Newborn Resuscitation Program

NEWBORN RESUSCITATION CRISBERT I. CUALTEROS, M.D. http://crisbertcualteros.page.tl

Which Babies Require Resuscitation? Most newly born babies are delivered vigorous Only about 10% of newborns require some assistance Only 1% need major resuscitative measures (intubation, chest compressions, and/or medications) to survive 

Apnea (In Utero or Perinatal) Primary Apnea When a fetus or a newborn first becomes deprived of oxygen, an initial period of attempted rapid breathing is followed by primary apnea and dropping heart rate. Primary apnea and the dropping of the heart rate will improve with tactile stimulation

Secondary Apnea If oxygen deprivation continues, secondary apnea ensues, accompanied by a continued fall in heart rate and blood pressure Secondary apnea cannot be reversed with just stimulation Assisted ventilation must be provided 

What Can Go Wrong Lack of ventilation of the newborn’s lungs results in sustained constriction of the pulmonary arterioles, preventing systemic arterial blood from being oxygenated Prolonged lack of adequate perfusion and oxygenation to the baby’s organs can lead to brain damage, damage to other organs, or death 

Preparation for Resuscitation Assemble equipment Test equipment

Evaluating the Newborn Immediately after birth, the following questions must be asked: All newborns require initial assessment to determine whether resuscitation is required 

Provide Warmth Prevent heat loss by Placing newborn under radiant warmer Drying thoroughly Removing wet towels

Opening the Airway Positioning on back or side, neck slightly extended  Open the airway by positioning the newborn in a “sniffing” position

Opening the Airway “ Sniffing” position aligns posterior pharynx, larynx, and trachea

Initial Steps Provide warmth Position; clear airway (as necessary) Dry, stimulate, reposition

Dry, Stimulate to Breathe, Reposition

Potentially Hazardous Forms of Stimulation Slapping back or buttocks Squeezing rib cage Forcing thighs onto abdomen Dilating anal sphincter Hot or cold compresses or baths Shaking

Clear Airway: No Meconium Present Suction mouth first, then nose “ M” before “N”

Evaluation: Decisions and actions during newborn resuscitation are based on Respirations, Heart Rate, and Color Click on the image to play video 

Central Cyanosis and Acrocyanosis

Free-flow Oxygen Free-flow oxygen is indicated for central cyanosis Free-flow oxygen cannot be given reliably by a mask attached to a self-inflating bag 

Delivering Free-flow Oxygen Heated and humidified Oxigen, if available (if given for longer than few minutes) Flow rate at approximately 5 L/min Enough oxygen for newborn to become pink

Meconium Present and Newborn Vigorous If Respiratory effort strong, and Muscle tone good, and Heart rate greater than 100 beats per minute (bpm) Then Use bulb syringe or large-bore suction catheter to clear mouth and nose 

Meconium Present and Newborn Not Vigorous Tracheal Suction Administer oxygen, monitor heart rate Insert laryngoscope, use 12F or 14F suction catheter to clear mouth Insert endotracheal tube into trachea Attach endotracheal tube to suction source Apply suction as endotracheal tube is withdrawn Repeat as necessary

Suctioning Meconium via Endotracheal Tube Suction for only 3 to 5 seconds as tube is withdrawn If no meconium is recovered, proceed to resuscitation If meconium is recovered, check heart rate No significant bradycardia -> Reintubate, suction again if needed Significant bradycardia -> Administer positive-pressure ventilation

Evaluation: Respirations, Heart Rate, Color 

Evaluation: Persistent Cyanosis, Apnea, or Heart Rate <100 For persistent apnea, begin positive-pressure ventilation/PPV promptly. Continued use of tactile stimulation in an apneic newborn wastes valuable time. 

Indications for Positive-Pressure Ventilation/ PPV Apnea/gasping Heart rate less than 100 beats per minute (bpm) even if breathing Persistent cyanosis despite 100% free-flow oxygen Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised infant 

Oxygen Concentration During PPV The Neonatal Resuscitation Program (NRP) recommends use of 100% oxygen when doing positive-pressure ventilation. However, research suggests that resuscitation with less than 100% oxygen may be just as successful. 

Oxygen Concentration During Positive-Pressure Ventilation If resuscitation is started with <100% oxygen, and there is no appreciable improvement within 90 seconds following birth, then, supplemental oxygen up to 100% should be administered. 

