Neonatal Resuscitation. Jess Paul UBC RCPC-EM Residency Program RCH Grand Rounds April 23, 2014
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1 + Neonatal Resuscitation Jess Paul UBC RCPC-EM Residency Program RCH Grand Rounds April 23, 2014
2 + NRP: Who cares?
3 + Who cares? 4.2% participation in a NNR 38.7% previous NNR training 75-85% rated comfort, knowledge, and preparedness for caring for sick neonates as poor or very poor
4 + Who cares? 90% make intrauterine to extrauterine transition without aide 10% require basic resuscitation 1% require advanced resuscitation
5 + NRP Stop, breathe WARM, DRY, STIMULATE!!! Ventilation
6 + NRP Lesson 1: Overview and Principles of Resuscitation Lesson 2: Initial Steps of Resuscitation Lesson 3: Use of Resuscitation Devices for Positive-Pressure Ventilation Lesson 4: Chest Compressions Lesson 5: Endotracheal Intubation and LMA Insertion Lesson 6: Medications Lesson 7: Special Considerations Lesson 8: Resuscitation of Babies Born Preterm Lesson 9: Ethics and Care at the End of Life
7 + Lesson 1: Overview and Principles of Resuscitation
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12 + Transition Trouble Persistent pulmonary Hypertension Failure of pulmonary arterioles to relax Systemic hypotension Poor cardiac contractility Bradycardia Lungs not filling with air Fluid remaining despite initial breaths Meconium blockage
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16 + Equipment No longer optional in the birth setting, and should be available for every birth: a. Compressed air source b. Oxygen blender to mix oxygen and compressed air with flowmeter c. Pulse oximeter for neonatal use and oximeter probe d. Laryngeal mask airway (size 1) Suction, warmer, intubation kit, umbilical catheter set
17 + Quiz What % of newborns need extensive resuscitation?
18 + Quiz A baby doesn t begin breathing in response to stimulation, you assume she is in apnea and should provide.
19 + The Bottom Line Only 10% require some assistance. Only 1% need major resuscitation measures. Ventilation!!! (most often fixes HR) Teamwork! Flow: A: Initial Steps B: Adequate Ventilation C: Chest Compressions D: Epinephrine
20 + Lesson 2: Initial Steps of Resuscitation
21 + 3 Essential Questions
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32 + CPAP/blended O2/sup O2 If HR >100 but not at target sats or if irregular resps Start at 21% O2 then blend up to target sat CPAP: 5-6 mm H20 pressure
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34 + Meconium!!!
35 + Suction to mm H2O
36 + Quiz 3 questions you ask at every delivery?
37 + Term infant, mec delievery, good tone and crying. Resuscitation?
38 + The Bottom Line Sniffing position Tackle stimulation Fetus has O2 sat of 60%, can take 10 mins to reach >90% If persistent apnea despite stimulation: PPV! Oximeter guided O2 targets Vigorous: Good tone Strong resp efforts HR <100
39 + Lesson 3: Positive Pressure Ventilation
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43 + OG: 8 F feeding tube
44 + Quiz Begin resuscitation of term newborns with %O2? Indications for PPV? (3) PPV PIP and PEEP pressures?
45 + The Bottom Line No blow-by or CPAP with self inflating bags PPV can be discontinued: HR >100 Appropriate O2 sats Onset of spontaneous resps Effective ventilation: Bilateral breath sounds Chest movement PPV: Apnea/gasping HR <100 Persistent cyanosis and low O2 if supp O2 at 100%
46 + Lesson 4: Chest Compressions HR <60 despite 30 seconds of adequate ventilation 100% O sec before pulse check If still HR <60; intubate and epi Rate: Chest compressions 90/min Breathes 30/min 3:1 ratio
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50 + Quiz A baby has required 60secs of chest compressions and is ventilated with a BMV. The chest is not moving well. The heart rate is 4 in 6 seconds. Now what?
51 + Quiz Chest compressions are indicated after seconds of adequate ventilation for a heart rate below? O2 concentration during CPR? Phrase used to time and coordinate CPR to ventilation? Time before HR check? Rate of CPR, rate of ventilation?
52 + The Bottom Line If HR <60 despite 30 secs of adequate ventilation, start chest compressions Once chest compressions; 100% O2 until oximeter working Two thumb technique preferred 1 and 2 and 3 and breathe cadence CPR 90/min and RR 30/min (3:1 ratio) HR check at sec, if HR < 60: intubate and epi
53 + Lesson 5: Endotracheal Intubation and LMA Insertion
54 + Intubation No RSI drugs needed No atropine pre treatment Miller blade 00 extreme preterm 0 preterm 1 term
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56 + LMA Size 1 Contraindicated in: Meconium Preterm infants (<32 wks) or <2000g
57 + Quiz Blade size for term infant? ETT size for 2000g infant?
