neonatal resuscitation

1. ARUNA SHASTRI
ROLL NO. 826
MSC, NURSING 2ND
YEAR

2.  Overview and Principles of Resuscitation
 Initial steps of resuscitation
 Positive – Pressure ventilation
 Chest compressions
 Endotracheal tube intubation and LMA
insertion
 Medications
 Special considerations
 Resuscitation of Preterm babies
 Ethics and Care at the end of life

3. Preterm
27%
Sepsis &
pneumonia
26%
Asphyxia
23%
Tetanus
7%
Congenital
7%
3%
Diarrhoea Others
7%
4 million neonatal deaths: When? Where?Why? Lancet 2005; 365:891–900

4.  Approximately 90% of newborns make
smooth transition from intrauterine to
extrauterine life requiring little or no
assistance
 10% of newborns need some assistance
 Only 1% require extensive resuscitation
 We must always be prepared to resuscitate,
as even some of those with no risk factors
will require resuscitation.

5. Assess baby’s risk for requiring resuscitation
Providewarmth
Position, clear airway if required
Dry, stimulate to breathe
Give supplemental oxygen, as required
Assist ventilation with positive
pressure
Intubate the trachea
Provide chest
compressions
Medications
Alwaysneeded
Needed less
frequently
Rarely needed

6. BEFORE BIRTH
Oxygen supply by placental
membranes
No role of lungs. Fluid filled
alveoli and constricted arterioles
due to low Po2 in fetal blood.

7. AFTER BIRTH
 Baby cries  takes first breath  air enters alveoli
 alveolar fluid gets absorbed  increased Po2
relaxes pulmonary arterioles  decreased PVR

8.  Low muscle tone
 Respiratory depression
(apnoea / gasping)
 Tachypnea
 Bradycardia
 Hypotension
 Cyanosis

9. Rapid
breathing
Irregular
Gasping
If the baby does not begin breathing immediately after being
stimulated, he or she is likely In secondary apnea and will require
PPV

10. PrimaryApnea
Stimulation
SecondaryApnea
Effective Positive pressure ventilation
Myocardium is depressed
Chest compressions, medications
Changes due to oxygen deprivation

11. Oral mucussucker
SuctionCatheter
Radiant warmer

13. ..

14. TRANSPOR
T
INCUBATO
R

16. Term / Preterm ?
 Term: smooth transition
 Preterm : stiff, under-developed lungs,
insufficient muscle strength, can’t maintain
temperature
Breathing/Crying ?
 Watch baby’s chest
 Gasping is a series of deep, single or stacked
inspirations that occur presence of
hypoxia/ischemia.Treated asapnea.

17. Good tone ?
 Term: flexed extremities
 Preterm/sick: flaccid/limp,
extended extremities

18. PRINCIPLE OF NEONATAL
RESUSCITATION
TEMPERATURE
AIRWAY
CIRCULATION
BREATHING

19.  Provide warmth :
Radiant warmer, don’t
cover with towels.
 Position head and
clear airway as
necessary
 Dry and stimulate
the baby to breathe,
reposition

20.  Suction mouth first, then
nose
 “M” before“N”
 Toprevent aspiration of
mouth contents

21. Vigorousif
1. Goodtone
2. GoodCry/
Breathing
3. HR>100/min

22. +········ ···········
.-
.;.
,
, ·········· ·······
.·.·.•
---- Correct
Incorrect
(hyperextension )
Incorrect
(flexion)

23.  Respirations
 Heart rate: Best is
auscultation, alternatively
pulsations at base of cord is
felt. Count for 6s and “x”10
 Oxygenation by oximeter

24. If Apneic or HR < 100bpm:
 Provide positive-pressure
ventilation,spo2 monitoring.
 If breathing, and heart rate is
>100 bpm but baby is cyanotic,
give supplemental oxygen,
spo2 monitoring. If cyanosis
persists, provide positive-
pressure ventilation
 If respiratory distress is
persistent , considerCPAPand
connectoximeter

25.  Free flow oxygen
 Oxygenmask
 Flow inflating bag
 T- piece resuscitator
 Oxygen tubing held
close to baby’s nose
 CPAP provided with
 Flow inflating bag
 T-piece resuscitator
 Start with room air and
increase to maintain
targetSpO2
Time TargetSpo2
1min 60-65%
2min 65-70%
3min 70-75%
4min 75-80%
5min 80-85%
10min 85-95%

27. Flow InflatingBag
T-PieceResuscitator
DEVICES USED
Self Inflatingbag

28.  Ventilation of the lungs is the
single most and most effective
step in newborn resuscitation
Indications:
 Gasping/apnea
 HR < 100/min
 SpO2 remains below target
values despite free flow
supplemental oxygen increased
to 100%.

