Neonatal resus ANZCOR Flashcards
Discuss planning of neonatal resus
Personnel
-ideally at least one person should be responisble for the care of each newborn
Equipment
AS listed in the next question
Environament
1) temperature:
- newborns are at risk of both hypothermia and hyperthermia prevention of both is key
- the newborn should be cared for in warm draft free area.
- For term and near term newborn infants drying and removing the wet linen reduces heat loss, when resus not required the mother body can keep the newborn warm. If resus needed place newborn under radiant warmer
- Inducing hypothermia in newborns 35+ with evolving moderate to severe hypoxic encphaloaphty will reduce the degree of brain injury and should be discussed
Check all resus equipment prior to resus
APGAR scores will need to be recored at 1 and 5 minutes and than 5 minutely until HR and breathing are normal
Discuss equipment needed for neonatal resus
General
- firm horizonatl padded resus surface
- ambient heater
- clock with time in seconds - APGAR
- warmed towels or simialr covering
- polyethylene bag or sheet big enough for a newborn less than 32 weeks gestation or <1500g
Airway
- Suction apparatus and catheters
- OPA size 0 and 00
- Intubation
- – Mill blade straight 00, 0 1
- –ETT size 2.5-4mm uncuffed
- –Stylet or introducer
- Co2 monitor
- Mec suction device
- magill forceps
- LMA size 1
Breathing
- Face mask
- Positive pressure ventilation device
- – T piece
- –Self inflating bag (<300ml) with removable o2 reservious
- NGT
C
- umbi venous chatheter kit
- perpierhal IV kit
- IO
- Dressing and syringes
D:
- ADrenlaine 1:10000 concentration 100 mic/ml
- Sodium chloride
- Blood
Discuss cord clamping
Deffering cord clamping for 30-60 seconds when compared to immediate clamping is asscoiated with increase placental transfusions and increased CO and higher more stable neontal BP.
Form term and late preterm infants borrn at > 34 weeks who are vigorous or deemed not to require immediate resus at birht ANZCOR suggest later clamping of the cord at >60 seconds
If born < 34 weeks not requiring resus cord clamping at > 30 seconds
Nil recommendations for those requiring resus
Discuss recommendation for management of the airway in neonates
1) the newborn who needs resuscitation should be palced on their back with the head in a neutral position - particualrly if there has been signifiacnt moulding during passage may require blanket or towel under shoulder to achieve this
- if resp efforts are present but not producing effective ventilation or the airway is obstructed consideration should be given to other methods to imrpove airway patentcy - jaw thrust, opening of motuh or in some cases suction
2) Suction only used if infants shows obvious signs of obsruction to either spont breathing or PPV
3) aspiration of MEC before or during birht can cause Mec aspiration sydnrome and all newborns born thorugh mec should be regarded as at risk
4) Vigorous newborns exposured to EMC to not require routine endotracheal suctioning or direct laryngoscopy
5) for new born requiring assisted ventilation the primary measure of success is a sustianed increase in HR – spo2 should also rise - all other normal indicators are still valid
6) If there is little or no visible chest wall movement vent technique should be improved - assuring facemask fits well with minimal leak and the head and jaw position is good. Two person technique. If still no success inflating pressure must be increased until chest wall movement is seen. Suctioning of the airway is somtimes required
Occasionally OPA are useful if the baby is particuarly micronathic or macroglossic
7) for spont breathing neonates with resp distress a trail of CPAP may be considered
8) for commencing intermittent PPV in newborns the suggested initial rpessure are 30cm H20 for term and 20-25 cm H2o for premature - on devices that can deliver peep 5cmh2o is the suggested initial setting
9) higher pressure may be required to aerate the lungs during the first few inflation than for subsequent . The minimal inflation required to achieve visible chest wall movement and an increase in heart rate should be used.
10) subsequent ventilation should be provided at a RR of 40-60 with an IT of 0.3-0.5
11) if unable ot achive adequte venilation with the above then intubation should be considered
12) pulse ox on the right arm is recommended during resus with the following targets
-1min 60-70%
-2 min 65-75%
-3 min 70-90%
4 min 75%
5 min 80%
10 min 85-90%
13) air should be used initially wiht supplemental o2 reserved for htos whose saturation do not meet the lower end of the targes above
Discuss tracheal intubation and ventilation in the new-born
Indications
- Ventilation via a facemask has been unsuccessful or prolonged
- special circumstances such as congenital diaphragmatic hernia or extremely low birth weight
- new-born without a detectable heartbeat consideration should be given to intubation as soon as possible after birth
Discuss ETT size and miller blade for intubation of infants
ETT size - uncuffed >1 kg size 2.5 1-2 kg size 3 2-3 kg size 3.5 >3kg size 3.5-4
Miller
Term - size 1 straight
preterm - size 0 straight
Very low birth weight – size 00 straight
Weight + 6cm as a rough guide for depth
Discuss verification of ETT
Improved HR and spo2 chest rise and fall co2 trace - false - ve if very low pulmonary flow, CXR US
Discuss LMA
Can be used in children >2kg and >34 weeks – size 1 is suitable for up to 5 kg
used when ETT has failed
Discuss chest compression in neonatal resus
Indications for chest compression
- HR >60 despite adequate assisted ventilation provided for 30 seconds
- as ventilation is the most effective action in a newborn and because compression are likley to compete with the performance effective ventilation should be ensured prior to compression
- once started should have as littel interruption as possible
Should be centred over the lower third of the sternum should compress the chest one third of the AP diameter - two thumbs on the lower third of the sternum for neonate 3:1 ratio at 120BPM
If compressions required fio2 should be increased to 100%
Discuss access and drugs in neonatal resus
Umbilical vein is the suggested IV route for adrenaline and it can also be used for fluid admin
If nil vascular access able to obatined ETT adrenaline is an option
Peripheral IVC is viable
IO -not common in neonates due to readily avialable umbilical catheter the fragility of small bones and small IO space - can be used if umbi and peripehral access not aviailable
DRUGS
- if HR lower tahn 60BPM after optimisation of venitlaiton and chest compression than IV adrenaline should be given
- 10 - 30 mic/kg of adrenaline every 3-5 minutes
Fluids
- Can trail a 10ml/kg bolus if suspceted fluid or blood loss – should be followed by product if occult bleeding is suscpected at 10ml/kg
Discuss neonatal resus in special cirumstances
1) congenital upper airway obsturciton
- a newborn who is pink when crying but cyanotic at rest should be suspected of choanal atresia or other upper airwya obsturction
- an oral airway may provide adequate relief of the obsturciton
2) congenital diaphragmatic hernia
- should not recieve BVM as is likley to make respiratory status worse
- early intubation or supraglottic device should be sued.
3) unexpetcted congential anomalies
- unless prior discussion should recieve full resus
4) pneumothorax
- rare but should be conisdered will need decompression
6) pleural effusion or ascites (inclyding foetal hydrops)
- Higher ventilation pressure often needed
- somtimes emergent thoraco/paracentesis is somtimes required
7) sepsis - cover
8) congenital heart disease
9) abdo wall defect
- gastroschisis or a large omphalocoele require special consideration to protect exposed abdominal contents from truama, dyring and heat loss or contimation. a polyethylene wrap or bag cna be used to enclose the abdomen or the whole lower body in order to reduce drying.
- NGT
- Again if resp support needed positive pressure without ETT can cause distention and reduction in blood flow leading to risk of ischaemia – early intubation should be considered
