1. Resuscitation Of Newborn

2. Perinatal stress ì Cathecolamines (CCA) are good - if neonate is deprived CCA less survival rate ì CCA maintain CO ì CCA redistribute blood flow towards important areas ì  BP and  HR   MVO 2 ì Neonates with  CCA have higher Apgar scores ì CCA are important in a transition to extrauterine life

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

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

5. Perinatal Cardiorespiratory physiology ì Normal breathing - 30/min @ 90 sec of age

6. Perinatal Cardiorespiratory physiology ì Normal breathing - 30/min @ 90 sec of age (reminder) ì Normal breathing - 40-60/min @ few minutes of age: ì Removal of increased CO2 produced by high metabolic rate ì Helps maintain FRC

7. Perinatal Cardiorespiratory physiology Circulation of the fetus: ì RV ~ 2/3 of CO ì LV ~ 1/3 CO ì Foramen ovale ì Ductus arteriosus ì Blood is coming from placenta - high O 2 content ì 95% of the blood coming from placenta goes to LA through foramen ovale

8. Circulation of the fetus: The numbers are combined ventricular output

9. Perinatal Cardiorespiratory physiology Circulation of the newborn: ì PVR is  due to pulmonary expansion, breathing,  pH, and  O 2 tension ì If neonate is born by CS -  PAP’s and PVR ì PVR is  : ì Hypoxia ì Acidosis ì Hypovolemia ì Hypoventilation ì Atelectasis ì Cold

10. Perinatal Cardiorespiratory physiology Changes in circulation of the newborn: ì  PVR -  pulmonary blood flow ì Right/left shunting will be decreased ì LA pressures are , and seal foramen ovale ì Ductus arteriosus closes (10-14 days) in response to ì O2 ì Ach ì Parasympathetic nerve stimulation ì PG ì If PaO 2 ~ 60-100 = closes, if 300-500 = remains open

11. Asphyxia   PaO 2 ì  PCO 2 ì  pH ì  Uteroplacental blood flow ì Maternal or Fetal disease (cause)

12. Asphyxia ì Intrauterine asphyxia: ì PaO2 decreases from 25-40 to 5 mmHg ì Anaerobic metabolism occurs ì pH drops < 7.0 : respiratory and metabolic acidosis ì Lactate is accumulating in the body ì Redistribution of blood flow in the body ì CO starting normal is now decreasing ì Because of high doses of opioids in the blood fetus may survive severe hypoxia (may reduce total O 2 consumption)

13. Asphyxia Intrauterine asphyxia: (monkeys)

14. Fetus assessment @ birth:

15. Resuscitation equipment

16. Initial evaluation of Newborn ì Bulb syringe suction ì Dry towel ì Breathing stimulation ì Strip the blood from umbilical cord: ì Increase blood volume ì Increase respiratory rate ì Increase lung water ì PAP ì PaCO 2 ì Be aware that baby can be hypovolemic from early clamping of the umbilical cord

17. Initial evaluation of Newborn ì Prolonged suction may cause vomiting and arrhythmias ì Examine HEENT Choanal atresia NG tube suction Cor Pulmo Abdomen Extremities Do regular Apgar scores: 1 and 5 minutes

18. Disorders associated with Asphyxia Maternal conditions ë Elderly primigravida (>35 years of age) ë Diabetes ë Hypertension ë Toxemia

19. Disorders associated with Asphyxia Maternal treatment with any of the following: ë Glucocorticoids ë Diuretics ë Antimetabolites ë Reserpine, lithium ë Magnesium ë Ethyl alcohol ë  -Adrenergic drugs (to stop premature labor) ë Abnormal estriol levels

20. Disorders associated with Asphyxia ë Anemia (hemoglobin level less than 10 g/100 mL) ë Blood type or group isoimmunization ë Previous birth of child with a hereditary disease ë Current maternal infection or infection during pregnancy with rubella, herpes simplex, or syphilis ë Abruptio placentae ë Placenta previa ë Antepartum hemorrhage ë History of previous infant with ëjaundice, ëthrombocytopenia ëcardiorespiratory distress ëcongenital anomalies

21. Disorders associated with Asphyxia ë Narcotic, barbiturate, tranquilizer, or psychedelic drugs ë Ethyl alcohol intoxication ë History of previous neonatal death ë Prolonged rupture of membranes

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

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

24. Disorders associated with Asphyxia Neonatal conditions ì Birth asphyxia ì Birth weight (inappropriate for gestational age) ì Meconium-staining of the skin, nails, or umbilical cord ì Signs of cardiorespiratory distress

25. Apgar Scores 8 - 10: ì 90% of all newborn ì Suction the baby ì Be sure is normothermic ì Be sure to repeat Apgar @ 5 minutes

26. Apgar Scores 5 - 7: ì Mild asphyxia suffered ì Usually respond to vigorous stimulation ì If not ventilate 80-100% face mask ì Score should go up

27. Apgar Scores 3 - 4: ì Moderately depression @ birth ì Usually they are cyanotic, bag/mask ventilation ì Place ET tube if necessary ì Draw ABG from umbilical artery (leave in) ì Use medication based on ABG’s

28. Apgar Scores 0 - 2: ì Severe asphyxia ì Immediate resuscitation ì Pulmonary resuscitation ì Vascular resuscitation (see next slides for resuscitation)

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

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

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

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

33. Vascular resuscitation: Umbilical Artery Catheterization ì 3.5 F if weight < 1500 g ì 5 F if weight > 1500 g ì Advance 3-5 cm from the umbilical cord cut ì 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

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

35. Correction of Acidosis: ì Respiratory acidosis  increase ventilation ì Metabolic acidosis  HCO 3 - ì If using Tromethamine* be aware of: ì Hypoglycemia ì Hypocalcemia ì Hypokalemia ì 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.

36. Correction of Acidosis: Potential side effects with administration of HCO 3 - ì HCO 3 - are hypertonic ~1800 mOsm/L  rapid intravascular infusion  intracranial hemorrhage ì H + + HCO 3 -  CO 2 to increase 1-3 mmol/L  if ventilation is inadequate  cardiac arrest ì 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.

37. Correction of Acidosis: Who requires HCO 3 -: ì If Apgar 2 min ~, 5 min ~ 5 and controlled ventilation and tactile stimulation  2 ml/kg HCO 3 - ì pH < 7.00 and PaCO2 is < 35 mmHg  1/ of base deficit* should be corrected * Base Deficit = 0.5 x weight in kg x (24 - [HCO 3 - ])

38. Correction of Hypovolemia: ì ~ 60 % of neonates are hypovolemic  early clamping of umbilical cord ì Detection of hypovolemia: ì ABP ì Physical exam: ì Skin color ì Perfusion ì Capillary refill time ì Pulse volume ì Extremity temperature ì CVP < 4 mmHg

39. Hypovolemia

40. Blood pressures in Neonates:

41. Rx. of Hypovolemia: ì 10 mL/kg of LR ì 1-2 g/kg of 25% albumen ì 10 mL/kg of plasma ì Cross-matched blood ì O-negative blood

42. Other causes of Hypotension: ì We must consider other causes of hypotension: ì Alcohol ì Hypomagnesemia ì Hypocalcemia ì Polycythemia (increased PVR)

43. Cardiac Massage: ì Code Pink should be activated for neonatal distress ì When: If HR < 100 in 1st minute ìDo CPR with thumbs on the precordium ì SBP generated should be in 80’s ìRate should be 100-150/min

44. Resuscitation Drugs:

45. Advice: ì Take PALS ì Take Code Pink Course