paeds & neonates 2011.pdf

7/27/2019 PAEDS & NEONATES 2011.pdf

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Paediatric & Neonatal Resuscitation

Guidelines 2011, Singapore


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2010 ILCOR review:

Paediatric Life Support

Task force identified 55 questions related to Paeds Resus

Evidence review by 2 or more independent reviewers for each topic Draft Consensus on Science and Treatment Recommendations Re-circulated and refined until consensus reached

Controversial / critical topics addressed at 2010 ILCOR conference

Final Consensus on Science and Treatment Recommendationspublished


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The Singapore National Resuscitation Council, Neonatal &

Paediatric Resuscitation Workgroup, 2010-2011

Chairman

Ng Kee-ChongKKH CICUDr Janil Puthucheary

Dr Chan Yoke HweeDr Siti Buang

Dr Irene Chan (VC)KKH Paeds Anaesthesia

A/Prof Agnes Ng

Dr Josephine Tan

KKH -CEDr Peter Wong

Dr Chong Shu-LingNUH - PICUDr Diana Lin

NUH - CEDr Kao Pao Tang

Neonatal Subcommittee

A/Prof Lee Jiun (NUH Neonates)

A/Prof Yeo CL (SGH-Neonates)

Dr Quek BH (KKH Neonates)

Dr Kenny Ee (Private)

Nursing Reps

ADN Lee Siew Kum

ADN Ong Lim Liew

SNM Tor Sow Khim


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1) BASIC PAEDIATRIC LIFE

SUPPORT

1a) RECOGNITION & ASSESSMENT OF

CARDIAC ARREST

One should take not more than 10 seconds todetermine if there is cardiac arrest.

The presence or absence of pulse is NOT areliable determinant of cardiac arrest.

Other determinants of cardiac arrest areunresponsiveness, gasping not breathingnormally, and without any signs of life.


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1b) INITIAL MANAGEMENT OF COLLAPSE

One should always ensure the safety of rescuer(s) andchild at the onset.

The initial assessment is to check for responsiveness ofthe child.

If the child is noted to be unresponsive, one shouldproceed to open the airway (head tilt chin lift). Check for breathing: Look, Listen and Feel for 10

seconds. Note that gasping is NOT breathing.

Check for pulse within 10 seconds (for health careprovider only) commence cardio-pulmonaryresuscitation (CPR) if there is cardiac arrest.


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Chest compression should be commencedbefore giving initial 2 rescue breaths.

If there is only a single rescuer, call forhelp only after 2 minutes of resuscitation.

If an automated external defibrillator (AED)is available, one should check for

shockable rhythm and intervene. (see

below)


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1c) COMPRESSION-VENTILATION RATIO

IN BASIC PAEDIATRIC LIFE SUPPORT

Layperson/Healthcare providers perform 30compressions followed by 2 ventilations (30:2)for single rescuer.

If second rescuer is available, the 1st rescuerperforms compressions and the 2nd rescuerperforms ventilations. Rotate the compressorrole every 2 minutes. The switch should takeless than 5 sec.

General rescuers who are unable or unwilling toprovide mouth-to-mouth ventilation areencouraged to perform at leastcompression-only CPR


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1d) CHEST COMPRESSION TECHNIQUE

For infants, use the two-finger technique for single rescuer and thethumb-encircling technique for two or more healthcare provider rescuers. For children, use the one- or two-hand technique. Achieve a compression of at least 1/3 of the antero-posterior chest diameter

in all children over the lower half of sternum (i.e. approximately 4 cm in

infants & 5 cm in children)

PUSH HARD-PUSH FAST at a compression rate of 100 per minute. There must be complete chest recoil after each compression. There must be minimal interruptions (less than 5 seconds) to minimise no-

flow time


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Two-finger chest compression


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Thumb encircling Technique


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One-/Two-Hand Chest Compression Technique


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1e) VENTILATORY RATES

Following return of spontaneouscirculation (ROSC) and with cessation of

CPR, continue ventilation, aiming to

achieve 12 (for > 8 yrs old) to 20 (for 1-8yrs old) breaths per minute.


