the critically ill neonate - code 3...
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Terry Cuellar, MN, RN, CCRN • Pediatric Outreach Educator • SSM Health Cardinal Glennon Children’s Hospital
Saint Louis, MO • Terrence.Cuellar@ssmhealth.com
Disclaimer
• I do not have a conflict of interest • This educational activity did not receive
commercial support or sponsorship • Pictures/videos used in this presentation were
gained from publically accessed sources.
The Critically Ill Neonate Thanks --
Glenn Barber, RNC-NIC Perinatal Outreach Educator
SSM Health Cardinal Glennon Children’s Hospital
Mary Hope, RN, BSN Perinatal Outreach Educator
SSM Health Cardinal Glennon Children’s Hospital
Objectives
• List the initial stabilization steps following the delivery of the newborn
• Discuss the importance of proper ventilation in the newborn needing assistance
• Identify the initial principles of neonatal resuscitation.
• List the principles of STABLE when transferring the newborn
Preparation • Thermoregulation Mother (or other warm body) Linens/towels Polyethylene bag or plastic bag
(2 gallon Ziploc bag)
• Suction Bulb syringe Suction catheter
• Bag/Mask
Ventilation bag/device (preferably newborn size)
Face mask (term & preterm newborn)
Preparation • Airway
Laryngoscope Blade size 0 & 1 (straight/curved) ETT sizes: 2.5, 3.0, 3.5 Carbon dioxide detector Tape to secure tube
• Medications Epinephrine 1:10,000 solution Isotonic crystalloid (NS)
• Miscellaneous Stethoscope, personal protection Pulse oximeter ECG monitor Broselow tape
At Delivery -- Decision-Making Process
• Is the neonate term? • Is the amniotic fluid
clear? • Is the neonate crying
or breathing effectively?
• Does the neonate have good muscle tone?
• ----------- yes
• ----------- yes
• ----------- yes
• ----------- yes
Well Baby!
At Delivery -- Routine Care
Initial Steps • Place in a warm environment – mother
• Increase temperature in ambulance
• Watch drafts
• Suction the mouth and nose – only if necessary
• Dry thoroughly
• Remove the wet linens
• Gently rubbing the back/trunk or flicking the feet provides tactile stimulation
• Place cap & cover with towels/blankets
• Skin-to-skin and encourage breastfeeding
Post - Delivery
• Apgar Scores • Done at 1 minute, 5 minutes and every 5 minutes as
long as score is <7
Meconium At Delivery -- Routine Care
Initial Steps • Place in a warm environment – mother
• Increase temperature in ambulance • Watch drafts
• Suction the mouth and nose – only if necessary • Don’t get over-aggressive with the bulb syringe
• Dry thoroughly • Remove the wet linens • Gently rubbing the back/trunk or flicking the feet provides tactile
stimulation • Place cap & cover with warm blankets
Meconium and Non-Vigorous At Delivery
• DO NOT provide routine intubation and tracheal suctioning, continue with initial steps
• Meconium-stained amniotic fluid remains a perinatal risk factor that requires presence of one resuscitation team member with full resuscitation skills, including endotracheal intubation
At Delivery -- Decision-Making Process
• Is the neonate term? • Is the amniotic fluid
clear? • Is the neonate crying
or breathing? • Does the neonate
have good muscle tone?
• ------------ yes • ------------ yes
• ------------- no (Gasping/apneic)
• ------------- no (Floppy/hypotonic)
Not Well Baby!
Baby that needs HELP Not vigorous - Compromised
• Not crying?
• Poor muscle tone – Floppy?
• Cyanotic?
• Apnea
• Gasping
• Low Heart Rate (<100) -- Apical
INDICATION FOR POSITIVE PRESSURE VENTILATION
Positive Pressure Ventilation • Oxygen – NO
• START WITH ROOM AIR Technique • Head position
• sniffing position • shoulder roll
• Good seal with mask (C over E) • Correct tempo (rate 40-60) • 20 – 25 cm H20 pressure if BVM
has a manometer
Good seal
Head Position (“Sniffing” – Slightly extended)
Kattwinkel J, McGowan JE, Zaichkin J. (2011). Textbook of Neonatal Resuscitation- 6th Edition. Elk Grove Village: American Academy of Pediatrics.
