Newer guidelines on neonatal resusitation

1. Neonatal Resuscitation GuidelinesWhat's new????
Dr Aakash Pandita
DNB Neonatology
Fernandez Hosipital

2. • Introduction
• Preparation /Anticipation
• Initial assessment
• Whom to resuscitate
• Steps of resuscitation
• New additions
• Conclusion

3. Introduction
• Approximately 10% of newborn's require some
assistance.
• Less than 1% require extensive resuscitation
measures
Because of the large total number of births, a significant number
will require some degree of resuscitation

4. Anticipate the risk
• Assessment of perinatal risk factors
• Assemble the appropriate personnel
• Organize access to supplies and check equipment
• Effective teamwork and communication

5. Initial Assessment?
• Assess the answers to the following 3 questions:
• Term gestation?
• Good tone?
• Breathing or crying

6. Whom to resuscitate?
• If the answer to any of these assessment questions is
“NO”
• A. Initial steps of stabilization
• B. Ventilate and oxygenate (HR/Breathing)
• C. Initiate chest compressions (HR < 60)
• D. Administer epinephrine and/or volume

7. Approximately 60 seconds (“the Golden Minute”) are allotted for
completing
initial steps, revaluating and beginning ventilation if required

8. New Entries
Umbilical cord management
DCC : less IVH, higher BP, blood volume, less need for
transfusion after birth, and less NEC
No evidence of decreased mortality or
decreased incidence of severe IVH
slightly increased level of bilirubin associated with more
need for phototherapy

9. New Entries
Consensus:
• DCC > 30 seconds is reasonable for both T/PT infants
who do not require resuscitation at birth
• No routine use of cord milking for infants < 29 weeks
of gestation outside of a research setting

10. New Entries
Temperature regulation
• Admission temperature strong predictor of mortality
at all gestational ages.
• Hypothermia increases risk of IVH, respiratory issues,
hypoglycaemia and late-onset sepsis
predictor of outcomes as well as a quality indicator

11. New Entries
Consensus
• Maintain temperature between 36.5-37.5°C
• Plastic wrap, radiant warmer, thermal mattress, warm
humidified gases and increased room temperature
• Hyperthermia (>38.0°C) should be avoided
• Rapid or slow cooling both acceptable

12. New Entries
Maintaining normothermia in resource-limited
settings
• Clean food-grade plastic bag up to the level of the
neck and swaddle
them after drying
• Kangaroo mother care

13. New Entries
Maternal hyperthermia in labour is associated with increased
mortality, neonatal seizures and encephalopathy

14. New Entries
Meconium Stained Amniotic Fluid
• Deterioration of pulmonary compliance, oxygenation and
cerebral blood flow velocity accompany tracheal suction
Non vigorous baby: Routine intubation for tracheal suction not
suggested

15. New Entries
Assessment of Heart Rate
• Increasing heart rate is most sensitive indicator of a
successful response to each intervention
• Underestimation of the newborn’s heart rate by
auscultation, palpation and pulse oximetry
• 3-lead ECG displayed a reliable heart rate faster
than pulse oximetry

16. New Entries
Consensus
During resuscitation of T/PT newborn's, use 3-lead ECG
for the rapid and accurate measurement of the newborn’s heart rate

17. New Entries
Administration of oxygen in Preterm
• Resuscitation of PT newborn's (<35) with high oxygen (65%) showed
no improvement in survival to hospital discharge
Resuscitate preterm < 35 weeks with low oxygen (21-30%)
and titrate to achieve preductal oxygen saturation

18. New Entries
Positive Pressure Ventilation/PEEP
• PEEP :supplementary oxygen required to achieve target oxygen saturation may be
slightly less when using PEEP.
5 cm H2O PEEP when PPV is administered to preterm newborn's
PPV delivered effectively with a flow-inflating bag, self-inflating bag or T-piece
resuscitator

19. New Entries
• Use of respiratory mechanics monitors have been reported
to prevent excessive pressures and tidal volumes
• Exhaled CO2 monitors may help assess that actual gas
exchange is occurring during face-mask PPV attempts.
Effectiveness, particularly in changing important outcomes,
has not been established

20. New Entries
LMA recommended during resuscitation > 34 weeks when tracheal
intubation is unsuccessful or is not feasible

21. New Entries
• CPAP decreases rate of intubation, duration of MV with potential benefit of
reduction of death and/or BPD without significant increase in air leak or
severe IVH.
spontaneously breathing PT infants with respiratory distress may be
supported with CPAP initially rather than routine intubation for
administering PPV

22. New Entries
Chest compression
100% Oxygen whenever chest compressions are provided
Supplementary oxygen concentration should be weaned as soon
as the HR recovers

23. • In asystolic /bradycardic neonates no routine use of
any single feedback device (ETCO2 monitors/pulse
oximeters) for detection of return of spontaneous
circulation
• Usefulness has not been well established

24. New Entries
Induced Therapeutic Hypothermia (Resource Limited setting)
TH may be considered and offered under clearly defined
protocols similar to those used in published clinical
trials and in facilities with the capabilities for
multidisciplinary care and longitudinal follow-up

25. New Entries
Withholding Resuscitation
• < 25 weeks, consider accuracy of gestational age assignment,
presence/absence of chorioamnionitis and the level of care
• Useful data for antenatal counselling provides outcome
figures for infants alive at the onset of labor, not only for
those born alive or admitted to a neonatal intensive care unit

26. Structure of educational programs to teach neonatal resuscitation
• Advantages in psychomotor performance, knowledge and confidence
when focused training occurred every 6 months or more
frequently.
Neonatal resuscitation task training should occur more frequently
than the current 2-year interval

28. Any Questions???