PEDIATRICS

BIOETHICS 23

M.02L NEONATAL RESUSCITATION  Blood oxygen levels increase

Dr. Balud | March 13, 2020  Pulmonary blood vessels relax
 Ductus arteriosus constricts
OUTLINE  Blood flow through lungs increases to pick up oxygen
I. Neonatal Resuscitation  Pulmonary arterioles dilate
II. Transition to Extrauterine Life  Pulmonary vascular resistance decreases
III. Pre-resuscitation Preparation  Pulmonary blood flow increases
IV. Birth and Initial Steps of Resuscitation
V. Positive Pressure Ventilation NORMAL TRANSITION
VI. Important Points in Neonatal Resuscitation  Fluid absorbed in alveoli
 Umbilical vessels constricts → increase BP
 Blood vessels in the lungs relax
I. NEONATAL RESUSCITATION
NEONATAL DEATHS WHAT CAN GO WRONG DURING TRANSITION?
 45% of under-five deaths in 2015  Lack of ventilation → sustained constriction of pulmonary
 35% of under-five deaths in 2015 arterioles → prevents oxygenation of systemic arterial blood
→ cyanosis
WHY LEARN NEONATAL RESUSCITATION?  Prolonged lack of adequate perfusion and oxygenation to
 Birth asphyxia 23% of approximately 4M neonatal deaths/yr baby’s organs:
worldwide o Brain damage
 For many NB appropriate resuscitation not readily available o Damage to other organs
o Improved by more widespread use of resuscitation o Death
techniques
IN UTERO OR PERINATAL COMPROMISE
WHICH BABIES REQUIRE RESUSCITATION? A. PRIMARY APNEA
 ALL newborns (NB) require assessment  When a fetus/newborn becomes deprived of oxygen:
 ~10% of NB requires some assistance to begin initial period of rapid breathing:
breathing at birth o Primary apnea
 <1% need extensive resuscitative measures to o Bradycardia
survive  RESPONDS WITH TACTILE STIMULATION

II. TRANSITION TO EXTRAUTERINE LIFE B. SECONDARY APNEA

FETAL PHYSIOLOGY  If oxygen deprivation continues
IN THE FETUS: o Secondary apnea
 Alveoli are filled with fluid o Continued fall of HR and BP
 Fetal gas exchange is at the level of placenta  Secondary apnea CANNOT be reversed by tactile
 Fetus are adapted to low po2 (20 mmHg) stimulation
 Pulmonary arterioles are constricted o Should be provided with POSITIVE PRESSURE
 Pulmonary blood flow is diminished VENTILATION
 Blood flow is directed across ductus arteriosus o RAPID IMPROVEMENT IN HEART RATE

III. PRE-RESUSCITATION PREPARATION

PREPARING FOR RESUSCITATION
PERSONNEL AND EQUIPMENT:
 ALL deliveries should be attended by at least 1 person
whose only responsibility is the baby and who is capable of
initiating resuscitation. Either that person or someone else,
who is available immediately, should have the skills required
to perform a complete resuscitation
 Prepare necessary equipment:
o Turn on radiant warmer
o Set delivery room temperature to 26°C
FETAL CIRCULATION
o Check the equipment
LUNGS AND CIRCULATION AFTER DELIVERY
 Fetal lung fluid leaves alveoli
PRE-RESUSCITATION BRIEFING
o Hematogenous
 Assess perinatal risk factors
o Lymphatics
 Identify team leader
o Aspiration
 Delegate tasks
o Vaginal squeeze  Identify who will document events
o Expelled  Determine what supplies & equipment will be needed
 Lung expands with air  Identify how to call for additional help

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 Pulse oximetry
 During resuscitation, it is recommended that an oximeter
TEAM LEADER probe be attached to newborn’s right hand or wrist to detect
 Mastery of the Neonatal Resuscitation Program (NRP) Flow preductal saturation
Diagram o May not function well if HR low → ECG monitor
 Effective leadership skills – good communication skill
o Clear directions
o Share information
o Delegate responsibilities ensuring coordinated care
o Maintaining professional environment
 Remain aware of entire clinical situation; maintain view of
big picture; not distracted by single activity

