Neonatal resuscitation

1. Neonatal
Resuscitation
Presented By
Dr. Akshay Golwalkar
Moderated By
Dr. Sunil Gavhane

2. FACTS
• 90% Don’t require any intervention
• 10% require intervention
• 1 % need major resuscitation
• Preterms are at high risk

3. How often do we use our resuscitation
skills?

4. Primary causes of death*
18 %Other causes
09 %Malformation
29 %Perinatal hypoxia
17 %Infection
27 %Prematurity
DeathsCause
*Text book of Neonatal Resuscitation 6th
edition

5. Alveoli are fluid
filled
Blood vessels are
constricted

6. After birth
Fluid in the
alveoli is
absorbed
Alveoli
• Expand
• Get filled with Air
1.

7. 2.
Pulmonary vessels dilate, causing
increased blood flow to lungs

8. Requirements
• Personnel
– At least one trained person for all
deliveries
– Two persons, if high risk; or for
advanced resuscitation

10. Bag, Mask,
& Oxygen
Suction
Equipment
Laryngoscope
and ETT Tube
Warmer &
Blankets

11. Resuscitation
•Is the newborn term?
•Is the newborn
breathing or crying?
•Does the newborn
have good muscle tone?
•Dry & remove
wet cloth
•Clear airway if
necessary
•Wrap in
prewarmed dry
cloth
•Breast feeds
•Ongoing
Evalution
YE
S
Baby is Delivered
( Ask)
Routine Care

13. Dry & Remove wet linen

14. Routine Care
• Vigorous term infants with no risk factors
• Babies who required but responded to initial
steps, They now can stay with Mother
• Skin to skin contact recommended
• Clear airway, dry newborn, provide ongoing
evaluation:
– Breathing
– Activity
– Color
• Transfer to New Born Nursery

16. Positioning

17. Clear Airway, if necessary

18. Clear airways
(if necessary)

19. Oral Suctioning
Deep suction should be performed

20. Stimulate

21. • Breathing :
Regular / Gasping / Irregular / Absent
• Heart Rate : >100/m OR< 100/m OR Absent
• SpO2
EVALUATE

23. Pulse Oximetry: Resuscitation
monitor
• Advantages
o Not affected by
acrocyanosis
o Be patient and
get a reading

25. Supplemental oxygen
Free-flow oxygen cannot be given reliably
by a mask attached to a self-inflating bag

26. PPV/Bag & mask ventilation

27. •HR below 100
•Apnoea/gasping
YE
S
•Start PPV
•Consider SpO2
monitering

28. Indications for Bag & Mask
ventilation
• Apnea or gasping respiration
OR
• Heart rate < 100 bpm
OR
• Saturation below target values despite
free flow supplemental oxygen

29. Key point
The most important and effective
action in neonatal resuscitation is
EFFECTIVE VentilationEFFECTIVE Ventilation

30. Selecting equipment
• Size of bag (200-750 ml)
: To deliver a tidal volume of 6-8 ml/kg
• Oxygen capability :
Oxygen source, reservoir

31. Oxygen Reservoirs

32. Safety features
Pop-up valve

33. Testing the self-inflating bag
• Squeeze against your palm
– Pressure felt
– Pressure release valve
– Pressure manometer
– Re-inflation

34. Without Reservoir

35. With Reservoir

36. Self inflating bag
• Advantages
• Easier to use
• Pressure release valve
• Don’t not need a gas source to inflate

37. Self inflating bag
• Disadvantages
• Requires a reservoir to deliver 100%
oxygen
• Can not be used to deliver 100% free flow
oxygen

38. Masks
• Cushioned/Non-cushioned
• Round/Anatomical shaped
• Size 0 or 1

39. The surface on which the baby is
placed should always be warm
as well as flat, firm and clean
POSITION

40. Correct position of mask

41. Positioning
• Positioning the infant & resuscitator

43. Forming & checking the seal

44. Ventilation rate and
pressure

45. Evaluation-Decision-Evaluation-Decision-
Action cycleAction cycle
Evaluation
Action Decision
30 sec30 sec

46. Signs of Effective
Ventilation
Sign of response to ventilation:Sign of response to ventilation:
• Improved heart rate
Signs of improvement in newborn:Signs of improvement in newborn:
• Improved heart rate, color, breathing, tone, and
saturation

