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NRP 8th edition
NRP changes - a) -umbilical cord management added to 4 prebirth questions replacing how many babies b) -initial steps reordered to better reflect common practice c) -an electronic cardiac monitor is recommended earlier in the algorithm. d) -IV/IO flush volume increased from 1 to 3ml e) -epi IV/IO/ETT doses simplified f) -expanded time frame for cessation of resuscitative efforts from 10 to 20 minutes after all appropriate steps performed and cessation of heart rate 4 prebirth questions - a) -gestational age b) -color of fluid c) -additional risk factors d) -umbilical cord management Initial NRP steps - -warm, dry, stimulate, position airway, suction if needed When is electric cardiac monitor recommended - -when an alternate airway becomes necessary Epi IV/IO/ETT changes - a) -suggested initial IV/IO dose is 0.02 mg/kg which equals 0.2ml/kg b) -suggested endotracheal dose 0.1mg/kg which equals 1ml/kg Anticipated resuscitation needs - a) -assessment of situation b) -system to assemble appropriate people based on that risk c) -method to access supplies d) -teamwork and communication e) -standard check list f) -team leader identified g) -pre-resuscitation briefing: identify possible interventions, assign roles Risk factors ante partum - a) -less than 36.0 or greater than 41. b) -preeclampsia, eclampsia
c) -maternal hypertension d) -multiple gestation e) -fetal anemia f) -poly/oligo g) -macrosomia/ IUGR h) -no prenatal care i) -fetal anomalies j) -hydrops Risk factors intrapartum - a) -emergency c/s b) -forceps or vacuum c) -breech d) -category II or III heart rate e) -general anesthesia f) -mag sulf g) -abruption/bleeding h) -chorio i) -opioids within four hours of delivery j) -shoulder dystocia k) -meconium l) -prolapsed cord m) -uterine rupture Personnel at delivery - a) qualified at every birth (skilled, just for baby, can start PPV) b) Risk factors present = 2 qualified people (more if high risk) c) qualified team readily available --> ready for endotracheal incubation, chest compressions, emergency vascular access, meds Why personnel important - a) -if normal transition doesn't occur, organs anaerobic metabolism (no oxygen) acid accumulation in tissues and blood vessels of intestines, kidneys, muscles and skin constrict b) -if PPV delayed, heart will begin to fail c) -worse outcomes if PPV not started within one minute Why umbilical cord delayed clamping: term and LPT - a) -improve early hematologic measures b) -neurodevelopmental outcomes c) -risk: hyperbilirubinemia
Preterm thermoregulation -
a) -radiant warmer b) -plastic wrap c) -increase room temperature d) -thermal mattress e) -warmed humidified air as soon as possible
Meconium -
a) -no routine tracheal suctioning. Possible harm from delayed PPV and intubation b) -bulb suction c) -meconium stained fluid is a risk factor, requires two team members and one needs to be able to intubate. d) -vigorous goes to moms chest e) -non vigorous goes to warmer for initial steps f) -if HR not increasing or chest not moving (me sopa) may consider tracheal suctioning g) -suctioning only required if unable to establish effective ventilation
Assessment -
a) -initial steps then assessment b) -is baby breathing or crying? If not, start PPV c) -if no respirations after initial steps, HR not needed. Start PPV. d) -if baby is breathing heart rate should be greater than 100. Use a stethoscope. Pulsation May underestimate. ECG is secondary assessment
Pulse ox placement -
a) -right hand b) -when resuscitation can be anticipated c) -PPV is started d) -central cyanosis beyond 5-10 minutes of life e) -supplemental oxygen f) -assessment of skin color poor indicator of saturation g) -if infant has poor perfusion, saturation results may be delayed
Starting values for oxygen -
a) -greater than 35 weeks: 21 percent b) -less than 35 weeks: 21-30 percent
c) -in preterm infants no benefit when using higher oxygen during resuscitation SpO2 guides - a) -1 minute 60- b) -2 minutes: 65- c) -3 minutes: 70- d) -4 minutes 75- e) -5 minutes: 80- f) -10 minutes: 85-
cyanosis -
a) -skin or mucous membranes blue b) -use pulse oximiter c) -oxygen carried by the hemoglobin inside red blood cells d) -color assessment is subjective, pulse ox is objective
When to use free flow oxygen -
-breathing and heart rate greater than 100 -no distress
When to use CPAP -
-breathing and heart rate greater than 100 -signs of distress -CPAP provides continuous airway pressure. Alveoli open at end of each breath When to use PPV - -not breathing -or breathing but heart rate less than 100 -gasping -unable to maintain saturation and on high O
Assessment of heart rate -
-stethoscope gold standard -if clinical assessment difficult or unreliable ise ECG. -ECG displays HR faster and more reliable than pulse oximeter When to use ECG -
-gestational age/ Confirmation of ETT placement - -CO2 detector -increasing heart rate -condensation in tube -chest movement -equal breath sounds Endotracheal tube size - -below 28 weeks, 2. -28-34 weeks: 3 -greater than 34: 3.
