Special Deliveries…. ….. With Love and Fresh Air

1. Special Deliveries….…..With Love and Fresh Air Monika Bhola, MD Neonatologist Rainbow Babies & Children’s Hospital

2. Conflict & Disclosures • I have no conflict of interest • However there is one disclosure…..I have a very soft spot for our respiratory department.

3. OBJECTIVES • Briefly Discuss some salient features of Neonatal Resuscitation • Highlight the differences in resuscitation of neonates vs. older children/adults • Oxygen use/misuse • Temperature management • Births outside of a major center

4. Transition to Extra-uterine Life • Transition from fetal life to extra-uterine life is the most complex physiologic adaptation that occurs in a human being’s life • Changes occur in almost every organ system but the primary changes are in the respiratory and cardiovascular systems

5. Clearance of fetal lung fluid • Surfactant secretion and breathing • Transition of fetal to neonatal circulation • Decrease in pulmonary vascular resistance and increased pulmonary blood flow • Endocrine support of the transition

6. NEWBORN RESUSCITATION • Approximately 10% require some assistance to begin breathing or 90% transition well • Less than 1% require extensive measures to survive (chest compressions and medications)

8. Term –Vigorous Baby • If the baby is term (>37) weeks and has good tone and respiratory effort- just dry the baby and keep the baby warm • Placing baby on the mom- skin to skin- is the best way to keep this baby warm

9. How is Baby CPR different? • It is still A-B-C • Or as I like to call it A-A-A-A-A - B & C • Their “arrest” is not necessarily an arrest- but apnea • Do not need 100% oxygen, initially • If compressions are needed – the landmarks are a little different

10. Oxygen at Birth • In the past we felt and some still do “It can’t hurt……..”

11. Words of Wisdom • “all substances are toxic: only the dose makes a thing not a poison.” • Paracelsus, 1524

12. “……the air that nature has provided for us is as good as we deserve.” • Priestley, 1775 • Compared to a candle • Lessons learnt from the past

13. Case Against Oxygen • Ischemia and Hypoxia → cellular changes affecting antioxidant defenses as well as enzyme activities, membrane transports, mitochondrial function • Hypoxia → ↓ATP synthesis and Na/K pump alteration → cell edema and hypoxanthine accumulation → + Oxygen = toxic reactive oxygen species • Superoxide anions, hydrogen peroxide, hydroxyl radicals, nitrogen reactive species

14. Ischemia → promotes proinflammatory cytokines and bioactive agents → tissue vulnerability on re-perfusion

15. Oxygen Use In utero the fetus develops in a relatively hypoxic environment with saturations of 50-60% Sudden exposure to 100% oxygen can worsen cell and tissue injury Oxygen free radicals-antioxidants, apoptosis and re-perfusion injury

16. Oxygen vs RA • Animal studies – severe hypoxia model • Resuscitation with 100% and RA • BP and blood flow restoration to brain and other markers were comparable • Recent studies have shown a distinct advantage to using RA

17. Case for Room Air (RA)…… • Meta analysis of 1082 newborns resuscitated with Room air initially and 1051 received 100% • The ones in which resuscitation was initiated with RA had a reduced risk of death • Saugstad et al, Neonatology, 2008

18. ……RA • A single breath of 100% oxygen in the first week of life– has resulted in decrease of minute volume • Also duplicated in mice studies • Delay in initiation of breathing with oxygen vs RA • Hyperoxia in newborn animals – causes histological changes in brain and other organs • In other animal studies- 100% oxygen in the first few days- saw evidence of pulmonary disease and cardiac failure more than a year later and lead to a shorter life span.