47. Contraindications
• Diaphragmatic hernia
• Non -vigorous baby born through
meconium stained liquor

48. No improvement
• Is chest rise adequate?
• Is adequate oxygen being
administered?

49. MR. SOPAMR. SOPA
•M- Adjust Mask on the face
•R- Reposition the head to open airway
oRe-attempt to ventilate…if not effective then
•S- Suction mouth then nose
•O- Open mouth and lift jaw forward
oRe-attempt to ventilate…if not effective then
•P- Gradually increase Pressure every few breaths until
visible chest rise is noted
oMax Pip 40cmH2O If still not effective then…
•A- Alternative Airway (ETT or LMA)

50. When to stop ?
• Heart rate above 100/min
• Spontaneous breathing
• Baby in Post Resuscitation care

51. Chest Compressions
Its a 2 personnel job

53. Indication
If after 30 seconds of EFFECTIVE bag
and mask ventilation with 100% oxygen,
Heart Rate is below 60 per minute
Indications

54. • Pump out blood from the heart during
compression and fill up blood in the heart
during release
• Must always be accompanied by ventilation
with 100% oxygen
Principle

55. Compress Release
Heart Heart
sternum
Mechanism of Chest
Compressions
sternum

56. • Position
– Neck slightly extended with firm support for the
back
– Lower 1/3rd
of sternum between nipple line &
sternum
• Pressure required – depth
– 1/3rd
of the AP diameter of chest
• Rate
– 90/min
Components

58. Two-finger method
Techniques of Chest
Compressions
Thumb method

59. Thumb Technique

60. • Easier with right
hand for right
handed
• Index and middle
or ring fingers
• Other hand used to
support the back
• Pressure applied
vertically
2 Finger Technique

61. 2 Finger Technique

62. Don’t lift your fingers/thumbs

63. • Advantages
• Better control of depth
• Less tiring
• Superior generation of peak systolic & coronary
perfusion pressure
• Nails do not hinder performance
• Disadvantages
• Difficult when baby is big
• Umbilicus difficult to canulate
Preferred method - Thumb

64. Rate
• 3 Chest Compressions then 1 ventilation
• 90 Chest Compressions to 30 ventilations in
one minute
Adequacy
• Palpate femoral/carotid pulse
Rate and Adequacy

65. • Consists of 3 compression & one ventilation
• 120 events in 60 seconds
• 1 cycles in 2 seconds
• ONE- AND – TWO – AND – THREE – ANDONE- AND – TWO – AND – THREE – AND
- BREATH- BREATH
Cycle of events

66. • No pressure to be
applied on ribs,
Xipisternum,
abdomen
• Do not lift
thumbs/fingers
Precautions

67. Dangers
• Broken ribs
• Lacerated liver
• Pneumothorax
Chest Compressions

68. • HR 60 per minute or more Stop CC, continue
BMV at 40-60/min
• If no improvement, check :
– Effectiveness of BMV
– Oxygen is 100%
– Technique of CC is correct
Evaluation after 30 sec of
CC & BMV

69. When to stop
chest compressions
• When heart rate is 60 per minute or more

70. Key points
• 2 personnel job
• Ensure 100 % oxygen
• Ensure adequate chest movement
during ventilation
• Co-ordinate B & M with CC at 3 : 1
• Check HR every 30 seconds
• Use thumb or 2 finger technique

71. Intubation

72. Indications for intubation
• Meconium suctioning in non vigorous baby
• Diaphragmatic hernia
• Prolonged or ineffective ventilation
• Elective
– VLBW
– with CC

73. Intubation equipment

74. Preparing laryngoscope
• No. 1 for full term
• No. 0 for preterm / LBW
• No. 00 for extremely preterm (optional)

75. 3.5
3.0
2.5
Stylet
>2000 gm
1000-2000 gm
<1000 gm

76. Selecting endotracheal tube
Tube Size
(ID mm)
Weight
(gm)
Gest. Age
(Wks)
2.5 < 1000 < 28
3.0 1000-2000 28-34
3.5 2000-3000 35-38
4.0 >3000 > 38
ID=Internal Diameter

