Presenter : Dr. Shalini Moderator : Dr. Deepti Dr. A.K Sethi

1. Neonatal Resuscitation including perinatal physiology and Neonatal assessment at the time of birth Presenter : Dr. Shalini Moderator : Dr. Deepti Dr. A.K Sethi University College of Medical Sciences & GTB Hospital, Delhi www.anaesthesia.co.in email: anaesthesia.co.in@gmail.com

2. Why learn neonatal resuscitation? Birth asphyxia accounts for approximately 5 million neonatal deaths yearly worldwide ( WHO,1995). For many of these newborns, appropriate resuscitation was unavailable.

3. Neonatal resuscitation • 10% neonates require some assistance at birth. • 1% neonates need extensive resuscitative measures. • Asphyxia accounts for 20-25% newborn deaths.

4. How does a baby receive oxygen before birth? • Oxygen diffuses across placental membrane from mother’s blood to baby’s blood. • Lungs receive very little blood. • Alveoli are fluid filled rather than air.

5. Very little flow to lungs

6. Before birth • Pulm arterioles constricted • Umbilical arteries feeding low pressure placenta circulation • High pressure in pulmonary circuit • Low pressure in systemic circuit • Very little pulmonary blood flow

7. After birth 1. • Alveoli • Expand • Get filled with air (O2) • Fluid in the alveoli is absorbed

8. After birth 2. Umbilical arteries and veins are clamped Sudden increase in systemic blood pressure

9. Pulmonary vessels dilate, causing increased blood flow to lungs 3.

10. Ductusarteriosus constricts 4. • Increased oxygen in blood • Increased pulmonary blood flow

11. Perinatal compromise results in.. • Primary apnea occurs after failure of initial period of rapid attempts to breathe – responds to stimulation( drying, suctioning, tactile) • Secondary apnea - if oxygen deprivation continues - baby not responding to tactile stimulation - requires assisted ventilation .

12. Changes due to oxygen deprivation

13. Consequences of interrupted transition • The compromised baby may exhibit 1 or more of the following clinical findings: • Low muscle tone • Respiratory depression (apnea / gasping) • Bradycardia • Hypotension • Cyanosis

14. Apgar score Calculated at 1 & 5 min after birth

15. Role of Apgar score in resuscitation • For resuscitation, not all elements are required • Resuscitation initiated before 1 min when Apgar is assigned • Initial golden minute can be lost while assigning Apgar score • Apgar score is great, but not for guiding resuscitation

16. Being Prepared for Resuscitation • ANTEPARTUM FACTORS • Maternal diabetes • PIH • APH • Maternal cardiac disease • Polyhydramnios • Oligohydramnios • Fetal hydrops • Multiple gestation • Fetal malformation • INTRAPARTUM FACTORS • Emergency LSCS • Premature labor • Prolonged labor • Significant intrapartum hemorrhage • Meconium stained fluid • Prolapsed cord • Persistent fetal bradycardia • Most of the time which baby to resuscitate can be anticipated depending on: • But,resuscitation condition may come as a surprise also

17. Being Prepared for Resuscitation • Adequate preparation • Trained Personnel : At least one At least two when high risk anticipated • Equipment • A radiant warmer : Heated and ready to use • All resuscitation equipment immediately available and in working order

18. Questions asked at the time of birth • Is the baby born at term ? • Is the baby breathing or crying ? • Is there good muscle tone ? • Is the color pink ? • Is the amniotic fluid clear of meconium ? • Now, amniotic fluid and color of baby has been removed from algorithm( 2010, AHA)

19. If yes to ALL the questions? Routine Care • Nearly 90% of newborns need this • Provide warmth by keeping the baby over mothers chest or placing under radiant warmer • Position by slightly extending neck • Clear the airway as necessary

21. Initial Steps • Provide warmth • Position; clear airway as necessary • Dry, stimulate and reposition • Give oxygen, as necessary

