Neonatal Resuscitation

NEONATAL RESUSCITATION

PRESENTED BY PHATTRAPONG TANSUPOL MD.

หลักการที่จะทำาให้การช่วยฟืน้ ชีวิตประสบความสำาเร็จ

1.ความพร้อมของบุคลากร 2.การฝึกฝน 3.การทำางานเป็นทีม 4.ACTION/EVALUATION/DECISION CYCLE 5.อุปกรณ์ที่เพียงพอ และพร้อมใช้งาน

ACTION/EVALUATION/DECISION CYCLE

EVALUATION

ACTION

DECISION

ASPHYXIA – THE BASIC

1.Primary

Apnea:  When asphyxiated,

the infant responds with a increased RR.  If the episode continues, the infant becomes apnic, followed by a drop in HR and a slight increase in BP.The infant will respond to stimulation and therapy with spontaneous respirations.

2. Secondary

apnea: after primary

apnea,  the infant responds with a period a gasping respirations, falling HR, and falling BP.The infant takes a last breath and then enters the secondary apnea period.The infant will not respond to stimulation and death will occur unless resuscitation begins immediately. *  Because after delivery of an infant it is impossible to differentiate between primary apnea and secondary apnea, assume the infant is in secondary apnea and begin resuscitation immediately.

ASPHYXIA CHANGE

APGAR SCORE

Anticipation and Recognition of the Neonate in Distress

1.Antepartum and intrapartum history Antepartum Factors Age > 35 years Maternal diabetes Pregnancy-induced hypertension Chronic hypertension Other maternal illness (e.g. CVS, thyroid, neuro) Previous Rh sensitization Drug therapy (e.g. magnesium, lithium adrenergic-blockers)

Intrapartum Abnormal Factors presentation Operative delivery Premature labour Premature rupture of membranes Precipitous labour Prolonged labour Indices of fetal distress (FHR abnormalities, biophysical profile)

1.Antepartum and intrapartum history CONT. Antepartum Factors Maternal substance abuse No prenatal care Previous stillbirth Bleeding - 2nd/3rd trimester Hydramnios Oligohydramnios Multiple gestation Post-term gestation Small-for-dates fetus Fetal malformations

Intrapartum Factors

Maternal narcotics (within 4 hrs of delivery) General anaesthesia Meconium-stained fluid Prolapsed cord Placental abruption Placenta previa Uterine tetany

Equipment Equipment and medications should be checked as a daily routine and then prior to anticipated need. Used items should be replenished as soon as possible after a resuscitation. The delivery room should be kept relatively warm and the radiant heater should be preheated when possible. Prewarming of towels and blankets can also be helpful in preventing excessive heat loss from the neonate.

Equipment SUCTION EQUIPMENT BULB SYRINGE SUCTION CATH NO 5 6 8 10 Fr 8 Fr FEEDING TUBE 20 ml SYRINGE MECONIUM ASPIRATOR

BAG-MASK EQUIPMENT FACE MASK ORAL AIRWAY OXYGEN

Equipment

CONT.

INTUBATION EQUIPMENT LARYNGOSCOPY-BLADE NO 0-1 BATTERY FOR LARYNGOSCOPE ETT NO 2.5 3.0 3.5 4.0 mm STYLET SCISSOR GLOVE

MISCELLANEOUS RADIANT WARMER-STETHOSCOPE-TAPESYRINGE-NEEDLE-ALCOHOL-UMBILICAL CATH

Initial Steps for Neonatal Resuscitation in Delivery Room ANTICIPATION ASSESSMENT OF ACTION 1.PREVENT HEAT LOSS Place the infant under an overhead radiant heater to minimize radiant and convective heat loss. Dry the body and head to remove amniotic fluid and prevent evaporative heat loss. This will also provide gentle stimulation to initiate or help maintain breathing.

Initial Steps for Neonatal Resuscitation in Delivery Room

CONT.

2.ABCDE STEP A-AIRWAY POSITION CLEAR AIRWAY-SUCTION MOUTH THEN NOSE

Initial Steps for Neonatal Resuscitation in Delivery Room

CONT.

