NEONATAL RESUSCITATIONRessa Novita Afandidr. Irman Permana, Sp.A , M.Kesdr. Tatan Tandubela, Sp.A, M.Kes

ASPHYXIA Asphyxia neonatorum is defined as a reduction of oxygen delivery and an accumulation of carbon dioxide owing to cessation of blood supply to the fetus around the time of birth.Asphyxia is reserved to describe a neonate with all the following conditions:

Profound metabolic / mixed acidosis (pH < 7.0)APGAR score 5 minutes : 0-3 Neonatal neurologic manifestationsMulti-system organ dysfunction

APGAR SCORES Give informations about condition of the baby and rescucitative efforts

It is not to determine whether the baby needs rescucitation

APGAR ScoresSign Score = 0 Score = 1 Score = 2----------------------------------------------------------------------------------------------------APPEARANCE Blue all over, Acrocyanosis Pink all over(color) or pale

PULSE Absent Below 100 Above 100(heart rate)

GRIMACE No response Grimace or Good cry(reflex irritability) weak cry

ACTIVITY Flaccid Some flexion of Well flexed, or active (muscle tone) extremities movements of extremities RESPIRATIONS Absent Weak, irregular, Good crying or gasping

============================================The APGAR score should be assigned at one minute and five minutes, finding the total score (0-10) at each time by adding up points from the table above. Continue to assign scores every five minutes thereafter as long as the APGAR score is less than 7.

EtiologyHigh Risk FactorsMaternal factor: hypoxia, anemia, diabetes, hypertension, smoking, nephritis, heart disease, too old or too young,etc Delivery condition: Abruption of placenta, placenta previa, prolapsed cord, premature rupture of membranes,etc Fetal factor: Multiple birth, congenital or malformed fetus,etc

Pathophysiology When fetal asphyxia happens, the body will show a self-defended mechanism which redistribute blood flow to different organs called inter-organs shunt in order to prevent some important organs including brain, heart and adrenal from hypoxic damage.

Fluid replaced by air in alveoliAirFirst breathSecond breathSubsequent breathsFetal lung fluidWhat normally happens at birth to allow a baby to get oxygen from the lungs ?RESPIRATORY SYSTEM TRANSITION

The physiology of asphyxia

Primary apneaSecondary apneaHeart RateBlood pressure

Degree of asphyxia: Apgar score 8~10: no asphyxia Apgar score 4~8: mild/cyanosis asphyxia Apgar score 0~3: severe/pale asphyxia

PREPARATIONEndotracheal tube

The appropiated-sized tube

Tube size(mm) (Inside diameter)Weight (g)Gestational age(wks)2,5< 1000< 283,01000 - 200028 - 343,52000 300034 383,5 4,0> 3000> 38

Non Re-breathing bag valve

Re-breathing bag valve

Oxygen Reservoir

Characteristics of resuscitation bag used to ventilate newborns:Size of bag: 750 mLNewborn require : 15-25 mL tiap ventilasi (5-8 mL/kg)Capable delivering 90%-100% oxygenWithout reservoar O2 concentration to baby: 40%With reservoar O2 concentration to baby: 90%-100%Appropriate-sized masksCover the chin, mouth and nose but not eyes

MASKSizeRimsShaped

Giving Oxygen12

Giving Oxygen 3

Assess babys response to birthInitial Steps in resuscitationResuscitation Bag and mask Chest compressions + Bag and mask Medications

Always needed by newborns

Needed less frequently

Rarely needed by newbornsWhich babies require resuscitation

THE RESUSCITATION FLOW DIAGRAM

ASSESSMENT (IN FEW SECONDS) assessed for these questions

1. Term gestation? 2. Breathing or crying?3. Good muscle tone?

Routine care

Provide warmth Clear air way Dry EvaluationBirthYes

Determine if a baby needs rescucitation in few seconds: Term gestation?

2. Breathing or crying ?

Assass whether the baby breathing spontaneously

No efforts intervension

Gasping intervension

3. Muscle tone ?Good muscle tone :flexed extremities and be active

Variable assesmenti. Provide warmth ii. Position;clear airway (as necessary)iii. Dry, stimulate, reposition30 secondsNo

i. PROVIDE WARMTHThe baby should be placed under a radiant warmer

ii.POSITION; CLEAR AIRWAY AS NECESSARY

Position by slightly extending the neckPositioned on the back or sideThe neck slightly extended in the sniffing positionPlaced rolled blanket under the shoulders

Clear airway1. If no meconeum is present dan meconium is present but the baby vigorous

