5 Million neonatal deaths each year worldwide. 20% caused by neonatal asphyxia. Improvement of the outcome of 1 million newborns every year

Size: px

Start display at page:

Download "5 Million neonatal deaths each year worldwide. 20% caused by neonatal asphyxia. Improvement of the outcome of 1 million newborns every year"

Derick Norman
5 years ago
Views:

1 1

2 5 Million neonatal deaths each year worldwide 20% caused by neonatal asphyxia Improvement of the outcome of 1 million newborns every year

3 International Liaison Committee on Resuscitation (ILCOR) American Academy of Paediatrics American Heart Association

4 5-10% of all newborns require some degree of active resuscitation 1-10% of all newborns require assisted ventilation

8 Early application of nasal CPAP: Less intubation Shorter ventilation Less postnatal cortisone administration Intubation and administration of surfactant in the first 30 minutes after birth Immediate intubation in ELBW without prenatal betamethasone prophylaxis

9 Present in 12% of deliveries Suction of the mouth, nose and pharynx after delivery of the head not recommended any longer! Don t stimulate the infant!! Endotracheal suction only for depressed infants (apnoea, bradycardia, hypotony)

10 Defect or hole in the diaphragma that allows the abdominal contents to move into the chest cavity. Treatment is usually surgical

12 Anticipated COMMUNICATIONwith obstetricians for risk deliveries At least 1 person solely for care of the infant 1 experienced person must be immediately available

13 At least 2 experienced people 1 person for ventilation, 1 person for circulation A team of3 peopleis desirable (one leader)

14 Question Answer Reaction Number of fetuses? > 1 More staff Gestation? preterm ventilation Drugs? Yes ventilation Amniotic fluid colour? Bleeding? Meconium stained Placental bleeding Suction, intubation Fluids 14

16 Initial evaluation by visual inspection (vitality, meconium, preterm, respiration, colour of skin, ect.) Further assessment based only on: Respiration Heart rate Colour

17 1. Respiration: Gasping or apnoea 2. Heart rate: Stethoscope or umbilical pulsations > 100/min 3. Colour: Central cyanosis Pallor 4.??

18 One of the most important measures reducing neonatal mortality Warm, Draft-free place Heat source (radiant warmer/mother) Rapidly dry the skin and remove wet linen Use of plastic wrapping in preterm infants < 1500g 2 randomised and 3 observational studies

20 Supine or lying on the side Head in a neutral position Correct overextension or flexion (towel under the shoulders)

21 21

22 Vigorous infants don t need suction Before ventilation clear the airway! First mouth, then nose Avoid pharyngeal stimulation in the first minutes after birth Apnoea Bradycardia

23 Drying and suctioning is enough stimulation (20-30 seconds) Secondary stimulation by rubbing the back of flicking the soles If these efforts are not succesful, assume secondary apnoea and ventilate!

24 Increasing evidence that room air is as effective as 100% oxygenin resuscitation of newborn infants Meta-analysis: 100%-O2 vs. room air (Cochrane 2004): Less mortality in the room air-group No detrimental effects 100% Oxygen must be available! The goal is to achieve a normoxaemia! Administer oxygen in the case of persistent, central cyanosis

25 Indications: When after 30 seconds of stimulation the baby presents: Apnoea Gasping respirations Bradycardia < 100/min Persistent cyanosis despite 100% oxygen Most newborns can be ventilated adequately with bag and mask

26 26

28 Neopuff TM Ventilation using Neopuff TM

29 Higher pressure and longer inflation time during first breaths Chest expansion and increase in the heart rate are the most reliable signs of adequate ventilation Use a rate of 30-60/min (30-40) Avoid a hypocapnia Utilization of PEEP?

30 Bags should be notlarger than 750 ml Pressure-release valve set at cm H2O Round masks seal better in small preterm infants

31 If the ventilation is not adequate: Check the seal between mask and face Clear airway obstructions Decompress the stomach with a 8F gastric tube

32 Indications: Despite adequate technique, bag-mask ventilation remains ineffective Chest compressions are performed Endotracheal administration of medicaments Special circumstances Meconium aspiration Congenital malformations Extreme immaturity

33 33

34 Intubate orally Calculate the depth of the tube: Weight in kilograms + 6 cm Use a straight blade: Size 0 for preterm infants Size 1 for term infants

35 Check the right position of the tube: Symmetrical chest motion Symmetric breath sounds (axillae) Fog of moisture during exhalation Absence of gastric inflation CO2 measurement in exhaled air

36 Bradycardia is usually the result of hypoxemia! Ventilation is the key therapeutic measure! Chest compressions diminish the effectiveness of ventilation Don t initiate until adequate ventilation is established!