22. Provide warmth • Place under radiant warmer • Leave the baby uncovered under warmer: - to allow full visualization - to permit radiant heat to reach the baby

23. Initial Steps • Provide warmth • Position; clear airway as necessary • Dry, stimulate and reposition • Give oxygen, as necessary

24. Position by slightly extending the neck

25. Clear Airway • Secretions removed from airway with a towel/ bulb syringe • Copious secretions- turn face to side • Gentle suction- Pressure < -100 mm Hg • Mouth before nose (M before N) • Stimulation of posterior pharynx causes vagal stimulation and bradycardia- STOP SUCTIONING • Now suctioning immediately with bulb syringe following birth is reserved for babies with obvious obstruction to spontaneous breathing or who require PPV (class2B)

26. Meconium present and baby vigorous • Vigorous Baby- Strong respiratory efforts, Good muscle tone, Heart rate > 100 bpm • 12F or 14F suction catheter or bulb syringe for suction of mouth or nose • ET suction not required

27. Meconium present and baby not vigorous • Insert laryngoscope • Clear mouth and posterior pharynx • Insert endotracheal tube into the trachea • Attach the ET to suction source • Apply suction as ET is slowly withdrawn • Repeat as necessary until no meconium or heart rate indicates further resuscitation • There is insufficient data to recommend a change in current practice of ET suctioning of non-vigrous babies with meconium staining. (class2B)

29. Initial Steps • Provide warmth • Position; clear airway as necessary • Dry, stimulate and reposition • Give oxygen, as necessary

30. Dry, stimulate to breathe and reposition • Use pre-warmed absorbent towels or blankets • Keep head in ‘sniffing’ position to maintain good airway • Suction and drying provide sufficient stimulation • If inadequate respiration then additional tactile stimulation given briefly by • Slapping or flicking the soles of the feet • Gently rubbing the back, trunk or extremities • Overly vigorous stimulation harmful

31. Acceptable methods of stimulation

33. Further Evaluation • Respiration-good chest movement - rate & depth of respiration • Heart Rate • Feel pulse at base of umbilical cord or auscultate • Count for 6 seconds and multiply by 10 • >100 bpm – normal • Now ,heart rate and respiration are to be evaluated • Color has been deleted from algorithm • Heart rate is best evaluated by auscultation

34. Indications of Bag & Mask Ventilation After evaluation if: • Baby is not breathing or is gasping • Heart rate is less than 100 bpm and /or Ventilation is the Single most important & most effective step in resuscitation of the compromised newly born baby • Along with bag & mask ventilation, SpO2 monitoring has been added

35. Targeted preductal SpO2 after birth 1min 60-65% 2min 65-70% 3min 70-75% 4min 75-80% 5min 80-85% 10min 85-95% These targets are achieved by • initiating resuscitation with air or • a blended oxygen & titrating the oxygen concentration • 100% oxygen to achieve SpO2 in above target range. • Term babies (≥ 37 weeks) • In term neonates :Start resuscitation with room air(21%) • In preterm neonates:Initiate resuscitation using O2 concentration between 30-90% • Role of CPAP has been mentioned in spontaneously breathing preterm baby with respiratory distress {class IIB}

36. Adequate bag & mask ventilation is present if • A noticeable rise and fall of chest • The presence of bilateral breath sounds • Improvement in the color and heart rate • Frequency=40 – 60 breaths per minute • PIP- for initial breaths 20-25 cm H 2O for preterm and 30-40 cm H 2O for term babies • PEEP likely to be beneficial for initial stabilization of preterm infants, if provided with suitable equipment(T-piece or flow inflating bags) • Continue bag & mask ventilation for 30 sec to evaluate HEART RATE • If HR > 100/Min & Spontaneously breathing baby Stop ventilation