Clear secretion Mouth and nose : wiping-suction Copious secretions Turn the head to the side secretions to collect =>removed easilyMechanic suction The negative pressure < 100 mmHg

If no meconeum is present

Mouth before nose

Be careful not to suction vigorously or deeplyVagal reflex bradycardia / apnea Gentle suctioning Adequate to remove secretions

Clear airway(if no meconeum is present)

Options: 1. with a self-inflating bag 2. oxygen pipe3. Oxygen mask

Oxygen concentration : 100%Oxygen flow: minimal 5 L / minuteThe baby become pink stopped graduallyIf cyanosis persistent: possitive pressure ventilation Giving Free Flow Oxygen

.Clear airway2. If meconeum is present

If meconeum is present and the baby is not vigorous depressed respirations depressed muscle tone heart rate < 100 bpm

direct suctioning of the trachea soon before respirations have occurred

iii. DRY_STIMULATION_REPOSITION

Position & suctioning stimulate spontaneous breathing

Tactile stimulation : 1. Flicking of the soles of the feet2. Rubbing the back/chest/abdomen/extremity

Tactile Stimulation

Options: 1. with a self-inflating bag 2. oxygen pipe3. Oxygen mask

Oxygen concentration : 100%Oxygen flow: minimal 5 L / minuteThe baby become pink stopped graduallyIf cyanosis persistent: possitive pressure ventilation Giving Free Flow Oxygen

Assess for these questions:1. Breathing .... Apnea / Breathing 2. Heart rate .. > 100 beats/minutes ? (in 6 seconds,multiply by 10)

Evaluate respirations,Heart rateObservational carebreathingHR> 100& PINKPINKProvide positive pressureventilationPost- resuscitationcareEffective ventilationHR > 100& PINKApneic OrHR < 100

Illustrative Pressures Initial breath after delivery : > 30 cmH2ONormal lungs: 15 - 20 cmH2Diseased or immature lungs : 20 40 cmH2O

How often should you squeeze the bag?40-60 breaths per minuteBreathe(squeeze)

Two.Three(release..)Breathe(squeeze)

Two..Three(release.)

If the chest is not rising?MR. SOPA

Mask adjustmetRepositionSwabOpen mouthPressureAlternative -- ETT

If you must continue bag and mask ventilation for more than several minute:Insert orogastric tube Gas forced into stomach disturbing ventilationGas in the stomach regurgitation of gastric contents aspiration

Provide positive-Pressure ventilationPost resuscitationcareEffective ventilationHR > 100& Pink30 secProvide positive-pressure ventilationAdminister chest compressionsHR > 60HR < 60

Indications for beginning chest compressions:

the heart rate remains

How do you position your hands on the chest to begin chest compressions?Two techniques: Thumb technique Two-finger technique

Two thumbs are used to depress the sternumThe hands encircle the torso and the fingers support the spineThe thumb technique

The middle finger and either the index finger or ring finger of one hand are used to compress the sternumThe Other hand is used to support the babys back

The two-finger technique

advantageUssually less tiringThe thumb techniquedisadvantageMore convinient if the baby is large or your hands are small It also make access to the umbilical core more difficult when medications become neccessary

FrequencyRatio 3 : 11 cycle (2 second) 11/2 second : 3 compression 1/2 second : 1 ventilation----- 90 compression + 30 ventilation on 1 minutes

one and two and Three and breathe

Heart rate > 60 x/minutes Discontinue chest compression, continue ventilation Heart rate > 100 x/minutes Discontinue chest compression and the baby begins to breathe spontaneously, you should slowly withdraw positive-pressure ventilation.Heart rate < 60 x/minutes Have Intubation (you most likely ) then you should give epinephrine

After 30 second chest compression + ventilation check heart rate

Provide positive-pressure ventilationAdminister chest compressionsAdminister epinephrineHR < 60

Indication to give epinephrine

Heart rate remains < 60 bpm after given 30 seconds of assisted ventilation and another 30 seconds of coordinated chest compressions and ventilationHow should epinephrine be given?

The umbilical vein (recommended) The endotracheal tube

Give epinephrinePreparation: 1:10.000 solution in 1 ml syringe Dose IV: 0,1-0,3 ml/kg larutan 1:10.000 ET: 0,3-1,0 ml/kg larutan 1:10.000Rate of administration : rapidly

If this does not happen you can repeat the dose every 3 to 5 minutes

Stopped Resuscitation Current data support that resuscitation of newborn after 10 minutes of asystole is very unlikely to result in survival or survival without severe disability.Parents clearly should have major role in determining the care delivered to their newborn.

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