Post on 02-Jun-2015
description
Neonatal Resuscitation
Todd Wylie, M.D.
Department of Emergency Medicine
University of Florida College of Medicine
Jacksonville
Physiology
• Fetal Circulation– Placenta
• Low vascular resistance
– Fetal lungs• High vascular
resistance
2011 UpToDate, Inc.
Physiology
• Fetal Circulation– Right-to-left
shunts• Foramen ovale• Ductus
arteriosus
2011 UpToDate, Inc.
Physiology
• Fetal Circulation– From the
placenta…• Oxygenated
blood…• Ductus
venosus into IVC…
• Right atrium…• Shunted thru
foramen ovale…
• Into left atrium
2011 UpToDate, Inc.
Physiology
• Fetal Circulation– From the SVC
and IVC…• Minimal mixing
with oxygenated blood…
• Right atrium to right ventricle…
• Shunted through ductus arteriosus…
• Into distal aorta
2011 UpToDate, Inc.
Physiology
• Fetal Oxygenation– Adequate tissue
oxygenation secondary to:
• Fetal hemoglobin• Decreased fetal
oxygen consumption
• Differential blood flow
2011 UpToDate, Inc.
Physiology
• Changes at Delivery
– Alveolar fluid clearance
– Lung expansion
– Circulatory changes
2011 UpToDate, Inc.
Physiology
• Difficulties Transitioning– Risk factors
• Maternal conditions (advanced age, diabetes, hypertension, substance abuse)
• Fetal conditions (prematurity, postmaturity, multiple gestation, anomalies)
• Antepartum problems (oligohydramnios, polyhydramnios, placental anomalies)
• Delivery (breech, transverse, meconium, maternal narcotics, difficult delivery)
Physiology
• Difficulties Transitioning– Lack of respiratory effort– Blockage of the airways– Impaired lung function– Persistent pulmonary hypertension– Cardiac anomalies
Neonatal Resuscitation
Introduction – Multiparous female to ED with severe contractions; is preterm (28 weeks); precipitous delivery of pre-term neonate as put into resuscitation bay.
PMH for mother –G6P6, Normal prenatal visits, estimate gestational age 28 weeks currently, no other issues.
Exam for mother – Awake, alert, stable, can provide appropriate history as needed
CASE 1
Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; note clear amniotic fluid.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’sAPGAR = 1
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• APGAR Score– Performed at 1 and 5 minutes– Evaluate condition after delivery and need for intervention
Component 0 1 2Appearance Whole body
cyanoticCyanotic extremities
Good color
Pulse No heart rate < 100 BPM > 100 BPM
Grimace No response to stimulation
Grimace Grimace, vigorous cry
Activity Limp, no movement
Some muscle tone
Active motion
Respiration Not breathing Slow, irregular Cries well
Quick Tangential Point
Neonatal Resuscitation
APGAR Score
“These scores should not be used to dictate appropriate resuscitative actions, nor should interventions for
depressed newborns be delayed until the 1-minute assessment.”
Textbook of Neonatal Resuscitation, 6th Edition; Page 35.
Quick Tangential Point
Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; note clear amniotic fluid.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’s APGAR = 1
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• What is the next step?– “ABCDs”
• Initial steps – provide warmth, suction Airway as necessary, dry, stimulate
• Reassess• Positive pressure ventilation (Breathing)• Reassess• Ventilation corrective steps (Breathing)• Reassess• Chest compressions• Reassess• Give Drugs
Neonatal Resuscitation
• Initial steps– Provide warmth
• Warm towels• Radiant warmer
– Clear airway as necessary
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmClear airway if needed
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
Neonatal Resuscitation
Reassessment
Patient remains: CyanoticApneicPulse is in the 50s
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Positive-pressure
ventilation (PPV)• Self-inflating bag• Position neck in
neutral position• Suction mouth and
nose• Ventilate at 40-60
bpm
– SpO2 monitoring• Right hand or wrist
– Reassess
HR less than 100?Gasping or
Apnea?
LaboredBreathingCyanosis
Positive-PressureVentilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airwaySpO2 monitor
CPAP?
