Special Deliveries….
…..With Love and Fresh Air
Monika Bhola, MD
Neonatologist
Rainbow Babies & Children’s
Hospital
Conflict & Disclosures
• I have no conflict of interest
• However there is one disclosure…..I have a
very soft spot for our respiratory
department.
OBJECTIVES
• Briefly Discuss some salient features of
Neonatal Resuscitation
• Highlight the differences in resuscitation of
neonates vs. older children/adults
• Oxygen use/misuse
• Temperature management
• Births outside of a major center
Transition to Extra-uterine
Life
• Transition from fetal life to extra-uterine
life is the most complex physiologic
adaptation that occurs in a human being’s
life
• Changes occur in almost every organ system
but the primary changes are in the
respiratory and cardiovascular systems
• Clearance of fetal lung fluid
• Surfactant secretion and breathing
• Transition of fetal to neonatal circulation
• Decrease in pulmonary vascular resistance
and increased pulmonary blood flow
• Endocrine support of the transition
NEWBORN
RESUSCITATION
• Approximately 10% require some assistance
to begin breathing or 90% transition well
• Less than 1% require extensive measures to
survive (chest compressions and
medications)
Term –Vigorous Baby
• If the baby is term (>37) weeks and has
good tone and respiratory effort- just dry
the baby and keep the baby warm
• Placing baby on the mom- skin to skin- is
the best way to keep this baby warm
How is Baby CPR different?
• It is still A-B-C
• Or as I like to call it A-A-A-A-A - B & C
• Their “arrest” is not necessarily an arrestbut apnea
• Do not need 100% oxygen, initially
• If compressions are needed – the landmarks
are a little different
Oxygen at Birth
• In the past we felt and some still do
“It can’t hurt……..”
Words of Wisdom
• “all substances are toxic: only the
dose makes a thing not a poison.”
»Paracelsus, 1524
• “……the air that nature has provided
for us is as good as we deserve.”
» Priestley, 1775
» Compared to a candle
» Lessons learnt from the past
Case Against Oxygen
• Ischemia and Hypoxia → cellular
changes affecting antioxidant defenses as well as enzyme
activities, membrane transports, mitochondrial function
• Hypoxia → ↓ATP synthesis and Na/K
pump alteration → cell edema and
hypoxanthine accumulation → +
Oxygen = toxic reactive oxygen
species
» Superoxide anions, hydrogen peroxide, hydroxyl
radicals, nitrogen reactive species
• Ischemia → promotes proinflammatory
cytokines and bioactive agents →
tissue vulnerability on re-perfusion
Oxygen Use
• In utero the fetus develops in a relatively
hypoxic environment with saturations of
50-60%
• Sudden exposure to 100% oxygen can
worsen cell and tissue injury
• Oxygen free radicals-antioxidants,
apoptosis and re-perfusion injury
Oxygen vs RA
• Animal studies – severe hypoxia model
• Resuscitation with 100% and RA
• BP and blood flow restoration to brain
and other markers were comparable
• Recent studies have shown a distinct
advantage to using RA
Case for Room Air (RA)……
• Meta analysis of 1082 newborns
resuscitated with Room air initially
and 1051 received 100%
• The ones in which resuscitation was
initiated with RA had a reduced risk
of death
•
Saugstad et al, Neonatology, 2008
……RA
• A single breath of 100% oxygen in the first week
of life– has resulted in decrease of minute volume
• Also duplicated in mice studies
• Delay in initiation of breathing with oxygen vs RA
• Hyperoxia in newborn animals – causes histological
changes in brain and other organs
• In other animal studies- 100% oxygen in the first
few days- saw evidence of pulmonary disease and
cardiac failure more than a year later and lead to
a shorter life span.
Baby Brains and Oxygen
• 70 preterm infants stabilized with
either RA or 80%
• Oxygen exposed neonates had
decreased cerebral blood flow for 2
hrs (Lundstrom et al, 1995)
• Similar findings by other researchers
also found decreased cerebral blood
flow velocity (Niijima etal)
What is the right balance?
• Compromised Fetus Anaerobic Metabolism
→ Production of Lactic acid
• If short → easily reversible with airway
establishment
• If prolonged energy failure
membrane depolarization
or death
→
→
cell
cellular injury
Target Spo2 after birth
1min
2min
3min
4min
5min
10min
60-65%
65-70%
70-75%
75-80%
80-85%
85-95%
How Can we safely deliver
oxygen
• Should have blenders
• Start resuscitation with RA for term babies
• Preterm babies 30-40%
• Don’t have blenders / home delivery/ ER/
ambulance
– Self inflating bag- without reservoir will
give about 40%
OXYGEN DELIVERY USING SELF
INFLATING BAG
FiO2 values obtained at different oxygen flow rates (range 0–10 L/min) over time during PPV
at a respiration rate of 40 to 60 per minute and PIP of 25 cm H2O.