Key Steps in Ventilation
Positive Pressure Ventilation
Tempo of Ventilation:
Breathe the baby --- Breathe the baby --- Breathe the baby (squeeze) (squeeze) (squeeze)
• Signs of Effective Ventilations • Chest movement - like normal respirations
• Breath sounds – Listen under axilla
• Best sign – the baby gets better!
• Heart rate increases
• O2 sats increase
• Muscle tone/activity improves
• Breathing/crying
• Color improves
Positive Pressure Ventilation – Avoid overventilation!
Troubleshooting Ventilations Head
• Reapply the mask – better seal • Reposition the head – neck slightly
extended Mouth
• Check mouth/suction for obstructions
• Open the mouth slightly
Bag • Squeeze the bag harder
Not improving – Consider Adjunct or Intubation
Neonatal Intubation
• Head in the “sniffing” position
• Do not use rocking motion • Look for landmarks. • Cricoid pressure may help
bring glottis into view • Use a 2 x 2 gauze to help
stabilize the ETT while securing the tube
Neonatal Intubation -- Appropriate Tube Size
Kattwinkel J, McGowan JE, Zaichkin J. (2011). Textbook of Neonatal Resuscitation- 6th Edition. Elk Grove Village: American Academy of Pediatrics.
Measuring ETT Placement
• ETT Depth insertion: Estimate the tip to lip measurement by the nasal-tragus length (NTL): this means taking a tape measure and measuring from midline septum to the tragus then adding 1cm
Example: this baby’s measurement is 9cm at the LIP (8+1)
Neonatal Intubation Medications used with intubation • Fentanyl 1 - 2 mcg/kg/dose
• Versed 0.05 – 0.1 mg/kg/dose
• Succinylcholine 1 – 2 mg/kg/dose
• Vecuronium 0.1 mg/kg/dose
• Atropine 0.02 mg/kg/dose
Oxygen and Newborns
Targeted Pre-ductal SPO2 After Birth
Kattwinkel J, McGowan JE, Zaichkin J. (2011). Textbook of Neonatal Resuscitation- 6th Edition. Elk Grove Village: American Academy of Pediatrics.
Dawson J A et al. Defining the Reference Range for Oxygen Saturation for Infants After Birth. Pediatrics 2010;125:e1340-e1347
Oxygen and Newborns Approach to Oxygen Therapy with Newborns
• Oxygen is a Drug
• It requires an appropriate dose in newborns
• The dose should be guided by responses (SPO2)
• Too Little – Injury
• Too Much - Injury
Oxygen and Newborns
The Bottom
Line
Establishing effective ventilation is the
primary objective in the management of the
apneic and/or bradycardic newborn
infant.
Chest Compressions (HR < 60)
• Intubate early and increase O2 to 100%!
• Apply cardiac monitor for assessing heart rate during chest compressions.
• Two thumb technique • Encircle the chest • Less tiring and better control of
compression depth • One cycle of 3 compressions and
1 breath takes 2 seconds
Chest Compressions (HR < 60)
• In most cases, you should have given at least 30 seconds of ventilation through a properly inserted endotracheal tube or laryngeal mask
• Once the endotracheal tube or laryngeal mask is secured, the compressor administers chest compressions from the head of the newborn and the person delivering ventilation via endotracheal tube or laryngeal mask moves to the side to make room for the compressor at the head of the bed
Epinephrine
• Epinephrine not indicated before adequate ventilations because: Time spent administering epinephrine is better spent establishing ventilations & oxygenation.
Epinephrine
• Indication – HR < 60 after 30 seconds of adequate ventilations and 60 seconds of chest compressions
• Concentration - 1:10,000 solution • Route - IV/IO (consider ETT route
ONLY while access is being obtained)
• Dose - IV/IO - 0.1 to 0.3 ml/kg ETT – 0.5 to 1.0 ml/kg
Volume
• Indicated for infant not responding to resuscitation steps and signs/history of shock.
