Neonatal resuscitation: indications, types, stages, medicines
According to statistics, every tenth newborn child is provided with medical assistance in the delivery room, and 1% of all those born need a full range of resuscitation. The high level of training of medical personnel allows to increase the chances for life and reduce the possible development of complications. Adequate and timely resuscitation of newborns is the first step towards reducing the number of deaths and the development of diseases.
Basic concepts of
What is neonatal resuscitation? This is a series of activities that are aimed at revitalizing the child's body and restoring the work of lost functions. It includes:
- cardiopulmonary resuscitation;
- intensive care;
- application of artificial ventilation;
- cardiac pacemaker installation, etc.
Preterm infants do not require resuscitation. They are born active, loudly screaming, the pulse and heart rate are within normal limits, the skin has a pink color, the child responds well to external stimuli. Such children are immediately put on the mother's stomach and covered with a dry warm diaper. From the respiratory tract aspirate mucous contents to restore their patency.
Carrying out cardiopulmonary resuscitation is considered emergency relief. It is performed in case of stopping breathing and work of the heart. After such intervention, in the case of a favorable outcome, the basics of intensive care are applied. Such treatment is aimed at eliminating possible complications of stopping the work of important organs.
If the patient can not independently maintain homeostasis, then the resuscitation of the newborn includes artificial lung ventilation( IVL) or the pacemaker setting.
What is needed to carry out resuscitation in the delivery room?
If the need for such activities is not great, then one person will be required for their implementation. In the case of severe pregnancy and the expectation of carrying out a full range of resuscitation in the maternity ward, there are two specialists.
Resuscitation of a newborn in the delivery room requires careful preparation. Before the birth process, you should check that you have everything you need and make sure that the equipment is working.
- You need to connect the heat source, so that the reanimation table and diapers are warmed up, wrap one diaper in the form of a roller.
- Check that the oxygen supply system is properly installed. There must be enough oxygen, properly adjusted pressure and flow rate.
- The availability of the equipment required to extract airway contents should be checked.
- Prepare tools to eliminate gastric contents in case of aspiration( probe, syringe, scissors, fixative material), meconium aspirator.
- Prepare and check the integrity of the resuscitation bag and mask, as well as the intubation kit.
The intubation kit consists of endotracheal tubes with conductors, a laryngoscope with different blades and spare batteries, scissors and gloves.
What is the success of the events?
Resuscitation of newborns in the delivery room is based on the following principles of success:
- availability of a resuscitation team - resuscitators must be present at all deliveries;
- coordinated work - the team must work together, complementing each other as one big mechanism;
- qualified staff - every resuscitator must have a high level of knowledge and practical skills;
- work taking into account the patient's reaction - resuscitation should begin immediately when they are necessary, further measures are taken depending on the reaction of the patient's body;
- serviceability of equipment - equipment for resuscitation should be serviceable and accessible at any time.
Reasons for the need for
The development of asphyxia, birth trauma, the development of congenital pathology, toxicosis of infectious genesis and other cases of unexplained etiology are among the etiological factors of oppression of the heart, lungs and other vital organs of the newborn.
Children's resuscitation of newborns and its need can be predicted even during the period of gestation. In such cases, the team of resuscitators should be ready to immediately help the baby.
The need for such activities can occur under the following conditions:
- many- or low-water;
- mother's diabetes;
- infectious diseases;
- fetal hypotrophy.
There are also a number of factors that already arise during childbirth. If they appear, you can expect the need for resuscitation. These factors include bradycardia in a child, cesarean section, premature and rapid delivery, presentation or detachment of the placenta, hypertension of the uterus.
Asphyxia of newborns
Development of disturbances in respiratory processes with hypoxia of the organism causes the appearance of disorders on the part of the circulatory system, metabolic processes and microcirculation. Then there is a disorder of the kidneys, heart, adrenals, brain.
Asphyxia requires immediate intervention to reduce the possibility of complications. Causes of respiratory distress:
- violation of airway patency( aspiration with blood, mucus, meconium);
- organic brain damage and CNS work;
- developmental defects;
- insufficient amount of surfactant.
Diagnostics of the need for resuscitation is conducted after assessing the state of the child on the Apgar scale.
|What estimated||0 points||1 point||2 points|
|Status||breathing No||Pathological, spasmodic||loud cry, rhythmic|
|HR||No||less than 100 beats per minute||more than 100 beats per minute|
|Color skin||cyanosis||Pink Leather, cyanotic extremities||Pink|
|Condition of muscle toning||None||Extremities slightly bent, weak tone||Active movements, good tone|
|Response to irritation factors||No||Weakly expressed||Well expressed|
An evaluation of the condition to 3 points indicates the development of severe asphyxia, from 4 to 6 - asphyxia of moderate severity. Resuscitation of a newborn in asphyxiation is carried out immediately after assessing his general condition.