B-BREATHING ADEQUACY 1.TACTILE STIMULATION slapping or flicking the soles of the feet rubbing the back gently Do not waste time continuing tactile stimulation if there is no response after 10 - 15 seconds.

2.FREE FLOW OXYGEN 3.PPV

Initial Steps for Neonatal Resuscitation in Delivery Room C-CARDIOVASCULAR RESUSCITATION D-DRUG -DIAGNOSIS E-ENVIRONMENT -EXTENDED CARE

CONT.

Resuscitation in the delivery room

PPV 1.INDICATION FOR PPV APNEA OR GASPING HR < 100 bpm CENTRAL CYANOSIS

2.BAG-Self inflating vs. flow dependent bag 3. Rate 40-60 bpm 4. Pressure used = a.  Initial breath after delivery = 30-40 cm H2O       b.  Normal delivery = 15-20 cm H2O        c.  Diseased Lungs =20-40 cm H2O

PPV CONT. 5. Technique/Trouble shooting problems of Bag mask ventilation a. Check for a good seal     b. Check for a patent airway      c. Are you using enough pressure ?

6.Checking for chest movement check mask position head position-hyperflexion or hyperextention secretion obstruction slighly open infant mount checking for pressure

Chest compression 1. Indications:  If after 15-30 seconds of positive pressure ventilation with 100% FIO2 the heart rate is a. below 60 bpm b.between 60-80 bpm and not increasing 2. Technique: a. 1 fingers breadth below nipple line, using 2 fingers        b. 1/2 to 3/4 compression depth        c. accompanied by ventilations, ratio is 3:1

METHOD

ENDOTRACHEAL TUBE INTUBATION 1.Indications for intubation:

a.  Prolonged bag and mask ventilation       b.  Bag and mask is ineffective       c. Tracheal suctioning

2.Tube size

Tube size Weight Gestational Age (ID mm) (gm) (weeks) 2.5 <1000 <28 3.0 1000-2000 28-34 3.5 2000-3000 34-38 3.5-4.0 >3000 >38

ดูว่าท่อหลอดลมอยู่ในตำาแหน่งท่ีเหมาะสมโดย 1.ฟั งปอดได้ยินเสียงเท่ากัน 2 ข้าง 2.ฟั งท่ก ี ระเพาะอาหารไม่ได้ยินเสียงลม 3.ทรวงอกเคล่ อ ื นไหวเท่ากัน 2 ข้าง

MEDITATION 1.Indication HR < 80 bpm despite 100% O2 and chest compression 30 sec No heart rate

Drug -adrenaline -volume expander -NaHCO3

-Dopamine

-Naloxone hydrochloride

Drug dosage Drug Epinephrine 1:10,000

Volume Expanders -NS or RL -5% Albumin -O-neg Blood Naloxone 0.4 mg/ml 1.0 mg/ml

Preparation 1 ml

40 ml

1 ml 1 ml

Dosage

Rate/Precautions

0.01-0.03 Give rapidly IV or ET mg/kg Repeat q 3-5 min 0.1-0.3 ml/kg (ET: dilute to 1-2 ml with NS) 10 ml/kg

Give IV over 5-10 min

0.1mg/kg 0.25ml/kg 0.1 ml/kg

Give rapidly IV or ET preferred

Drug dosage cont. Reserved for prolonged resuscitations only

Sodium Bicarbonate 20 ml (0.5 mEq/ml = 4.2% soln) 10 mlx2

Dopamine 100 ml (6 x weight in kg = mg of dopamine diluted to 100 ml)

2 mEq/kg Give slowly, over at least (4ml/kg) 2 min, IV ONLY, Infant must be ventilated

Continuous infusion by pump

ทารกที่ไม่ตอบสนองควรคิดถึง 1.inadequate ventilation: missplaced ETT,inadequate pressure,air leak syndrome

2.Shoke: asphyxia,hypovolumic,septic 3.Congenital anomalies: pulmonary hypoplasia,severe cardiac disease

THE END Thank you