Newborn resuscitation programme(NRP)

1. Newborn resuscitation programme(NRP) Renu Singh

2. Burden of the problem • Birth asphyxia • 23% of the 1 million neonatal deaths in India • Long term neurological complications • Death • NNR (Neonatal resuscitation) :simple, inexpensive, cost effective method • Problem: NNR often not initiated, incorrect use of methods

3. The Golden minute • The “first minute after birth” • Anxiety for parents, health providers • Period of transition from intrauterine to extra uterine life • Major: No/minimal assistance • 10%: assistance to begin breathing at birth • 1%: extensive resuscitative measures • First Golden Minute Project: skill based training

4. Successful NNR: factors • Anticipation: call a skilled personnel • Adequate preparation • Accurate evaluation, algorithm based • Prompt initiation of support

6. Resuscitation: initial steps • Provide warmth • Head position “ sniffing position” • Clearing the airway • Drying the baby • Tactile stimulation for breathing

7. Sniffing position Extension of neck with help shoulder roll:: to open the airway

8. Newly born infant • Specifically the Infant at time of birth • (A)Do not require resuscitation • (B)Require resuscitation • Rapid assessment of 3 characters • Term gestation? • Crying or breathing? • Good muscle tone?

9. Newly born infant Term gestation? Crying or breathing? Good muscle tone? YES :Do not require resuscitation • Dry • Skin to skin contact • Covered with dry linen to maintain temperature • Ongoing observation: breathing, color, activity

10. Newly born infant Term gestation? Crying or breathing? Good muscle tone? NO :require resuscitation; One/more of the following actions in sequence • Initial steps in stabilization(warmth, clear airway, dry, stimulate) • Ventilation • Chest compressions • Administration of epinephrine& /or volume expansion

11. AAP Algorithm

12. IAP Algorithm

13. The golden minute • <30 seconds: complete initial steps • Warmth • Drying • Clear airway if necessary • Stimulate • 30-60 seconds: assess 2 vital characteristics • Respiration (apnea/gasping/labored/unlabored) • Heart rate (<100/>100bpm)

14. <60 seconds of birth • If gasping/apnea If heart rate<100 beats per minute PPV( positive pressure ventilation) Spo2 monitoring by pulse oximeter • Simultaneous evaluation of 3 vitals • Heart Rate, • Respiration, • oxygenation status

15. Targeted SPO2 after birth

16. Increase in heart rate is the most sensitive indicator of a successful response to each step practiced

17. PPV: Positive pressure ventilation • Form of assisted ventilation • Needed when there is no improvement in HR • Also assess chest wall movements • Should be delivered at rate of 40-60 breaths /min, maintain HR>100 /min • Devices: BMV, ET (endotracheal tube),LMA(laryngeal mask airway)

18. Bag & mask ventilation

19. Endotracheal tube • Initial endotracheal suctioning of non vigorous meconium stained newborn • If BMV is ineffective/prolonged • When chest compressions are performed

20. Endotracheal tube

21. LMA(Laryngeal mask airway) • Fits over laryngeal inlet • Done when BMV is unsuccessful • When tracheal intubation is unsuccessful or not feasible

22. LMA(Laryngeal mask airway)

23. Chest compressions • Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec • Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest • 2 techniques: • 2 thumb-encircling hands technique • Compression with 2 fingers ,second hand supporting the back • 3:1 ratio::[ 90 comp:30 ventilations]

24. Chest compressions

25. medications • Rarely indicated • Most important step to treat bradycardia is establishing adequate ventilation • HR remains <60bpm,despite adequate ventilation(ET) with 100% Oxygen & chest compressions • Epinephrine or volume expansion or both

26. Epinephrine • Route of administration: intravenous(IV),ideal • Recommended dose: 0.01-0.03 mg/kg per dose • Desired concentration: 1:10,000 0.1 mg/ml

27. Volume expansion • Suspected or known blood loss • Isotonic crystalloid solution • Blood • Dose calculation: 10 ml/kg

29. Post resuscitation care • Needed for those who required PPV • At risk of deterioration • Need monitoring ,evaluation • NICU may be necessary

30. NNR : not indicated • Conditions with certainly early death • Extreme prematurity(GA<23 weeks) • Birth weight<400g • Anencephaly • Chromosomal abnormality: Trisomy 13

31. NNR: nearly always indicated • High rate of survival • Acceptable morbidity • GA≥ 25 weeks • Those with most congenital malformations

32. NNR? • Conditions associated with uncertain prognosis • Survival borderline • Parental desires concerning initiation of resuscitation should be supported

33. Discontinuing resuscitative efforts • Newly born baby with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes

34. MCQ1 For successful neonatal resuscitation following is/are needed except: • Anticipation • Adequate preparation • Skilled personnel • Delayed initiation of support

35. MCQ1 • For successful neonatal resuscitation following is/are needed except: • Anticipation • Adequate preparation • Skilled personnel • Delayed initiation of support

36. MCQ2 • Following are true in relation to initial steps of neonatal resuscitation except • Provide warmth • Tactile stimulation • Clear airway and intubation • Drying the baby

37. MCQ2 • Following are true in relation to initial steps of neonatal resuscitation except • Provide warmth • Tactile stimulation • Clear airway and intubation • Drying the baby

38. MCQ3 • The following is the primary measure of adequate ventilation • Chest wall movement • Improvement in heart rate • Pink extremities • Spo2 of 80%

39. MCQ3 • The following is the primary measure of adequate ventilation • Chest wall movement • Improvement in heart rate • Pink extremities • Spo2 of 80%

40. MCQ4 • Endotracheal intubation may be indicated at several points during neonatal resuscitation except • If BMV is ineffective • When chest compressions are performed • Endotracheal suctioning of vigorous meconium stained newborns • For special resuscitation circumstances like extremely LBW

41. MCQ4 • Endotracheal intubation may be indicated at several points during neonatal resuscitation except • If BMV is ineffective • When chest compressions are performed • Endotracheal suctioning of vigorous meconium stained newborns • For special resuscitation circumstances like extremely LBW

42. MCQ5 • The recommended compression to ventilation ratio in neonatal resuscitation is • 2:1 • 3:1 • 4:1 • 5:1

43. MCQ5 • The recommended compression to ventilation ratio in neonatal resuscitation is • 2:1 • 3:1 • 4:1 • 5:1

44. MCQ6 • The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation • 0.01-0.03,IV • 0.01-0.03,IM • 0.03-0.05,1V • 0.05-0.1,IV

45. MCQ6 • The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation is • 0.01-0.03,IV • 0.01-0.03,IM • 0.03-0.05,1V • 0.05-0.1,IV

46. MCQ7 • Recommended method/clinical indicator of confirming ET placement is • Condensation in ET • Chest movement • Equal breath sounds on auscultation • Exhaled C02 Detection

47. MCQ7 • Recommended method/clinical indicator of confirming ET placement is • Condensation in ET • Chest movement • Equal breath sounds on auscultation • Exhaled C02 Detection