Newborn resuscitation programmeNRP Renu Singh Burden of the
Newborn resuscitation programme(NRP) Renu Singh
Burden of the problem Birth asphyxia 23% of the 1 million neonatal deaths in India Long term neurological complications Death NNR (Neonatal resuscitation) : simple, inexpensive, cost effective method • Problem: NNR often not initiated, incorrect use of methods • • •
The Golden minute • The “first minute after birth” • Anxiety for parents, health providers • Period of transition from intrauterine to extra uterine life • Major: No/minimal assistance • 10%: assistance to begin breathing at birth • 1%: extensive resuscitative measures • First Golden Minute Project: skill based training
Successful NNR: factors • • Anticipation: call a skilled personnel Adequate preparation Accurate evaluation, algorithm based Prompt initiation of support
Resuscitation: initial steps • • • Provide warmth Head position “ sniffing position” Clearing the airway Drying the baby Tactile stimulation for breathing
Sniffing position Extension of neck with help shoulder roll: : to open the airway
Newly born infant • Specifically the Infant at time of birth • (A)Do not require resuscitation • (B)Require resuscitation • Rapid assessment of 3 characters – Term gestation? – Crying or breathing? – Good muscle tone?
Newly born infant Term gestation? Crying or breathing? Good muscle tone? YES : Do not require resuscitation – Dry – Skin to skin contact – Covered with dry linen to maintain temperature – Ongoing observation: breathing, color, activity
Newly born infant Term gestation? Crying or breathing? Good muscle tone? NO : require resuscitation; One/more of the following actions in sequence – Initial steps in stabilization(warmth, clear airway, dry, stimulate) – Ventilation – Chest compressions – Administration of epinephrine& /or volume expansion
AAP Algorithm
IAP Algorithm
The golden minute • <30 seconds: complete initial steps • • Warmth Drying Clear airway if necessary Stimulate • 30 -60 seconds: assess 2 vital characteristics • Respiration (apnea/gasping/labored/unlabored) • Heart rate (<100/>100 bpm)
<60 seconds of birth • If gasping/apnea If heart rate<100 beats per minute PPV( positive pressure ventilation) Spo 2 monitoring by pulse oximeter • Simultaneous evaluation of 3 vitals • Heart Rate, • Respiration, • oxygenation status
Targeted SPO 2 after birth 1 minute 60 -65% 2 minutes 65 -70% 3 minutes 70 -75% 4 minutes 75 -80% 5 minutes 80 -85% 10 minutes 85 -90%
Increase in heart rate is the most sensitive indicator of a successful response to each step practiced
PPV: Positive pressure ventilation Form of assisted ventilation Needed when there is no improvement in HR Also assess chest wall movements Should be delivered at rate of 40 -60 breaths /min, maintain HR>100 /min • Devices: BMV, ET (endotracheal tube), LMA(laryngeal mask airway) • •
Bag & mask ventilation
Endotracheal tube • Initial endotracheal suctioning of non vigorous meconium stained newborn • If BMV is ineffective/prolonged • When chest compressions are performed
Endotracheal tube
LMA(Laryngeal mask airway) • Fits over laryngeal inlet • Done when BMV is unsuccessful • When tracheal intubation is unsuccessful or not feasible
LMA(Laryngeal mask airway)
Chest compressions • Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec • Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest • 2 techniques: – 2 thumb-encircling hands technique – Compression with 2 fingers , second hand supporting the back – 3: 1 ratio: : [ 90 comp: 30 ventilations]
Chest compressions
medications • Rarely indicated • Most important step to treat bradycardia is establishing adequate ventilation • HR remains <60 bpm, despite adequate ventilation(ET) with 100% Oxygen & chest compressions • Epinephrine or volume expansion or both
Epinephrine • Route of administration: intravenous(IV), ideal • Recommended dose: 0. 01 -0. 03 mg/kg per dose • Desired concentration: 1: 10, 000 0. 1 mg/ml
Volume expansion • • Suspected or known blood loss Isotonic crystalloid solution Blood Dose calculation: 10 ml/kg
Asses if resuscitation is needed, keep warm, position, clear, dry, stimulation Give oxygen as necessary Positive pressure ventilation Endotracheal intubation Chest compression drugs
Post resuscitation care • • Needed for those who required PPV At risk of deterioration Need monitoring , evaluation NICU may be necessary
NNR : not indicated • • • Conditions with certainly early death Extreme prematurity(GA<23 weeks) Birth weight<400 g Anencephaly Chromosomal abnormality: Trisomy 13
NNR: nearly always indicated • • High rate of survival Acceptable morbidity GA≥ 25 weeks Those with most congenital malformations
NNR? • Conditions associated with uncertain prognosis • Survival borderline • Parental desires concerning initiation of resuscitation should be supported
Discontinuing resuscitative efforts • Newly born baby with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes
MCQ 1 For successful neonatal resuscitation following is/are needed except: 1. Anticipation 2. Adequate preparation 3. Skilled personnel 4. Delayed initiation of support
MCQ 1 • For successful neonatal resuscitation following is/are needed except: 1. Anticipation 2. Adequate preparation 3. Skilled personnel 4. Delayed initiation of support
MCQ 2 • Following are true in relation to initial steps of neonatal resuscitation except 1. Provide warmth 2. Tactile stimulation 3. Clear airway and intubation 4. Drying the baby
MCQ 2 • Following are true in relation to initial steps of neonatal resuscitation except 1. Provide warmth 2. Tactile stimulation 3. Clear airway and intubation 4. Drying the baby
MCQ 3 • The following is the primary measure of adequate ventilation 1. Chest wall movement 2. Improvement in heart rate 3. Pink extremities 4. Spo 2 of 80%
MCQ 3 • The following is the primary measure of adequate ventilation 1. Chest wall movement 2. Improvement in heart rate 3. Pink extremities 4. Spo 2 of 80%
MCQ 4 • Endotracheal intubation may be indicated at several points during neonatal resuscitation except 1. If BMV is ineffective 2. When chest compressions are performed 3. Endotracheal suctioning of vigorous meconium stained newborns 4. For special resuscitation circumstances like extremely LBW
MCQ 4 • Endotracheal intubation may be indicated at several points during neonatal resuscitation except 1. If BMV is ineffective 2. When chest compressions are performed 3. Endotracheal suctioning of vigorous meconium stained newborns 4. For special resuscitation circumstances like extremely LBW
MCQ 5 • The recommended compression to ventilation ratio in neonatal resuscitation is 1. 2: 1 2. 3: 1 3. 4: 1 4. 5: 1
MCQ 5 • The recommended compression to ventilation ratio in neonatal resuscitation is 1. 2: 1 2. 3: 1 3. 4: 1 4. 5: 1
MCQ 6 • The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation 1. 0. 01 -0. 03, IV 2. 0. 01 -0. 03, IM 3. 0. 03 -0. 05, 1 V 4. 0. 05 -0. 1, IV
MCQ 6 • The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation is 1. 0. 01 -0. 03, IV 2. 0. 01 -0. 03, IM 3. 0. 03 -0. 05, 1 V 4. 0. 05 -0. 1, IV
MCQ 7 • Recommended method/clinical indicator of confirming ET placement is 1. Condensation in ET 2. Chest movement 3. Equal breath sounds on auscultation 4. Exhaled C 02 Detection
MCQ 7 • Recommended method/clinical indicator of confirming ET placement is 1. Condensation in ET 2. Chest movement 3. Equal breath sounds on auscultation 4. Exhaled C 02 Detection
- Slides: 47