37 General indication: Heart rate < 60/min despite adequate ventilation with for 30 seconds

38 2 thumb-encircling technique seems to be more effective Compress 1/3 of the anterior-posterior diameter of the chest The compression should be shorter than the relaxation

43 Avoid simultaneous delivery of compression and ventilation! 3 compressions and then 1 breath 90 compressions and 30 breaths in a minute One second for the inspiration One second for 3 compressions

44 Epinephrine Naloxone Volume expanders Bicarbonate

45 The tracheal route is the most rapidly accessible (epinephrine) Umbilical vein Just under the skin level (blood returns) For all medicaments and volume expanders An intraosseous access can be an alternative

46 Hypoglycaemia in animals with asphyxia is associated with: Higher mortality Larger necrotic area in the brain Clinical studies: Worse neurological outcome in patients with asphyxia and hypoglycaemia In any case of resuscitation try to achieve a normal blood glucose level!

47 No controlled studies in newborn infants Worse neurological outcome in paediatric patients receiving high doses Indications: Bradycardia < 60/min despite 30 seconds of adequate ventilation and chest compressions

48 1 ml = 1 mg (1:1000) Dilute in 10 ml (1ml = 100 µg) (1:10000) Administer µg/kg (0,1-0,3 ml) i.v. Up to 100 µg/kg (1 ml) e.t. Repeat every 3-5 minutes No high doses i.v!

49 Suspect hypovolaemia when the infant doesn't respond to resuscitation No difference between crystalloids and albumine-containing solutions (3 randomised studies in newborn infants with arterial hypotension) Isotonic crystalloid solution (less expensive, less risk) O-neg red blood cells for haemorrhage 10 ml/kg in 5-10 minutes

50 Naloxon can theoretically increase the neurological damage due to asphyxia! Dose: 0.1 mg/kg i.v., s.c., i.m. Short half life!! Contraindicated in recent narcotic abuse of the mother!!

51 Drying (stimulation) always Suctioning secretions if not vital Oxygen if cyanosis is persistent

52 Apnoea HR < 100/min B : Breathing (ventilation) Bag and mask ventilation If ineffective, check the technique Consider endotracheal intubation

53 HR < 60/min C : Circulation Endotracheal intubation as soon as possible Chest compressions

54 HR < 60/min D : Drugs Epinephrine Repeat every 3-5 min, if necessary

55 Neonatal resuscitation Assess Measure Time A: Vital baby? Drying 30s Aspirate B: Apnoea/HF<100 Ventilation 30s C: HR<60 Intubation 30s Chest compressions D: HR<60 Epinephrine every 5 min

57 Holand 25ga Japan 21ga Canada 22 ga: parents' request 23-24ga: depending on the birth of newborn 25ga: resuscitation always with the exception of newborns with congenital lethal

58 Local protocols should dictate the procedures Protocols must be regularly reviewed and modified as necessary

59 In patients with borderline survival In patients with high rates of morbidity When the burden to the child is high

60 Ethically equivalent Initiation of resuscitation doesn'tmandate continued support Partial support can worsen the outcome Discontinue after 10 minutes of failed resuscitation

61 In situation in which a very high mortality and an unacceptable prognosis for the few survivors is expected: GA < 23 weeks Birth weight < 400g Proved trisomy 13 or 18 Anencephalia

62 QUESTIONS? 62

63 THANK YOU!! 63

Neonatal Life Support Provider (NLSP) Certification Preparatory Materials

Neonatal Life Support Provider (NLSP) Certification Preparatory Materials NEONATAL LIFE SUPPORT PROVIDER (NRP) CERTIFICATION TABLE OF CONTENTS NEONATAL FLOW ALGORITHM.2 INTRODUCTION 3 ANTICIPATION OF RESUSCITATION