10/13/2017. Newborn Care. Objectives. Cardiac Anatomy. Managing Transitional Physiology

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Newborn Care Managing Transitional Physiology Mary Coughlin MS, NNP, RNC-E President and Founder Caring Essentials Collaborative Boston, MA Objectives Upon

describe at least 3 evidence-based strategies to support these 5 essentials components of successful transition Cardiac Anatomy Classical Triad Preload the

[NB unique to cardiac muscle] Afterload - the load against which the ventricle must eject blood and is probably best thought of in terms of vascular resistance

Torsion - the concept of a wringing motion of contraction as a result oblique layers of fibers that twist the ventricle and squeeze blood towards outflow tract

1 Newborn Care Managing Transitional Physiology Mary Coughlin MS, NNP, RNC-E President and Founder Caring Essentials Collaborative Boston, MA Objectives Upon completion of the learning session participants will: The learner will list the 5 essentials components for successful neonatal transition The learner will describe at least 3 evidence-based strategies to support these 5 essentials components of successful transition Cardiac Anatomy Classical Triad Preload the initial stretching of cardiac muscle fibers prior to contraction Contractility ability of sarcomeres* to change their contractile force (independent of preload) [NB unique to cardiac muscle] Afterload - the load against which the ventricle must eject blood and is probably best thought of in terms of vascular resistance Additional Components Recoil - a rapid filling phase that occurs during the early stages of diastole in which blood is effectively suctioned into the ventricles Torsion - the concept of a wringing motion of contraction as a result oblique layers of fibers that twist the ventricle and squeeze blood towards outflow tract Rotation as blood enters the heart, it forms highly reproducible rotational flow patterns allowing it to slingshot into the ventricles in early diastole Finnemore et al

Functional Differences in Fetal Circulation Compliance 2 x that of the adult heart Passive vs Active Ventricular Filling is lower in the fetus Heart Rate higher in the fetus

from low-resistance placenta Closure of right-to-left shunts FO closes when LA pressure > RA pressure DA: left-to-right flow w/in minutes, closes over days Rapid decrease in

increased glucose needs Increased catecholamine levels to support blood pressure 2014 Caring Essentials Collaborative Morton & Brodsky 2016 Transitional Circulation in the

2 Functional Differences in Fetal Circulation Compliance 2 x that of the adult heart Passive vs Active Ventricular Filling is lower in the fetus Heart Rate higher in the fetus > reduced diastolic filling time Contractility reduced in the fetus, but increases over gestation Finnemore et al 2015 Transitional Physiology Increased SVR with separation from low-resistance placenta Closure of right-to-left shunts FO closes when LA pressure > RA pressure DA: left-to-right flow w/in minutes, closes over days Rapid decrease in pulmonary vascular resistance w/ onset ventilation Airway fluid clears via active Na+ absorption & changes in airway pressure w/ ventilation Increased metabolic rate > increased glucose needs Increased catecholamine levels to support blood pressure 2014 Caring Essentials Collaborative Morton & Brodsky 2016 Transitional Circulation in the Preterm Infant Low inherent contractility Poor tolerance of high systemic vascular resistance Impaired diastolic filling Persistence of fetal shunt pathways Finnemore et al

Decrease in pulmonary vascular resistance and

Endocrine support of the transition Hillman

3 Essentials for Successful Transition 1. Clearance of fetal lung fluid 2. Surfactant secretion, and breathing 3. Transition of fetal to neonatal circulation 4. Decrease in pulmonary vascular resistance and increased pulmonary blood flow 5. Endocrine support of the transition Hillman et al 2012 Neonatal Golden Hour Sharma 2017 Delayed Cord Clamping Vali et al

Delayed Cord Clamping Delivery Room Checklists Use a checklist to prepare for all high-risk

debriefings, and other methods Obtain a pulse oximetry reading by 2 min of life and continuously

temperature Optimize initial respiratory support Lee et al 2014 Best Practices in Supporting

Environment State Level of consciousness Spontaneous respirations Vagal tone Pain & Stress

4 Delayed Cord Clamping Delivery Room Checklists Use a checklist to prepare for all high-risk neonatal resuscitations Improve teamwork and communication in the delivery room using briefings, debriefings, and other methods Obtain a pulse oximetry reading by 2 min of life and continuously monitor the heart rate and oxygen saturation (all VLBW or infants requiring PPV) Maintain normal temperature Optimize initial respiratory support Lee et al 2014 Best Practices in Supporting Transition (External) Temperature Light Sound (Internal) Blood volume Saturation Perfusion Environment State Level of consciousness Spontaneous respirations Vagal tone Pain & Stress Prevention Assessment Management Presence Proximity vs. Separation Family ADLs Position Microbiome Nutrition Coughlin

Discussion References Coughlin, M. (2016). Trauma-informed care in the NICU. New York, NY.: Springer Publishing Company. Finnemore, A. & Groves, A. (2015).

Physiology of transition from intrauterine to extrauterine life. Clinics in Perinatology, 39(4), 769-783. References Katheria, A.C., Brown, M.K., Rich, W.

Lee, H.C., Powers, R.J., Bennett, M.V., et al. (2014). Implementation methods for delivery room management: a quality improvement comparison study.

5 Discussion References Coughlin, M. (2016). Trauma-informed care in the NICU. New York, NY.: Springer Publishing Company. Finnemore, A. & Groves, A. (2015). Physiology of the fetal and transitional circulation. Seminars in Fetal & Neonatal Medicine, 20, Hillman, N., Kallapur, S.G., & Jobe, A. (2012). Physiology of transition from intrauterine to extrauterine life. Clinics in Perinatology, 39(4), References Katheria, A.C., Brown, M.K., Rich, W., & Arnell, K. (2017). Providing a placental transfusion in newborns who need resuscitation. Frontiers in Pediatrics, 25 January, doi: /fped Lee, H.C., Powers, R.J., Bennett, M.V., et al. (2014). Implementation methods for delivery room management: a quality improvement comparison study. Pediatrics, 134(5), e1378-e1386. Morton, S. & Brodsky, D. (2016). Fetal physiology and the transition to extrauterine life. Clinics in Perinatology, 43(3),

6 References Sharma, D. (2017). Golden hour of neonatal life: Need of the hour. Maternal Health, Neonatology, and Perinatology, 3(16), Vali, P., Mathew, B., & Lakshaminrusimha, S. (2015). Neonatal resuscitation: evolving strategies. Maternal Health, Neonatology, and Perinatology, 1(4),

Neonatal Resuscitation. Dustin Coyle, M.D. Anesthesiology

Neonatal Resuscitation. Dustin Coyle, M.D. Anesthesiology Neonatal Resuscitation Dustin Coyle, M.D. Anesthesiology Recognize complications Maternal-fetal factors Maternal DM PIH Chronic HTN Previous stillbirth Rh sensitization Infection Substance abuse/certain