NEONATAL

RESUSCITTION
PRESENTER:DR AMRITHA
MODERATOR:DR SHALINI,DR ROSHIN
 Birth asphyxia-1/5 th of all neonatal deaths
 10 % of all neonates require some form of active resuscitation at birth
 1% intensive resuscitative measures
 Neonatal resuscitation involves a series of quick steps which involves
ongoing evaluation and resuscitation of newborn baby
NEED FOR RESUSCITATION-RISK
FACTERS
ANTEP •PIH
•PREVIOUS NEONATAL DEATHS
•IUGR
•DIABETES

ARTUM
•ANEMIA
•TWINS
•HYPERTENSION

INTRAP •PREMATURITY
•ANTEPARTUM HEMORRHAGE
•OPERATIVE DELIVERY
•BREECH
•PROM

ARTUM
•FOETAL DISTRESS
•NARCOTIC ADMINISTRATION
•ANAESTHESIA
•MSAF
PATHOPHYSIOLOGY
 Transition of newborn baby from fluid filled womb to air filled room
2 TYPES OF APNOEA

 Primary apnoea-bradycardia+,responds to tactile stimulation

 Secondary apnoea-bradycardia +,requires resuscitation-
oxygen,ventilation,chest compression and medications
PREPARATION FOR RESUSCITATION
TECHNIQUES OF RESUSCITATION