PRE-BIRTH QUESTIONS
1. What is the expected gestational age?
2. Is the amniotic fluid clear? o PEA treated similarly as asystole
3. How many babies are expected
4. Are there additional risk factors? INDICATION OF OXYGEN SUPPLEMENTATION
 When the O2 sats remain below the target range for baby's
IV. BIRTH AND INITIAL STEPS OF RESUSCITATION age
SIGNS OF A COMPROMISED NEWBORN  If baby is breathing:
 Poor muscle tone o Free flow O2 via flow-inflating bag or T-piece
 Depressed respiratory drive resuscitator
 Bradycardia o If prolonged supplementation needed: heat and
 Low blood pressure humidify
 Tachypnea  If baby has labored breathing or O2 says persistently remain
 Cyanosis below the target, consider:
o PPV
QUESTIONS TO ANSWER o CPAP via flow-inflating bag or T-piece resuscitator
 Is the baby term (GESTATION)? attached to mask
 Is the baby breathing or crying (BREATHING)?  Should only be considered if baby is breathing, HR
 Is the baby active (TONE)? at least 100 BPI
 If any of these is answerable by NO, proceed to the next
step HOW DO YOU GIVE SUPPLEMENTAL OXYGEN?
 One can begin resuscitation with room air (21% FiO2)
INITIAL STEPS OF RESISCITATION  Gradually increase the oxygen requirement using O2
 Radiant warmer switched on, temperature set at BLENDER, guided by the TARGET saturation according to
26°C age in minutes
 Provide warmth  Free flow oxygen delivered via:
 Position o O2 mask
 Suction airways as necessary o Flow inflating bag and mask
o Sniffing position o O2 tubing held close to baby’s mouth & nose
o Mouth before nose o T-piece resuscitator
o Wipe with cloth; bulb syringe
 Dry (remove wet linen) TARGETED PREDUCTAL SPO2
 Stimulate the baby to breath AGE IN MINUTES TARGETED O2 SAT
o Rub the spine 1 60 - 65%
o Flick/slap the soles 2 65 - 70%
 Rewarm and assess baby 3 70 - 75%
4 75 - 80%
VIGOROUS BABY 5 80 - 85%
 Strong respiratory efforts 10 85 - 95%
 Good muscle tone
 HR >100 bpm WHEN TO STOP GIVING FREE FLOW OXYGEN?
o Assume that a baby who is crying and with good tone  No more central cyanosis
has a HR of >100 bpm  Oximetry saturations are above 85-90%
 If cyanosis or oxygen saturation <85% persists despite
WHAT TO EVALUATE administration of FFO, baby may have significant lung
 Heart rate disease
o Stethoscope; 6 sec (x 10)
 Breathing/crying

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 If ventilation adequate and baby remains cyanotic or oxygen increasing

saturation <85%, consider congenital heart disease or HR not increasing,  Continue PPV that moves the
primary pulmonary hypertension chest is moving chest
 Repeat assessment after another
MECONIUM-STAINED FLUID 15 sec of PPV that moves the
 Meconium-stained fluid & vigorous baby chest
o Stay with mother, perform routine care (EINC) HR not increasing,  Announce chest isn't moving
o Clear airway with bulb syringe chest is NOT moving  Perform ventilation corrective
 Meconium-stained & non-vigorous baby steps until you achieve chest
o Bring to radiant warmer movement
o Perform initial steps (clear airway with bulb syringe)  Alert team + chest movement
o If baby is not breathing or HR <100 bpm after initial  Continue PPV that moves chest
steps, do PPV  Reassess after 30 sec of PPV
that moves the chest
V. POSITIVE PRESSURE VENTILATION (PPV)
INDICATIONS OF PPV: VENTILATION CORRECTIVE STEPS
 Apnea or gasping  Check the following:
 HR <100 bpm o M: Mask readjustment
 Breathing baby with HR >100 bpm but persistently o R: Reposition head of baby
desaturating despite targeted O2 saturation o S: Suction secretions
o O: Open mouth
START PPV o P: Pressure adjustment (increase, not more than 40)
 Baby is not breathing (apnea) or if baby has gasping o A: Alternate airway
respirations
 Baby appears breathing, but HR <100 bpm SECOND HEART RATE ASSESSMENT
 Baby has labored breathing and HR <100 bpm HR >100 bpm  Continue ventilating
 Baby appears nonvigorous, meconium stained after  If HR consistently >100 bpm
performing initial steps of resuscitation  Adjust oxygen concentration
 Gradually decrease rate & pressure
A. BREATHING of PPV
 VENTILATION of the lungs is the single most important  Observe for effective spontaneous
and effective step in cardiopulmonary resuscitation of a respirations
compromised newborn HR >60 but <100  Continue ventilating as long as baby
bpm shows steady improvement
BAG AND MASK EQUIPMENT  Monitor O2 sat and adjust O2
 Mask should cover the chin
concentration to meet target sats
 Mouth and nose bridge  If this rate of HR remains, quickly
 Anatomic vs round reassess ventilation technique
 Cushioned vs non-  Monitor HR, chest movement,
cushioned RR, O2 sats
HR <60 bpm  Quickly reassess ventilators
technique
FREQUENCY OF VENTILATION
 Adjust O2 concentration to meet
 40 - 60 cycles/min
target saturation
 Breath … 2… 3…, breath… 2… 3…
 If not done already, insert alternative
 Begin with peak inspiratory pressure of 20-25 cm H 2O; full
airway
term 30-40 cmH2O
 Call for additional help
 PEEP: begin with 5 cmH2O
 If HR remains < 60 after 30 sec of
PPV that moves the chest through
SIGNS OF EFFECTIVE VENTILATION:
alternative airway, increase O2
 Rapid improvement of HR, color, and muscle tone
concentration to 100%, begin chest
compression
SIGNS OF IMPROVEMENT IN THE NEWBORN:
 Improved heart rate, breathing, color, muscle tone, and
ALTERNATIVE AIRWAYS:
oxygen saturation
 Laryngeal masks
 Endotracheal tube
FIRST HEART RATE ASSESSMENT
Weight AOG ET Size
 After 15 sec of initiating PPV, check if HR is increasing:
<1 <28 2.5
HR increasing  Continue PPV then recheck after
1-2 28-34 3.0
another 15 sec
>2 >34 3.5
HR NOT increasing  Asst. should announce HR not

