Special ConsiderationsSpecial ConsiderationsSpecial ConsiderationsSpecial Considerations

ObjectivesObjectivesObjectivesObjectives

Special situations that may complicate

resuscitation

Subsequent management after resuscitation

How the principles of NRP can be applied beyond

immediate newborn period or outside Delivery

Room

What complications should you consider What complications should you consider if baby does not improveif baby does not improve

What complications should you consider What complications should you consider if baby does not improveif baby does not improve

Ascertain

Does the baby fail to begin spontaneous

respiration

Does PPV fail to result in adequate ventilation

Does the baby remain cyanotic or have

bradycardia despite good ventilation

When baby fails to begin spontaneous When baby fails to begin spontaneous respirationrespiration

When baby fails to begin spontaneous When baby fails to begin spontaneous respirationrespiration

Consider Narcotic administration to the mother

Use Naloxone if mother has received narcotics

within the last 4 hrs but only after:

Establishing PPV and when the baby has normal

heart rate and color

Do not use Naloxone if mother is addicted to

narcotics or is on methadone maintenance:

This may induce seizures in newborn

When baby fails to begin spontaneous When baby fails to begin spontaneous respirationrespiration

When baby fails to begin spontaneous When baby fails to begin spontaneous respirationrespiration

Other maternal drugs which may cause neonatal

respiratory depression:

Magnesium sulfate or non-narcotic analgesics or

general anesthetics

These will not respond to Naloxone

Continue PPV and transport the baby to NICU

NaloxoneNaloxoneNaloxoneNaloxone

Concentration: 1.0 mg/ml & 0.4mg/ml

Recommended Route: Intravenous

Not recommended for Endotracheal use

Dose: 0.1 mg/kg

Metabolic AcidosisMetabolic AcidosisMetabolic AcidosisMetabolic Acidosis

Use of Sod. Bicarb during resuscitation

controversial

Ascertain ventilation is adequate before

giving Sod Bicarb

Most often restoration of circulating volume

and adequate oxygenation resolves acidosis

Preferably after the Blood gas analysis

Sodium bicarbonateSodium bicarbonateSodium bicarbonateSodium bicarbonate

To correct metabolic acidosis

Recommended Conc. – 4.2 % Not available

Use 7.5% solution which is available

Recommended

Route – Umb. Vein (NEVER Endotracheally)

Dose – 2 meq/kg

Rate of admn. – No faster than 1meq/kg/min

What if PPV fails to result in adequate What if PPV fails to result in adequate ventilation of Lungsventilation of Lungs

What if PPV fails to result in adequate What if PPV fails to result in adequate ventilation of Lungsventilation of Lungs

Consider Mechanical Blockage of airway

Meconium or mucus in pharynx or trachea

Choanal Atresia

Pharyngeal airway malformation (Robin Syndrome)

Other rare conditions e.g. Laryngeal web

What if PPV fails to result in adequate What if PPV fails to result in adequate ventilation of Lungsventilation of Lungs

What if PPV fails to result in adequate What if PPV fails to result in adequate ventilation of Lungsventilation of Lungs

Consider Impaired Lung Function

Pneumothorax

Congenital Pleural effusion

Congenital Diaphragmatic Hernia

Pulmonary Hypoplasia

Extreme immaturity

Congenital pneumonia

Choanal AtresiaChoanal AtresiaChoanal AtresiaChoanal Atresia

Congenital obstruction of posterior nasopharynx Oral Airway

Robin SyndromeRobin SyndromeRobin SyndromeRobin Syndrome

Normal Newborn

Jaw

Tongue

Newborn with Robin Syndrome

Abnormally small Jaw

Tongue airway at posterior pharynx

Robin SyndromeRobin SyndromeRobin SyndromeRobin Syndrome

Prone positioning and a nasopharyngeal tube are often effective

Impaired Lung FunctionImpaired Lung FunctionImpaired Lung FunctionImpaired Lung Function

PneumothoraxBreath sounds diminished

Transillumination of chest

X-ray chest is diagnostic

Drain it with Scalp vein Insert 21 or 23 G

perpendicular to chest wall just over

the top of rib 4th IC space i.e. level of

nipple in Anterior axillary line

Pleural effusion

Drainage of PneumothoraxDrainage of PneumothoraxDrainage of PneumothoraxDrainage of Pneumothorax