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1f) AUTOMATED EXTERNAL

DEFIBRILLATORS (AEDs)

AEDs can be used for children aged 1 year andabove.

These AEDs should preferably be capable ofidentifying arrhythmias in children accurately; in

particular they are extremely unlikely to advise ashock inappropriately.

Those aged 1 to 8 years old should preferablybe used with paediatric pads or software whichtypically attenuates the output of the machine to50 to 75 joules (recommended for children 1 to 8years old).


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If an unattenuated shock or manuallyadjustable machine is not available, anunmodified adult AED may be used inchildren more than 1 year old .

For patients less than 1 year old, theincidence of shockable rhythms in infantsis very low except when they suffer fromcardiac disease. In these cases the risk/benefit ratio may be favourable and use ofan AED (preferably with dose attenuator)

should be considered.


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1g) FOREIGN BODY AIRWAY OBSTRUCTION

(FBAO)

There are no major changes to the managementof paediatric FBAO treatment.

Infants should have chest thrusts to helpdislodge the FB. Infants should NEVER be given

abdominal thrusts (Heimlich manoeuvre) forFBAO care.

Children aged 1 year and above may be givenabdominal thrusts (Heimlich manoeuvre) forFBAO care. Those given abdominal thrusts

should be examined subsequently by adoctor for possible abdominal injury.


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2) ADVANCED PAEDIATRIC RESUSCITATION /

MANAGEMENT BY HEALTHCARE

WORKERS

2a) INITIAL MANAGEMENT OF COLLAPSE

Pulse check (if done) should not take morethan 10 seconds.

Pulse should be assessed at the brachial(for infants); femoral for infants & children)

and carotid (for children).


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2b) NEONATAL VERSUS INFANT

RESUSCITATION

Newborns who require CPR in the nurseryor NICU should be managed as for anewborn in the delivery room. (ie 3:1 chest

compression to ventilation ratio).

Newborns in other settings (eg pre-hospital, ED, PICU) should be

resuscitated according to the infantguidelines. (ie 30:2 if non-intubated)


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2c) COMPRESSION-VENTILATION RATES IN

PAEDIATRICS (HEALTHCARE WORKERS)

NOT INTUBATED

Layperson/Healthcare providers perform 30 compressionsfollowed by 2 ventilations (30:2) for single rescuer.

If second rescuer is available, 1st rescuer performs compressionsand 2nd rescuer performs ventilations. Rotate the compressor roleevery 2 minutes. The switch should take less than 5 seconds.

General rescuers who are unable or unwilling to provide mouth-to-mouth ventilation are encouraged to perform at least compression-only CPR.

INTUBATED

After intubation, compression rates should be at between at least100 to 120 compressions per minute with 8 to 10 asynchronousventilatory breaths.


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2d) OXYGEN CONCENTRATION IN

PAEDIATRIC RESUSCITATION

Ventilate with 100% oxygen during activeCPR.

Once resuscitated (with return ofspontaneous circulation), oxygenconcentration should be judiciously titrated

and lowered to the lowest minimum

required by that child while maintaining a

SpO2 of between 94% to 98%.


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2e) USE OF CUFFED VERSUS

UNCUFFED ETT

Except for newborns, infants and childrenmay be intubated with cuffed ETTs.

Indications for use of cuffed ETTs in non-neonatal patients less than 8 years oldinclude when lung compliance is poor;

airway resistance is high; or if there is a

large air leak from the glottis.


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UNCUFFED CUFFED

NEONATES (PREMATURE) Gestational Age inweeks / 10

NOT USED

NEONATES (FULL TERM) 3.5 NOT USEDINFANTS 3.5 to 4.0 3.0 to 3.5CHILD (1-2 YEARS OLD) 4.0 to 4.5 3.5 to 4.0CHILD (2 YEARS AND

ABOVE)AGE (yrs)/4 + 4 AGE (yrs)/4 +

3.5

The recommended size of ETTs


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2f) DEFIBRILLATION

Patients with ventricular fibrillation (VF) andpulseless ventricular tachycardia (VT) should be

defibrillated

The defibrillation doses in paediatrics should be4 J/ kg for the first and every subsequent shock,

followed each by 1-2 minutes of CPR..