 EVALUATION
 INITIAL STEPS
 VENTILATION
 CHEST COMPRESSIONS
 MEDICATIONS
EVALUATION
RAPIDLY ASSESSED FOR
Respiration-
 Observing chest movements
 spontaneous,vigorous,apneic or gasping
Heart rate-
 Auscultation over precordium
 Palpation of umbilical cord pulsations
 HR >100/min
 Pulse oximetry
 ECG
Colour/oxygen saturation
 Centrally or peripherally cyanosed
 Pale or pink
 Central cyanosis-face ,tongue,mucosa
 Pallor-hypotension,severe anemia,hypothermia or acidosis
ILCOR(International Liason Committee on Resuscitation-2020
guidelines)-use of pulse oximeter in the immediate neonatal period
Target preductal saturations after birth are as follows
Temperature
 Measure of quality-measured and recorded after birth
 Maintained between 36.5 to 37.5 degree Celsius
 Very preterm(<33 weeks) and very lowbirth wt(<1500 g)-increased
risk
TABC OF RESUSCTATION
INITIAL STEPS- TO BE COMPLETED
WITHIN 60 SEC
 PREVENTION OF HEAT LOSS
 POSITIONING
 SUCTIONING
 EVALUATION
 TACTILE STIMULATION
PREVENTION OF HEAT LOSS
 Radiant heat source-radiant warmer,bulb ,heater
 Prewarmed mattress/linen
 Baby dried thoroughly-wet linen removed-wrapped in warm sheets-
placed skin to skin on mothers chest to maintain warmth
 VLBW babies-large body surface area and immature skin
 Plastic wrap-food or medical grade,heat resistant plastic
POSITIONING
 Positioned in his back or side with head in neutral or slightly extended
position
 For extension-1 inch shoulder roll
SUCTIONING-when amniotic fluid is clear
 Healthy vigorous babies-may not require suctioning
 Secretions wiped from nose and mouth with a gauze or towel
 Suctioning-first from mouth and then from nose
 Bulb syringe/suction catheter(8 or 10 Fr)
 Suction pressure-80 to 100mmHg
 Aggressive pharyngeal suctioning-laryngeal spasm
vagal bradycardia
delay in spontaneous respiration
-when meconium is present
 Aspiration of meconium - cause severe meconium aspiration
syndrome
If the baby is vigorous at birth
 Strong respiratory effort
 Cry
 Good muscle tone
 Heart rate >100
 Clear the airway by suctioning mouth first and then the nose with
suction catheter, no intubation suctioning is required
If the baby is not vigorous at birth-drying and stimulation delayed
 Depressed respiration DIRECT LARYNGOSCOPY-
HYPOPHARYNX
 Depressed muscle tone TRACHEAL SUCTION WITH ETT
 Heart rate < 100
 Suction under direct vision using laryngoscope→insert endotracheal
tube in to trachea.
 Attach a suction device to ET tube, apply suction as the tube is slowly
withdrawn, repeat if necessary OR until quantam of meconium
recovered is minimal
 Depressed respiration or heart rate-secondary apnoea-to start PPV
 When the baby is stabilized-gastric lavage to remove swallowed
meconium
TACTILE STIMUALTION
 Stimualtion by drying and suctioning-usually adequate
 Additional tactile stmulation-flick of toes,rubbing the back once or
twice along with free flow oxygen
 Primary apnoea-responds to tactile stimulation
 Secondary aponea-PPV
OXYGEN ADMINISTRATION
 recommended to start resuscitation with room air /blended oxygen(40
to 60%)
 O2 conc increased or decreased according to preductal saturation
 If HR <60/min after 90 sec resuscitaton with room air/40% o2 –
increase Fio2 to 100 % till recovery of normal HR
If asphyxia persists –secondary apnoea
 VENTILATION
 CHEST COMPRESSIONS
 MEDICATIONS
VENTILATION
PPV –indicated for babies with
 Apnoea
 Gasping respiration
 Bradycardia HR <100/min
 Persistant central cyanosis despite use of 100 % o2
Optimal rate of PPV
 40 to 60 breaths /min
 Initial pressure-30 to 40 cm H20 followed by 15 to 20 cm H20
 Peak inflation pressure 30cmH20-term newborns
20 to 25 cmH20-preterm
 Adequacy of ventilation measured by
1. Increase in HR
2. Chest expansion
REASONS FOR INADEQUATE RESPONSE TO VENTILATION
 poor seal between mask and face
 Airway obstruction-reposition of neck,clear secretions,open infant’s
mouth
 Inadequate inflation pressure
 Inadequate o2
If resuscitation with bag and mask continued for 2 min-orogastric tube(6
to 8 Fr) to deflate the stomach
After 30 sec of ventilation:
 Spontaneous regular respiration+ and HR >100/min-IPPV stopped
 Respiration inadequate or HR <100/min-IPPV continued by bag and
mask/ETT
 If HR <60/min-IPPV continued with chest compressions and ET
intubation
ASSISTED VENTILATION DEVICES
 Resuscitaton bag
 Face masks
 Endotracheal intubation
 CPAP
 Laryngeal mask airway
RESUSCITATION BAG AND MASK
Resuscitation bag
 Resuscitation bag volume-240 ml
 Tidal volume-5 to 8 ml
 Self inflating bag with air and o2 inlet,patient outlet and valve
assembly
 O2 source
 Reservoir bag
 Pressure release valve(30 to 35 cm H20) and a pressure gauge
Face masks
 Forms seal around mouth without covering eyes with cushioned
edges
 Sizes-0 and 1(anatomical/round shaped)
2 important contraindications to bag and mask ventilation
-thick meconium stained liquor before tracheal suction
-diaphragmatic hernia
ENDOTRACHEAL INTUBATION
INDICATION
 Ineffective or prolonged bag and mask ventilation with chest
compressions
 Tracheal suctioning required for thick meconium
 Elective in diaphragmatic hernia,extremely LBW babies
 For administration of medications
Oral intubation using laryngoscope with straight blade(0-preterm,1-term)
 Infant in flat surface with head in midline and neck slightly extended
 Operater stands at the head end
 Blade of laryngoscope slide over the tongue and tip introduced into
