Resuscitation Of Newborn

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Resuscitation Of Newborn
Presented May 2003

• Darko J. Vodopich MD
• Anesthesia Resident _at_ CWRU - MHMC

Revised by Greg Gordon MD
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Perinatal stress

• Cathecolamines (CCA) are good - if neonate is
  deprived CCA less survival rate
• CCA maintain CO
• CCA redistribute blood flow towards important
  areas
• ?BP and ?HR ? ?MVO2
• Neonates with ? CCA have higher Apgar scores
• CCA are important in a transition to
  extrauterine life

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Perinatal Cardiorespiratory physiology

• Fetal lungs
• 24 days -arises from the foregut
• 26-28 weeks -terminal airways developed
• 30-32 weeks -final surface active material (SAM)
  developed
• Plasma ultrafiltrate is a normal part of the
  lungs
• Every day IU (intrauterine) 50-150 ml/kg/day of
  plasma is produced
• Plasma is swallowed in the gut and excreted by
  kidneys

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Perinatal Cardiorespiratory physiology

• Plasma ultrafiltrate (2)
• 2/3 is expelled during vaginal delivery
• 1/3 is removed capillaries, lymphatics,
  breathing
• If fluid is retained into lungs causes TTN
  (transient tachypnea of newborn).
• Causes
• Small infants
• Preterm infants
• Rapidly born
• Cesarean section born babies

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Perinatal Cardiorespiratory physiology

• Normal breathing - 30/min _at_ 90 sec of age

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Perinatal Cardiorespiratory physiology

• Normal breathing - 30/min _at_ 90 sec of age
  (reminder)
• Normal breathing - 40-60/min _at_ few minutes of
  age
• Removal of increased CO2 produced by high
  metabolic rate
• Helps maintain FRC

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Perinatal Cardiorespiratory physiology

• Circulation of the fetus
• RV 2/3 of CO
• LV 1/3 CO
• Foramen ovale
• Ductus arteriosus
• Blood is coming from placenta - high O2 content
• 95 of the blood coming from placenta goes to LA
  through foramen ovale

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• Circulation of the fetus
• The numbers are
• combined ventricular output

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Perinatal Cardiorespiratory physiology

• Circulation of the newborn
• PVR is ? due to pulmonary expansion, breathing,
  ? pH, and ? O2 tension
• If neonate is born by CS - ??? PAPs and PVR
• PVR is ?
• Hypoxia
• Acidosis
• Hypovolemia
• Hypoventilation
• Atelectasis
• Cold

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Perinatal Cardiorespiratory physiology

• Changes in circulation of the newborn
• ? PVR - ? pulmonary blood flow
• Right/left shunting will be decreased
• LA pressures are ?, and seal foramen ovale
• Ductus arteriosus closes (10-14 days) in
  response to
• O2
• Ach
• Parasympathetic nerve stimulation
• PG
• If PaO2 60-100 closes, if 300-500 remains
  open

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Asphyxia

• ? PaO2
• ? PCO2
• ? pH
• ? Uteroplacental blood flow
• Maternal or Fetal disease (cause)

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Asphyxia

• Intrauterine asphyxia
• PaO2 decreases from 25-40 to 5 mmHg
• Anaerobic metabolism occurs
• pH drops lt 7.0 respiratory and metabolic
  acidosis
• Lactate is accumulating in the body
• Redistribution of blood flow in the body
• CO starting normal is now decreasing
• Because of high doses of opioids in the blood
  fetus may survive severe hypoxia (may reduce
  total O2 consumption)

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Asphyxia

• Intrauterine asphyxia
• (monkeys)

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Fetus assessment _at_ birth

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Resuscitation equipment

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Initial evaluation of Newborn

• Bulb syringe suction
• Dry towel
• Breathing stimulation
• Strip the blood from umbilical cord
• Increase blood volume
• Increase respiratory rate
• Increase lung water
• PAP
• PaCO2
• Be aware that baby can be hypovolemic from early
  clamping of the umbilical cord

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Initial evaluation of Newborn

