Neonatal resuscitation Flashcards
Initial assessment of all neonates
- Term or preterm?
<28 weeks, <1500g polyethylene wrap + heat source
- Good tone? Floppy? Not moving, extended posturing?
- Are they crying? 20 seconds stimulation - cool room, drying
If not crying, <100bpm first response
- ABC
- Temperature, handling and skin protection, pulse 02
Preparation for specific conditions: preterm, meconium stained, antenatal airway problem, multiples, diagnosis of defect not compatible with life
- Preterm <28 weeks, <1500g
Prepare polyethylene wrap (bag with square hole), heat source, dry, hat
- Born through meconium aspirate
Connect large bore suction catheter before stimulated to breathe. Prepare suction for vocal cords under direct vision should the iinfant be depressed at birth
- Antenatal diagnosis airway
Have LMA, guedel, anaesthetics
- Not compatible with life
Couselled prior to birth
Decision about treatment
Airway
- Supine
- Head neutral
- Clear airway, may need 10/12 G
- Stimulate to breathe
- Keep warm
- Assess breathing and HR
Breathing
- Reassess breathing and HR
Xbreathing, HR <100 w/ poor muscle tone, breathing ineffectively–>PPV indicated at rate of 40-60 inhalation per minute air (21%) initially for term infants or 30% oxygen for very preterm infants who are less than 32 weeks gestation, <1500g
Use T piece, self inflating bag, flow inflating bag
- Apply pulse oximeter to right hand or wrist->titrate oxygen accordingly for >90%
- Reassess after 30 seconds of effective positive ventilation
- Consider goals for 02 saturations
After 1min pre-ductal 02 sats 60-70%
By 3–>70-90
By 10–>85-90
N to be cyanotic for first few mins
If breathing, >100HR dont need 02 to pink em up
Circulation
- HR 60-100 maintain ppv until HR >100 and breathing spontaneously and effectively
- If <60
Star external compression and PPV 3: 1
+Fi02 to 100%
Reassess after 30 seconds of effective PPV, EC
- Remains <30->need advanced resuscitation
- When >60 External chest compressions can cease, 40-60 inhalations of PPV until >100 and breathing effectively
Drugs
- <60 BPM after ECC and PPV for 1 minute–>Venous access, adrenaline indicated
10-30mcg/kg (0.1-0.3ml/kg of 1:10 000 solution, 0.1mg/ml or 100mcg/ml) Rapid bolus with saline flush - Use three way tap through umbilical vein- flush with saline
- Volume expanders
Saline or Rhesus negative O blood, 10ml/kg if shock/blood loss cause
DIsorders of transition
- Before / during
Compromised blood flow
Antepartum hemorrhage
Placental abruption
Cord prolapse
Cord compression
Cord tight around neck
Maternal pre-eclampsia
Uterine rupture
- At time of birth
Failure to breath
Lungs not aerated
Considerations that ventilation not effective
- Bradycardia
- Depression of respiratory drive
- Blood pressure falls
- Cyanosis >10 minutes, poor muscle tone
Causes of failure to breath at birth
- Airway obstruction
Meconium, cartilage, laryngeal web, malformation, failure of lungs to form properly
- Preterm
- ve hydrostatic pressure to force liquid from alveolar - Birth injury
Cervical spine
IU infection
NM disorders
- Air leak
Pneumothorax from PPV
- Effects of maternal drugs
Magnesium sulphate, Narcotics, C section
Air or oxygen for term and preterm
- Term: air 21%
- Preterm 21-30%
T piece: initial settings and set up
- Initial
10L/min
Max pressure 50cm H20 PIP–> 30cmH20 for term newborm, 20-25cm H20 preterm
Peep 5-8 cm/H20
- Gas supply
Inlet to supply line, oulet to patient supply
- Attach, test, turn gas flow to 10L, set max pressure to 50cmH20
