NEONATAL RESUSITATION

For NIME Students

Instructor: Kokeb Desta

Lecturer &Senior Anesthetist

Debirebirhan Universty

College of Medicine
Department of Anesthesia

Group Activity
Why we learn neonatal resuscitation?
What are the main physiologic change
before birth and after birth of a neonate?
What are the main problem that reveres the
normal physiologic transition of a neonate
Discuss the steps in neonatal resuscitation
What equipment we need during resuscitation
What are the main ethical issues during
resuscitation

INTRODUCTION TO
NEONATAL RESUSITATION
Objectives
Changes in physiology when a baby is born
Recommended steps in neonatal resuscitation
Equipment and personnel in neonatal
resuscitation
Team work in neonatal resuscitation
Ethical issues in post resuscitation of a
neonate

4 million newborn deaths Why?

almost all are due to preventable conditions

Causes of neonatal death

(n=258)

Not
established
14.7%

Congenital
m alform ation
5.4%
Prem aturity
15.2%

Others
10.7%

Birth asphyxia
20.9%

Infection
33.2%

Others: Hypothermia, RD, Jn, Pulm. Haemorrhage, Seizure etc.

ICMR 2006

Neonatal resuscitation
Asphyxia accounts for 20-25%
newborn deaths
10% neonates require some assistance
at birth
1% neonates need extensive
resuscitative measures

The most important and

effective action is to ventilate
the babys lungs

Neonatal resuscitation
Airway
Breathing

Circulation

Neonatal resuscitation
Airway
Breathing

Circulation

Before birth
Gas exchange in placenta
Lung receives very little blood
Alveoli are fluid filled

Very little flow to lungs

Blood vessels are

constricted

Alveoli are fluid filled

Before birth
Pulm arterioles constricted

High pressure in pulmonary

circuit

Umbilical arteries feeding low

pressure placenta circulation

Low pressure in systemic

circuit

Very little pulmonary blood

flow

After birth
1.

Fluid in the alveoli is absorbed

Alveoli

EXPAND

GET FILLED WITH AIR (O2)

After birth
2.
Umbilical arteries
and veins are
clamped

Sudden increase in
systemic blood
pressure

Pulmonary vessels dilate, causing

increased blood flow to lungs

3.

After birth
Pulm arterioles dilate

Umbilical arteries and veins

are clamped

Low pressure in pulmonary

circuit

High pressure in systemic

circuit

Dramatic increase in
pulmonary blood flow

Ductus arteriosus constricts

4.

Increased oxygen in blood

Increased pulmonary blood flow

Before

After

Neonatal resuscitation
normal transition after birth
Prevented or reversed by
Hypoxia / hypercarbia
Hypovolemia
Sepsis
Cold

What can go wrong

Inadequate breathing hence lung fluid not
absorbed
Meconium may block airway
Blood loss may occur
Persistence of constricted pulmonary vessels
Myocardium may be depressed
Organ systems may be affected by
hypoxia/ischemia

Consequences of
interrupted transition
1.
2.
3.
4.
5.
6.

Low muscle tone

Resp depression (apnea / gasping)
Tachypnea
Bradycardia
Hypotension
Cyanosis

Neonatal resuscitation
Ask at birth?

Term baby?
Breathing / crying?
Good muscle tone?
Yes to all = routine care
Dry baby
Wipe nose and mouth if needed
Skin to skin with mother
Observe

Neonatal resuscitation
Ask at birth?
Term baby?
Breathing / crying?
Good muscle tone?

No to any = put baby under warmer and

assess

Neonatal resuscitation
suctioning
Suction baby ONLY if
Airway obstruction is present
PPV is needed

Routine suctioning of babies can

cause
Apnea
Bradycardia

DO NOT USE SUCTIONING TO

STIMULATE A BABY TO BREATH

Neonatal resuscitation
meconium
No suctioning for vigorous baby
Suctioning for depressed baby only
Suction before stimulation
Adjustable suction attached to an ETT
0.5 mm smaller than predicted

Do not delay PPV if heart rate is falling

During laryngoscopy may decide to intubate with
a clean normal size tube

Neonatal resuscitation
assessment under warmer
Dry and stimulate baby
Check respirations and HR (not color)
By 60 sec after birth suction and start
PPV (40-60 breaths/min) for
Apnea or gasping or HR < 100
Low O2 saturation with 100% free-flow O2

