NEW BORN RESUSCITATION -DR GGRAO

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SEE PRACTICALLY NEW BORN RESUSCITATION BY DR GANGADAR RAO emal: doctorhyderabad@gmail.com

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NEW BORN RESUSCITATION & MECONIUM ASPIRATION :

NEW BORN RESUSCITATION & MECONIUM ASPIRATION Dr. G GANGADHAR RAO GUNTUR MEDICAL COLLEGE FORMER PAEDIATRICIAN YASHODA HOSPITAL SEC. Department of Pediatrics COMPOSITE HOSPITAL CRPF HYDERABAD 1 DR.GANGADHAR RAO G M09493864912 DR.GANGADHAR RAO G M09493864912 Email: doctorhyderabad@gmail.com

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MECONIUM ASPIRATION SYNDROME:

MECONIUM ASPIRATION SYNDROME Mortality and morbidity is 28% to 40% of MAS . INCIDENCE IS 8.8%, USUALLY POSTMATURE INFANTS, APGAR SCORE 1- 5 Min. IS LESS THAN 6 3 DR.GANGADHAR RAO G M09493864912

What is Meconium?:

What is Meconium? In Greek - means "Poppy juice". Black Green, Thick sticky odorless and acidic 4 DR.GANGADHAR RAO G M09493864912

Contents:

Contents Water 72%-80% Intestinal secretions Epithelial cells Swallowed Amniotic fluid Mucopolysacchrides 80% of dry wt. Cholesterol and Sterol precursors Proteins Lipids 8% dry wt. Bile acids and salts Enzymes Blood substances Squamous cells and Vernix caseosa. 5 DR.GANGADHAR RAO G M09493864912

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Pathogenesis:

Pathogenesis Bile salts are blamed for. Exact cause unknown. Inflammatory response by lung tissue. 7 DR.GANGADHAR RAO G M09493864912

Introduction:

Introduction Cause of Respiratory failure in newborn. Inhalation of Meconium causes respiratory distress. Degree of severity vary. Meconium in Amniotic fluid 10%-20% of total deliveries. Mortality and morbidity in 28% to 40% of MAS . 8 DR.GANGADHAR RAO G M09493864912

Incidence :

Incidence Amniotic fluid stained in 16.5% (India) MAS develop in 18.7% MAS 1.44% in all births No seasonal variation 9 DR.GANGADHAR RAO G M09493864912

Definition:

Definition Meconium below the vocal cords. Mild MAS < 40% Oxygen needed for < 48 hrs. Moderate MAS > 40% Oxygen needed for > 48 hrs. Severe MAS Ventilation > 48 hrs often with persistent pulmonary hypertension. 10 DR.GANGADHAR RAO G M09493864912

Working definition:

Working definition Staining of Liquor Umbilical cord. Skin and nail. Respiratory distress after 1 hr of birth. Radiological features of Aspiration pneumonitis. 11 DR.GANGADHAR RAO G M09493864912

Causes in-utero:

Causes in-utero Meconium staining rarely before 38wt Levels of motilin Maturity of myelination of gut Lack of strong peristalsis of gut Good sphincter tone ‘Cap’ viscous meconium in rectum Foetal distress – hypoxia Diving reflex Umbilical cord compression Gut maturation Breech presentation Listeriosis in foetus – foetal diarrhoea 12 DR.GANGADHAR RAO G M09493864912

Risk factor:

Risk factor Maternal hypertension and diabetes mellitus Maternal heavy smoking. Chronic Respiratory and CVS disease. Post term pregnancy. Pre eclampsia / Eclampsia. Oligohydramnios. Poor biophysical profile. Foetal distress (Abnormal Heart Rate) 13 DR.GANGADHAR RAO G M09493864912

Mechanism of injury:

Mechanism of injury Mechanical Obstruction. Pneumothorax – “Ball Valve”. Pneumonitis Bile salts Bile acids Release of cytokines Pulmonary Vasoconstriction. Surfactant Inactivation. 14 DR.GANGADHAR RAO G M09493864912

Pathophysiology:

Pathophysiology 15 DR.GANGADHAR RAO G M09493864912

Clinical Features:

Clinical Features Usually full term and post term Signs of post maturity. Green Yellow staining of nails, skin and umbilical cord. Afebrile, Fever or hypothermia if infected. Resp. rate > 120/min. Subcostal, Intercostal and sternal retraction. Use of accessory muscles Flaring of nostrils Grunt Increased Ant. Post diameter Apnoea Rhonchi and crepitations. 16 DR.GANGADHAR RAO G M09493864912

Clinical Features - Contd..:

Clinical Features - Contd.. CVS 1. Hypoxic myocardial damage. 2. Hypotension 3. CCF 4. S 2 may be single 5. Murmur of tricuspid regurgitation Abd 1. Distended (Aerophagia) 2. Liver and Spleen displaced. 3. Constipation. 4. Absent bowel sounds in severe cases. 5. Urinary retention. CNS: 1. Hypoxic ischemic Encephalopathy. 2. Signs of birth asphyxia. 17 DR.GANGADHAR RAO G M09493864912

