NEONATAL RESUSCITATION -NRP 2010

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BASE ON NRP 2010 GUIDELINE

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NEONATAL RESUSCITATION:

NEONATAL RESUSCITATION DR. karnika GODARA Mlb mc jhansi DR. SURENDRA GODARA MAMC AGROHA

Evolution of Resuscitation Guidelines:

Evolution of Resuscitation Guidelines 1979 - Initial Guidelines: Emergency Cardiac Care Committee of AHA 1985 - 1979 guidelines updated and endorsed by AAP 1990 - Updated Textbooks of Neonatal Resuscitation by AHA & AAP 1990 - NNF started NALS workshop 1992 - Revised guidelines by AHA in JAMA 2000 & 2005- ILCOR/AHA Revisions of Guidelines 2010 – Revised NRP guidelines by AHA,AAP, IAP

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INTRODUCTION AND OVERVIEW

4 million newborn deaths – Why? almost all are due to preventable conditions:

4 million newborn deaths – Why? almost all are due to preventable conditions

Neonatal resuscitation:

Neonatal resuscitation A irway B reathing C irculation The most important and effective action is to ventilate the baby’s lungs !

Neonatal resuscitation:

Neonatal resuscitation A irway B reathing C irculation

Before birth:

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

Very little flow to lungs:

Very little flow to lungs

Alveoli are fluid filled :

Alveoli are fluid filled Blood vessels are constricted

Before birth:

Before birth Pulm arterioles constricted Umbilical arteries feeding low pressure placenta circulation Low pressure in systemic circuit Very little pulmonary blood flow High pressure in pulmonary circuit

After birth:

After birth Fluid in the alveoli is absorbed Alveoli EXPAND GET FILLED WITH AIR (O 2 ) 1.

After birth:

After birth Umbilical arteries and veins are clamped Sudden increase in systemic blood pressure 2.

Pulmonary vessels dilate, causing increased blood flow to lungs:

Pulmonary vessels dilate, causing increased blood flow to lungs 3.

After birth:

After birth Pulm arterioles dilate Umbilical arteries and veins are clamped High pressure in systemic circuit Dramatic increase in pulmonary blood flow Low pressure in pulmonary circuit

Ductus arteriosus constricts:

Ductus arteriosus constricts Increased oxygen in blood Increased pulmonary blood flow 4.

Before:

Before After

What can go wrong:

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:

Consequences of interrupted transition Low muscle tone Resp depression ( apnea / gasping) Tachypnea Bradycardia Hypotension Cyanosis

Changes due to oxygen deprivation:

Changes due to oxygen deprivation

Some dictums:

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

Apgar score:

Apgar score

Apgar score is great, but not for guiding resuscitation:

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

NEONATAL RESUSCITATION:

NEONATAL RESUSCITATION

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90% of newborns transit comfortably to extrauterine life. 10% require some assistance at birth. Approximately 1% require extensive resuscitative measures. Need for anticipaton/ preparation/ evaluation and prompt support. Resuscitation :Requirement

Is resuscitation needed?:

Is resuscitation needed? NRP 2006 Routine Care Routine Care NRP 2000 Routine Care TERM GESTATION BREATHING OR CRYING GOOD MUSCLE TONE NRP 2010

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Routine Care ( STAY WITH MOTHER) TERM GESTATION ? BREATHING OR CRYING ? GOOD MUSCLE TONE ? PROVIDE WARMTH: place baby on mother’s chest, dry and cover the baby with dry linen CLEAR AIRWAY: wipe baby’s mouth and nose if needed . DRY: use a prewarmed dry and warm linen ONGOING EVALUATION YES

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Routine Care TERM GESTATION ? BREATHING OR CRYING ? GOOD MUSCLE TONE ? PROVIDE WARMTH POSITION CLEAR AIRWAY DRY STIMULATE REPOSITION NO INITIAL STEP

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Anticipate Prepare Universal precautions

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Anticipate Prepare Universal precautions Wash your hands Draught free, warm room - temperature > 25 0 C Clean, dry and warm delivery surface Radiant heater Two clean, warm towels/clothes A folded piece of cloth Self inflating bag - newborn size Infant masks in two sizes - normal and small newborn Suction device Oxygen (if available) Clock

HAND WASHING ASEPTIC PRECAUTIONS :

Anticipate Prepare Universal precautions HAND WASHING ASEPTIC PRECAUTIONS

Provide warmth :