• Prolonged suction may cause vomiting and
  arrhythmias
• Examine HEENT
• Choanal atresia
• NG tube suction
• Cor
• Pulmo
• Abdomen
• Extremities
• Do regular Apgar scores 1 and 5 minutes

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Disorders associated with Asphyxia

• Maternal conditions
• Elderly primigravida (gt35 years of age)
• Diabetes
• Hypertension
• Toxemia

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Disorders associated with Asphyxia

• Maternal treatment with any of the following
• Glucocorticoids
• Diuretics
• Antimetabolites
• Reserpine, lithium
• Magnesium
• Ethyl alcohol
• ?-Adrenergic drugs (to stop premature labor)
• Abnormal estriol levels

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Disorders associated with Asphyxia

• Anemia (hemoglobin level less than 10 g/100 mL)
• Blood type or group isoimmunization
• Previous birth of child with a hereditary
  disease
• Current maternal infection or infection during
  pregnancy with rubella, herpes simplex, or
  syphilis
• Abruptio placentae
• Placenta previa
• Antepartum hemorrhage
• History of previous infant with
• jaundice,
• thrombocytopenia
• cardiorespiratory distress
• congenital anomalies

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Disorders associated with Asphyxia

• Narcotic, barbiturate, tranquilizer, or
  psychedelic drugs
• Ethyl alcohol intoxication
• History of previous neonatal death
• Prolonged rupture of membranes

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Disorders associated with Asphyxia

• Conditions of labor and delivery
• Forceps delivery other than low elective
• Vacuum extraction delivery
• Breech presentation or other abnormal
  presentation
• Cesarean section
• Prolonged labor
• Prolapsed umbilical cord
• Cephalopelvic disproportion
• Maternal hypotension
• Sedative or analgesic drugs given intravenously
  within 1 hour of delivery or intramuscularly
  within 2 hours of delivery

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Disorders associated with Asphyxia

• Fetal conditions
• Multiple births
• Polyhydramnios
• Meconium-stained amniotic fluid
• Abnormal heart rate or rhythm
• Acidosis (fetal scalp capillary blood)
• Decreased rate of growth (uterine size)
• Premature delivery
• Amniotic fluid surfactant test negative or
  intermediate within 24 hours of delivery

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Disorders associated with Asphyxia

• Neonatal conditions
• Birth asphyxia
• Birth weight (inappropriate for gestational age)
  
• Meconium-staining of the skin, nails, or
  umbilical cord
• Signs of cardiorespiratory distress

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Apgar Scores

• 8 - 10
• 90 of all newborn
• Suction the baby
• Be sure is normothermic
• Be sure to repeat Apgar _at_ 5 minutes

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Apgar Scores

• 5 - 7
• Mild asphyxia suffered
• Usually respond to vigorous stimulation
• If not ventilate 80-100 face mask
• Score should go up

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Apgar Scores

• 3 - 4
• Moderately depression _at_ birth
• Usually they are cyanotic, bag/mask ventilation
• Place ET tube if necessary
• Draw ABG from umbilical artery (leave in)
• Use medication based on ABGs

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Apgar Scores

• 0 - 2
• Severe asphyxia
• Immediate resuscitation
• Pulmonary resuscitation
• Vascular resuscitation
• (see next slides for resuscitation)

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Pulmonary resuscitation

• Breath for the baby 30-60/min
• Hold every 5th breath for 2-3 sec for
  atelectasis
• Apply 1-3 cm H2O of PEEP
• Respect 5 differences in airway compared to
  adults
• Closely monitor effects of ventilation
• Keep POX mid 90s, and try wean off high
  inspired FiO2 - retinopathy of prematurity
• Provide routine tracheal suctioning
• 1st tracheal intubation apply suction and leave
  2nd in place if necessary

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Pulmonary resuscitation

• Be aware of meconium aspiration
• If baby lt 2000 g rare meconium aspiration
• 10 meconium mother stain fluid ? 60 babies
  will have in the trachea
• ?????
• 15 will develop respiratory complications
• 10 will have PTX or pneumomediastinum
• All neonates should be observed for 24 h
• Prone to Persistent Fetal Circulation syndrome
• Unless severe asphyxia at birth good prognosis

