Prepararation
Equipment for infant resuscitation should be readily available at all time,suction bulb,oxygen source plus bag and mask oral airway,laryngoscope and endotracheal tube(ET).(3)
Following birth the infant kept head down until the poste
rior pharynx and nose are cleared by suction.
The airway is maintained by extension of the head but Not over extension in neonate since it will worse airway obstruction because the neck is flexible.
The depressed infant may respond to clearing of the airway stimulation and oxygen administration helps the vasodilata
tion of the pulmonary vessels.
The respiration may be stimulated by slaping the sole of the feet or rubbing the back for the normal neonate but not for the depressed neonate.
Both depressed and normal newborn infants should be dried off immediately since loss of body heat from evaporation can jepordize the neonate.
Care of infants with Apgar score of 7-10(1)
Dry off and suction the mouth and pharynx with the suction bulb.
Care of infants with Apgar score of 4-6(1)
a.As above
b.Allow the infant to breath oxygen by mask. If the infant is
not breathing spontaneously,positive pressure mask
ventilation with the neck moderate extension and towell
roll under the shoulders should be instituted at approxi
mately thirty breaths per min. If respirations appear
irregular the infant should be assisted with positive
pressure until the respiratory pattern improve.
not breathing spontaneously,positive pressure mask
ventilation with the neck moderate extension and towell
roll under the shoulders should be instituted at approxi
mately thirty breaths per min. If respirations appear
irregular the infant should be assisted with positive
pressure until the respiratory pattern improve.
c.If the infant does not become pink on 100% oxygen after
1-2 minutes inspect the pharynx and glottis with direct
laryngoscopy and clear the airway.
1-2 minutes inspect the pharynx and glottis with direct
laryngoscopy and clear the airway.
d If there is gastric distension put in a suction catheter or
feeding tube via the mouth and empty the stomach.
feeding tube via the mouth and empty the stomach.
Care of infant with Apgar score of 0-3
a Dry off the infant and suction the mouth and pharynx with a suction bulb.
b.Begin positive pressure mask ventilation with 100% oxygen
at a rate of 30 breaths per minute. If the heart rate less
than 70 times per minute, intubate the infant with a
2.5,3.or 3.5 ID.
at a rate of 30 breaths per minute. If the heart rate less
than 70 times per minute, intubate the infant with a
2.5,3.or 3.5 ID.
c.If the infant remain bradycardia give atropine 0,1 mg via
the umbilcal vein.
If there is no heartbeat start external cardiac massage,the neonate's chest should be grasphed in both hands so that the rescuer's middle fingers are joined to support the neonate's back,while compression of midsternum is provided by both thumbs at a rate 30 interpossed with 2 ventilation.
the umbilcal vein.
If there is no heartbeat start external cardiac massage,the neonate's chest should be grasphed in both hands so that the rescuer's middle fingers are joined to support the neonate's back,while compression of midsternum is provided by both thumbs at a rate 30 interpossed with 2 ventilation.
Depth of compression =1/5-1/4 AP diameter of chest. If asystole persist, epinefrine of 1:10.000 solution should be given.(1 cc epinefrine 1:1000 is diluted in 10 cc solution,give 0,1 cc/kg ig iv, intracheal or intraosseus but Not intracardial).
Establish ECG monitoring to differentiate between Asystole,Ventricular fibrilation(VF) or Ventricular tachycardia(VT) etc.
If there is a coarse VF: (5,8)
1. External DC counter shock
2. May start as low as 30 wattsec in infant
3. Followed by chest compression and ventilation (30:2).Do
not reassess the rythm or feel for a pulse.After 2 minutes
of CPR, check the rythm and give another shock(if
indicated)
not reassess the rythm or feel for a pulse.After 2 minutes
of CPR, check the rythm and give another shock(if
indicated)
4. Persistent VF treated with lidocaine 1mg/kg
If there is fine VF:(5)
1.Epinefrine 1: 10.000 dilution iv.
2.Continue chest compression and ventilation during 2-3
minutes.
minutes.
3.If VF become coarse, DC shock as above.
Epinefrine increase cardiac contractility and coarsening of VF pattern.
If there is a doubt about wether the rythm is asystole or fine VF do Not attempt defibrilation instead continue chest compression and ventilation. Repeat epinefrine every 3-5 minute thereafter if VF/VT persist until return of spontaneous circulation (ROSC)(8).
If capillary filling is markedly decreased give 10 cc/kg of 5% albumin,ringer lactate or normal saline. Hypertonic solution should not be given via umbilical vein. Insert iv canula,at least 18 Fr even in neonate, blood transfusion will be difficult through 20 Fr.
Cutdown immediately to save time wasted in efforts to start percutaneous catheter or scalp vein needles, will avoid accidental Sc injection of irritant drugs such as Ca gluconate, Bicarbonas natricus or glucose 50% etc.(5)
Isoprenaline should never be used in cardiac arrest, as a pure beta adrenergic it increases myocardial oxygen consumption while reducing diastolic pressure and coronary blood flow.(7)
More recent studies suggest that bicarbonate natricus(bicnat)does not improve the success of defibrilation or resuscitation(Minuek & Sharm).
Hypernatremia and hyperosmolarity cause by bicnat administration are frequent during and following CPR and are ascociated with a poor outcome (Matter et all 1974) (7)
It has been reported the liberation of CO2 following administration of bicnat causes paradoxical CNS acidosis,probably because CO2 readily diffuses across the blood brain barrier (BBB) while bicnat diffuse more slowly.(Kellip 1975) (7)
It is probably bicnat should not be used during CPR unless known preexisting severe metabolic acidosis and blood gases indicates severe metabolic acidosis.