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Complications:

Complications Pneumothorax Pneumomediastenum Pneumopericardium Pneumoperitonium Subcutaneous Emphysema Broncho pulmonary Dysplasia Persistent Pulmonary Hypertension Pulmonary damage Cerebral damage (Hypoxic) Secondary Bacterial Infection Renal Failure Complication of intubation and ventilation 19 DR.GANGADHAR RAO G M09493864912

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Diagnosis:

Diagnosis Meconium stained amniotic fluid (MSAF ) Presence of meconium in trachea. Radiological features. Always suspect MAS in MSAF . 21 DR.GANGADHAR RAO G M09493864912

Investigations:

Investigations Hb % normal White cell count R Thrombocytopenia with PPH Disseminated Intravascular coagulation PaCO 2 Low – Normal - Raised Metabolic acidemia Culture for sepsis Parameters of renal failure Urine analysis – Normal except in renal failure Color is Greenish brown due to Meconium pigment ECG -Normal ECHO – Reduced cardiac contractility 22 DR.GANGADHAR RAO G M09493864912

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Radiology:

Radiology Use: Determine the extent of intrathoracic pathology Identify areas of atelectasis and air block syndromes. Assure appropriate positioning of endotracheal tube and umbilical artery catheter. 24 DR.GANGADHAR RAO G M09493864912

Radiology - Contd..:

Radiology - Contd.. Patchy infiltrates. Increased anterioposterior diameter. Atelectasis. Flattening of diaphragm. Retrosternal lucency. Small pleural effusions in about 33% cases. Pneumothorax and/or pneomediastinum in 25% cases. Diffuse chemical pneumonitis Cardiomegaly to be detected due to underlying perinatal asphyxia 25 DR.GANGADHAR RAO G M09493864912

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Management:

Management Minimal handling Routine care – Thermal environment, hydration, oxygen. Suction of oropharynx every 30 min Chest Physiotherapy Correction of Acidosis Monitor BP and Renal functions Blood gas monitoring. Ventilation IPPV 60-80 / min, CPPV – unusual. IV tolazoline for PPHT Antibiotic if infection suspected. 27 DR.GANGADHAR RAO G M09493864912

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Prevention:

Prevention Optimum Antenatal care Risk factors for MAS Monitoring of foetal heart for foetal distress Foetal scalp blood pH where possible Expediate delivery if foetal distress Avoid post maturity (more than 42 wt.) Presence of two skilled persons in resuscitation for every delivery in labour room 29 DR.GANGADHAR RAO G M09493864912

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Prevention contd.:

Prevention contd. Intrapartum MSAF present: Aspirate oropharynx first then nasopharynx after the birth of head. Assess the newborn after birth. 31 DR.GANGADHAR RAO G M09493864912

Classification:

Classification Vigorous Newborn: Strong spontaneous Resp. Effort Good muscle tone Heart rate > 100/min Monitor for MAS Non Vigorous Newborn : Airway suction Direct laryngoscopy and suction 32 DR.GANGADHAR RAO G M09493864912

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NEW BORN RESUSCITATION Intubate:

NEW BORN RESUSCITATION Intubate Suction through Intubation tube. Continue tracheal aspiration with meconium aspiration till “little or no meconium is aspirated or heart rate indicates resuscitation”. Aspirate Gastric meconium Last 4 slides 40 DR.GANGADHAR RAO G M09493864912

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Do’s:

Do’s Oropharyngeal suction at perineum in all MSAF babies. Intrapartum fetal heart rate monitoring in all MSAF babies. Anticipate passage of meconium or MAS during birth of all IUGR babies in the labor room. Skillful resuscitation and assistance are key points in management. Do intubate neonates born through MSAF who are depressed (non vigorous babies) at birth irrespective of consistency of meconium. 50 DR.GANGADHAR RAO G M09493864912

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Dont’s:

Dont’s Do not go by the consistency of meconium in management for intubation. Do not apply cricoid pressure, chest compression or occlude airway by fingers to prevent initiation of respiration in MSAF babies. Do not ignore the general condition of baby during intubation. Thank you 52 DR.GANGADHAR RAO G M09493864912

CH CRPF PHOTOES – (SEE FILE):

CH CRPF PHOTOES – (SEE FILE) 53 DR.GANGADHAR RAO G M09493864912

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Thank you Dr. G GANGADHAR RAO STUDENT OF GUNTUR MEDICAL COLLEGE FORMER PAEDIATRICIAN YASHODA HOSPITAL SEC. Department of Pediatrics COMPOSITE HOSPITAL CRPF HYDERABAD 64 DR.GANGADHAR RAO G M09493864912

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Thank you Dr. G GANGADHAR RAO M.B.B.S (GUNTUR MEDICAL COLLEGE) FCIP, DCH FORMER PAEDIATRICIAN YASHODA HOSPITAL SEC. Department of Pediatrics COMPOSITE HOSPITAL HYDERABAD INDIA 65 DR.GANGADHAR RAO G M09493864912 Email: doctorhyderabad@gmail.com

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