Co2 detector -
-single use -keep in package until ready to use -may take up to 6 breaths for a color change -may not have color change in very small babies -yellow means yes, purple means problem
Ventilation of newborn lungs -
Single most important and effective step in neonatal resuscitation
chest compressions: when -
-after 30 seconds of effective PPV that moves the chest with bag mask (ETT preferred) if HR less than 60
Chest compressions: how -
-two thumb method preferred (generates higher blood pressure and coronary perfusion and less rescuer fatigue) -from head of bed once ETT secured -60 seconds -ECG -100 percent O -when there is not a response to ventilation, hypoxemia leads to anaerobic metabolism which results in acidosis -insufficient blood flow to coronary arteries: cardiac muscle function depressed
-compressions will increase blood pressure in aorta -pause will allow heart to refill and for coronary arteries to be perfused
Chest compressions: specifics -
-place things on lower 1/3 of sternum (below nipple line) -compress sternum 1/3 the anterior posterior diameter of the chest -allow full recoil during the breath -3 compressions to 1 breath (2 seconds) -120 events per minute (90 compressions to 30 breaths)
Chest compressions continued -
-with HR less than 60, pulse odometer is less reliable -pulse odometer depends on distal blood flow and with limited cardiac output, central shunting and vasoconstriction results in poor distal arterial blood flow -stop chest compressions to check heart rate, ECG will pick up chest compressions
Chest compressions without improvement -
-CARDIO
-chest movement (is chest moving with each breath) -Airway (is the airway secured with ETT or LMA -Rate (are 3 compressions to 1 breath every two seconds) -Depth(is the depth 1/3 of the AP diameter -Inspired Oxygen (is 100 percent O2 being given with PPV) Epinephrine frequency - -every 3-5 minutes Epinephrine: ETT dose - -1ml/kg -0.1mg/kg Epinephrine: UVC/PIV/IO dose - -0.2ml/kg -0.02mg/kg
-infants apgar score 0 at 20 minutes and heart rate still zero may stop resuscitation efforts after consultation with physician -dependent on many factors, especially if full resuscitation efforts have been attempted and parents wishes -an apgar score of zero at 20 minutes is a strong predictor of mortality and morbidity on late preterm and term infants
Premature baby considerations -
-lower gestational ages increased risk for resuscitation -imcreased risk of injury from efforts -temp regulation challenges -immature lungs -immature tissues -infection risk -smaller blood volumes -immature brain -limited metabolic reserve pT considerations slide 2 - -prior to delivery take steps -CPAP vs intubation when appropriate -use lowest inflation pressure, peep available -consider surfactant -lowest oxygen, use pulse ox -handle gentle, avoid trendelenburg -slow infusion of fluids -monitor temperature, blood glucose, apnea/bradycardia Premature delivery: talking to parents - -goals of care -establish a relationship -discussion outside of stress of delivery -outcomes data if needed -have supper person present -use interpreter if needed -avoid negative or unrealistic outcomes -simple terminology Post resuscitation care -
-supplemental O2, PPV, CPAP, or mechanical ventilation -closer assessment -at risk for abnormal transition