- Set PIP, set PEEP
- Good seal on face
- Check seal
Look, listen, soft whistle, PEEP 5cm on manometer, PIP of 30 may be reached on manometer despite face leak up to 90%
- If -ve HR +PIP by increments of 5-10cmH20
- If >100, good chest wall movements->decrease PIP by 5cmH20
Benefits of T piece, trouble shooting
- Consistent PIP and PEEP
- Xachieveing set PIP-> Check seal, reposition head. consider intubation
- X desired PIP and PEEP after checking with test lung
Check flow rate 8-10L gas flow
Check max pressure release and adjust if needed
If signs of poor ventilation with face mask->consider
- Seal
- Head position
- Pressure
- Gas supply, flow rate
Options for ventilation
- T piece
- Self inflating
- Flow inflating
Features of self inflating bag: set up, limitations
- Choose correct size (240ml, TV = 5-10ml/kg) 2. Choose correct mask 3. Assemble bag and mask 4. Test functionality air out, lips open, pressure releif valve max pressure(not accurate) 35-45, connect 02 source, ensure inflates 5. Create good seal 6. Continually reasses ventilation technique= >100HR, rise and fall of chest, +oxygenation
Maternal Risk factors for new born to require resuscitation
- Maternal
Heavy sedation
Previous neonatal death
No antenatal care
Size/date discrepance
Young, >35
Substance use
Drugs, Fever, illness, chorioA Poly/oligoH, PROM >18 hours, Bleeding in 2/3, HTN, DM, Anemia
Fetal Risk factors for new born to require resuscitation
- Fetal
Congenital
IU infection
Perinatal infection
Multiples
41 weeks
LGA, FGR
Rhesus/isoimmunisation
-ve fetal movements before labour
Intrapartum Risk factors for new born to require resuscitation
- Intrapartum
Non-reassuring CTG
Abnormal positioning
Prolapsed cord
Prolonged labour
Prolonged 2nd stage
Precipitate labour (rapid expulsion, may not be aseptic)
Antepartum hemorrhage
Meconium in amniotic with non-reassuring CTG
Narcotics to mother w/i 4 hours of delivery
Forceps/vacuum assisted delivery
Overview of post resuscitation care
- Monitoring
- Assess need for NICU/special care
- Blood glucose
- Antibiotics
- Induction of hypothermia for hypoxic-ischemic encephalopathy
- ?Interhospital transfer->Speak with QLD emergency medical systems coordination centre
- Continuing care of family
- Management of fluid and electrolytes
- Imaging if needed >30%, oxygen required at 6 hours, ETT->CXR w/i 1 hour Assists diagnosis: HMD, TTN, congenital anomalies, pulmonary hypoplasia, pneumothorax, air leaks
Monitoring post-resuscitation
- Oxygen saturation
- Heart rate
- Respiratory rate and pattern
- Blood glucose
- Blood gas, FBC, UEC
- Fluid balance and nutrition
- BP, temperature, neurological
- Check placenta
Define mild hypothermia, moderate hypothermia and severe, how to warm
- Mild hypothermia 36-36.4 2, Moderate 32-35.9 3. Severe
Effects of hypothermia
- ++Metabolic rate 2. ++Oxygen consumption 3. +Glucose utilisation
Fluid requirements in first 24 hours
- 60ml/kg/day
- 10% glucose
- BW X 60/24
Sodium and potassium usually not required in the first 24 hours
Features suggestive of hypoxic-ischemic encaphlopathy
- -ve activity. 2. decorticate/decerebrate, 3. hypotonia. 4. poor/no reflex 5. brady, apnoeic, dilated pupils Risks 1. induction 2. >35, >1800g,
Monitoring of glucose
- Check BGL asap after resus.
Initially check from UVC w/i first hour, confirm with true blood glucose
- Maintain >2.5
- Avoid large boluses of>100=200mg/kg
- 1ml 10% glucose contains 100mg glucose
What is advanced resuscitation
- UVC (0.1-0.3ml/kg)
- IV
- IO
- ETT (0.5-1ml/kg) W/ adrenalin
