AIRWAY MANAGEMENT- NEONATES (Neonatal Resuscitation) CHAKAFA N K (Clinical Anaesthetist)

Introduction At least 10% of all newborns require some assistance at birth ie the initial steps of resuscitation And 1% require extensive resuscitation There are 1 million deaths per year resulting from Birth asphyxia(WHO,1995) A significant number will have respiratory problems and a large number will have seizures and later problems such as cerebral palsy.

Definitions Airway mgt is a process of ensuring that there is an open pathway between patient’s lungs and the outside world The lungs are safe from aspiration. Neonate – baby less than 28 days

Neonates compared to older children Neonates are small Large surface area to weight ratio Born wet so they are prone to rapid evaporative heat loss New born babies are in transition from placental to pulmonary respiration Large tongue Proportionally large head and occiput

Essential equipment for resuscitation of the newborn Firm flat padded resuscitation surface Source of warmth( overhead heater, warm dry towels,radiator,hot water bottle wrapped in towels. Clear plastic bags for preterm babies under 30wks Good light source Clock or timer to record time of birth, assessment and response to resuscitation Airway equipment: facemask 0 and 1,oropharyngeal airway size 000,00 and 0, self inflating bag with reservoir, neonatal face masks, laryngoscope and blade with spare bulb Miller (1,0), Mackintosh blade(1,0) , tracheal tubes (2.5 ,3 for pre term and 3.5 or 4 for term, stylets, size 1 LMA

Equipment cont’d Nasogastric tube Adhesive tape Oxygen Stethoscope to assess HR and breath sounds IV cannulae, 24 g, umblical catheter Drugs : N/saline, adrenaline 1:10000,10% glucose, sodium bicarbonate,naloxone

Assessment Was th e baby born after full term gestation? Is the amniotic fluid clearof meconium and evidence of infection? Is the baby crying? Does the baby have a good muscle tone?

Healthy child If the answer to all 4 of these questions is “yes” then there is no need for any resuscitation Do not separate the child from the mother Dry the baby, place onto the mother’s chest Cover the child with a dry cloth Observation of breathing , activity and colour should be ongoing

Asphyxiated baby If the answer is “no” then the child is in danger, so the child should receive one or more of the following : Initial steps in stabilization(provide warmth, position, clear airway, dry, reposition) Ventilation Chest compressions Administration of epinephrine and /or volume expansion

Heat Loss Minimise heat loss especially in pre term babies Warm towels, dry the child as soon as possible Change towels Place the child under a radiant heater This must be done in 20 – 30 seconds

Airway Maintain head in neutral position with face parallel to the surface on which the baby is lying Avoid overextension/ flexion of the neck Provide a jaw thrust Oropharyngeal airway may be helpful- large tongue

Meconium aspiration Some babies may pass meconium in utero Inhalation of meconium before birth or during birth can cause severe pneumonitis. Remove any thick particulate by means of a large bore suction device or a penguin Do not suction the nose before the mouth- this will stimulate the baby to gasp and to aspirate pharyngeal secretions Intubation is necessary in a floppy child.

Ventilation Ventilate the lungs with either room air or 100% oxygen Well fitting mask to the nose and mouth Inflate the lungs with at a pressure of around 30cm of water Aim at inspiratory time of 2-3secs Give at least 5 inflations

Circulation Re evaluate HR If HR is above 100 then it’s a firm indication that lungs are adequately aerated Assess chest movement If HR has not improved ---- START CHEST COMPRESSIONS

Chest compressions Indicated for a HR that is less than 60 despite adequate ventilation Necessary to bring oxygenated blood from the lungs back to the coronary arteries Both hands encircling the chest Place thumbs together centrally over the lower sternum Rate- 120/min For every 3 compressions give one breath aiming at 40 breaths/min

Assessment Look for response after 30-60secs of chest compressions If HR is above 100 then it indicates that you are succeeding However if the HR has not improved or is absent then consider DRUGS

Drugs Epinephrine 1:10000 0.1-0.3ml/kg IV Epinephrine 1:10000 0.5 1ml/kg per ET Give ET only while IV access is being established Repeat every 5 minutes Caution- higher doses in newborns may result in brain and heart damage. Sodium bircabonate (4,2% soln) 2mEq/kg IV over 2 min if severe metabolic acidosis is suspected

Post resuscitation care Glucose – 10% dextrose water 2ml/kg iv Phenobarbital (seizures) 20mg/kg slow iv Dopamine(hypotesion)- 2- 20mcg/kg

Discontinuing Resuscitative Efforts Infants without signs of life i.e. no heart beat and no respiratory effort after 10min of resuscitation

THANK YOU FOR YOUR TIME