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Pneumothorax

• In 1 all vaginal deliveries
• In 10 meconium stained deliveries
• 2-3 neonates require mechanical ventilation
• To suspect always look the chest movement
• To diagnose
• CXR
• Small clod light placed over the thorax (glow)
• Rx 22-G blunt needle 2nd intercostal space

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Surfactant

• Greatly improved outcome in premature neonates
• Decreased incidence of
• Pulmonary gas leaks
• Hyaline membrane disease
• BPD
• Pulmonary interstitial emphysema
• Rx 5ml/kg intratracheal after delivery
• Be aware of initial transient desaturation

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Vascular resuscitation

• Umbilical Artery Catheterization
• 3.5 F if weight lt 1500 g
• 5 F if weight gt 1500 g
• Advance 3-5 cm from
• the umbilical cord cut
• Carefully 0.1 ml of air
• may obstruct the blood
• flow to the legs for several hours

The oximetric system for measuring arterial
oxygen saturation continuously. The catheter
contains fiberoptics that transmit light to and
from blood passing the catheter tip
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Vascular resuscitation

• Umbilical Venous Catheterization
• Insert 3-5 cm into IVC (see size on the slide
  before)
• Connect the catheter into transducer
• Proof to be in IVC - deflection during
  inspiration
• Be aware that air bubbles may cross foramen
  ovale and emboli brain

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Correction of Acidosis

• Respiratory acidosis ? increase ventilation
• Metabolic acidosis ? HCO3-
• If using Tromethamine be aware of
• Hypoglycemia
• Hypocalcemia
• Hypokalemia
• Apnea
• THAM is a 0.3 molar solution of
  tris(hydroxymethyl)- aminomethane adjusted to a
  pH of approximately 8.6 with 0.5 acetic acid.
  The solution is hypertonic (380
  milliOsmoles/liter). Administer by slow IV push.

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Correction of Acidosis

• Potential side effects with administration of
  HCO3-
• HCO3- are hypertonic 1800 mOsm/L ? rapid
  intravascular infusion ? intracranial
  hemorrhage
• H HCO3- ? CO2 to increase 1-3 mmol/L ? if
  ventilation is inadequate ? cardiac arrest
• In acidotic, hypovolemic neonates with intense
  peripheral vasoconstriction hypotension may
  occur ? correcting the acidosis (? PVR the
  neonate will not have adequate blood volume to
  fill intravascular space.

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Correction of Acidosis

• Who requires HCO3-
• If Apgar 2 min , 5 min 5 and controlled
  ventilation and tactile stimulation ? 2 ml/kg
  HCO3-
• pH lt 7.00 and PaCO2 is lt 35 mmHg ? 1/ of base
  deficit should be corrected
• Base Deficit 0.5 x weight in kg x (24 -
  HCO3-)

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Correction of Hypovolemia

• 60 of neonates are hypovolemic ? early
  clamping of umbilical cord
• Detection of hypovolemia
• ABP
• Physical exam
• Skin color
• Perfusion
• Capillary refill time
• Pulse volume
• Extremity temperature
• CVP lt 4 mmHg

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Hypovolemia
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Blood pressures in Neonates
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Rx. of Hypovolemia

• 10 mL/kg of LR
• 1-2 g/kg of 25 albumen
• 10 mL/kg of plasma
• Cross-matched blood
• O-negative blood

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Other causes of Hypotension

• We must consider other causes of hypotension
• Alcohol
• Hypomagnesemia
• Hypocalcemia
• Polycythemia (increased PVR)

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Cardiac Massage

• Code Pink should be activated for neonatal
  distress
• When If HR lt 100 in 1st minute
• Do CPR with thumbs on the precordium
• SBP generated should be in 80s
• Rate should be 100-150/min

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Resuscitation Drugs
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Advice

• Take PALS
• Take Code Pink Course
• All available in MHMC