Turn the baby to side with

pneumothorax side superior

A 18 or 20G catheter is inserted

perpendicular to chest wall

Just over the top of the rib in the

4th IC space (at the level of

Nipples) in ant. axillary line

Aspirate with 20 ml syringe

through a stopcock

Impaired Lung FunctionImpaired Lung FunctionImpaired Lung FunctionImpaired Lung Function

Congenital Diaphragmatic HerniaScaphoid abdomen

Diminished breath sounds

Persistent respiratory distress, PPHN

and cyanosis

Immediate endotracheal Intubation

Avoid PPV with mask

10 F Orogastric tube to evacuate

stomach contents

Impaired Lung FunctionImpaired Lung FunctionImpaired Lung FunctionImpaired Lung Function

Other Conditions

Pulmonary Hypoplasia

Severe oligohydramnios may cause this, as

amniotic fluid needed for lung development

Extreme Immaturity

Congenital pneumonia

What if Baby Remains Cyanotic or What if Baby Remains Cyanotic or Bradycardic Despite Good VentilationBradycardic Despite Good VentilationWhat if Baby Remains Cyanotic or What if Baby Remains Cyanotic or

Bradycardic Despite Good VentilationBradycardic Despite Good Ventilation

Ensure Chest is moving adequately, breath

sounds are good and 100% O2 is being given

Consider Congenital Heart Disease

Babies with CHD are seldom critically ill at birth.

Problems with ventilation are almost always the

cause of a failure of successful resuscitation

What Should be Done after Successful What Should be Done after Successful ResuscitationResuscitation

What Should be Done after Successful What Should be Done after Successful ResuscitationResuscitation

Post Resuscitation Care : Management of

Temperature

Fluid & Electrolytes

Pneumonia, PPHN, Hypotension

Seizures & apnea

Hypoglycemia

Feeding issues

HypotensionHypotensionHypotensionHypotension

Hypoxic insult to heart muscle or decreased

vascular tone

Murmur of TR may be heard

Sepsis or blood loss may be contributing factors

Monitor Heart rate and BP

Volume expansion, Blood transfusion or

inotropes may be required

Fluid ManagementFluid ManagementFluid ManagementFluid Management

Higher risk of Renal failure, SIADH

Monitor body weight, urine output, serum

electrolytes & calcium

Modify fluid and electrolyte intake accordingly

Other ProblemsOther ProblemsOther ProblemsOther Problems

Seizures or Apnea

Symptoms of HIE or Hypocalcemia/ Hyponatremia

Anticonvulsant (Phenobarbital): Be cautious

Hypoglycemia: Frequent Blood sugar monitorint

Feeding Problems: Risk of ileus, GI bleeding, NEC

Temperature Management:

Maintain Normal body temperature

Modest hypothermia experimental

Avoid Hyperthermia

Baby born outside or beyond Baby born outside or beyond immediate newborn periodimmediate newborn period

Baby born outside or beyond Baby born outside or beyond immediate newborn periodimmediate newborn period

Baby born at home or in a vehicle

A baby who develops apnea in Nursery

A 2-week old baby with sepsis who presents to the

Doctor’s clinic with shock

An intubated baby in the NICU suddenly

deteriorates

Principles remain the same

Priority is to restore ADEQUATE VENTILATION

Baby born outside or beyond Baby born outside or beyond immediate newborn periodimmediate newborn period

Baby born outside or beyond Baby born outside or beyond immediate newborn periodimmediate newborn period

Temperature control: Baby is usually not wet Turn up the heat in the room or vehicle Dry the baby with bath towels, a blanket or clean clothing Skin to skin contact: cover both mother & baby with

blanket

Clearing airway Use bulb syringe Wipe mouth & nose with clean cloth wrapped around your

index finger

Baby born outside or beyond Baby born outside or beyond immediate newborn periodimmediate newborn period

Baby born outside or beyond Baby born outside or beyond immediate newborn periodimmediate newborn period

Ventilation Tactile Stimulation Mouth to Mouth and nose

or Mouth to Mouth with nose pinched

Vascular Access Umbilical vein may not be an option Cannulation of peripheral vein or Intraosseus needle