Yes
Neonatal Resuscitation
Reassessment
Somewhat improved heart rate and color
Heart rate increases to 90’s with continued PPV
Oxygen saturation in the 80’s
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Pulse oximetry– Attached to preductal location on right upper extremity– Saturation may normally remain low for several minutes after
deliveryTargeted preductal SpO2 after
delivery
1 min 60-65 percent
2 min 65-70 percent
3 min 70-75 percent
4 min 75-80 percent
5 min 80-85 percent
10 min 85-95 percent
Quick Tangential Point
Neonatal Resuscitation
Reassessment
Somewhat improved heart rate and color
Heart rate increases to 90’s with continued PPV
Oxygen saturation in the 80’s
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Ventilation
corrective steps• Continue BMV
ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
Neonatal Resuscitation
• Ventilation Corrective Steps – 3 possible reasons for ineffective ventilation– Inadequate mask seal– Airway is blocked– Not enough pressure used
Measures to improve positive-pressure ventilation
M Mask adjustment
R Reposition airway
S Suction mouth and nose
O Open mouth
P Pressure increase
A Airway alternative
Quick Tangential Point
Neonatal Resuscitation
Reassessment
Heart rate increases to > 100 with continued PPV
Attempts to provide supplemental oxygen result in decreasing oxygen saturation and decreasing heart rate
Obvious inadequate respiratory effort
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
Your kind of stuck here aren’t you…
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
Neonatal Resuscitation
• Consider placing an orogastric tube to…– Suction gastric contents– Serve as vent for air in
stomach
• Consider endotracheal intubation for…– PPV beyond a few minutes– Meconium and floppy– Chest compressions– PPV with inadequate
improvement– Special circumstances
What to do if positive-pressure ventilation is to be continued…
Neonatal Resuscitation
Reassessment
Heart rate with PPV remains above 100
Color improved
Continue to provide respiratory support (oxygen saturation in low 90’s)
NICU team present with warmer
CASE 1
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
Introduction – Multiparous female to ED in labor; precipitous delivery as put into resuscitation bay of term neonate. Meconium stained amniotic fluid.
PMH for mother –G6P6, Normal prenatal visits, due date 2 days from now, no other issues.
Exam for mother – Awake, alert, stable, can provide appropriate history as needed
CASE 2
Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; meconium stained.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’s (< 60)APGAR = 1
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Initial steps– Provide warmth
• Warm towels• Radiant warmer
– Clear airway as necessary
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmClear airway if needed
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
Hold On!!!
Neonatal Resuscitation
• Meconium is present and baby is NOT vigorous– Provide warmth
• Warm towels• Radiant warmer
– Before drying (!!!)• Oropharynx and
hypopharynx suctioned • Trachea suctioned under
direct visualization
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmDirect suctioning of trachea
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
Neonatal Resuscitation
• To suction the trachea– Insert a laryngoscope– Suction mouth and
posterior pharynx– Insert endotracheal
tube– Attach to meconium
aspirator– Suction
Quick Tangential Point
Neonatal ResuscitationQuick Tangential Point
Neonatal Resuscitation
Reassessment
No improvement in respirations (apneic), heart rate (50’s), or color (cyanotic)
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Positive-pressure
ventilation (PPV)• Self-inflating bag• Position neck in
neutral position• Suction mouth and
nose• Ventilate at 40-60
bpm
– Reassess
HR less than 100?Gasping or
Apnea?
LaboredBreathingCyanosis
Positive-PressureVentilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airwaySpO2 monitor
CPAP?
Yes
Neonatal Resuscitation
Reassessment
Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone)
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Ventilation
corrective steps• Continue BMV
ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
Neonatal Resuscitation
Reassessment
Neonate with no improvement (apneic, heart rate in 50’s, poor color and tone)
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Heart rate < 60
BPM• Chest
compressions (90/min)
• Continue ventilation at 30 BPM
– Reassess
Ventilation correctivesteps
Chest compressionsConsider intubation
Coordinate with PPV
Yes
HR < 60?
No
Continueventilation
Yes
HR < 60?
HR < 100 but > 60?
Neonatal Resuscitation
• Indications for endotracheal intubation– PPV beyond a few minutes– Meconium and floppy– Chest compressions– PPV with inadequate
improvement– Special circumstances
Quick Tangential Point
Sondeintubation new.jpg; Author – bigomar2
Neonatal Resuscitation
How do you select the endotracheal tube size?
Weight (grams) Gestational age (wks) Tube size (mm)
< 1,000 < 28 2.5
1,000 – 2,000 28 – 34 3.0
2,000 – 3,000 34 – 38 3.5
> 3,000 > 38 3.5 – 4.0
Quick Tangential Point
Neonatal Resuscitation
Reassessment
Neonate with improved heart rate (is now up to 80’s)
Need to continue PPV
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Continue positive
pressure ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
Neonatal Resuscitation
Reassessment
Heart rate improves with PPV to 100’s
NICU team present with warmer
CASE 2
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
Introduction – Young female with history of drug abuse (prescription pain medications) to ED in labor; precipitous delivery as put into resuscitation bay of near-term neonate.
PMH for mother – G2P1, drug abuse (prescription pain medications – is currently abusing), 1 prenatal visit, thinks due date is “a couple weeks from now.”
Exam for mother – post-partum, speech somewhat slurred
CASE 3
Neonatal Resuscitation
Initial Description of Neonate – Placed in warmer; is not breathing or crying; poor muscle tone; cyanotic; note clear amniotic fluid.