Provide warmth

Position, clear airways (as necessary) :

Position, clear airways (as necessary)

Sniffing Position Vs Flexed neck:

Sniffing Position Vs Flexed neck

Position, clear airways (as necessary) :

Position, clear airways (as necessary)

Dry, stimulate, reposition:

Dry, stimulate , reposition

Dry, stimulate, reposition:

Dry, stimulate , reposition

Dry, stimulate, reposition:

Dry, stimulate, reposition

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Resuscitation when meconium present

Resuscitation when meconium present:

Resuscitation when meconium present Meconium -stained, depressed infants should receive tracheal suctioning immediately after birth and before stimulation, presuming the equipment and expertise is available. Tracheal suctioning is not necessary for babies with meconium -stained fluid who are vigorous. No role of intrapartum pharyngeal suctioning. No differentiation between thin/ thick meconium .

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Tracheal suction

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Initial tracheal suction Minimal meconium Initial steps Significant meconium Assess HR Significant bradycardia No significant bradycardia Repeat tracheal suction

Case - 1 :

Term Liquor clear Crying Actively moving Case - 1

Case 2:

Case 2 Term Liquor clear Poor cry Limp

Case - 3 :

Term woman, early labor Membranes ruptured and thick meconium revealed Breathing Limp Case - 3

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Routine Care TERM GESTATION ? BREATHING OR CRYING ? GOOD MUSCLE TONE ? EVALUATE FOR HEART RATE AND RESPIRATION NO INITIAL STEP OXYGEN SUPPLEMENTATION GIVE POSITIVE PRESSURE VENTILATION HR<100 OR APNEA OR GASPING HR>100 WITH NORMAL OR LABORED BREATHING SPO₂ < EXPECTED CONSIDER CPAP IF PRETERM

OXYGEN SUPPLEMENTATION:

OXYGEN SUPPLEMENTATION Supplementary O2 ranging 21% to 100% recommended whenever IPPV is indicated and no appreciable improvement in SPO₂ within 90 seconds of IPPV. SPO₂ less then expected on pulse oximetry with central cynosis . Targeted pre- ductual SPO₂ after birth 1 min. 60-65% 2 min. 65-70% 3 min. 70-75% 4 min. 75-80% 5 min. 80-85% 10 min. 85-95%

OXYGEN SUPPLEMENTATION:

OXYGEN SUPPLEMENTATION In term baby begins resuscitation with room air. Supplementary blended oxygen with air to be used if there is no appreciable improvement within 90 seconds of PPV. Adjust the oxygen supply according to pulse oximetry measurements to avoid hyperoxia . In Pre term baby begins resuscitation with supplementary blending oxygen with air and adjust the oxygen supply according to pulse oximetry measurements.

A B C FREE FLOW OXYGEN WITH (A) CUPPED HAND (B) MASK (C) FLOW INFLATING BAG:

OXYGEN SUPPLEMENTATION A B C FREE FLOW OXYGEN WITH (A) CUPPED HAND (B) MASK (C) FLOW INFLATING BAG

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CYNOSIS PERSIST Post-resuscitation care Provide positive-pressure ventilation* Administer chest compression Administer epinephrine and/ or volume * * Endotracheal intubation may be considered at several steps HR <60 HR <60 HR >60 Effective Ventilation, HR>100 & Pink CONSIDER CPAP IF PRETERM

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Positive pressure ventilation

Resuscitation Devices:

Resuscitation Devices Three types Flow inflating bag (anesthesia bag) Self inflating bag T Piece resuscitator Flow inflating bag (anesthesia bag) Self inflating bag(AMBU) T Piece resuscitator

Flow inflating bag:

Flow inflating bag Fill only when oxygen from a compressed source flows into them Depend on a compressed gas source Must have a tight face-mask seal to inflate Use a flow-control valve to regulate pressure-inflation

Flow inflating bag will not work if:

Flow inflating bag will not work if The mask is not properly sealed over the newborn’s nose and mouth There is a tear in the bag The flow-control valve is open too wide. The pressure gauge is missing

Flow inflating bag:

Flow inflating bag Advantages Delivers 100% oxygen at all times Easy to determine the adequacy of seal “Stiffness” of lungs can be felt Can be used to deliver 100% free flow oxygen Disadvantages Requires a tight seal to remain inflated Requires a gas source to inflate No safety pop-off valve Requires more experience

Self inflating bag(AMBU):

Self inflating bag(AMBU)