58 + The Bottom Line ETT sized by weight Blade by GA Depth: wt in kg +6 No LMA <32 wks mec Indications: Non-vigorous mec suctioning If BMV not effective or prolonged During chest compressions Special circumstances: Extreme prematurity Surfactant administration Diaphragmatic hernia
59 + Lesson 6: Medications Epi only if HR<60 after 30 sec adequate ventilation ETT epi only while IV being established only IO? Epi 1:10,000 1m1/kg by ET (max 3ml dose) 0.1m1/kg by IV Q3-5min
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61 + Umbilical Vein Catheter Steps sterile field : antiseptic, gloves, PPE Loose tie at base 3.5F (<3.5 kg); 5 F (>3.5kg) 3 way stopcock and 3ml syringe Cut perpendicular at 1-2cm above skin Depth 2-4cm Withdrawal blood Epi, NS flush, and secure with tape
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64 + NEJM UVC Video Emergent UVC JMvcm
65 + Fluid Replacement Fetal/maternal hemorrhage or fetal shock NS/Ringers/Whole blood 10ml/kg IV over 5-10mins
66 + Quiz What is the potential problem with ETT epi? Pulse check how often? If HR <60, how often for epi? Epi concentration? Epi by umbilical vein should be followed by what? Fluid resuscitation dose?
67 + The Bottom Line Epi only if HR<60 after 30 sec adequate ventilation ETT epi only while IV being established only Fluid Fetal/maternal hemorrhage or shock despite resuscitation NS/Ringers/whole blood 10ml/kg IV over 5-10 mins Epi 1:10,000 1m1/kg by ET x 1(max 3ml dose) 0.1m1/kg by IV Q
68 + Lesson 7: Special Considerations
69 + Choanal Atresia
70 + Pierre Robin Syndrome
71 + Congenital Diaphragmatic Hernia
72 + Pneumothorax (transillumination)
73 + Pleural effusions
74 + Hypoglycemia IV glucose: <4 and symptomatic <2.5 and asymptomatic for 0-4 hrs of age <3.5 and asymptomatic for 4-24 hrs of age D10W 2ml/kg then D10W infusion ml/kg/day Repeat Q10-20mins Avoid D25W as hyperosmolar
75 + Maternal Opioid Use Naloxone 0.1mg/kg Only after initial resuscitation Not for chronic/methadone maternal use Pulmonary hypertension Supp O2 or PPV Congenital Heart Disease Metabolic Acidosis No bicarb unless adequate ventilation
76 + Therapeutic Hypothermia >36 wks and perinatal asphyxia Seizures Altered LOC Hypotonia Hyporeflexia Can improve outcomes of severe hypoxic-ischemic encephalopathy Initiated within 6 hrs C for 72 hrs
77 + Quiz Baby with choanal atreasia. What do you do? A mec baby has been resuscitated and then develops acute respiratory deterioration. A? should be expected.
78 + The Bottom Line Diaphragmatic hernia: intubate and OG Choanal atresia: oral airway Pierre Robin: prone and NP airway Congenital cardiac disease rarely causes acute issues Naloxone only after resus in recent maternal opioid use babies Ongoing monitoring of temp, BG, O2 sat
79 + Lesson 8: Preterm Resuscitation Increased heat loss Weak chest muscles Immature immune systems Fragile intracranial capillaries Small blood volume Limited surfactant
80 + <29 wk: polyethylene bag wrap and warmer Monitor O2 sat from beginning; avoid hyperoxia Giving PEEP Don t give surfactant until fully resuscitated Handle baby gently No trendelenburg
81 + Quiz In addition to a warmer, what else can you use to keep a 27 week baby warm? A baby at 30 wk GA, required PPV for an initial HR of 80. She responds quickly with rising HR and spontaneous respirations. At 2 mins of age, she is breathing, has a HR of 140 and CPAP at 50% O2. Her sats are 95%. What should you do: Increase the O2 concentration? Decrease the O2 concentration? Leave the O2 concentration the same?
82 + The Bottom Line Increased risk of resuscitation in preemies More vulnerable to hyperoxia: target 85-95% Increased heat loss bag wrap <29 weeks PEEP if intubated Decrease risk of brain injury Continuous monitoring
83 + Lesson 9: Ethics and Care at the End of Life Discontinuation of resuscitation: 10 mins of no HR
84 + Practicality
85 + The Very Bottom Line Vigorous: stay with mom (even if meconium) Warm, dry, stimulate Ventilation!!! No chest compressions until ventilation until adequate for 30 sec and HR <60 Umbilical vein catheter is not that hard
86 + Acknowledgements Kristyn Chatwin: RCH NRP Coordinator References: AHA. Textbook of Neonatal Resuscitation. 6 edition. Elk Grove Village, Dallas, Tex: American Academy of Pediatrics; Anon. Addendum to the NRP Provider Textbook 6th Edition; Recommendations for specific modifications in the Canadian context Lo MD, Mazor SS. Chapter 11 Neonatl Resuscitation. In: Rosen s Emergency Medicine-Concepts and Clinical Practice.Vol 1. 8th ed. Anon. CPS Medications for Neonatal Rsuscitation Program 2011 Canadian Adaptation. Kester-Greene N, Lee JS. Preparedness of urban, general emergency department staff for neonatal resuscitation in a Canadian setting. CJEM. 2013;15(0):1 7. Anderson J, Leonard D, Braner DAV, Lai S, Tegtmeyer K. Umbilical Vascular catheterization. New England Journal of Medicine
Addendum to the NRP Provider Textbook 6 th Edition Recommendations for specific modifications in the Canadian context
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