vallecula or onto epiglottis
 Cricoid pressure may be required
 Depth of insertion of oral ETT-baby’s wt in Kg + 6 cm
 Confirmation of position-
1. auscultation for equal breath sounds in axillae,
2. absent over stomach,
3. Rise of chest with ventilation
4. Absence of gastric inflation
5. Improvement in HR,colour,activity
6. EtC02 tracing
7. Final confirmation-chest X ray(ETT tip at T2)
 Complications of intubation-hypoxia(limiting each intubation attempt to
20 sec)
-bradycardia
-apnoea
-pneumothorax
-soft tissue injury
-infection
USE OF CPAP
 CPAP in preterm babies who are breathing spontaneously but are having
respiratory distress
 CPAP in preterm infants-reduces rates of
intubation,mechanicalventilation,surfactant use and duration of ventilation
 Use in term babies-controversial
LARYNGEAL MASK AIRWAY
 LMA - effective for ventilating newborns >2Kg or 34 wks gestation
 Limited data on the use of LMA in small preterm (2Kg or 34 wks)
 Consider LMA - if facemask vent/ET is unsuccessful or not feasible
 LMA has not been evaluated - meconium-stained fluid, during chest
compressions, or for administration of emergency intratracheal
medications
CHEST COMPRESSION
 HR < 60/min after 30 sec of bag and mask ventilation with 100 % o2
 Chest compression should always be accompanied by ventilation with
100 % o2
 Compressions
- On the lower third of the sternum
- Depth approx 1/3 AP diameter of the chest
 Techniques of compression
a) - 2 thumb - encircling hands technique
b) - 2 fingers with a second hand supporting the back
 Compressions and ventilations should be coordinated
 Chest should be permitted to re-expand fully during relaxation, but
thumbs should not leave the chest
 Compressions to ventilation Ratio - 3:1 (90 & 30 / mins)
 HR assessed every 30 sec and chest compressions are continued till
HR > 60/min
 Increased chances of pneumothorax,broken ribs
MEDICATIONS
 rarely used
 Bradycardia due to –inadequate lung inflation or hypoxia-improves with
adequate ventilation
 HR < 60/min despite adequate ventilation with 100 % o2 and chest
compression
 Routes of administrations
1. Umbilical vein-5 Fr catheter passed just below skin level-free flow of blood
2. Intraosseous route
3. Peripheral veins
4. Intratracheal instillations
Drugs used-
volume expanders,
 naloxone,
 adrenaline,
 sodium bicarbonate
VOLUME EXPANDERS
 Blood loss suspected in newborn who responds poorly to resuscitation(ventilation,chest
compression,epinephrine)
 Fluids of choice-0.9% normal saline
-uncrossmatched type O Rh negative blood
 Initial volume of 10 ml/kg over 5 to 10 min maybe repeated if inadequate respone
 Avoid vol. expanders rapidly in premature
→ Intraventricular hemorrhage
 Volume expansion-less pallor,correction of metabolic acidosis,blood pressure and
peripheral pulses improve
-
NALOXONE
 Not a DOC as a part of initial resuscitative efforts in delivery room
 HR and color must first be restored by supporting ventilation before
administration
 Preferred recommended route - IV or IM (0.1 mg/kg)
 Avoid naloxone in infants of mothers with opioid abuse (seizures)
 Indicated in infant for reversal of respiratory depression, secondary to
maternal opioids, given 4 hrs before delivery
 Half-life < original maternal opioid
- Monitor neonate closely for recurrent apnoea or hypoventilation
- Subsequent doses of naloxone may be required
EPINEPHRINE
 Hr < 60 /min after 30 sec of IPPV and chest compressions or if there is
asystole
 Epinephrine 1:1000 diluted to 1:10000-0.01to 0.03 mg / kg=0.1 to
0.3 ml/kg as rapid IV bolus
 ET tube-higher dose-0.05 to 0.1 mg/kg
 It has ionotropic and chronotropic effects,HR increases aove 100 /min
within 30 sec
 If bradycardia persists may be repeated after 3 to 5 min
SODIUM BICARBONATE
 No role in brief arrests
 Used in cases of prolonged arrests that do not respond to therapy
 Detrimental properties-hyperosmolarity and CO2 generating
properties
TO DO OR NOT
 Resuscitation not indicated
- When gestation, birth wt, or congenital anomalies are
associated with poor mortality
- Ex: -extreme prematurity, anencephaly, trisomy13

 Resuscitation indicated
- In conditions with ↑ed survival & acceptable morbidity
- Ex: - gestational age >25 wks & most congenital
malformations

 In certain conditions parental desires concerning initiation of

resuscitation should be supported
 Discontinuing Resuscitative Efforts
 New born baby with no detectable HR
- Consider stopping resuscitation if HR undetectable for 10
mins.
 To continue resuscitation beyond 10 mins with no HR consider factors
like
- Presumed etiology of the arrest
- Gestation of the baby
- Presence or absence of complications
- Potential role of therapeutic hypothermia,
- Parents feelings about acceptable risk of morbidity
 Asystole > 10 min despite all resuscitative measures or no breathing
after 20 min or only gasping after 30 min of ventilation,resuscitation
may be discontinued
 Family should be counselled and provided emotional support.
PROCEDURES AFTER
RESUSCITATION
Important to document the condition of baby at birth and response to
resuscitation
 APGAR score at 1 and 5 min and recorded thereafter every 5 min until
the baby is stable
 Usefull for ongoing clinical care ,communication and medicolegal
purposes
References

 Understanding Paediatric Anaesthesia 4th edition-Rebecca Jacob

 2020 AHA guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care
Thank you