Oxygen Concentration During Positive-Pressure Ventilation If oxygen is unavailable, use room air to deliver positive-pressure ventilation. 

Bag and Mask: Equipment Mask should cover Tip of Chin Mouth Nose

Preparation Checklist Select appropriate-sized mask Be sure airway is clear Position baby’s head Position yourself at baby’s side or head Before beginning positive-pressure ventilation:

Positioning Mask on Face Do not jam mask down on face Do not allow fingers or hands to rest on eyes Do not put pressure on throat (trachea)

Face-Mask Seal An AIRTIGHT seal is essential to achieve effective Positive Pressure Ventilation To improve face-mask seal -Use light downward pressure -Gently squeeze mandible up toward mask

Evaluate for Signs of Effective Ventilation and improvement in the newborn Breathing Improved heart rate Color Tone Saturation 

Frequency of Ventilation: 40 to 60 breaths per minute

Causes and Solutions for Inadequate Chest Expansion Condition Actions Inadequate seal Reapply mask to face and lift jaw forward Blocked airway Reposition the head, suction secretions; Ventilate with the newborn’s mouth slightly open Not enough pressure Increase pressure until there is a perceptible chest movement Consider endotracheal intubation 

Over-inflation of Lungs If too much pressure is being used, the baby appears to be receiving very deep breaths. Danger of causing Pneumothorax

Newborn Not Improving Heart rate less than 60 despite 30 seconds of positive-pressure ventilation

Continued Positive-Pressure Ventilation Orogastric tube should be inserted to relieve gastric distention

Continued Positive-Pressure Ventilation Gastric distention may Elevate diaphragm, preventing full lung expansion Cause regurgitation and aspiration Orogastric tube should be inserted to relieve gastric distention

Insertion of Orogastric Tube Equipment 8F feeding tube 20-mL syringe

Insertion of Orogastric Tube Measuring correct length

Chest Compressions: Compress the heart against the spine Increase intrathoracic pressure Circulate blood to vital organs, including the brain 

Chest Compressions: 2 People Needed One person compresses chest One person continues ventilation

Chest Compressions Technique: Thumb Technique (Preferred) Less tiring Better control of compression depth 2-Finger Technique Better for small hands Provides access to umbilicus for medications

Chest Compressions: Positioning of Thumbs or Fingers Run your fingers along the lower edge of the rib cage until you locate the xyphoid Place your thumbs or fingers on the sternum, above the xyphoid and on a line connecting the nipples 

Chest Compressions: Thumb Technique Thumbs compress sternum Fingers support back

Chest Compressions: 2-Finger Technique Tips of middle finger and index or ring finger of one hand compress sternum Other hand supports back

Chest Compressions: Compression Pressure and Depth Depress sternum one third of the anterior-posterior diameter of chest

Chest Compressions: Complications Laceration of liver Broken ribs

Chest Compressions: Coordination With Ventilation 

Chest Compressions: Coordination With Ventilation One cycle of 3 compressions and 1 breath takes 2 seconds The breathing rate is 30 breaths per minute and the compression rate is 90 compressions per minute. This equals 120 “events” per minute 

Chest Compressions: Stopping Compressions After 30 seconds of compressions and ventilation, stop and check heart rate 

Chest Compressions: Heart Rate Remains Less than 60 bpm Check adequacy of ventilation Consider Endotracheal Intubation if not already done Insert an umbilical catheter to give epinephrine 

Endotracheal Intubation: to be discussed by Dr. Ronald Limchiu

Chest Compressions: Heart Rate Remains Less than 60 bpm After 30 seconds of compressions and ventilation, stop and check heart rate Consider Epinephrine 

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

Epinephrine Indications 30 seconds of assisted ventilation followed by 30 seconds of coordinated compressions and ventilation _____________ Total = 60 seconds  Epinephrine, a cardiac stimulant, is indicated when the heart rate remains below 60 beats per minute despite Note: Epinephrine is not indicated before adequate ventilation is established.

Medication Given: No Improvement

Failure to Initiate Spontaneous Respirations Consider Brain injury (hypoxic ischemic encephalopathy) Severe acidosis, congenital neuromuscular disorder Sedation secondary to maternal drugs

Narcotic Antagonist: Naloxone Hydrochloride

NEWBORN RESUSCITATION “ THANK YOU FOR YOUR ATTENTION”

Newborn Resuscitation Program

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