Neonatal/Pediatric Neonatal/Pediatric Cardiopulmonary CareCardiopulmonary Care

ResuscitationResuscitation

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When To Resuscitate

Need usually related

Combination of

Can occur in

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Causes of Fetal Asphyxia

4

Apnea

Doesn't work

Fetus begins rapidrespirations

Ventilations ceaseHR dropsBP drops

Primary Apnea

Hypoxia, hypercarbia,acidosis

= asphyxia

2nd attempt to breath (weak, gasping) efforts weaken

& cease

Secondary Apnea

No further attemptto breathe

Stimulates chemoreceptors& baroreceptors

Hypoxia

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Effect of Asphyxia on Lungs

Initial adaption to extra-uterine life requires 2 steps:

–

–

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Effect of Asphyxia on Lungs

AsphyxiaAsphyxia

Apneic or ineffectiveApneic or ineffectiverespirationsrespirations

Negative pressure notNegative pressure notgenerated to opengenerated to open

Alveo li to push fluid outAlveo li to push fluid out

PaOPaO22 , PaCO, PaCO22 ,, pHpH

PulmonaryPulmonaryvasoconstrictionvasoconstriction

PulmonaryPulmonaryhypertensionhypertension

Blood flow continuesBlood flow continuesthrough d.a. & f.o.through d.a. & f.o.(by-passing lungs)(by-passing lungs)

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Effect of Asphyxia on Lungs

If asphyxia severe with lactic acidosis

Ventilation alone will not changeacid-base imbalance

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Effect of Asphyxia on Lungs

In severe cases - might be beneficial to give HCO3

- to–

–

–

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Effect of Asphyxia on Lungs

NOTE:

Adequate ventilation must be maintained when bicarb

given!!!

Why??

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Effect of Asphyxia on Lungs

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Preparation For Resuscitation

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Basics of Neonatal Resuscitation

A -

B -

C -

3 steps:3 steps:

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Resuscitation Cycle

EvaluationEvaluationDecisionDecision

ActionAction

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Steps in Resuscitation

1st step =

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Mechanisms of Heat Loss

Radiation– Loss to

Conduction– Loss to

Evaporation– Loss when

Convection– Loss to

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Causes of Heat Loss

17ColdStress

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Steps in Resuscitation

Next Step = Open airwayNext Step = Open airway

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Steps in Resuscitation

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Evaluate Respiratory Effort

Evaluateheart rate

PPV with100% O2

None orgasping Spontaneous

Below 100

15 - 30 sec.

Evaluaterespirations

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Evaluate Heart Rate

Above 100

Evaluatecolor

Provide oxygen

Observe andmonitor

Pink orperipheral cyanosis

Blue

Evaluateheart rate

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Indications for PPV

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Positive Pressure Ventilation

Flow-inflating bag

Self-inflating bag

Pressure gauge

Oxygen flow 5-8 lpm

Pop-off at 30-40 cmH2O

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PPV Technique Slightly extend neck Mask held with thumb &

forefinger Bag squeezed with

fingertips Initial rate - Done for 15-30 sec.,

then re-evaluate May require -

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Re-evaluate Heart Rate

Below 100

Continueventilation

Chestcompressions

60 - 100

HR not increasing

Continueventilation

Chestcompressionsif HR < 100

HR increasing

Continueventilation

Above 100

Watch forspontaneousrespiration . . .

Then discontinueventilation

Immediate resuscitation if HRis below 80 after 30 sec. PPVwith 100% oxygen and chestcompressions

Re-evaluateheart rate

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Chest Compressions

2 fingers or thumbs Lower 1/3 of sternum Sternum depressed

1/2-3/4 inches 3:1 compression-to-ventilation ratio Continue for 30 sec., stop for 6 sec. to

re-evaluate HR DC’d when HR > 80, then re-evaluate RR

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Indications for Intubation

Bag/mask ventilation is difficult or ineffective

Prolonged PPV is required Thick meconium is present in amniotic

fluid Suspicion of diaphragmatic hernia

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ETT Sizes

Selecting Appropriately Sized Endotracheal Tubes

TUBE SIZE (MM) WEIGHT GESTAT IONAL AGE2.5 <1000 g <28 weeks3.0 1000-2000 g 28-34 weeks3.5 2000-3000 g 34-38 weeks4.0 >3000 g >38 weeks