29. Appropriate
Sizes
Mask should
Rest on Chin
Cover Mouth
& Nose

30. Suction & Position
Cup the chin in
the mask and
then cover the
nose
Light Pressureon
mask to create a
seal
Anteriorpressure
on posterior rim
of mandible

31. 40 to 60 breaths per minute
StartWith 21% ( higher in preterm's) oxygen and
increase according to target Saturation
Initial Pressure at 20mmH2O

32.  Most Important sign is the rising of HR
 Improvement in OxygenSaturation
 Equal and adequate breath sounds B/L
 Good Chest rise

33.  Heart rate
 Oxygenation by
oximeter
If heartrate <100 bpm

34. Corrective steps Action
M MaskAdjustment Ensure Good seal ofmask
on face
R Repositionairway Sniffing Position
S Suction Mouth and nose If secretionspresent
O Openmouth Ventilate with baby mouth
slightly open and lift the
jaw forward
P Pressureincrease Gradually increase the
pressure every few breaths
A Airwayalternative Consider ET or Laryngeal
maskairway

35.  Place an OG tube, Suction gastriccontents
and leave the end open.

36. If heart rate <60
bpm despite
adequate ventilation
for 30 seconds,

37. Indications :
 HR <60/min
despite at least
30 sec of
effective PPV
Strongly consider Endotracheal intubation at this point
as it ensures adequate ventilation and facilitates the
coordination of ventilation and chest compressions

38. Rationale:
 HR<60/min despite PPV indicates
very low O2 levels and significant acidosis
 depressed myocardium  no blood in
lungs to get oxygenated(supplied by PPV)
 Chest compressions + effective ventilation
(ET/PPV)  oxygenation of blood 
recovery of myocardium to function
spontaneously  HR increases  O2 supply
to brain increases

39. Principle:
 Rhythmic compressionsof
sternumthat
 Compress the heart against the
spine
 Increases intrathoracic pressure
 Circulate blood to vital organs
 Chest compressions 
compresses heart & increased
Intrathoracic pressure  blood
pumped into arteries
 Pressure released  bloodenters
heart fromveins

40. Positions :
 Chest compressions are of
little value unless the lungs
are effectivelyventilated
 2 persons are required
 1 – chest compressions
provider should have accessto
the chest with his hands
positioned correctly
 2 –Ventilation providershould
be at head end to maintain
effective mask-face seal or to
stabilize ET tube

41. Technique:
 Thumb technique: 2
thumbs depress the
sternum, hands encircle the
torso and the fingers
support the spine.
Preferred technique
 2 – Finger technique: Tips
of middle & index/ring
finger of one hand
compresses sternum, other
hand supports the back.

42.  Thumb technique is
preferred as
 Better control of depth of
compression
 Can provide pressure
consistently
 Superior in generating
peak systolic and coronary
arterial perfusion
pressure.

43. For small chests with
thumbs overlapped

44. Correct
{pressure on sternum)
.t-----
Incorrect
{lateral pressure)

45. 2- finger technique

47.  Depth : 1/3rd of the
anter0posterior
diameter of chest.
 Duration of
downward stroke
should be shorter
than the duration
of release
 Do not lift the
fingers off the
chest

48. Complications:
 Laceration of liver
 Breakage of ribs

49. Coordination of chest compressions and
ventilation:
 Avoid giving compression and ventilation
simultaneously
 1 breathe after every 3 compressions
 Ratio is 1 : 3 or 30: 90 per minute
 One cycle: 2 sec, 3Compresssions + 1 ventilation
 1 minute : 30 cycles or 120 events (90 compressions +
30 breaths)

50. When to stop chest compressions?
 Reassess after 45-60 sec, if HR > 60/minstop
chest compressions and increase breaths to
40-60 per minute.
If HR is not improving…
 Insert an umbilical catheter and giveIV
epinephrine

52.  WHENTOCONSIDER INTUBATION?
Indications in resuscitation
 Baby is floppy, not crying, and preterm
 HR < 100/min, gasping/apnea
 HR < 100/min inspite of PPV
 HR < 60/min
 No adequate chest rise and no clinical
improvement
 If chest compressions are needed, intubation
provides better coordination and efficacy of PPV
 Toadminister drugs

