AIRWAY MANAGEMENT- NEONATES (Neonatal Resuscitation) CHAKAFA N K (Clinical Anaesthetist)

AIRWAY MANAGEMENT- NEONATES (Neonatal Resuscitation)

CHAKAFA N K(Clinical Anaesthetist)

Introduction

• At least 10% of all newborns require some assistance at birth ie the initial steps of resuscitation

• And 1% require extensive resuscitation• There are 1 million deaths per year resulting

from Birth asphyxia(WHO,1995)• A significant number will have respiratory

problems and a large number will have seizures and later problems such as cerebral palsy.

Definitions

• Airway mgt is a process of ensuring thati) there is an open pathway between patient’s

lungs and the outside world ii) The lungs are safe from aspiration. Neonate – baby less than 28 days

Neonates compared to older children

• Neonates are small• Large surface area to weight ratio• Born wet so they are prone to rapid

evaporative heat loss• New born babies are in transition from

placental to pulmonary respiration• Large tongue• Proportionally large head and occiput

Essential equipment for resuscitation of the newborn

• Firm flat padded resuscitation surface• Source of warmth( overhead heater, warm dry

towels,radiator,hot water bottle wrapped in towels.• Clear plastic bags for preterm babies under 30wks• Good light source• Clock or timer to record time of birth, assessment and response

to resuscitation• Airway equipment: facemask 0 and 1,oropharyngeal airway size

000,00 and 0, self inflating bag with reservoir, neonatal face masks, laryngoscope and blade with spare bulb Miller (1,0), Mackintosh blade(1,0) , tracheal tubes (2.5 ,3 for pre term and 3.5 or 4 for term, stylets, size 1 LMA

Equipment cont’d

• Nasogastric tube• Adhesive tape • Oxygen • Stethoscope to assess HR and breath sounds• IV cannulae, 24 g, umblical catheter• Drugs : N/saline, adrenaline 1:10000,10%

glucose, sodium bicarbonate,naloxone

Assessment

Was th e baby born after full term gestation?Is the amniotic fluid clearof meconium and

evidence of infection?Is the baby crying?Does the baby have a good muscle tone?

Healthy child

• If the answer to all 4 of these questions is “yes” then there is no need for any resuscitation

• Do not separate the child from the mother• Dry the baby, place onto the mother’s chest• Cover the child with a dry cloth• Observation of breathing , activity and colour

should be ongoing

Asphyxiated baby

• If the answer is “no” then the child is in danger, so the child should receive one or more of the following :

i) Initial steps in stabilization(provide warmth, position, clear airway, dry, reposition)

ii) Ventilationiii) Chest compressionsiv) Administration of epinephrine and /or volume

expansion

Heat Loss

• Minimise heat loss especially in pre term babies

• Warm towels, dry the child as soon as possible• Change towels • Place the child under a radiant heater• This must be done in 20 – 30 seconds

Airway

• Maintain head in neutral position with face parallel to the surface on which the baby is lying

• Avoid overextension/ flexion of the neck• Provide a jaw thrust • Oropharyngeal airway may be helpful- large

tongue

Meconium aspiration

• Some babies may pass meconium in utero• Inhalation of meconium before birth or during

birth can cause severe pneumonitis.• Remove any thick particulate by means of a

large bore suction device or a penguin• Do not suction the nose before the mouth- this

will stimulate the baby to gasp and to aspirate pharyngeal secretions

• Intubation is necessary in a floppy child.

Ventilation

• Ventilate the lungs with either room air or 100% oxygen

• Well fitting mask to the nose and mouth• Inflate the lungs with at a pressure of around

30cm of water• Aim at inspiratory time of 2-3secs• Give at least 5 inflations

Circulation

• Re evaluate HR• If HR is above 100 then it’s a firm indication

that lungs are adequately aerated• Assess chest movement• If HR has not improved ---- START CHEST

COMPRESSIONS

Chest compressions

• Indicated for a HR that is less than 60 despite adequate ventilation

• Necessary to bring oxygenated blood from the lungs back to the coronary arteries

• Both hands encircling the chest• Place thumbs together centrally over the lower

sternum• Rate- 120/min• For every 3 compressions give one breath aiming at 40

breaths/min

Assessment

• Look for response after 30-60secs of chest compressions

• If HR is above 100 then it indicates that you are succeeding

• However if the HR has not improved or is absent then consider DRUGS

Drugs

• Epinephrine 1:10000 0.1-0.3ml/kg IV• Epinephrine 1:10000 0.5 1ml/kg per ET• Give ET only while IV access is being established• Repeat every 5 minutes• Caution- higher doses in newborns may result in

brain and heart damage.• Sodium bircabonate (4,2% soln) 2mEq/kg IV over

2 min if severe metabolic acidosis is suspected

Post resuscitation care

• Glucose – 10% dextrose water 2ml/kg iv• Phenobarbital (seizures) 20mg/kg slow iv• Dopamine(hypotesion)- 2- 20mcg/kg

Discontinuing Resuscitative Efforts

• Infants without signs of life i.e. no heart beat and no respiratory effort after 10min of resuscitation

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