77. Preparing endotracheal tube
• Shorten the tube to 13 cm
• Replace ET tube connector
• Insert stylet (optional)

78. Additional items
Tape : For securing the tube
Suction equipment
Oxygen
• For free flow oxygen during intubation
• For Use with the resuscitation bag
Resuscitation Bag and Mask
• To ventilate the infant in between intubation
• To check tube placement

79. Positioning the infant
• On a flat surface
• Head in midline
• Neck slightly extended
• Optimal viewing of glottis

81. Intubation view

82. Vocal cord guide

83. Lip reference mark: (6 + weight in kilos)
cm
9-10 cm at the lip for
this term infant

84. Tube in Rt. Main bronchus
• Breath sounds only on right chest
• No air heard entering stomach
• No gastric distention
Action
Withdraw the tube, recheck

85. Tube in esophagus
• No breath sounds heard
• Air heard entering stomach
• Gastric distention may be seen
• No mist in tube
Action
Remove the tube, oxygenate the infant with a
bag and mask, reintroduce ET tube

86. Complications of intubation
• Hypoxia
• Bradycardia
• Apnea
• Pneumothorax
• Soft tissue injury
• Infection

87. Minimizing hypoxia during
intubation
• Providing free-flow
oxygen (Assistant’s
responsibility)
• Limiting each intubation
attempt to 20 seconds

88. CPR Medications

90. 2:1000 newborns
MEDICATIONS

91. No drugs for me!No drugs for me!

92. MEDICATIONS
• Epinephrine
• Volume expansion

93. Neonatal Resuscitation
No role of
• Atropine
• Calcium
• Dexamethasone
• Dextrose
• Intra cardiac adrenaline
• Naloxone

94. Epinephrine
• Formulation 1:1000
• Dilution 1:10000 (Ten times)
0.2 ml in 1.8 ml
• Load 1 ml (in 1ml syringe)
• Dose 0.1-0.3 ml/kg
• Route IV (preferable)
• Rate Rapid bolus

95. Epinephrine
Follow up: if HR < 60 or 0
• Repeat epinephrine q 3-5 minutes
• Ensure:
effective ventilation
effective chest compressions
endotracheal intubation
(if not done already)
• Consider using volume expander

96. What is expected response
• After 30 seconds of administration and
continued PPV and CC
– HR should increase to > 60 bpm
• If no response repeat the dose every 3-5
minutes
• Repeat doses should preferably be give IV

97. “If the baby appears to be in shock
and is not responding to
resuscitation, administration of a
volume expander may be indicated”
!
Shock - HypovolemiaShock - Hypovolemia

98. Signs of Hypovolemia
• Pallor persisting beyond oxygenation
• Weak pulses
• Low blood pressure
• Lack of response to resuscitation
Hypovolemia is a common but often
unrecognized cause of need for
resuscitation

99. Volume Expansion
• Indicated when there is no response to
resuscitation and there is evidence of
blood loss or hypovolemia
• Repeated doses may be necessary if
there is minimal response after the first
dose
• Umbilical vein remains preferred route
but intraosseous acceptable

100. Medication Administration via
Umbilical Vein
• Preferred route for
intravenous access
• 3.5F or 5F end-hole
catheter
• Sterile technique
Placing catheter inPlacing catheter in
umbilical veinumbilical vein

102. Volume Expanders
• Normal saline
• Ringer’s lactate
• Whole blood (O Neg cross matched
with mother’s blood)

103. Normal saline
Indications
• Evidence or suspicion of acute blood
loss with signs of hypovolemia and/or
baby responding poorly to resuscitation

104. • Dose – 10ml/kg
• Route – Umbilical vein
• Preparation – large syringe
• Rate of administration – 5-10 minutes
In premature babies: Rapid boluses may induce ICH
Normal saline

105. Volume expanders
• Effect : Volume expansion, correction
of metabolic acidosis
• Expectation : Better BP & pulses, less
pallor
• Follow up : If signs of hypoperfusion
persist, repeat volume
expander, consider sodium
bicarbonate or dopamine

107. !! THANK YOU !!