delivery room resuscitation of newborns with congenital ... delivery room resuscitation of newborns

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  • DeliveryRoomResuscitationofNewbornswithCongenital

    AnomaliesAnneAdes,MD,MSEd

    DirectorofNeonatalEducationTheChildrensHospitalofPhiladelphiaAssociateProfessorofClinicalPediatrics

    PerelmanSchoolofMedicineattheUniversityofPennsylvania

  • Objectives

    Learnerswillbeabletoidentifywhynewbornswithcongenitalanomaliesmayrequireadditionalresuscitationmeasures

    Learnerswillbeabletodescribeprocesstodevelopguidelinesfordeliveryroomresuscitationofnewbornswithcongenitalanomalies

    Learnerswillbeabletorecognizetheneedtobenchmarkandidentifybestpracticesforresuscitationofnewbornswithcongenitalanomalies

  • Ibelievethatdeliveryroommanagementcanaffectoutcomesofnewborns.

    ILCORNRP

  • Ibelievethatdeliveryroommanagementcanaffectoutcomesofnewbornswithcongenital

    anomalies.

  • EarlyNeonatalResuscitation

  • NRPGuidelineDevelopment

    InternationalLiaisonCommitteeonResuscitation

    Expertconsensus

    Evidencebased

  • DevelopmentofNRPGuidelines

    SteeringcommitteeofNRPreviewsILCORworksheets

    Developnationalguidelinesandresuscitationalgorithm

  • TheBeginning

  • Initial StepsOnlysuctionbabieswithobviousobstructiontospontaneousbreathingorwhorequirePPV

  • EvaluationandNextSteps

  • WhatsMissing

    Deliveryroomconsiderationsforneonateswithmostanomalies

  • WHENMORETHANNRP ISNEEDED

    Ibelievethatdeliveryroommanagementcanaffectoutcomesofnewbornswithcongenitalanomalies.

  • Youarecalledtothedeliveryofa

    34weekmalewithamyelomeningocele

    38weekfemalewithleftcongenitaldiaphragmaticherniawithliverup,LHRof0.9andO:Eof0.27

    37weekmalewithtranspositionofthegreatarteriesandintactventricularseptum(TGAwithIVS)

  • SuttonRMetal.EmergMedClinNAm.2012.

    RESUSCITATIONBUNDLE

  • RESUSCITATIONBUNDLE

    OutcomesOutcomes

    StandardizeCare

    StandardizeCare

    DeliverCareDeliverCare

    EvaluateCare

    EvaluateCare

  • GUIDELINEDEVELOPMENT

    OutcomesOutcomes

    StandardizeCare

    StandardizeCare

    DeliverCareDeliverCare

    EvaluateCare

    EvaluateCare

  • GoalofGuidelineDevelopment

    Identificationofappropriate

    DeviationsfromtheNRPalgorithm

    AdditionstoNRPguidelines

  • APPROACH

    Reviewofexistingevidence Expertopinion Consensusopinion Commonsense

  • EvidenceBase

    CDHEURO

    ReissI,Neonatology2010.

  • EvidenceBase

    InfantswithPrenatallyDiagnosedAnomalies:SpecialApproachestoPreparationandResuscitation

    ColbyCE,Clin Perinatol.2012

    61References:Fetaldiagnosis:25PrenatalManagement:4Mode/Timingofdelivery:10PostnatalManagement/Outcomes:15DELIVERYROOMMANAGEMENT:0

  • APPROACH

    Reviewofexistingevidence Expertopinion Consensusopinion Commonsense

  • OptimalCareGuidelines

    Diseasespecific Congenitaldiaphragmatichernia Lunglesion Omphalocele Gastroschisis Congenitalheartdisease Sacrococcygeal teratoma Myelomeningocele

  • FrameworkofGuidelines

    Prenatalhistory/evaluation

    Deliveryroomanticipation/considerations/preparation

    Deliveryroomresuscitation

  • Prenatalhistory/evaluation

    CDH:LHR,O:E

    CCAM:CVR,types

    MMC:fetalrepairpatch,hindbrainherniation

  • Deliveryroomanticipation/considerations/preparatio

    n Respiratorydistress Hypoxia

    Equipment Howtodressomphalocele,MMC Whattodowiththoracoamniotic shunt StartingFiO2

  • OptimalCareGuidelinesDeliveryRoomResuscitation

    InitialassessmentoftheneonatewithshouldevaluaterespirationsandheartrateaccordingtoNRPguidelines.Theresuscitationgoalistoestablishanairwayandhemodynamicstability,optimallywithinanhourofdelivery.

  • AcquisitionandMaintenanceSafetyTechniques

    OutcomesOutcomes

    StandardizeCare

    StandardizeCare

    DeliverCareDeliverCare

    EvaluateCare

    EvaluateCare

  • Acquisition

    Session1 Lecture1

    BasicsofNRP Simulation1

    Introtosimulation Lecture2

    Cardiacdeliveries Simulation2

    Cardiacscenarios

  • Acquisition Session2

    Lecture3 Lunglesions

    Simulation3 Congenitaldiaphramatic hernia,Congenitalcysticadenomatoidmalformation

    Lecture4 Myelomeningocele,Bladderoutletobstuctions,pretermissues

    Simulation4 Preterm,Bladderoutletobstructionwithpulmonaryhypoplasia

  • Acquisition

    Session3 Lecture5

    Abdominalwalldefects,sacrococcygealteratomas

    Simulation5 Omphalocele,SCTscenario

    Lecture6 EXutero IntrapartumTreatment,criticalairway

    Simulation6 EXITscenario

  • Acquisition

    Session4 Lecture7

    Question/answer SDUproceduresreview

    Simulation7 Scavengerhunt,basicscenario

    Simulation8 Myelomeningocele,abruptioninapatientwithCHD,gastroschisis

  • Maintenance

    One2hoursessionevery6months Scenarios

    Staffrequests Actualexperiences

  • JustInTime

    Rarecases Complicatedcases Practice

  • SafetyTechniques

    Pleasespeakup

  • Reflect,Review,Register,Research

    OutcomesOutcomes

    StandardizeCare

    StandardizeCare

    DeliverCareDeliverCare

    EvaluateCare

    EvaluateCare

  • Reflection

  • Review

    QualityImprovement Multidisciplinarymeeting Videoreview

  • Registry

    Cancentervariationindeliverroommanagementexplainoutcomedifferences? Identificationofbestpracticecenters Databaseofdeliveryroomcare

  • Research

    Doneonateswithcongenitalanomalieshavespecificidentifiabledeliveryroomneeds/morbiditiesthatcanbeanticipated?

  • Summary

    Objective:convinceyouthatcareinthedeliveryroomimpactsoutcomesofneonateswithcongenitalanomalies

    Perhapsnotyetbutifwedonttrythenwewillneverknow

  • Wearewhatwerepeatedlydo.Excellence,then,isnotanact,butahabit.

    Aristotle

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