Trevisamuto D etal, Pediatrics 2013;131:e 1144-1149
Airway
• Proper equipment for Neonates
• Correct Size Face mask- Term and Preterm
• Self inflating Bags-240 ml
• Anesthesia bag
• Manometer
• T-piece/ Neopuff
• ET tubes- 2.5, 3.0, 3.5 - uncuffed
• LMA – Size 1
• Miller Laryngoscope blades-Size 1 & 0
Chest Compressions
• Lack of gas exchange with
simultaneous hypoxia and carbon
dioxide elevation- most common
reason that newborns fail to
transition successfully
• If there is significant hypoxemia and
acidosis- the myocardium could be
depressed
Airway…. (again!)
• It is ABSOLUTELY essential to
establish EFFECTIVE ventilation for
30 secs–prior to chest compressions
• Corrective measures should be tried if
unable to get effective ventilation
• M-R-S-O-P-A
MRSOPA- (Corrective Measures)
M
Mask Seal
R
Reposition of head
S
Suction
O
Open Mouth
P
Pressure Increase
A
Alternate Airway
Temperature Management
Thermo Neutral Zone in
Humans
• Unclothed resting adult—23-28⁰ C
(73⁰F)
• Unclothed full term neonate—32-35⁰
C (90⁰ F)
• Unclothed 1 Kg preterm neonate–
35⁰C (95⁰ F)
Heat Loss In New Borns
Temperature and Resuscitation
• WHO recommends that the DR temperature
should be about 72⁰F or mid 70’s
• If preterm delivery is expected then
the temperature should be around 77-79⁰F
• Other modes of keeping the baby warm
–
–
–
–
–
Radiant Warmer
Warm blankets
Warm gel packs
Baby hats
Thermal plastic wrap
Picture of Basic Equipment
Infant PortableThermal
Packs
Warm Blankets
Consequences of Hypothermia
in Preterm Infants
• 36.5-37.5ºC
• Every 1º drop in baby’s temperature
increases mortality risk by 28% !!!!!
Other sobering data….
• Hypothermia is associated with increase in
morbidity
• Respiratory Distress
• Metabolic derangements
• Intra Ventricular Hemorrhage
• Infection
• Increased hospital length of stay
Hyperthermia
• Elevated temperature increases the risk of
death or impairment – almost 4 fold
increased risk
• This is worse if there has already been a
brain injury
• A rise of just 1.5ºC above normal can
cause significant impairment
Not Too Hot
Not Too Cold
Special Considerations
Viability
• Less than 23 weeks- survival chances
are very poor
• Survival has improved over the years
• NRP recommends offering
resuscitation if 23 weeks and
>400gms
Survival
Gestation 23
weeks
al age
Survival
24
weeks
50-60% 7080%
25
weeks
26
weeks
27
weeks
7585%
8090%
>90%
Special Considerations in
Preterm Infants
• Greater risk for injury
• Lung-Protective strategy should start right
at birth- GENTLE VENTILATION
• PPV is the cornerstone of respiratory
support
• Very crucial to establish FRC- PEEP
• Need to deliver adequate Tidal Volume- PIP
Post Resuscitation
• Temperature
• Sugar- Never give new borns > D10W
IV fluids
• IV access
• Normal D.stick-35-40
Emergency IV acess
• If unable to start PIV- may place
emergency Umbilical vein catheter
• Place an umbilical tie
• Clean with Betadine
• Place a sterile catheter (5Fr) in the vein
(largest vessel) till you get blood return (23 cms in preterm infants and about 5 cms
in term
• Avoid Intraosseous in preterm infants.
Neonatal Encephalopathy
• These babies should be transferred to a tertiary
care center ASAP
• Therapeutic cooling –significantly decreases
mortality and neuro-developmental impairment
• Therapeutic hypothermia should be instituted in a
controlled environment and within 6 hrs
• Prevent hyperthermia
• Aim at keeping temperature at low end of normal
Abdominal Anomalies
• Gastroschisis- omphalocele
• Place sterile wrap soaked in saline around anomalie
• Prevent excessive insensible water loss
• Place in sterile bowel bag
• Place a replogle to decompress the bowel
• Start IV- Fluids and Antibiotics
Airway Anomalies
• Pierre Robin or severe micrognathia and if
in respiratory distress:• Place in supine position
• If respiratory distress continues- may need
a stable airway
• Intubation
• LMA
• Nasopharyngeal ET tube
Congenital Diaphragmatic
Hernia
• If in distress will need intubation
• Avoid using bag and mask PPV- will worsen
• Consider this diagnosis if you have a
newborn with a scaphoid abdomen
• Decompress the bowel
• Intubate
“Useful Accessory”
Placenta
Love & Fresh Air ?!*@#
What was that all about?
• Warmth- gentle ventilation = Love
• RA or OWL (Oxygen with Love) = Fresh
Air