Self inflating bag:

Self inflating bag Advantages Does not need a gas source to inflate Pressure release valve Easier to use DisAdvantages Will inflate even without adequate seal Requires a reservoir to deliver 100% oxygen Can not be used to deliver 100% free flow oxygen

Masks:

Masks Cushioned/Non-cushioned Round/Anatomical shaped Size 0 or 1

Correct position of mask:

Correct position of mask

BAG & MASK VENTILATION:

BAG & MASK VENTILATION

PowerPoint Presentation:

CYNOSIS PERSIST Post-resuscitation care Provide positive-pressure ventilation* Administer chest compression Administer epinephrine and/ or volume * * Endotracheal intubation may be considered at several steps HR <60 HR <60 HR >60 Effective Ventilation, HR>100 & Pink CONSIDER CPAP IF PRETERM

Indications:

Indications Apneic or gasping following initial steps and tactile stimuloation HR<100/min in a spontaneously breathing baby Spontaneously breathing infant - cyanotic despite free flow oxygen Contraindications Diaphragmatic hernia Non -vigorous baby born through meconium stained liquor

Forming & checking the seal:

Forming & checking the seal Positioning & holding the mask: Enclose chin, mouth & nose, ensure snug seal, avoid pressure over neck and eyes Squeeze the bag with finger tips: Don’t squeeze empty the bag with whole hand Observe chest movements: Noticeable rise and fall of chest, shallow and easy breathing

Ventilation rate and pressure:

Ventilation rate and pressure Rate : 40-60 breaths/minute Squeeze-two-three-squeeze Pressure : Increase in HR &/or Noticeable rise and fall of chest Initial breath: 30-40 cms H 2 O Later : 15-20 cms H 2 O

Improvement:

Improvement Increasing HR Improving color Spontaneous breathing

No improvement / deterioration:

No improvement / deterioration Chest movement not adequate Inadequate seal Reapply mask Blocked airway Reposition Clear secretions Ventilate with open mouth Insufficient pressure Increasing pressure Corrective step M -Mask adjustment R -reposition S -suction mouth and nose O- open mouth P -pressure increase A -airway alternative

Orogastric catheter:

Orogastric catheter Indication Need for bag and mask ventilation for over 2 minutes Technique Use 6-8 Fr size, measure the length, aspirate gastric contents, leave outer end open

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Ventilate for 30 seconds Rate 40-60 bpm Increasing HR, visible rise and fall of chest Check heart rate with stethoscope or umbilical palpation for 6 seconds Less than 6 beats (< 60bpm) 6-10 beats (60-100bpm) More than 10 beats (>100 bpm) Continue ventilation Initiate chest compression Consider intubation Continue ventilation Consider intubation Check for spontaneous breathing No Yes Continue positive pressure ventilation Consider intubation Consider OG tube insertion Need of post-resuscitation care Gradually discontinue positive pressure ventilation Provide tactile stimulation Provide free flow oxygen Need of post-resuscitation care

Chest compressions:

Chest compressions

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CYNOSIS PERSIST Post-resuscitation care Provide positive-pressure ventilation* Administer chest compression Administer epinephrine and/ or volume * * Endotracheal intubation may be considered at several steps HR <60 HR <60 HR >60 Effective Ventilation, HR>100 & Pink CONSIDER CPAP IF PRETERM

Indication :

Indication If after 30 seconds of effective bag and mask ventilation with 100% oxygen, heart rate is below 60 per minute When to stop chest compressions When heart rate is 60 per minute or more

Principle:

Principle Pump out blood from the heart during compression and fill up blood in the heart during release Must always be accompanied by ventilation with 100% oxygen Position Neck slightly extended with firm support for the back Lower 1/3 rd of sternum between nipple line & sternum Pressure required – depth 1/3 rd of the AP diameter of chest Rate 90/min Components

Chest Compressions :

Chest Compressions Position Lower third of sternum Between nipple line and xiphisternum

Techniques of Chest Compressions :

Techniques of Chest Compressions Thumb method Two-finger method

Chest Compressions :

Chest Compressions

Preferred method - thumb:

Preferred method - thumb Advantages Better control of depth Less tiring Superior generation of peak systolic & coronary perfusion pressure Nails do not hinder performance Disadvantages Difficult when baby is big Umbilicus difficult to cannulate .

