Special considerationsResuscitation of premature babiesEthics and Care at End of Life: Special considerations Resuscitation of premature babies Ethics and Care at End of Life


Special considerations: Special considerations Situations that may complicate resuscitation and cause ongoing problem Post-resuscitation management Resuscitation outside hospital or beyond time of birth


Difficult situations: Difficult situations Not able to ventilate adequately Cyanosis despite adequate ventilation Bradycardia despite adequate ventilation No spontaneous breathing despite adequate ventilation


Not able to ventilate: Not able to ventilate Mechanical blockage of airways Meconium or mucus in pharynx or trachea Tracheal suction Choanal atresia Pass small-caliber suction catheter, oral airway Pharyngeal malformation (Robin syndrome) Prone, nasopharyngeal airway Other rare conditions (laryngeal web) Emergency tracheostomy


Not able to ventilate: Not able to ventilate Impaired lung functions Pneumothorax Diminished air entry, transillumination, X-ray, drain Congenital pleural effusion Hydrops, Drain Congenital diaphragmatic hernia Intubate, orogastric tube Pulmonary hypoplasia Extreme prematurity High inflation pressure Congenital pneumonia


Cyanosis/Bradycardia despite adequate ventilation: Cyanosis/Bradycardia despite adequate ventilation Cyanotic heart disease Congenital heart block Ensure adequate ventilation


No spontaneous breathing despite adequate ventilation: No spontaneous breathing despite adequate ventilation Brain injury (HIE, severe acidosis, congenital neuromuscular disorder) Sedation due to drugs given to mother (narcotic drugs, magnesium sulfate, general anesthesia, non-narcotic analgesics)


Naloxone: Naloxone Indications Continued respiratory depression after PPV has restored a normal heart rate and color AND History of maternal narcotic administration within past 4 hours


Naloxone: Naloxone Recommended concentration = 1.0 mg/ml Route: IV preferred; IM acceptable but delayed onset of action; ET not recommended Dose: 0.1 mg/kg May require repeated administration


Post-resuscitation care: Post-resuscitation care Temperature control Close monitoring of vital signs Laboratory studies


Post-resuscitation care: Post-resuscitation care Look for complications Pulmonary hypertension Pneumonia/other lung complications Metabolic acidosis Hypotension Seizures Apnea Hypoglycemia Feeding problem


Resuscitation outside hospital or beyond time of birth: Resuscitation outside hospital or beyond time of birth Same principles (Restore adequate ventilation) Alternative heat source (Skin-to-skin contact) Clear airway (Bulb syringe, wipe with a cloth) Ventilation (Mouth-to-mouth-and-nose) Vascular access (Peripheral vein cannulation/intraosseus needle)


Resuscitation and Prematurity : Resuscitation and Prematurity Thin skin, large surface area and ↓ fat Oxygen toxicity Weak muscles - difficulty in breathing Immature nervous system –less respiratory drive Immature lung Fragile brain capillaries Small blood volume


Additional Resources Needed : Additional Resources Needed Additional trained personnel Additional means of maintaining temperature Re closable, food grade polyethylene bag Portable warming pad Transport incubator Additional means to control oxygenation (in a hospital in which babies at <32 weeks gestation are born electively) Compressed air source Oxygen blender Pulse oximeter


Keeping a premature baby warm : Keeping a premature baby warm Increase temperature of the delivery room Pre-heat the radiant warmer Pre- warmed transport incubator


Keeping a premature baby warm: Keeping a premature baby warm If baby is born at less than 28 weeks gestation, consider placing him below the neck in a re closable polyethylene bag without first drying the skin Avoid overheating


Oxygen in a premature baby : Oxygen in a premature baby Connect a blender to compressed oxygen and air sources and to PPV device Start somewhere between room air and 100% oxygen Attach a pulse oximeter to baby’s foot or hand Heart rate displayed by pulse oximeter should agree with heart rate that you palpate or hear


Oxygen in a premature baby : Oxygen in a premature baby Adjust oxygen concentration to achieve an oxygen saturation that gradually increases to 90% Accept 70% to 80% if-heart rate is increasing and oxygen saturation is increasing If saturation is less than 85% and not increasing, increase oxygen concentration Decrease oxygen concentration of saturation rises above 95%


Oxygen in a premature baby: Oxygen in a premature baby ! Resuscitation efforts not to be delayed while waiting for pulse oximeter to display a strong signal


Ventilation in a premature baby : Ventilation in a premature baby Consider giving CPAP if the baby Is breathing spontaneously and has a heart rate above 100 bpm but has Labored breathing or Is cyanotic or Has low oxygen saturation By using flow-inflating bag or T-piece resuscitator


CPAP: CPAP


Ventilation in a premature baby: Ventilation in a premature baby Use lowest inflation pressure necessary to achieve adequate response Initial inflation pressure of 20-25 cm H2O May need higher pressure if no improvement in heart rate and no chest rise


Ventilation in a premature baby: Ventilation in a premature baby Prophylactic surfactant as per your practice ! Baby should be fully resuscitated before surfactant is given


How to decrease chances of brain injury in a premature baby?: How to decrease chances of brain injury in a premature baby? Gentle handling No head-down position Avoid excessive positive pressure or CPAP Adjust ventilation and oxygen concentration gradually and appropriately (use pulse oximeter and blood gas) Do not give rapid infusion of fluids Avoid infusion of hypertonic solutions


Post-resuscitation management of a premature baby: Post-resuscitation management of a premature baby Monitor blood sugar Monitor for apnea and bradycardia Give and adjust ventilation and oxygen concentration gradually and appropriately Give feeding slowly and cautiously Increase suspicion of infection


Ethics and neonatal resuscitation: Ethics and neonatal resuscitation Primary role in determining goals of care with parents Informed consent based on complete and reliable information (may not be available before or immediately after delivery)


Not to initiate resuscitation: Not to initiate resuscitation Confirmed gestational age of less than 23 weeks or birth weight less than 400 gm Anencephaly Confirmed trisomy 13 or 18 If parents wish: confirmed gestational age of 24-25 weeks Based on your survival rates and local policy


Counseling parents before a high risk birth: Counseling parents before a high risk birth Obstetrician and neonatologist perspectives may be different Short and long term outcome of babies of different gestation in your hospital Discuss resuscitation and level of care to be given to baby Documentation


When to stop resuscitation?: When to stop resuscitation? No heart rate after 10 minutes of complete and adequate resuscitation No evidence of other causes of compromise