Neonatal resuscitation
PPV

Start with AIR with term babies

Best to use a PPV device with a pressure
gauge
30 cm H20 (term) and 25 cm H20 (premature)

Be sure you are ventilating

Rising heart rate
Chest rise
Breath sounds
Rising O2 saturation

Neonatal resuscitation
ventilation correction steps
M - mask adjustment
R - reposition baby, shoulder roll
S - suction
O - open mouth

P - pressure of ventilation
increase slowly to max of 40 cm H2O
A - airway
LMA #1
ETT

Neonatal Resusitation
chest compressions
Neonatal chest compressions:
90 compressions/min +
30 breaths /min
3:1 ratio

Neonatal Resusitation
chest compressions
DO NOT Start Chest
compressions unless
baby has received 30
sec of Effective
ventilation and HR <
60

Neonatal Resusitation
chest compressions
Use 100% O2 with chest compressions
Coordinate ventilation and chest
compressions
Intubation recommended after 30 sec of
chest compressions
Reassess baby after 45-60 sec of CPR

Neonatal resuscitation
epinephrine

Used if heart rate is < 60 after

30 sec of PPV and
45-60 sec of PPV and chest compressions
Epinephrine 1:10,000 solution (0.1mg/ml)
0.1-0.3 ml/kg IV
0.5-1.0 ml/kg ETT
1.0 ml saline flush
Continue CPR
Reassess after 60 sec
May repeat dose q 5 min

Neonatal resuscitation
Volume resuscitation
10 ml/kg IV given over 5-10 min
Normal saline
Ringers lactate
O neg whole blood

Intraosseous route.
Achieves adequate plasma
concentrations in a time comparable with
injection through a central venous
catheter
Also enables withdrawal of marrow for
venous blood gas analysis and
measurement of electrolytes & Hb
concentration.

INTRAOCIOUS ROUTE

Prequetion
Sterility
Short period of time

Changes due to oxygen

deprivation

Some dictums
If a baby does not breathe immediately
after being stimulated >>> secondary
apnea
Assume every apneic baby is in
secondary apnea
Longer the duration of compromise,
longer it takes for recovery

 The
resuscitation
flow
diagram

Evaluation-Decision-Action
cycle
Evaluation

Action

Decision

Evaluation: By 3 signs
1. Respiration

Breathing / crying
Apnea

2. Heart rate

<100 or not
< 60 or not

3. Color

Central cyanosis
Peripheral cyanosis / pink

 The
resuscitation
flow
diagram

Apgar score

Apgar score is great, but not

for guiding resuscitation
For resuscitation, not all items are
required
Resuscitation initiated before 1 min
when Apgar is assigned
Classification different

Requirements
Personnel
At least one trained person for all deliveries
Two persons, if high risk; or for advanced
resuscitation

Equipment

Neonatal resuscitation
equipment

Radiat Warmer
Warm cloth and cotton
Amubag/ if possible with gage
Oxygen
Suction machine /suction bulb
Airway equipment
Straight blades #1 , #0
ETTs 2.5, 3.0, 3.5, 4.0 + stylet
LMA #1 + 5ml syringe
Oral airway

Neonatal resuscitation
equipment

Suction catheters (6F, 8F)

Clock + stethoscope
Epinephrine 1:10,000 (0.1mg/ml)
Pulse oximeter very useful
Syringe, intraocious needle
fluids

PERSON DEDICATED TO CARE OF THE

BABY

Risk factors of asphyxia

Only 50% resuscitation needs are
identified prior to birth

Premature babies : concerns

1. May be surfactant deficient
2. Immature brain, poor resp drive
3. Weak muscles, not able to breathe
4. More prone to hypothermia

5. More likely to be infected

6. Prone to intraventricular hemorrhage
7. Small blood volume, prone to hypovolemia
8. Immature tissues, prone to oxygen toxicity

Care after
resuscitation

Ethical issues
Apply the four main ethical principles
during initiation and stopping of
resuscitation
Communicate parents in decision making
When it may be appropriate to with hold
resuscitation
How long to continue resuscitation
attempt when the baby is not responding

Prevent, prevent, prevent

Infection :

asepsis

HIV

universal precautions

THE END!!.
Thanks' ALL.