Rate & adequacy :

Rate & adequacy Rate 3 CC then 1 ventilation (1:3) 90 CC to 30 ventilation in one minute Adequacy Palpate femoral/carotid pulse

Chest Compressions :

Chest Compressions Dangers Broken ribs Lacerated liver Pneumothorax Precautions No pressure on the ribs, xiphisternum , abdomen Do not lift thumbs/fingers

Evaluation after 30 sec of CC & BMV:

Evaluation after 30 sec of CC & BMV HR 60 per minute or more Stop CC, continue BMV at 40-60/min If no improvement, check : Effectiveness of BMV Oxygen is 100% Technique of CC is correct

ENDOTRACHEAL INTUBATION:

ENDOTRACHEAL INTUBATION

Indications for intubation:

Indications for intubation Meconium suctioning in non vigorous baby Diaphragmatic hernia Prolonged PPV Ineffective B & MV Elective < 1Kg with CC for medication

Preparing laryngoscope:

Preparing laryngoscope No. 1 for full term No. 0 for preterm / LBW No. 00 for extremely preterm (optional)

Selecting endotracheal tube:

Selecting endotracheal tube Tube Size Weight Gest. Age 2.5 (ID mm) <1000 gm < 28 wks 3.0 (ID mm) 1000-2000 gm 28-34 wks 3.5 (ID mm) 2000-3000 gm 35-38 wks 4.0 (ID mm) >3000 gm > 38 wks ID=Internal Diameter

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correct incorrect ET INSERTION

Tip to lip distance (6+wt. in kg):

Tip to lip distance (6+wt. in kg) Weight Distance 1 kg 7 cm 2 kg 8 cm 3 kg 9 cm

Confirming ET tube placement:

Confirming ET tube placement Correct placement ETCO 2 - the recommended method Signs Bilateral breath sounds Equal breath sounds Rise of the chest with each ventilation No air heard entering stomach No gastric distention Improvement in HR Mist formation in tube Confirmation of tip position in trachea Chest X-ray: tip at T 2

Three actions after intubation:

Three actions after intubation 1. Note the cm. Mark on the tube at level of the upper lip 2. Secure the tube to the infant’s face 3. Shorten tube 4 cm. from the lip margin

Complications of intubation:

Complications of intubation Hypoxia Bradycardia Apnea Pneumothorax Soft tissue injury Infection

Minimizing hypoxia during intubation:

Minimizing hypoxia during intubation Providing free-flow oxygen (Assistant’s responsibility) Limiting each intubation attempt to 20 seconds

LMA –LARYNGEAL MASK AIRWAY:

LMA –LARYNGEAL MASK AIRWAY Effective for ventilation during resuscitation in term and near term newborns limited data in small preterm infants. May enable effective ventilation if -bag-mask ventilation is unsuccessful and -tracheal intubation fails or not feasible NOT TO BE USED IN: In the setting of meconium stained amniotic fluid When chest compression is required In VLBW babies For delivery of medications

Medications:

Medications EPINEPHRINE: cardiac stimulant. dose: 0.01-0.03 mg/kg [0.1-0.3 ml/kg] i.v . 1:10,000 (recommended route) or 0.03-0.1 mg/kg [0.3- 1ml/kg] endotracheal 1:10,000 IV preferred. IT only if IV access not available VOLUME EXPANSION: NS/ RL/ 10ml/kg i.v . [umbilical vein ]. Naloxone History of maternal narcotic administration within past 4 hours Recommended concentration = 1.0 mg/ml Route: IV preferred; IM acceptable but delayed onset of action; ET not recommended Dose: 0.1 mg/kg

Special considerations about Resuscitation of premature babies:

Special considerations about Resuscitation of premature babies

Preterm infants:

Preterm infants Avoid excessive chest wall movements (large tidal volume) Monitoring of pressure may help to provide consistent inflations and avoiding unnecessary high pressure CPAP after resuscitation may be helpful

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

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 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 “Wet-in-bag” Resuscitation

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 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% ! 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 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

CPAP:

CPAP

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

Preterm - summary:

Preterm - summary Are at risk for needing resuscitation Use blended oxygen and air, and a pulse oximeter Spo2 85-95% Use low inflation pressures Consider giving surfactant. AVOID- trendlenberg position and rapid i.v . fluid/ hypertonic fluids MONITOR FOR – hypoglcemia , apnea, bradycardia , desaturation , IVH, sepsis, hypothermia. If heart rate does not increase rapidly to > 100 bpm , correct any ventilation problem and use FiO2 100%.

