Neonatal/Pediatric Cardiopulmonary Care Resuscitation

2 When To Resuscitate n Need usually related n Combination of n Can occur in

3 Causes of Fetal Asphyxia n n n n

4 Apnea

5 Effect of Asphyxia on Lungs n Initial adaption to extra- uterine life requires 2 steps: – –

6 Effect of Asphyxia on Lungs Asphyxia Apneic or ineffective respirations Negative pressure not generated to open Alveo li to push fluid out PaO 2 , PaCO 2 ,  pH  pH Pulmonaryvasoconstriction Pulmonaryhypertension Blood flow continues through d.a. & f.o. (by-passing lungs)

7 Effect of Asphyxia on Lungs If asphyxia severe with lactic acidosis  Ventilation alone will not change acid-base imbalance 

8 Effect of Asphyxia on Lungs n In severe cases - might be beneficial to give HCO 3 - to –

9 Effect of Asphyxia on Lungs n NOTE: Adequate ventilation must be maintained when bicarb given!!! Why??

10 Effect of Asphyxia on Lungs

11 Preparation For Resuscitation n n n

12 Basics of Neonatal Resuscitation n A - n B - n C - 3 steps:

13 Resuscitation Cycle Evaluation Decision Action

14 Steps in Resuscitation 1st step =

15 Mechanisms of Heat Loss n Radiation –Loss to n Conduction –Loss to n Evaporation –Loss when n Convection –Loss to

16 Causes of Heat Loss n n n

17 Cold Stress

18 Steps in Resuscitation n n Next Step = Open airway

19 Steps in Resuscitation

20 Evaluate Respiratory Effort Evaluate heart rate PPV with 100% O2 None or gasping Spontaneous Below sec. Evaluate respirations

21 Evaluate Heart Rate Above 100 Evaluate color Provide oxygen Observe and monitor Pink or peripheral cyanosis Blue Evaluate heart rate

22 Indications for PPV n n n n

23 Positive Pressure Ventilation n Flow-inflating bag n Self-inflating bag n Pressure gauge n Oxygen flow 5-8 lpm n Pop-off at cmH 2 O

24 PPV Technique n Slightly extend neck n Mask held with thumb & forefinger n Bag squeezed with fingertips n Initial rate - n Done for sec., then re-evaluate n May require -

25 Re-evaluate Heart Rate

26 Chest Compressions n 2 fingers or thumbs n Lower 1/3 of sternum n Sternum depressed 1/2-3/4 inches n 3:1 compression-to-ventilation ratio n Continue for 30 sec., stop for 6 sec. to re-evaluate HR n DC’d when HR > 80, then re-evaluate RR

27 Indications for Intubation n Bag/mask ventilation is difficult or ineffective n Prolonged PPV is required n Thick meconium is present in amniotic fluid n Suspicion of diaphragmatic hernia

28 ETT Sizes

29 Laryngoscope Blades n Size 1 for n Size 0 for n

30 Intubation Technique n Same as adult n Limit attempts to - n Provide blow-by oxygen at - n ETT tip midway between carina & clavicles n Cut ETT to leave -

31 Medications - Uses n n n

32 Medications - Routes n n n n

33 Instillation Into ETT NAVEL NNAAVVEELLO2O2NNAAVVEELLO2O2

34 Medications - Indications n HR < 80 despite PPV and chest compressions for at least 30 sec. n HR is 0

35 Epinephrine n Powerful sympathomimetic – – – n 1st drug given n IV or ETT, delivered rapidly n Repeated q3-5’ until HR -

36 Volume Expanders n Given if hypovolemic –  BP –Pallor with adequate oxygenation –HR > 100 with weak pulses –Failure to respond to resuscitation n Whole blood, 5% albumin, plasma expanders, NS n IV, may be repeated as needed

37 Sodium Bicarbonate n Prolonged arrest & not responding n Alkaline to buffer metabolic acidosis n Only given when ventilation is adequate n IV

38 Narcan (naloxone) n Reversal of narcotic depression –Demerol (meperidine) –Morphine sulfate –Fentanyl (Sublimaze) n IV, IM, sub-q, ETT n Given rapidly

39 Dopamine n n n n n n

40 APGAR Scoring n n n n

41 APGAR Scoring

42 Serum Glucose n Nutritional needs of fetus supplied by Mom & regulated by placenta n Fetus prepares for postnatal life by  energy stores & developing enzyme- dependant processes for usage of stored energy Sources

43 Serum Glucose n Glycogen – – n Triglycerides (brown fat) – – Energy Storage

44 Serum Glucose At 2 hours - By 3 days - Post-delivery

45 Serum Glucose Term - Preterm - Hypoglycemia

46 Hypoglycemia - Signs n Tremors n Irritability n  or  Moro reflex n Apnea/tachypnea n Cyanosis n Seizures n Lethargy n Hypothermia n Weak/high-pitched cry n Poor feeding n Vomiting n CV failure

47 Hypoglycemia

48 Hypoglycemia - Causes n Hyperinsulinism n Prematurity n IUGR n Starvation n Sepsis n Shock n Asphyxia n Hypothermia n Glucogen Storage Disease n Galactosemia n Adrenal insufficiency n Polycythemia n Congenital heart defects n Iatrogenic causes

49 Hyperinsulinism n Fetus of diabetic Mom n Rh incompatibility n Insulin-producing tumors n Maternal tocolytic therapy (ritodrine, terbutaline)

50 Glucose Measurement n Glucose Test Strip “Dextrostik” n “One Touch” n Lab sample (blood glucose)

51 Hypoglycemia Treatment n Early feeding (oral) n D 10 W –200 mg/kg bolus over 1-3 minutes –Con’t IV, 4-8 mg/kg/min. until feedings started n Treat cause

52 Umbilical Blood Sampling n n

53 Umbilical Vein Catheter (UVC) n Usually placed in - n Drug administration during -

54 Umbilical Artery Catheter (UAC) n n n Indications

55 Umbilical Artery Catheter (UAC) n 5 Fr. catheter (>1250 g), 3.5 Fr. catheter (<1250 g) n Sterile procedure n Heparinized-filled catheter n Tip L3-4 for low catheter, T8 for high catheter (in aorta below renal a., above bifurcation of femoral a.) Placement

56 UAC

57 Umbilical Artery Catheter n n n n n Complications

58 Umbilical Artery Catheter n n n n Sampling Technique