38. Indications of chest compressions • Heart rate less than 60 bpm despite 30 sec of effective positive pressure ventilation with 100% oxygen • Start chest compressions while continuing assisted ventilation • Coordinate compression with ventilation • One cycle of event consists of 3 compression plus 1 ventilation • 120 events per 60 sec i.e ( 90 compression+ 30 breath) • At least 1/3rd of anteroposterior diameter of the chest • Compression of chest followed by release taken as ONE COMPRESSION • Higher ratio(15:2) should be considered if arrest is of cardiac origin {class IIB} • Reevaluate after 30 sec, if heart rate< 60bpm proceed to next step

39. TechniquePosition of Hands on Chest Thumb technique ( preferred )

40. TechniquePosition of Hands on Chest Two finger technique

41. When to Stop chest Compressions? • After approx. 30 sec of CC & PPV • Count Heart Rate • If >60 - Stop Chest compressions, continue PPV • Continue PPV at 40 - 60 BPM • Till Heart rate >100 • Baby breathing spontaneously

42. Indications of endotracheal Intubation • Prolonged PPV required • Bag & mask ineffective: Inadequate chest expansion • If chest compressions required: Intubation may facilitate coordination and efficiency of ventilation • Tracheal suction required : e.g. MSAF • Diaphragmatic Hernia • Role of LMA has been mentioned • Effective for ventilating newborns with weight>2000g or >34wks gestation {classIIB} • Limited data in preterm newborns • LMA use should be considered if face mask ventilation or intubation unsuccessful {classIB}

44. Medications used during resuscitation • If HR < 60/Min, despite continued PPV & Chest compressions • Medications used are: • Epinephrine • Volume expanders • Naloxone

45. Epinephrine • Indications • HR <60 /min after PPV & CC for 30 secs • Route of administration • Intravenous • Endotracheal route (when I.V line is not secured ) • Recommended • Conc. – 1:10,000 (0.1mg/ml) • Route – ET/ IV • Dose – 0.01-0.03 mg/kg , (0.05-0.1mg/kg E.T) • Rate of admn. – as rapidly as possible • Now, intravenous route is first preferred route

46. Volume Expander • Indications: • Poor response to other resuscitative measures • Evidence of blood loss or suspected ( pale skin, poor perfusion, weak pulse) • Crystalloid • Normal Saline • Ringer Lactate or • O-negative blood cross-matched with mother’s blood • Dose – 10ml/kg • Route – Umbilical vein • Preparation – large syringe • Rate of administration – 5-10 min In premature babies: Rapid boluses may induce ICH

47. Naloxone • Indications : • A history of maternal narcotic administration within the past 4 hours • Severe respiratory depression is present after PPV has restored a normal HR & color • Recommended • Concentration: 1.0 mg/ml • Route: Intravenous • Dose: 0.1 mg/kg • Administration of naloxone as a part of initial resuscitative effort is not recommended in newborn with respiratory depression

48. What to do if still no improvement? • If no improvement seen despite all efforts Ensure adequate ventilation, chest compressions, drug delivery • If still HR < 60/min, consider • Airway malformation • Lung problems • Pneumothorax • Diaphragmatic hernia • Cong. Heart disease • If HR absent or no progress • Ethical considerations of when to D/C Resuscitation

49. Premature babies : concerns • Premature babies are physiologically & anatomically immature, at risk of complications as: • May be surfactant deficient,prone to injury from PPV • Immature brain capillaries, poor respiratory drive • Weak muscles, not able to breathe • More prone to hypothermia • More likely to be infected • Small blood volume, prone to hypovolemia • Immature tissues, prone to oxygen toxicity

50. What additional resources do you need? • Additional resources during resuscitation of preterm baby • Additional trained personnel (at least 2) • Additional means of maintaining temperature (at greater risk of hypothermia) • Room temperature 26 0C • Plastic wraping {classI} • Exothermic mattresses {class IIB} • Oxygen blender (to titrate oxygen conc.) • Pulse oximetry • Role of CPAP has been mentioned in preterm babies only