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:

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 Not able to ventilate

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)

Post-resuscitation care:

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

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

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

A-AIRWAY B-BREATHING C-CIRCULATION D-DRUGS :

A -AIRWAY B -BREATHING C -CIRCULATION D- DRUGS

AHA/AAP Neonatal Resuscitation Guidelines 2010: Summary of Major Changes and Comment on its Utility in Resource-Limited Settings:

AHA/AAP Neonatal Resuscitation Guidelines 2010: Summary of Major Changes and Comment on its Utility in Resource-Limited Settings Resuscitation step Recommendations (2005) Recommendations (2010) Comments/LOE 1) Assessment for need of resuscitation Four questions • Gestation-term or not? • Amniotic fluid- clear or not? • Tone- Good? • Breathing /Crying? Three questions • Gestation-term or not? • Tone- Good? • Breathing /Crying? • Instead of 4 questions now 3 questions are asked at initiation of resuscitation. • “Amniotic fluid- clear or not” not part of assessment at birth. However, tracheal suction of nonvigorous babies with meconium stained amniotic fluid (MSAF) still to be continued (part of clearing airway in initial steps) 2) Routine care(Given if answer to all three question is YES) Provide warmth • Clear airway • Dry • Assess color • Provide warmth • Assure open airway • Dry • Ongoing evaluation(color, activity and breathing • Emphasis on placing baby on mothers chest in skin to skin contact 3) Initial steps • Provide warmth • Position; Clear airway(if required) • Dry, stimulate, reposition • Provide warmth • Open airway( no routine suction) • Dry , stimulate No change except for terminology

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4) Assessment (after initial steps and 0ngoing) 4.1) Assessment for need for progressive steps after initial steps 4.2) Assessment of heart rate Look for 3 signs • Hear rate • Color • Respiration Palpation of umbilical cord pulsation for 6 sec and multiply by 10 Look for 2 signs • Heart rate • Respiration( Labored, unlabored, apnea, gasping) Auscultation of heart at the precordium is the most accurate • Color has been removed from the signs of assessment • Pre-cordial auscultation better than umbilical cord palpation for detection of heart rate (LOE2,) 5) Positive pressure ventilation (PPV) 5.1) Indication for PPV 5.2) Assessment of effectiveness of resuscitation steps once PPV is started Indications are(any 1 out of 3) • Heart rate < 100/min • Apnea or gasping • Persistent central cyanosis despite free flow oxygen Heart rate Color Respiration Indications (1 out of 2) • Heart rate < 100/min • Apnea or gasping Heart rate Pulse oximetry Respiration • Persistent central cyanosis is not mentioned in the indication for PPV; use pulse oximetry to assess oxygenation • Increase in HR most sensitive indicator of resuscitation efficacy

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5) Oxygenation 5.1) Assessment of Oxygenation 5.2) Target saturation (pre- ductal ) • Based on color • Pulse oximetry recommended for only preterm < 32weeks with need for PPV Not defined • Based on pulse oximetry for both term and preterm in case of following situations a. Anticipated need for resuscitation b. Need for PPV for more than few breaths c. Persistent cyanosis d. Supplementary Oxygen Target SpO2 ranges provided as a part of algorithm • Attach probe to right hand or wrist (measure pre-ductal saturations) • Attach neonatal probe before connecting it to machine • Recording of tracing may take 1-2 min • Pulse oximetry should not replace clinical Assessment 1min- 60-65% 2 min- 65-70% 3min- 70-75% 4min- 75-80% 5min- 80-85% 10min- 85-95% (same for both term and preterm) 6) Initial oxygen concentration for resuscitation in case of PPV Term babies(≥ 37 weeks ) • Start with 100% O2 during PPV • if room air resuscitation is started O2 up to 100% should be given if no improvement within 90 seconds • In case non availability of O2- start room air Preterm babies(<32weeks) • Start with oxygen between 21-100% • Advocates use of blender for graded O2 • Pulse oximetry for targeting SPO2-85-95% Term babies (≥ 37 weeks) • Start with room air (21%) • No improvement in heart rate or oxygenation - use up to 100% to attain target saturations • Use blender for graded increased in delivered oxygen concentrations Preterm(<32weeks) • Initiate resuscitation using O2 concentration between 30-90% • Uses blended air oxygen mixture judiciously guided by pulse oximetry LOE-2 • shift from 100% to 21% O2 for term babies needing PPV • Supplemental oxygen started at 90 sec from birth in case of no improvement • Use of blender and pulse oximetry is recommended for term babies also • Preterm start with O2 concentration 30-90% and then increase or decrease