Sequence of the state assessment
- The child is placed under a heat source, his skin is dried with a warm diaper. The contents are extracted from the nasal cavity and mouth. Tactile stimulation is performed.
- The evaluation of breathing is performed. In the case of a normal rhythm and the presence of a loud scream, go to the next stage. With irregular breathing, the ventilator is given oxygen for 15-20 minutes.
- Heart rate assessment is in progress. If the pulse is higher than 100 beats per minute, then the next stage of the examination is carried out. In the case of a heart rate of less than 100 strokes, ventilators are used. Then the effectiveness of the measures is evaluated.
- Pulse below 60 - indirect cardiac massage + mechanical ventilation.
- Pulse from 60 to 100 - IVL.
- Pulse above 100 - IVL in case of irregular breathing.
- After 30 seconds, with ineffective indirect massage with mechanical ventilation, it is necessary to carry out drug therapy.
- The skin color is inspected. Pink color indicates the normal state of the child. With cyanosis or acrocyanosis, it is necessary to give oxygen and observe the condition of the baby.
How is primary resuscitation carried out?
Be sure to wash and treat hands with antiseptic, wear sterile gloves. The child's birth time is fixed, after taking the necessary measures - is documented. The newborn is placed under a heat source, wrapped with a dry warm diaper.
To restore airway patency, you can lower the head end and put the baby on the left side. This will stop the aspiration process and will remove the contents of the mouth and nose. Gently suction the contents without resorting to a deep introduction of the aspirator.
If such measures do not help, the resuscitation of the newborn continues through the rehabilitation of the trachea with the help of a laryngoscope. After the appearance of breathing, but the absence of its rhythm, the child is transferred to the ventilator.
The Neonatal Resuscitation and Intensive Care Unit accepts the child after primary resuscitation to provide further care and support for life functions.
Ventilation of the lungs
The stages of neonatal resuscitation include artificial ventilation. Indications for ventilation:
- lack of breathing or the appearance of convulsive respiratory movements;
- pulse is less than 100 times per minute, regardless of the state of breathing;
- resistant cyanosis in normal operation of respiratory and cardiovascular systems.
This complex of activities is carried out with the help of a mask or bag. The head of the newborn is slightly thrown back and a mask is applied to the face. It is held with index fingers and thumbs. Others withdraw the jaws of the child.
The mask should be on the area of the chin, nose and mouth. It is enough to ventilate the lungs at a frequency of 30 to 50 times per minute. Ventilation with a bag can cause air to enter the stomach cavity. You can remove it from there with the help of a gastric tube.
To control the effectiveness of the exercise, it is necessary to pay attention to the rise of the chest and change in heart rate. The child continues to monitor until the rhythm of breathing and cardiac contractions are fully restored.
Why and how is intubation performed?
Primary neonatal resuscitation also includes intubation of the trachea, in the event of an ineffectiveness of the ventilator for 1 minute. The right choice of tube for intubation is one of the important points. It is done depending on the weight of the child and his gestational age.
Intubation is also performed in the following cases:
- need to remove meconium aspiration from the trachea;
- for prolonged ventilation;
- facilitating the manageability of resuscitation measures;
- injection of epinephrine;
- deep prematurity.
On the laryngoscope, turn on the lighting and take it in the left hand. With your right hand, hold the head of the newborn. The blade is inserted into the mouth and held to the base of the tongue. Raising the blade toward the handle of the laryngoscope, the resuscitator sees a vocal cavity. The tube for intubation is injected from the right side into the oral cavity and is passed through the vocal cords at the moment of their opening. This happens on inhalation. The handset is held before the planned mark.
Remove the laryngoscope, then the conductor. The correctness of the introduction of the tube is checked by squeezing the respiratory bag. The air enters the lungs and causes a chest excursion. Then the oxygen supply system is connected.
Indirect cardiac massage
Resuscitation of a newborn in the delivery room involves an indirect heart massage, which is indicated at a heart rate of less than 80 beats per minute.
There are two ways to conduct an indirect massage. When using the first, pressing on the chest is done using the index and middle finger of one hand. In another version, the massage is performed with the thumbs of both hands, and the remaining fingers participate in supporting the back. The resuscitator-neonatologist spends pressure on the border of the middle and lower third of the sternum, so that the thorax cuffs by 1.5 cm. The frequency of pressing is 90 per minute.
It is necessary to watch, so that inhaling and pressing on the chest are not carried out simultaneously. In a pause between pressure, you can not remove your hands from the surface of the sternum. Pressing on the bag is done after every three pressings. For every 2 seconds, you need 3 pressure and 1 ventilation.