• Solution - Normal Saline • Dose -10 ml/kg IV/IO over
5 -10 minutes • Slow push through 24g PIV
Cord Clamping
• Current evidence suggests that cord clamping should be delayed for at least 30 to 60 seconds for most vigorous preterm newborns.
• There is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth.
Post-Stabilization Care and Transfer – Remember STABLE
Sugar – Hypoglycemia
Temperature – Cold Stress
Airway – Support oxygenation & ventilation
Blood Pressure - Shock
Lab Work – Blood gas, CBC
Emotional Support
Hypoglycemia
• Know your treatment protocol • Well baby – encourage feeding • IV fluids - D10W/D12.5W without electrolytes
D50W - Dilute 1:1 twice D25W - Dilute 1:1 once
• IV bolus - 2 ml/kg (only for hypoglycemia)
• Continuous IV rate - 80 ml/kg/day or ~ 3 ml/kg/hour
Access in Newborns
• Hands and antecubitals • Saphenous vein is easy to
palpate, although sometimes not visible.
Prevention of Hypothermia • Dry • Remove wet linen • Place hat on infant’s head • Place infant on mother/father • Chemical thermal mattress
– Place towel b/t baby and mattress
• Pre-warm objects • Increase temperature of ambulance/minimize drafts • Saran wrap/plastic bag – Airway Caution
Detrimental Effects of Hypothermia
• Hypoxia • Hypoglycemia • Respiratory distress • Increased risk for sepsis • Increased risk for intraventricular hemorrhage • Increased risk for pulmonary hemorrhage
Airway Support
• GASPING is not breathing! –Initiate PPV
• Rate 40 – 60 Breathe the baby --- Breathe the baby --- Breathe the baby (squeeze) (squeeze) (squeeze)
• Pressure – least amount required for chest movement, and improved heart rate and color
–Consider intubating the baby
Evaluating for Shock • Blood Pressure
•MBP equal to gestational age • Respiratory Distress
–retractions, nasal flaring, grunting, tachypnea, apnea
• Poor Perfusion –prolonged capillary refill: check palms, soles of feet, sternum, forehead
• Weak peripheral pulses •brachial and femoral
• Color –Cyanosis, Pallor, mottling
• Heart Rate –Normal 120-160 –Tachycardia (>200) or Bradycardia (<100)
Treatment for Shock
• Goal - Increase Cardiac Output Establish IV/IO access Only an umbilical catheter should be used to access the umbilical vein Careful not to go through the bone Volume
• Normal Saline 10 ml/kg bolus over 5 – 10 minutes
Correct underlying problems affecting heart function
• Hypoxia, hypoglycemia, hypothermia, acidosis
Lab Work
• Blood Gas (Arterial or Capillary)
• Blood Glucose
• Blood Culture
• Blood Count (CBC) –Infection can be devastating for babies –Signs and symptoms of sepsis often subtle and nonspecific –Antibiotics at receiving hospital
Heelsticks
• Choose site – Warm the foot if possible – Avoid the calcaneus – Avoid sticking a previously
punctured site
Emotional Support
• Understand different reactions to a given situation
• Maintain parental bond • A few minutes of tenderness
and understanding can give you hours of peace!
References
Dawson J A et al. Defining the Reference Range for Oxygen Saturation for Infants After Birth. Pediatrics 2010;125:e1340-e1347
Karlsen KA. (2013). The S.T.A.B.L.E. Program. Post-resuscitation/Pre-transport
Stabilization Care of Sick Infants. Guidelines for Neonatal Healthcare Providers – 6th Edition. Park City, UT
Kattwinkel J, McGowan JE, Zaichkin J. (2011). Textbook of Neonatal Resuscitation
- 6th Edition. American Academy of Pediatrics. Elk Grove Village, IL. Niermeyer, S.,Keenan, W., Little, G., Singhal, N. (2010). Helping Babies Breathe -
1st Edition. American Academy of Pediatrics. Elk Grove Village, IL. Verklan MT, & Walden M. (2010). Core Curriculum for Neonatal Intensive Care
Nursing, 4rd ed. Saunders. St. Louis, MO.
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