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7) Peripartum suctioning for neonates born through meconium stained amniotic fluid • No routine oropharyngeal and nasopharyngeal Suction • Tracheal suction only in non-vigorous babies born through meconium stained amniotic fluid (MSAF) • No routine oropharyngeal and nasopharyngeal suction required • Tracheal suction of nonvigorous babies with MSAF still to be continued though evidence for the same is conflicting • No evidence for or refuting tracheal suction even in non vigorous babies born through MSAF • However no change suggested to existing practice 8) Initial breath strategy Positive pressure ventilation (PPV • No specific recommendation for short or long inflation time • No specific PIP recommendation • No specific recommendation for PEEP • Guiding of PPV looking at chest rise and improvement in heart rate • No specific recommendation for short or long inflation time as evidence is conflicting • PIP- for initial breaths 20- 25 cm H2O for preterm and 30-40 cm H2O for term • PEEP likely to be beneficial for initial stabilization of preterm infants, if provided with suitable equipment (T-piece or flow inflating bags) • Guide the PPV looking at heart rate and oxygenation especially in preterm, chest rise less reliable • No specific recommendation for inflation time (LOE 1) • Addition of PEEP in preterm suggested (LOE 2) 9) CPAP in delivery room Suggested for preterm babies ( < 32 weeks) with respiratory distress Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP or ventilation as per local practice(Class IIB; LOE B) • CPAP is now mentioned in the algorithm for persistent cyanosis or labored Breathing • No evidence to support or refute its use in term. • May be considered for preterm infants with respiratory distress

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10) Airway management 10.1) Confirmation of endotracheal tube placement 10.2) Laryngeal mask airway Exhaled CO2 detection is recommended except in cardiac asystole where direct laryngoscopy may have to be done For near term and term infants > 2500g may be used with no definite mention of indications Exhaled CO2 detection is recommended except in cardiac asystole where direct laryngoscopy may have to be done LMA may be used for infants >2000g and ≥ 34 weeks in case bag and mask is ineffective and tracheal intubation is unsuccessful or not feasible(LOE 2) Indications for endotracheal intubation are same as are recommendations for confirming its placement in trachea. LMA not recommended - in cases of meconium stained AF, during CPR and for drug administration 11) Chest compression • Ratio of compression 3:1 • Two thumb technique better than two finger technique • The compression is applied at the lower one third of sternum • The depth of compression should be one-third of the antero-posterior diameter of the chest • Ratio of compression 3:1 unless cardiac arrest is due to a clear cardiac etiology where ratio of 15:2 may be considered • Two thumb technique better than two finger technique • The compression is applied at the lower one third of sternum • The depth of compression should be one-third of the antero-posterior diameter of the chest No major changes in the guidelines and most recommendations are based on low level of evidence

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12) Drugs 12.1) Naloxone Naloxone considered in case of infants born to mothers with history of opiod exposure within 4 hours of delivery and there is persistent respiratory depression even after restoration of heart rate and color by effective PPV • Naloxone is not recommended as part of initial resuscitation in babies with respiratory depression. • Focus needs to be on effective ventilation • Safety and long term effects on naloxone not established(LOE 5) • Naloxone is not indicated in delivery room. 13) Supportive care 13.1)Therapeutic Hypothermia 13.2)Delayed cord clamping No sufficient evidence to recommend routine use of modest systemic or selective cerebral hypothermia after resuscitation in infants with suspected asphyxia Avoid hyperthermia in such cases Not recommended Therapeutic hypothermia (whole body or selective head cooling) recommended for infants ≥ 36weeks with moderate to severe hypoxic ischemic encephalopathy as per the protocol used in major cooling trials with provision for monitoring for side effects and long term follow up For uncomplicated births both term and preterm not requiring resuscitation – delay cord clamping by at least 1 minute Lack of supporting evidence from resource-limited settings, need of intensive and multidisciplinary care during therapeutic hypothermia and established follow-up services after discharge limit the applicability in middle- and low-income Countries Delaying cord clamping for at least 1 min in all infants not requiring resuscitation at birth(LOE1)

CASE:

CASE

ALL OF YOU ARE SUCH A WONDERFUL AUDIENCE:

ALL OF YOU ARE SUCH A WONDERFUL AUDIENCE THANK YOU

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