HYDERABAD


Thank you

Dr. G GANGADHAR RAO

STUDENT OF GUNTUR MEDICAL COLLEGEFORMER PAEDIATRICIAN YASHODA HOSPITAL SEC.

Department of Pediatrics COMPOSITE HOSPITAL CRPF HYDERABAD


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Pediatrics new born resuscitation dr.gangadhar rao g m+91 949 3864 912