19. Baby Brains and Oxygen • 70 preterm infants stabilized with either RA or 80% • Oxygen exposed neonates had decreased cerebral blood flow for 2 hrs(Lundstrom et al, 1995) • Similar findings by other researchers also found decreased cerebral blood flow velocity (Niijimaetal)

20. What is the right balance? • Compromised Fetus Anaerobic Metabolism → Production of Lactic acid • If short → easily reversible with airway establishment • If prolonged energy failure → cell membrane depolarization → cellular injury or death

21. Target Spo2 after birth 1min 60-65% 2min 65-70% 3min 70-75% 4min 75-80% 5min 80-85% 10min 85-95%

22. How Can we safely deliver oxygen • Should have blenders • Start resuscitation with RA for term babies • Preterm babies 30-40% • Don’t have blenders / home delivery/ ER/ ambulance • Self inflating bag- without reservoir will give about 40%

23. OXYGEN DELIVERY USING SELF INFLATING BAG FiO2 values obtained at different oxygen flow rates (range 0–10 L/min) over time during PPV at a respiration rate of 40 to 60 per minute and PIP of 25 cm H2O. Trevisamuto D etal, Pediatrics 2013;131:e 1144-1149

24. Airway • Proper equipment for Neonates • Correct Size Face mask- Term and Preterm • Self inflating Bags-240 ml • Anesthesia bag • Manometer

25. T-piece/ Neopuff

26. ET tubes- 2.5, 3.0, 3.5 - uncuffed • LMA – Size 1 • Miller Laryngoscope blades-Size 1 & 0

27. Chest Compressions Lack of gas exchange with simultaneous hypoxia and carbon dioxide elevation- most common reason that newborns fail to transition successfully If there is significant hypoxemia and acidosis- the myocardium could be depressed

28. Airway…. (again!) • It is ABSOLUTELY essential to establish EFFECTIVE ventilation for 30 secs–prior to chest compressions • Corrective measures should be tried if unable to get effective ventilation • M-R-S-O-P-A

29. MRSOPA- (Corrective Measures)

30. Temperature Management

31. Thermo Neutral Zone in Humans • Unclothed resting adult—23-28⁰ C (73⁰F) • Unclothed full term neonate—32-35⁰ C (90⁰ F) • Unclothed 1 Kg preterm neonate– 35⁰C (95⁰ F)

32. Heat Loss In New Borns

33. Temperature and Resuscitation • WHO recommends that the DR temperature should be about 72⁰F or mid 70’s • If preterm delivery is expected then the temperature should be around 77-79⁰F • Other modes of keeping the baby warm • Radiant Warmer • Warm blankets • Warm gel packs • Baby hats • Thermal plastic wrap

34. Picture of Basic Equipment

35. Infant PortableThermal Packs

36. Warm Blankets

39. Consequences of Hypothermia in Preterm Infants • 36.5-37.5ºC • Every 1º drop in baby’s temperature increases mortality risk by 28% !!!!!

40. Other sobering data…. • Hypothermia is associated with increase in morbidity • Respiratory Distress • Metabolic derangements • Intra Ventricular Hemorrhage • Infection • Increased hospital length of stay

41. Hyperthermia • Elevated temperature increases the risk of death or impairment – almost 4 fold increased risk • This is worse if there has already been a brain injury • A rise of just 1.5ºC above normal can cause significant impairment

42. Not Too HotNot Too Cold

43. Special Considerations

44. Viability • Less than 23 weeks- survival chances are very poor • Survival has improved over the years • NRP recommends offering resuscitation if 23 weeks and >400gms

45. Survival

46. Special Considerations in Preterm Infants • Greater risk for injury • Lung-Protective strategy should start right at birth- GENTLE VENTILATION • PPV is the cornerstone of respiratory support • Very crucial to establish FRC- PEEP • Need to deliver adequate Tidal Volume- PIP

47. Post Resuscitation • Temperature • Sugar- Never give new borns > D10W IV fluids • IV access • Normal D.stick-35-40

48. Emergency IV acess • If unable to start PIV- may place emergency Umbilical vein catheter • Place an umbilical tie • Clean with Betadine • Place a sterile catheter (5Fr) in the vein (largest vessel) till you get blood return (2-3 cms in preterm infants and about 5 cms in term • Avoid Intraosseous in preterm infants.