Actions for water contamination with meconium
Features of neonatal resuscitation include assistance in staining amniotic fluid with meconium and evaluating a child on Apgar scale less than 6 points.
- In the process of delivery after the appearance of the head from the birth canal immediately aspirate the contents of the nasal cavity and mouth.
- After the birth and placement of the baby under the heat source, it is advisable to hold the intubation with the largest possible tube to extract the contents of the bronchi and trachea.
- If it is possible to extract the contents and it has an admixture of meconium, then it is necessary to re-intubate the newborn with another tube.
- Ventilation is established only after all the contents have been extracted.
Pediatric neonatal resuscitation is based not only on manual or hardware interventions, but also on the use of medications. In the case of ventilation and indirect massage, when the measures are ineffective for more than 30 seconds, medicines are used.
Resuscitation of newborns involves the use of adrenaline, a means to restore the volume of circulating blood, sodium bicarbonate, naloxone, dopamine.
Adrenaline is injected through the endotracheal tube into the trachea or into the vein in a jet. The concentration of the drug is 1:10 000. The drug is used to increase the strength of heart contraction and acceleration of heart rate. After endotracheal administration, continue IVL, so that the drug can be evenly distributed. If necessary, the agent is administered after 5 minutes.
Calculation of the dose depending on the weight of the child:
- 1 kg - 0.1-0.3 ml;
- 2 kg - 0.2-0.6 ml;
- 3 kg - 0.3-0.9 ml;
- 4 kg - 0.4-1.2 ml.
In case of blood loss or the need to replenish the volume of circulating blood, albumin, physiological sodium chloride solution or Ringer's solution is used. The drugs are injected into the vein of the umbilical cord( 10 ml per 1 kg of the child's body weight) slowly for 10 minutes. The introduction of fillers BCC allows you to increase blood pressure, reduce acidosis, normalize the pulse rate and improve tissue metabolism.
Resuscitation of newborns, accompanied by effective ventilation, requires the introduction of sodium bicarbonate into the umbilical vein to reduce signs of acidosis. The drug should not be used until adequate ventilation of the child's lungs is established.
Dopamine is used to increase the cardiac index and glomerular filtration. The drug dilates the blood vessels of the kidneys and increases the sodium clearance with the use of infusion therapy. Introduced intravenously microfluidically under constant monitoring of blood pressure and heart rate.
Naloxone is administered intravenously at a rate of 0.1 ml of the drug per 1 kg of the child's body weight. The remedy is used in cases where skin color and pulse are normal, but there are signs of respiratory depression. A newborn should not be given naloxone when the mother uses narcotic drugs or undergoes treatment with narcotic analgesics.
When to stop resuscitation?
Ventilation continues until the child attains 6 points in Apgar. This evaluation is carried out every 5 minutes and lasts up to half an hour. If after this time the newborn has an indicator less than 6, then it is transferred to the ICU of the maternity home, where further resuscitation is carried out, intensive therapy of newborns.
If the effectiveness of resuscitation measures is completely absent and asystole and cyanosis is observed, the activities last up to 20 minutes. At occurrence of even the slightest signs of efficiency, their duration increases for all time, while measures give a positive result.
Neonatal Resuscitation Department
After a successful recovery of the lungs and heart, the newborn is transferred to the intensive care unit. There doctors work is aimed at preventing possible complications.
Newborn after resuscitation needs to prevent the onset of cerebral edema or other CNS disorders, restoration of kidney function and excretory function of the body, normalization of blood circulation.
The child may experience metabolic disturbances in the form of acidosis, lactic acidosis, which is caused by impaired peripheral microcirculation. From the side of the brain, there may be convulsive seizures, hemorrhage, cerebral infarction, edema, and development of a coma. Also, there may be violations of the function of the ventricles of the heart, acute kidney failure, atony of the bladder, insufficiency of the adrenal glands and other endocrine organs.
Depending on the condition of the baby, it is placed in a kuvez or oxygen tent. Specialists observe the work of all organs and systems. Feed allow the child only after 12 hours, in most cases - through the nasogastric tube.
Errors that are forbidden to be allowed
It is strictly forbidden to carry out activities, the safety of which is not proved:
- to pour the baby with water;
- squeeze his chest;
- hit the buttocks;
- direct to the face an oxygen stream and the like.
An albumin solution can not be used to increase the initial BCC, as this increases the risk of a fatal outcome of a newborn.
Carrying out resuscitation does not mean that the baby will have any abnormalities or complications. Many parents expect pathological manifestations after the newborn was in the intensive care unit. Reviews of such cases show that in the future children have the same development as their peers.