Neonatal resuscitation Flashcards
Newborn life support algorithm
1st minute: - Gasping, crying?
NO: Stimulate, open airway
if HR<100, laboured breathing, persistant cyanosis:
Monitor sats, positive pressure ventilation
After 1 minute:
HR>100: Continue CPAP if needed, otherwise post resus care
HR>60 but <100: continue CPAP, check no leaks, consider increasing O2
HR< 60: Start compressions: 3 compressions to 1 breath , 100% O2, ET tube or LMA
Reassess, if still HR<60 consider adrenaline, umbi vein access etc
https://www.nzrc.org.nz/assets/Guidelines/Neonatal-Resus/All-Neonatal-guidelines-June-2017.pdf
Define Newborn and neonate.
What are the differences in their resuscitation
Newborn - within the first minutes to hours of life. Unclear when they transition to being a neonate.
Neonate - the first 28 days of life.
Newborns:
- initial steps to dry and stimulate
- compression: vent ratio 3:1 vs 15:2
What is the physiology of newborn arrest and resuscitation?
- Newborn arrest is almost always due to respiratory arrest as a result of hypoxia, vs adult arrest most commonly cardiac in aetiology.
- Hypoxia can occur in utero, or can be caused by loss of supply by fetoplacental unit, with slow/inadeqaute change to pulmonary ventilation.
- Brain becomes hypoxic and respiratory centres in brainstem stop initiating breaths, meanwhile muscles becomes atonic.
- The neonatal myocardium has a great resilience to ischemia (due to glycogen stores) and can keep pumping using (less efficient) anaerobic mechanisms for a number of minutes although at a lower than normal heart rate.
- Unlike adults, because left ventricular blood in the neonate is still being pumped forward by the beating heart, the oxygen level in that blood rapidly falls as it is not being replenished by blood exposed to effective ventilation or a functioning placenta.
- If ventilation is restored or established the first sign will be a rise in heart rate.
Explain the physiology of primary and secondary apnoea.
Primary apnoea
- Hypoxia causes cerebral hypoxia and thus diminishing muscle tone and respiratory centres in brainstem stop initiating respiratory effort.
- Myocardial hypoxia results in slower heart rate, initially due to vagal stimulus, and maintained by myocardial anaerobic respiration.
- Increasing diastole and cardiac filling time, causes increased stroke volume.
- BP is maintained by vasoconstriction of non-essential body organs
Gasping
- Ongoing hypoxia, but primitive centres in spinal cord take over respiratory initiation. Causing slow, gasping, exaggerated breaths at rate 12 breaths/min.
- Heart rate continues to fall
Secondary hypoxia
- After variable period of time, if persisting hypoxia, gasping will gradually stop and heart rate will continue to diminish as the myocardial reserve only provides resilience for a matter of minutes.
What is used for initial and then ongoing assessment on the newborn?
Tone, breathing, heart rate
Tone, breathing, heart rate, O2 sats (by pulse ox)
Apgars should be done at 1 minute and 5 minutes.
If APGAR <7 at 5mins or ongoing concerns or rescusitation needed, APGAR repeated every 5 minute until 20 minutes
.
All efforts should be made to keep the newborn on the mother, unless…
- Not breathing
- Poor tone
- Not maintaining HR>100 consistently
What should be initiated if newborn has respiratory effort, HR>100 but shows any of: grunting, intercostal/subcostal recession/indrawing of lower ribs/sternum?
- CPAP at 5cm/H20 with air
- Reassess after 1 min - if 02 sats low -consider starting PPV or blending O2/air
If HR<100, gasping or apnoea after initial drying and stimulation, what would your next step be?
- Start PPV with air
- PIP 30 cm/H20 (20-25 in prematurity)
- PEEP 5 cm/H20
Reassess after 1 minute - if no improvement:
- check airway, seal, ventilation technique
- consider blending some oxygen into air to improve saturations
- Consider increasing pressures
- consider airway adjuncts incl intubation
What are the target oxygen saturations in the first 10 mins of resus?
Minute: 1 - 60-70 2 - 65-85 3 - 70-90 4 - 75-90 5 - 80-90 10 - 85-90
- If sats >90% on oxygen - consider reducing blended oxygen level
- If starting chest compressions change to 100% oxygen
What specific cases would you consider early intubation?
- orofacial deformity
- gastroschisis/omphalocele
- diaphragmatic hernia
- Often consider wide bore orogastric tube to drain air too to decompress stomach
How should chest compressions be conducted, and when should they stop?
- Both thumbs placed over lower third of sternum, hands encasing rib cage
- Compress to 1/3 depth of chest, ratio 3:1, ensuring not delivered at same time as breaths
- Rate of 90 bpm (if intubated, continuous compression at 120bpm)
- Turn oxygen up to 100% when starting compressions
- Start attempt to gain vascular access in order to give adrenalin as soon as obtained
- Only stop compressions when HR maintained >60bpm
How and when do you give adrenalin?
- If started compressions, AND HR still <60 despite compressions and adequate ventilation
- Give via UVC
- Dose 10-30 mcg/kg of 1:10,000 adrenalin fast push
- Repeat every 3-5 minutes if HR<60
- If unable to get vascular access can be given down ET tube, or via IO
What special considerations are there for premature babies needing resuscitation?
- Leave 3-4 cm cord under clamp in case needs UVC
- Do not dry
- Wrap in polyethylene plastic wrap
- Gentle handing and careful use of skin cleaning agents
- Consider addition techniques otmainaitn normothermia 36.5-37.5 (ambient room temp 26, exothermic heated mattress, warmed rescuistaion gases and fluid, head covering)
- Avoid initial inflation breaths
- Set PIP 20-25 cm/H20
- Careful use of oxygen titrated to O2 sats, generally use lower concentration at 30% oxygen (rather than 60-100%)
- Once intubated give endotracheal surfactant
What are the important aspects of post-resuscitation care?
- Admit to SCBU/NICU
- Maintain normothermia 36.6-37.5
- Ongoing monitoring of RR/HR/sats ; APGARs 1 min, 5 min, every 5 mins till breathing and HR normalises
- Check BSLs - maintain >2.5mmol/L
- If hypovolemic/shocked give IV crystalloid 10ml/kg
- Give ET surfactant
- Investigations for causes - cord gases, FBC, BC
- Consider starting antibiotics
- Review for consideration if head cooling warranted; and timely transfer to appropriate territory unit if required
- Careful debrief with parents/family
- Early involvement of parents in care and contact with baby
- Debrief of team for pastoral reasons and training
- Careful documentation of events with timeframes
What are the indications for head cooling?
Head cooling to improve outcomes as result of moderate/severe HIE (defined clinically or on EEG)
Identify at risk newborns:
- prolonged resuscitation
- acidemia on cord gases: pH <7.0, BE < -12
- 10 min APGAR ≤ 5
Monitor for signs of mod/severe HIE on neurological status for first few hours after birth
mild: - hyperalertness - uninhibited moro / stretch reflex - sympathetic effects - normal EEG Mod - reduced consciousness - hypotonia - decreased spontaneous movements Severe: - seizures - stupor - flaccidity - depressed brainstem and autonomic functions (e.g. spontaneous breathing) - EEG = isopotential or infrequent periodic discharges