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B. CIRCULATION  If after epinephrine administration and there is still poor

 Provide CHEST COMPRESSION as you continue PPV in a response:
coordinated fashion o Recheck ventilation
 Once baby requires chest compression, INTUBATE the o Recheck effectiveness of chest compression
trachea o Recheck intubation
Depth (Tip to lip) wt in kg + 6 o Manner of epinephrine deliver
Internal diameter: <1 kg 2.5  Consider volume loss
1 – 2 kg 3  If with previous history of blood loss (abruptio, previa)
>2 kg 3.5 or 4 considering giving plasma expanders:
 Locate the site of compression: Plain NSS
o Run your fingers along the lower edge of the rib cage Alternative Plain LRS, O Rh (-) fresh whole blood
until you locate the xiphoid process Route Intravenous
o Draw an imaginary line between the nipples Dose 10 ml/kg
o Place your compressing finger on the sternum between Rate 5-10 mins
the xiphoid process and below the imaginary nipple line VI. IMPORTANT POINTS IN NEONATAL RESUSCITATION
 Compress 1/3 of the AP diameter of the chest  Most important and effective action in neonatal resuscitation
o One cycle: 3 compressions + 1 ventilation is VENTILATION of the lungs
o 1 minute: 90 compressions + 30 ventilations  Effective PPV in secondary apnea usually results in rapid
o Continue doing this for a duration of 60 seconds improvement of the heart rate
o Cadence: and…1… and… 2… and… 3… and… breathe…  If HR does not increase with PPV, ventilation may be
and 1… inadequate and/or chest compressions and epinephrine may
be necessary
TWO-THUMB TECHNIQUE (A)  HR <60 bpm: additional steps may be needed
 Most preferred  HR >60 bpm but <100 bpm: stop compression, continue
 Less tiring PPV
 Thumbs either on top of each other/side by side; other  HR >100 bpm and breathing: PPV may be stopped
fingers encircle the baby’s chest  HR >100 bpm but not breathing effectively or breathing
 Better control of the depth of compression with labor: continue PPV
 Majority, but not all, of neonatal resuscitation can be
anticipated by identifying antenatal and intrapartal risk
factors

ALWAYS NEEDED Assess baby’s risk for requiring

BY ALL NEWBORNS resuscitation
Provide warmth
Position, clear airway, if required
Dry, stimulate to breath
NEEDED LESS Give supplemental oxygen as
FREQUENTLY required
Assist ventilation with positive
TWO-FINGER TECHNIQUE (B) pressure
 Better for small hands Intubate the trachea
 One hand act as compressor; the other hand on the back act RARELY REQUIRED Provide chest compressions
as cardiac board BY NEWBORNS Administer medications
 Fingers tend to be displaced from the chest; need to keep
relocating the site of compression to resume compression

C. EVALUATE END
 Breathing
 Heart rate (if <60 bpm, proceed to the next step)

D. DRUGS/MEDICATIONS
 Proceed to insertion of umbilical venous catheter
 Administer Epinephrine:
Route Intravenously (endotracheally while
inserting umbilical venous catheter)
Concentration 1:10,000
Dose 0.1 to 0.3 ml/kg (intravenously); 0.5 to
1 ml endotracheally
Rate Rapid
Interval 3-5 mins

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