53.  WHENTOCONSIDER INTUBATION?
 Special conditions
 Meconium aspiration if baby is depressed in
which it is the first step to be done
 Extreme Prematurity
 Surfactant administration
 Suspected diaphragmatic hernia

54.  Laryngoscope with extra
blades and bulbs
 Straight blades
 Term – 1
 Preterm – 0
 Extremely preterm - 00

55. Weight GA(weeks) Tubesize(mm)
(internaldiameter)
Below 1 kg 28 2.5
1-2 kg 28-34 3.0
2-3kg 34-38 3.5
>3kg >38 3.5-4.00

57.  Add 6 to baby’swt.
Wt Depth of
insertion
< 750g 6cm
1kg 7cm
2kg 8cm
3kg 9cm
4kg 10cm

58.  Watching the tube passing between cords
 Watching for chest movements
 Listening for breath sounds ( Axilla and stomach)
 Colourimeter/Capnography ( Can also be used for PPV
with mask or LMA
 Improvement in HR andSpo2
 Vapour Condensing insidetube

59. Mechanism of action :
 Increases systemic vascular resistance
 Increases coronary artery perfusion pressure
 Improves blood flow to myocardium and
restores depletedATP
Indications :
 If HR remains < 60/min even after 30 sec of
effective ventilation preferably after intubation
and atleast another 45-60 sec of coordinated
chest compressions and effective ventilation

60. Administration :
 Intravenous (recommended)
 Endotracheal
Preparation and dosage:
 Adrenaline vial 1ml = 1mg (1:1000 solution)
 Dilute with NS to make 1:10,000 solution (1ml =
100 mcg)
 IV : 0.1-0.3 ml/kg = 10-30 mcg/kg
 ET : 0.5 – 1 ml/kg = 50-100 mcg/kg
 Give rapidly – as quickly as possible
 Can repeat every 3-5 minutes

61. Indications:
 Bradycardia not improving with adrenaline
 Placenta previa/Abruption
Volume Expanders:
 Normal saline (recommended)
 Ringer lactate
 Dosage: 10 ml/kg
 Route : Umbilical vein
 Rate: over 5-10 min , rapid infusion may
cause IVH in <30 weeksbabies

62.  Additional resources , additional personnel,
additional thermoregulation strategy
▪ Portable warming pad
▪ Polyethylene Plastic wrap (< 29wk)
▪ Prewarmed transport incubator
 Use of Oxymeter, blender to targetSpo2
85%- 95%
 Use Lower PIP 20-25 cm of H2O during PPV
 Consider giving CPAP
 ConsiderSurfactant

63.  Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks and E/O
Acute perinatal HIE
 Monitor for Apnea, bradycardia, BP,SPo2
&Urine output.
 Monitor B. Sugars, electrolytes , Hematocrit,
Platelets,ABG
 Maintain adequate oxygenation & support
ventilation as needed

64.  Delay feeds, Start IV fluids,consider
parenteralnutrition
 Consider inotropes , fluid bolus
 Ensure adequate ventilation before giving
sodium bicarbonate(only in severe metabolic
acidosis)

65.  Choanal atresia – oralAirway
 Pierre Robin : place prone , 12F Et through
nose with tip in post pharynx
 Laryngeal web, cystic hygroma,Cong.Goiter-
ET/tracheostomy
 Pneumothorax : Percutaneous needle
aspiration
 Pleural effusion : Percutaneous needle
aspiration
 Congenital Diaphragmatichernia

66.  Meeting and discussing with parents and
documenting the conversation.
 WhereGA ( < 23wks ), B.wt ( < 400g) and / or
Cong.Anomalies are associated with certainly
early death and unacceptably high morbidity
among rare survivors resuscitation is not
indicated
 After 10 minutes of continuous and adequate
resuscitative efforts, discontinuation of
resuscitation may be justified if there are no
signs of life (no heart beat and no respiratory
effort).

67.  Doing the simple things better is probably the
most cost-effectivepolicy.
 Resuscitation can come as complete surprise
So be prepared for resuscitation.
 It may take several hours to learn but it
should be implemented over seconds.
 Practice makes one perfect.

68.  Neonatal resuscitationTextbook 6th ed.
 4 million neonatal deaths:When?Where?
Why? Lancet 2005; 365: 891–900
 Park’sTextbook of Preventive andSocial
Medicine , K. park 21st Edition .