Blind repetition of bicnat is not good therapy since alkalosis or under corrected acidosis is undesireable and severe hypo or hypercapnia can lead to increased irritability and decrease cardiac output.(5)
CaCl2 should no longer be used during CPR unless spesific indication exist.If the cardiac arrest is precipitated or contributed by severe hyperkalemia,severe hypocalcemia or Calcium channels blockers overdose calcium may prove useful.
In recent years however a better understanding of mechanism of cell damage, high developed with anoxia or ischemia,cellular phosphate energy stores are rapidly depleted,allowing a large shift of calcium into cell. Because of this increase intracellular calcium, it has been suggested that additional administration of calcium during CPR is useless or worse than useless.
In the vascular smooth muscle the inflow of calcium result in vasoconstriction and this may impede reperfusion of heart and brain.(7)
Dextrose or glucose should not be given during CPR since glucose in condition of hypoxia that glucose is metabolized produces lactic acidosis. Hypotonic solution should be avoided because it will increase brain edema.
The narcotic depressed infant may have central depression of respiration as his only problem. Therefore he may present as a depressed infant who rapidly pink when ventilated but ventilation is stopped breaths very slowly or not at all.If such a sleepy infant's mother has received narcotic medication within 1-3 hours prior to delivery,narcotic antagonist should be considered.The drug of choice is naloxone (in a dose of 0,01mg per kg ) which may be given via the umbilical vein.(5)
The problem of narcotic depressed infant is almost universally caused by analgesics given during labor; it is very rare among infants whose mothers take heroin or mathadone. Infact in these infants naloxone may precipitate an acute withdrawal syndrome.(5).
Transport of infant should be moved to the special care nursery as soon as he is stabilized. Resuscitative efforts should generally proceed in the delivery room until the heart rate is greater than 100 beats per minute,ventilation is established or controlled,the infant is responding and perfusion appears adequate.
The infant with a low Apgar score,who has responded to resuscitation should not be kept in the delivery room if he becomes pink,cries and is in no distress.
All premature infants even if not manifesting depression should be taken to the special care nursery,shortly after delivery (i.e.5-7 minutes after birth) for observation.(5)
If necessary an elevator should be called waiting on the delivery floor to expedite the transport but speed should not excessive to the point pf endangering the infant.
If the infant is being ventilated,the person breathing for the infant should determine the speed of transport.
Grunting, by raising intra alveolar pressure can partially compensate for a lack of surfactant in an infant with RDS.
An endotracheal tube prevents this activity and if left in place with the infant breathing spontaneously,promotes alveolar collapse.Therefore a sick premature infant who requires intubation and ventilation initially but then starts breathing spontaneously should be probably be left and have breathing assisted until he arrives in the newborn care nursery.It is better to extubate the infant after transport than to risk the development of respiratory insuficiency en route.(5)
SUMMARY :
About 35% of all death during the first year of life,occur within the first 24 hours and half of these are related to anoxia and pulmonary pathology.
Diabetic mothers and premature infant prone to have hyaline membrane disease (RDS).and 30% of neonatal fatalities caused by RDS. Infant are primary nose breather and the upper airway predisposed to obstruct due to narrow passage of the nose,glottis and trachea.
The Apgar scoring is numerical index of the aviability of newborn infant at 1 and 5 minutes after completion of childbirth is evaluated for heart rate, respiratory effort,muscle tone,reflex respons to stimulation and color.
Infant with Apgar score less than 4 is considered seriously depressed, begin positive pressure mask ventilation with 100% oxygen,if the heart rate less than 70 beats per minute as soon as intubate,when no heart beat attempt external massage at a rate 30 interpose with two ventilation.
The infant with a low Apgar score who has responded to resuscitation should not be kept in the delivery room even if he becomes pink,cries, and is in no distress and all the premature infants even if not manifesting depression should be taken to the special care nursery for observation.
REFERENCE :
1.Pieter R,Lebowizt P: Newborn Resuscitation in Textbook of Clinical Anesthesia Procedures of The Massachusett General Hospital,1st edit,Little Brown Company, USA 1978,pp.244-52.
2.Thorton L.H,Perkins: Resuscitation of the Newborn in textbook of Emergency Anesthesia 2nd edit,Edward Arnold Publishers,London 1974,pp.214-27.
3.Snow J.C: Resuscitation of the Newborn in Handbook of Manual Anesthesia. 1st edit,The Asian Edition Little Brown and Company,Boston,Igaku shoin Ltd. Tokyo,1977.pp 444.
4.Stewart J.David: Cardiac Pulmonary Resuscitation in Handbook Manual Pediatric, Churchill Livingstone, Newyork Edinburg and London 1979,pp.286-91.
5.Levin M.Richard : Cardio Pulmonary Resuscitation in Handbook of Pediatric Respiratory Intensive Care, Medical Examination Publishing Co Inc.USA 1976 pp.265-73.
6.Smith M.Robert: Unspected Cardiac Asystole in Handbook of Anesthesia for Infant and Children,4th edit,The CV.Mosby Company,St.Louis,Toronto,London,1980,pp.605-8.
7.Otto W,Ch,Nunn F.J.: Cardio Pulmonary Resuscitation in Textbook of General Anesthesia,5thedit,Butterworth,London,Boston,Singapore,Sydney,1989,pp.1333-44.
8.Workshop Module of Cardio Pulmonary Resuscitation 2005,Medical Faculty Airlangga University,2006.
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