Special considerations Resuscitation of premature babies Ethics and Care at End of Life

1. Special considerationsResuscitation of premature babiesEthics and Care at End of Life

2. Special considerations • Situations that may complicate resuscitation and cause ongoing problem • Post-resuscitation management • Resuscitation outside hospital or beyond time of birth

3. Difficult situations • Not able to ventilate adequately • Cyanosis despite adequate ventilation • Bradycardia despite adequate ventilation • No spontaneous breathing despite adequate ventilation

4. Not able to ventilate • Mechanical blockage of airways • Meconium or mucus in pharynx or trachea Tracheal suction • Choanal atresia Pass small-caliber suction catheter, oral airway • Pharyngeal malformation (Robin syndrome) Prone, nasopharyngeal airway • Other rare conditions (laryngeal web) Emergency tracheostomy

5. Not able to ventilate • Impaired lung functions • Pneumothorax Diminished air entry, transillumination, X-ray, drain • Congenital pleural effusion Hydrops, Drain • Congenital diaphragmatic hernia Intubate, orogastric tube • Pulmonary hypoplasia • Extreme prematurity High inflation pressure • Congenital pneumonia

6. Cyanosis/Bradycardia despite adequate ventilation • Cyanotic heart disease • Congenital heart block Ensure adequate ventilation

7. No spontaneous breathing despite adequate ventilation • Brain injury (HIE, severe acidosis, congenital neuromuscular disorder) • Sedation due to drugs given to mother (narcotic drugs, magnesium sulfate, general anesthesia, non-narcotic analgesics)

8. Naloxone • Indications • Continued respiratory depression after PPV has restored a normal heart rate and color AND • History of maternal narcotic administration within past 4 hours

9. Naloxone • Recommended concentration = 1.0 mg/ml • Route: IV preferred; IM acceptable but delayed onset of action; ET not recommended • Dose: 0.1 mg/kg • May require repeated administration

10. Post-resuscitation care • Temperature control • Close monitoring of vital signs • Laboratory studies

11. Post-resuscitation care • Look for complications • Pulmonary hypertension • Pneumonia/other lung complications • Metabolic acidosis • Hypotension • Seizures • Apnea • Hypoglycemia • Feeding problem

12. Resuscitation outside hospital or beyond time of birth • Same principles (Restore adequate ventilation) • Alternative heat source (Skin-to-skin contact) • Clear airway (Bulb syringe, wipe with a cloth) • Ventilation (Mouth-to-mouth-and-nose) • Vascular access (Peripheral vein cannulation/intraosseus needle)

13. Resuscitation and Prematurity • Thin skin, large surface area and ↓ fat • Oxygen toxicity • Weak muscles - difficulty in breathing • Immature nervous system –less respiratory drive • Immature lung • Fragile brain capillaries • Small blood volume

14. Additional Resources Needed • Additional trained personnel • Additional means of maintaining temperature • Re closable, food grade polyethylene bag • Portable warming pad • Transport incubator • Additional means to control oxygenation (in a hospital in which babies at <32 weeks gestation are born electively) • Compressed air source • Oxygen blender • Pulse oximeter

15. Keeping a premature baby warm • Increase temperature of the delivery room • Pre-heat the radiant warmer • Pre- warmed transport incubator

16. Keeping a premature baby warm • If baby is born at less than 28 weeks gestation, consider placing him below the neck in a re closable polyethylene bag without first drying the skin • Avoid overheating

17. Oxygen in a premature baby • Connect a blender to compressed oxygen and air sources and to PPV device • Start somewhere between room air and 100% oxygen • Attach a pulse oximeter to baby’s foot or hand • Heart rate displayed by pulse oximeter should agree with heart rate that you palpate or hear

18. Oxygen in a premature baby • Adjust oxygen concentration to achieve an oxygen saturation that gradually increases to 90% • Accept 70% to 80% if-heart rate is increasing and oxygen saturation is increasing • If saturation is less than 85% and not increasing, increase oxygen concentration • Decrease oxygen concentration of saturation rises above 95%

19. Oxygen in a premature baby ! Resuscitation efforts not to be delayed while waiting for pulse oximeter to display a strong signal

20. Ventilation in a premature baby • Consider giving CPAP if the baby Is breathing spontaneously and has a heart rate above 100 bpm but has • Labored breathing or • Is cyanotic or • Has low oxygen saturation • By using flow-inflating bag or T-piece resuscitator

21. CPAP

22. Ventilation in a premature baby • Use lowest inflation pressure necessary to achieve adequate response • Initial inflation pressure of 20-25 cm H2O • May need higher pressure if no improvement in heart rate and no chest rise

23. Ventilation in a premature baby • Prophylactic surfactant as per your practice ! Baby should be fully resuscitated before surfactant is given

24. How to decrease chances of brain injury in a premature baby? • Gentle handling • No head-down position • Avoid excessive positive pressure or CPAP • Adjust ventilation and oxygen concentration gradually and appropriately (use pulse oximeter and blood gas) • Do not give rapid infusion of fluids • Avoid infusion of hypertonic solutions

25. Post-resuscitation management of a premature baby • Monitor blood sugar • Monitor for apnea and bradycardia • Give and adjust ventilation and oxygen concentration gradually and appropriately • Give feeding slowly and cautiously • Increase suspicion of infection

26. Ethics and neonatal resuscitation • Primary role in determining goals of care with parents • Informed consent based on complete and reliable information (may not be available before or immediately after delivery)

27. Not to initiate resuscitation • Confirmed gestational age of less than 23 weeks or birth weight less than 400 gm • Anencephaly • Confirmed trisomy 13 or 18 • If parents wish: confirmed gestational age of 24-25 weeks Based on your survival rates and local policy

28. Counseling parents before a high risk birth • Obstetrician and neonatologist perspectives may be different • Short and long term outcome of babies of different gestation in your hospital • Discuss resuscitation and level of care to be given to baby • Documentation

29. When to stop resuscitation? • No heart rate after 10 minutes of complete and adequate resuscitation • No evidence of other causes of compromise