Biphasic defibrillators are preferable as they areassociated with less post-shock myocardial

dysfunction.


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Adrenaline should be given after the 3rd shock andevery alternate shock

Amiodarone should be given (after the 3rd and 5thshock) along with adrenaline

The defibrillation pads can either be placed antero-laterally (1 pad on the right and 1 on the left axilla) orantero-posteriorly (1 pad on the left chest anteriorly and

1 posteriorly at the left scapula) Rule out and manage the correctable Hs (hypoxia;hypovolaemia; hypo- hyperkalaemia/metabolic;hypothermia, hypoglycaemia) and Ts (tensionpneumothorax; toxins/therapeutic disturbances;tamponade cardiac; thromboembolism-coronary or

pulmonary)


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Use and Role of AEDs in Infants / Children

AED has been recommended for use in children

between 1 year old to 8 years old

The AED should be one that recognises paediatric

shockable rhythms. Ideally, the correct AED with

paediatric attenuator should be used.

The dose attenuator will decrease the delivered

energy to a lower dose more suitable for a child

aged 1 to 8 years old (ie 50J-75J).


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AED in Infants

For infants with VF/pulseless VT the optimal dosefor defibrillation has not been established.Animal studies suggest that the youngmyocardium may be able to tolerate high dosesof energy.

AHA recommends the prefer method of shockdelivery for infants with a shockable rhythm inthe following order :

1. Manual defibrillator 2. AED with dose attenuator 3. AED without dose attenuator


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2g) INTRAVASCULAR ACCESS / IO

Bone marrow samples can be used forcross match; chemical analysis; and blood

gas measurements.

Samples can damage autoanalysers andthese samples should preferably be used

in cartridge analysers instead.

The benefits of semi-automated IOdevices remain to be seen.


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3) NEONATAL LIFE SUPPORT &

RESUSCITATION3a) INITIAL ASSESSMENT & INTERVENTION

Heart rate should remain the vital sign by which to judgethe need for and efficacy for resuscitation. The mostaccurate way of assessing the heart rate is byauscultation of the praecordium. Palpation of theumbilical pulse can also be used to provide a rapidestimate of the pulse.

Heart rate should be reassessed every 30s in a babywho needs resuscitation.

If baby appears blue, it is recommendedto check oxygenation with a pulse oximeter


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Acceptable pre-ductal SpO2

1 min 60-65%

2 min 65-70%

3 min 70-75%4 min 75-80%

5 min 80-85%

10 min 85-95%


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3b) AIR/OXYGEN FOR RESUSCITATION

Term babies:

For term babies receiving resuscitation at birth with positivepressure ventilation, it is recommended to begin with air as opposedto 100% oxygen.

If despite effective ventilation there is no increase in heart rate oroxygenation (preferably guided by oximetry), use of higher oxygenconcentration should be considered until recovery of a normal heartrate.

Preterm:

For babies less than 32 weeks, it is recommended that blendedoxygen be given judiciously guided by oximetry. If blended oxygen is not available, resuscitation may beinitiated using what is available.


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3c) DELAY IN CORD CLAMPING FOR THOSE

WHO DO NOT REQUIRE RESUSCITATION

For uncompromised babies, there may bebenefits in delaying the clamping of the

umbilical cord for at least 1 minute from

the complete delivery of the infant. There is insufficient evidence to

recommend an appropriate time for

clamping the cord in babies who are

severely compromised at birth


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Effects of Delayed Cord Clamping

Term Infants

Improvement in iron status and other haematological indicesover the next 3 to 6 months Greater phototherapy need for jaundice ( no well controlled

analysis available)

