Neontal resus Flashcards
List general equipment needed for neonatal resus
General
- firm horizontal padded resuscitation surface
- Overhead warmer
- light for the area
- clock with timer in seconds
- warmed towels or similar covering
- polyethelyene bag or sheet big enough for a newborn less than 32 weeks gestation or <1500 g birth wieght
- steth
- pulse ox
- ECG
List airway equipment to prepare for neontal resus
Airway
- Suction apparatus and suction catheters (6F,8F and either 10-12F)
- Oropharyngeal airway sizes 0 and 00
- Intubations
- –laryngeoscope with miller blade 00,0, 1
- –spare bulb and batteries
- –ETT (2.5 -4mm uncuffed)
- –Endotrachral stylet or introducer
- ETCo2
- meconsium suction device
- magills
- supraglottic airway size 1
List breathing equipment to prepare for neonatal resus
Face mask
Positive pressure ventilation deveice
-t-piece
-self inflating bag(<300ml) with a removable o2 reservior
Mediacl gases
Feeding tubes for gastric decompression (6-8F)
List circulation equiptment to prepare for neontal resus
Umbi catheter -peripehral IV kit Skin preap Tapes Syringes and needls IO
List drugs
Adrenaline 1:10000
sodium chloride
Blood
Discuss cord clamping
Delaying cord clamping for 30-60 seconds when comapred to immediate clamping is associated with icnreased placental tranfusions increased cardiac output and higher and more stable neonatal blood pressure.
There is good evidence from animal studies that among the benefits placental transfsions can fill the expanding pulmonary vascular bed obviating the need to fill it be left to right flow
For term or late perterm ANZCOR reccomende latera lcamping of the cord at 60 seconds or longer
For infants at less than 34 weeks gestation who do not require immediate resus ANZCOR suggest deferring clamping the cord for at least 30 seconds insufficient evidence for those requiring resus
Discuss airway management of the neonate (position, suctioning and tactile stimulation)
1) Position
- the newborn who needs resus should be placed on their back with the head in a neutral or slightly extended position
- Particularly if moulding during birth has caused prominence in the occiput a 2cm thick blanket or towel placed under the shoulder may help in maintaining good position
- If resp efforts are present but not producing effective ventilation consideration to other methods to improve patency - lower jaw support opening of the mouth and in some cases upper airway suction
- 1)Suction
- in general suction should not be used as can interfere with PEEP and resus – except when obvious signs of obstruction either to spont breathing or PPV - 2) ETT suction
- for newborns who are vigorous after exposure to mec liqour routine ETT suctioning is discouraged
- for nonvirgours infants systematic review that included 3 RCTs found no benifit for routine ETT suction.
- ANZCOR reccomends against orutine direct laryngoscopy with or without suction for all newborns
2) Tactile stimuation
- Drying and stimulation are both assessment and resus interventions.
- If in repsonse the preterm newbron fails to establish respiration and HR is below 100 by 1 minute of age CPAP or PPV should be commenced
- If breathing CPAP may be sufficient to augment endogenous effort
- if not breathing IPPV (intermittent PPV) should be started
Discuss airway management of the neonate (PPV and mask choice)
3) PPV
- After stimulation PPV should be started if the heart rate is less than 100 BPM and not increasing eand either the newborn remains apnoeic or the breathing is inadequate
- Primary measure of effectiveness of ventilation is prompt improvement of HR which is sustained
- If not able to achieve - inflating pressure may need to be increased and adjuncts used.
- 1)
- T-piece, self inflating bag (approx 240mls) and flow inflating bag are all acceptable devices to ventilate newborns - 2)
- T-piece is ILCOR recommendation showing reduced rates of mortality bronchopulmonary dyplsia and rates of intubation
- Flow inflating bag with manometry is acceptable and self inflating bag as back up
- T-piece - assists user to detect mask leak, has consistent peak inflation pressures, delievers PEEP or CPAP, can deliver sustained inflation
- Flow inflating as t-piece but more user dependent
- Self inflating inconsistent peak pressure, inability to deilver peep wihtout valve, inability to deliver sustianed infaltion - 3)
- Facemask must seal around the mouth nose but not cover the eye or overlap the chin
3.4) initiating ventilation
Discuss airway management of the neonate (intiating ventilation, PEEP)
- 4) for commencing intermittent positive pressure ventilation in newborns the suggested initial pressures are 30cm h20 for term and 20-25 cm h20 of premature newborns
- on devices that can deliver peep 5Cm h20 is suggested can raise to 8 but nil higher due to risk of pneumohtoax
- caution with inflation of a newborn
- PIP does not correlate well with volume delivered in the context of changing resp mechanics but may help provide consistent inflation and avoid unnecessary pressure
- Subsequent ventilation should be provided at 40-60 BPM with inspiratory time of 0.3-0.5 - 5) Assessing effectiveness
1) HR improves to >100 and is sustained
2) otherwise similar to adultus
Discuss airway management of the neonate (oxygenation)
Resus in 21% unless not meeting targets Targeteted pre-ductal spo2 after birth 1 min - 60-70 2mon 65-85 3 min 70-90 4 min 75 -90 5min 80-90 10 minu 85-90
Discuss indications for intubation in the neonate
1) ventilation via facemask or SGD has been unsuccessful (persistent low heart rate, o2 sats falling or failing to rise) or prolonged
2) special circumstances such as congenital diaphragmatic hernia or extremely low birth weight
3) newborns born without detectable heartrate, consideration should be given to intubation as soon as possible after birth
Discuss Laryngoscope and ETT size and depth of insertion
ETT internal diamter = gestational age in weeks/10
Typically 2.5 mm tube for infants <1kg 3mm tube for ingants 1-2 kg 3.5mm tube for infant 2-3 kg 3.5-4 for infant over 3 kg
Miller blade size 1 for term and larger preterm
Size 0 for preterm infants <32 weeks
size 00 for extremely low birth weight infants
Supraglottic size 1 cna be used for term and near term infants >34 weeks
Discuss chest compression in neonatal resus
INdicated when the heart rate is <60 despite adequate assisted ventilation for 30 seconds
Centred over the lower third fo the sternum and should compress the chest one third of the chest AP diameter allow for recoil.
ANZCOR suggest a technqiue using 2 thumbs on the lower third of the sternum
3:1 ratio at 90 compression per minute
if intubation 120 compression per minute without interruption to CPR
If compression fio2 to 100
List routes of administration of drugs during neonatal resus
Umbi vein - suggested route
Peripheral vein
IO
ETT - used only if other routes fail
List mediations that may be required in neonta resus
Adrenaline
- given if HR has not increased to above 60BPM after optimising ventilation and chest compression should be given as soon as possible
- Dose 10-30mic/kg 1:10000 as quick push - repeat every 3-5 minutes
Volume
- Fluids should be used if suspected blood loss, the newborn appears to be in shock and has not responded adequately to other resus measures.
- Blood loss may be occult and trial of fluid in nonresponders is reasonable however in the absence of bleeding fluid resus is not beneficial and can be detrimental
- 10ml/kg