Exam – Cyanotic neonate, unresponsive, floppyNo respiratory effort/apneicHeart rate 50’sAPGAR = 1
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Initial steps– Provide warmth
• Warm towels• Radiant warmer
– Clear airway as necessary
– Dry and stimulate
– Reassess
Term Gestation?Breathing or crying?
Good tone?Routine
Care
WarmClear airway if needed
DryStimulate
HR less than 100?Gasping or
Apnea?
No
Yes
30 sec
Neonatal Resuscitation
Reassessment
Remains cyanoticApneic Pulse is 50 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Positive-pressure
ventilation (PPV)• Self-inflating bag• Position neck in
neutral position• Suction nose and
mouth• Ventilate at 40-60
bpm
– Reassess
HR less than 100?Gasping or
Apnea?
LaboredBreathingCyanosis
Positive-PressureVentilation
SpO2 monitoring
HR below 100?
Yes
5-10 breaths
No
Clear airwaySpO2 monitor
CPAP?
Yes
Neonatal Resuscitation
Reassessment
Patient remains cyanoticApneicPulse is < 60 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Heart rate less
than100 BPM• Ventilation
corrective steps• Continue BMV
ventilation
HR below 100? Postresus.care
Ventilation correctivesteps
Yes
No
HR < 60?
No
Continueventilation
YesHR < 100 but > 60?
Neonatal Resuscitation
Reassessment
Patient remains cyanoticApneicPulse is < 60 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Heart rate < 60
BPM• Chest
compressions (90/min)
• Continue ventilation at 30 BPM
– Reassess
Ventilation correctivesteps
Chest compressionsConsider intubation
Coordinate with PPV
Yes
HR < 60?
No
Continueventilation
Yes
HR < 60?
HR < 100 but > 60?
Neonatal Resuscitation
Reassessment
Patient remains cyanoticApneicPulse is < 60 BPM
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Subsequent steps– Vascular access– Drugs
• Epinephrine • Volume expansion
– Reassess
HR < 60?According to
condition
Vascular accessIV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and Chest compressions
Yes
Every 3-5 min
No
Yes
Neonatal Resuscitation
• Vascular access– Umbilical vein catheter
• Aseptic technique• Depth of 2-4 cm
Quick Tangential Point
Neonatal Resuscitation
• Epinephrine– Action – increases heart
rate and myocardial contractility, causes peripheral vasoconstriction
– Indication – heart rate < 60 despite adequate ventilation and chest compressions
– Dose – 0.01 mg/kg of 1:10,000 solution IV
• Isotonic saline– Action – increases
intravascular volume– Indication – hypovolemia– Dose – 10 ml/kg of 0.9 NS
over 5-10 minutes
Quick Tangential Point
Drugs
Neonatal Resuscitation
Reassessment
Heart rate now > 100
Cyanosis resolving
NICU team present
CASE 3
Copyright: Author: Jules Atkins, RM, Supplied by: Brandi Catt, 2006-01-27
Neonatal Resuscitation
• Summary of resuscitation steps– Initially provide warmth, clear airway, dry and stimulate infant– If meconium staining and non-vigorous infant, suction before
stimulation– If infant continues with poor respiratory effort or HR < 100, start
PPV with BMV, initiate pulse oximetry– If not improving take ventilation corrective steps– Intubate if BMV is ineffective or prolonged, or chest
compressions are being performed– If HR < 60 despite adequate ventilation, start chest
compressions at 90 per minute– If HR rate < 60 despite adequate ventilation and chest
compressions, administer IV epinephrine
Neonatal Resuscitation
• Suction equipment – Bulb syringe – Mechanical suction– Meconium aspirator – 8F feeding tube
• Vascular access– Umbilical vessel
catheterizations supplies
• Intubation equipment – Laryngoscope with straight
blades– Face masks (preterm and
term infant sizes) – Oxygen source
• Medications – D10 solution – Epinephrine– Isotonic solution (0.9 NS) – Naloxone
• Miscellaneous – Radiant warmer – Warm towels – Cardiac monitor – Pulse oximeter – Oropharyngeal airways
Equipment
Neonatal Resuscitation
• Subsequent steps– Vascular access– Drugs
• Epinephrine • Volume expansion• Sodium
bicarbonate
– Reassess
HR < 60?According to
condition
Vascular accessIV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and Chest compressions
Yes
Every 3-5 min
No
Yes
Neonatal Resuscitation
• Subsequent steps– Vascular access– Drugs
• Epinephrine • Volume expansion• Sodium
bicarbonate
– Reassess
HR < 60?According to
condition
Vascular accessIV Epinephrine
(0.01 mg/kg of 1:10,000)
HR < 60
Continue PPV and Chest compressions
Yes
Every 3-5 min
No
Yes