PreTerm Infants

Reduced blood transfusion in the immediate postnatal and ensuingweeks for preterm babies

Reduced incidence of intraventricular haemorrhage Increased incidence of jaundice and use of phototherapy but no

reports of increase exchange transfusion


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3d) ASPIRATION OF MECONIUM

Intrapartum oropharyngeal suctioning ofthe infant born through meconium stained

amniotic fluid is no longer recommended

For the non-vigorous infant born throughmeconium, there is no change in current

practice of direct oropharyngeal and

tracheal suctioning


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3e) TEMPERATURE MANAGEMENT FOR

PRETERM BABIES

Preterm babies less than 28 weeks should becompletely covered in a food-grade plastic wrapor bag up to their necks, without drying,immediately after birth.

They should then be nursed under a radiantwarmer and stabilized. They should remainwrapped until their temperature has beenchecked.

It is recommended that delivery roomtemperature be maintained at least26 degrees Celsius


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3f) VENTILATION

There is no difference between longer or shorter inflationbreaths

Positive end expiratory pressure (PEEP) may beconsidered in preterm infants who present withrespiratory distress

Spontaneously breathing preterm infants who haverespiratory distress may be supported with CPAP(continuous positive airway pressure) or intubation andventilation. The most appropriate choice may be guidedby local expertise and preferences.

As for ventilation devices, there is yet no clinicalevidence that compares T-piece withflow-inflating bags or self-inflating bags


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3g) CPR FOR NEW BORN

CPR for newborns remains as 3:1(compression to ventilation) ratio.


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3h) CONFIRMATION OF PLACEMENT OF

ETT

A prompt increase in heart rate is the bestindicator that the tube is in the trachea and

providing effective ventilation.

Detection of exhaled carbon dioxide, inaddition to clinical assessment, can be

used to confirm ETT placement.


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3i) VOLUME EXPANSION

Early volume replacement with crystalloid or redcells is indicated for babies with blood loss who

are not responding to resuscitation. Give a bolus

of 10 mls/kg initially. This may be repeated if

successful.

There is insufficient evidence to support routineuse of volume administration in the infant with no

blood loss who is refractory to ventilation, chest

compression, and epinephrine.


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3j) ROUTE & DOSE OF ADRENALINE

Adrenaline via the intravenous route is preferred. Thedose of IV adrenaline used remains 0.01 to 0.03mg/kg.

For intravenous route, there is no evidence to suggestthat a higher dose is better.

Limited case reports suggest higher dose of adrenalineshould be used if administered through the ETT. If IVroute is not available, ETT adrenaline may be consideredat a dose 0.05 to 0.1mg/kg.

In neonates/newborn, the concentration of adrenaline forboth intravenous and endotracheal route should be1:10,000.


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3k) POST RESUSCITATION CARE

Glucose Control

Hypoglycaemia is associated with poorneurological outcome.

Glucose should be monitored afterresuscitation.


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3k) POST RESUSCITATION CARE

Therapeutic Hypothermia For Moderate

Or Severe Hypoxic Ischaemic

Encephalopathy (HIE)

Term or near term newborn babies withmoderate to severe HIE should be offered

therapeutic hypothermia.

(33.5 to 34.5 degrees Celsius).


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3l) WITH-HOLDING RESUSCITATION/

NON-INITIATION OF RESUSCITATION

Where gestation, birth weight and/or congenitalanomalies are associated with almost certaindeath and unacceptably high morbidity is likelyamong the rare survivors, resuscitation is not

indicated. This will include the following - extreme

prematurity (gestational age less than 23 weeks&/or birth weight less than 400 g), anomaliessuch as anencephaly; and confirmed

Trisomy 13.


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3m) DISCONTINUATION OF

RESUSCITATION

If there is no return of heart rate after 10minutes, evidence suggests that the newly

born is likely to suffer from severe

neurological impairment or death. Hence, it is suggested that if there is no

return of heart rate after 10 minutes of

adequate resuscitation, it is acceptable to

discontinue resuscitation.


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??QUESTIONS??

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