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Laryngoscope Blades

Size 1 for

Size 0 for

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Intubation Technique

Same as adult Limit attempts to - Provide blow-by oxygen at - ETT tip midway between carina &

clavicles Cut ETT to leave -

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Medications - Uses

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Medications - Routes

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Instillation Into ETT

N N A A V V E E L L

OO22

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Medications - Indications

HR < 80 despite PPV and chest compressions for at least 30 sec.

HR is 0

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Epinephrine

Powerful sympathomimetic–

–

– 1st drug given IV or ETT, delivered rapidly Repeated q3-5’ until HR -

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Volume Expanders

Given if hypovolemic BP– Pallor with adequate oxygenation– HR > 100 with weak pulses– Failure to respond to resuscitation

Whole blood, 5% albumin, plasma expanders, NS

IV, may be repeated as needed

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Sodium Bicarbonate

Prolonged arrest & not responding

Alkaline to buffer metabolic acidosis

Only given when ventilation is adequate

IV

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Narcan (naloxone)

Reversal of narcotic depression– Demerol (meperidine)– Morphine sulfate– Fentanyl (Sublimaze)

IV, IM, sub-q, ETT Given rapidly

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Dopamine

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APGAR Scoring

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APGAR Scoring

0 1 2A ppearance Totally cyanotic Pink body, blue

extremitiesTotally pink

P ulse Absent Under 100 Over 100

G rimace Unresponsive Frown or grimace Crying, sneeze orcough

A ctivity Flaccid, limp Some flexion ofextremities

Active flexion,good motion

R espirations Absent Irregular, weak,gasping

Crying, vigorousbreathing

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Serum Glucose

Nutritional needs of fetus supplied by Mom & regulated by placenta

Fetus prepares for postnatal life by energy stores & developing enzyme-dependant processes for usage of stored energy

Sources

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Serum Glucose

Glycogen– –

Triglycerides (brown fat)– –

Energy Storage

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Serum Glucose

At 2 hours -

By 3 days -

Post-delivery

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Serum Glucose

Term -

Preterm -

Hypoglycemia

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Hypoglycemia - Signs

Tremors Irritability orMoro reflex Apnea/tachypnea Cyanosis Seizures

Lethargy Hypothermia Weak/high-pitched cry Poor feeding Vomiting CV failure

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Hypoglycemia

CNS dysfunction Apnea Death

Hypoglycemia

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Hypoglycemia - Causes Hyperinsulinism Prematurity IUGR Starvation Sepsis Shock Asphyxia

Hypothermia Glucogen Storage Disease Galactosemia Adrenal insufficiency Polycythemia Congenital heart defects Iatrogenic causes

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Hyperinsulinism

Fetus of diabetic Mom

Rh incompatibility

Insulin-producing tumors

Maternal tocolytic therapy (ritodrine,

terbutaline)

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Glucose Measurement

Glucose Test Strip “Dextrostik”

“One Touch”

Lab sample (blood glucose)

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Hypoglycemia Treatment

Early feeding (oral) D10W

– 200 mg/kg bolus over 1-3 minutes– Con’t IV, 4-8 mg/kg/min. until feedings

started Treat cause

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Umbilical Blood Sampling

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Umbilical Vein Catheter (UVC)

Usually placed in -

Drug administration during -

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Umbilical Artery Catheter (UAC)

Indications

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Umbilical Artery Catheter (UAC)

5 Fr. catheter (>1250 g), 3.5 Fr. catheter (<1250 g)

Sterile procedure Heparinized-filled catheter Tip L3-4 for low catheter, T8 for high

catheter (in aorta below renal a., above bifurcation of femoral a.)

PlacementPlacement

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UAC

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Umbilical Artery Catheter

Complications

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Umbilical Artery Catheter

Sampling Technique