NEONATAL ADVANCED LIFE SUPPORT|Neonatal Resuscitation|

NEONATAL ADVANCED LIFE SUPPORT|Neonatal Resuscitation|

Definition:

Measures taken to revive newborns who have difficulty in establishing respiration at birth and includes suctioning, positive pressure ventilation, external cardiac massage, intubation and medication and necessitated by the neonate’s condition at one minute after birth.

Purpose:

·        To establish and maintain a clear airway.

·         To ensure effective circulation.

·         To correct any acidosis present.

·         To prevent hypothermia, hypoglycemia and hemorrhage.

·         To administer medications if needed.

Requirements:

·         A draught free, warm room with temperature 26-28 .

·         A clean, dry and warm delivery surface.

·         A radiant warmer.

·         A source of oxygen.

·         A source of regulated suction device.

·         Two trained personnel for one neonate.

Articles:

Ø  Suctioning articles:

·         Suction device (mucus extractor for single use).

·         Suction catheters (6, 8 and 10Fr).

·         Feeding tubes (8Fr).

·         20 ml syringe.

·         Bulb syringe.

Ø  Bag and mask articles:

·         Infant resuscitation bag with pressure release valve capable of delivering 90-100% oxygen (240-500ml).

·         Face masks.

·         Oral airways (newborn and premature sizes)

·         Oxygen with flowmeter and tubings.

Ø  Intubation articles:

·         Laryngoscope with straight blades No.0, No.1.

·         Extra bulbs and batteries for laryngoscope.

·         Endotracheal tubes (2.5, 3.0, 3.5 and 4.0 mm internal diameter).

·         Styllet.

·         Scissors.

Ø  Medications:

·         Epinephrine 0.01-0.03 mg/kg IV.

·         Crystalloid 10 mL/kg IV.

·         Naloxone is not recommended.

·         Sodium bicarbonate 4.2% (1mEq/2ml), 7.5% strength is approximately (0.9mEq/ml).

·         Slow infusion pump.

·         Volume expander:

o   5% albumin solution.

o   Normal saline.

o   Ringer’s lactate.

o   Dextrose 5%.

·         Dextrose 10% concentration 250 ml.

·         Sterile water 30 ml.

·         Normal saline 30 ml.

Ø  Miscellaneous:

·         A shoulder roll (0.5 to 2 inch thickness.

·         Stethoscope.

·         Pulse oxymeter.

·         Gloves.

·         Radiant warmer.

·         Adhesive tape, bandage and scissors.

·         Syringes of 1ml, 2ml, 5ml and 20ml sizes.

·         Needles No.21, 22 and 26G.

·         T connectors.

·         Umbilical cord clamp and 2 clean, warm towels.

·         Umbilical catheters (2.5-5Fr).

·         A clock with seconds.

·         Scalp vein set or IV cannulas.

Pre procedural Steps:

·         Ensure room temperature is 26-28 .

·      Switch on the radiant warmer 15-20 minutes prior to anticipated time of birth and keep two sterile draw sheets to warm.

·         Ensure that self-inflating bag is working well and and all the parts are attached correctly and then block the mask by making an airtight and with the palm of your hand, then squeeze the bag:

o   Do you feel pressure against your hand? (Yes)

o   Can you force the pressure release valve open? (Yes)

o   Is there a crack or leak in the bag? (No)

o   Is the pressure release valve missing or stuck or closed? (No)

o   Is the patient outlet completely blocked? (No)

o   Does the bag re-inflate quickly when you release your grip? (Yes)

·         Make sure that the reservoir fits well into reservoir port. The bag should fit well to the port, inflate well, the layers should not stick together and should not be damaged.

·         Check the pressure of suction device, it should be 80-100mmHg and 60-80mmHg for term and preterm neonate respectively.

·         Ensure availability of humidified oxygen and the humidification chamber. Fill the chamber with distilled water up to the marked level.

·         Switch on the saturation monitor and ensure that saturation probe is working well. Clean the probe and its tubing with spirit swab and keep it ready for use.

·         Check laryngoscope and its blades. The blades should fit well, and bulb must be screwed tight. Check the batteries and if not working well replace.

·         Ensure availability of two health care personals trained in NALS.

·         Alert the team.

TABC of Resuscitation:

The components of the neonatal resuscitation procedure are described as the acronym TABC of resuscitation:

Ø  Maintenance of temperature:

·         Provision of radiant heat source.

·         Drying the baby.

·         Removing wet linen.

Ø  Establishment of an open airway:

·         Position the infant.

·         Suction the mouth, nose and in some instances the trachea (in meconium stained liquor).

·         If necessary, insert an ET tube to ensure open airway.

Ø  Initiation of breathing:

·         Tactile stimulation.

·         Positive pressure ventilation, using either bag and mask or bag and ET tube.

Ø  Maintenance of circulation:

·         Stimulate and maintain the blood circulation by chest compression or medications.

Procedure:

Nursing Action	Rationale
Assess the APGAR score.	Helps to know if resuscitation measures are to be instituted.
Place infant under warmer, quickly dry off amniotic fluid, replace wet sheets with a dry one.	Prevents heat loss.
Place the baby on his back with slightly head down 15  tilt, neck slightly extended.	Straightens the trachea and opens the airway. Hyperextension may cause airway obstruction.
Suction the mouth first and then nose.	Clears the airway passage. Infants often gasps when the nose is suctioned and may aspirate secretion from the mouth into lungs.
Give tactile stimulation if does not breathe (Flick or tap the sole of foot twice or rub the back). Do not slap.	Tactile stimulation may bring spontaneous respiration.
Check the vital signs and color of the newborn.	Helps in determining further need for resuscitation.

Evaluation:         

Evaluation should be done on respiration, heart rate and color. If the baby is apneic, heart rate is less than 100b/min and central cyanosis is present, proceed for bag and mask ventilation or positive pressure ventilation.

BAG AND MASK VENTILATION

Indications:

·         Apnea.

·         Heart rate less than 100b/min.

Procedure:

Nursing Action	Rationale
Place the newborn on his back with head slightly extended.	Helps in opening airway. Hyperextension may cause airway obstruction.
A tight seal is to be formed over the infant’s mouth and nose with the face mask.	Prevents leakage of oxygen from the sides of the masks.
Ventilate at a rate of 40-50b/min.
Ventilate for 15-30seconds and evaluate.	Spontaneous respiration may be initiated with initial attempts to ventilate.
Have an assistant to evaluate, listen to the heart rate for 6 seconds and multiply by 10.

Evaluation:

·         If heart rate is above 100b/min and spontaneous respirations are present, discontinue bagging.

·         If heart rate is 60-100b/min and increasing, continue ventilation, check whether chest is moving adequately.

·         If heart rate is below 80b/min, start chest compression.

·         If heart rate is below 60b/min, in addition to bagging and chest compressions, consider intubation and initiate medications.

·         Signs of improvement:

ü  Increasing heart rate.

ü  Spontaneous respiration.

ü  Improving color.

Continue to provide free flow oxygen by face mask after respirations are established. If the baby deteriorates, check the following:

·         Placement of face mask for tight seal.

·         Head position and presence of secretions.

·         Presence of air in the stomach preventing chest expansion.

·         Oxygen being delivered (100% or not).

·         For bagging lasting for more than 2 minutes, insert an orogastric tube to vent the stomach.

CHEST COMPRESSION

·         Chest compressions consist of rhythmic compressions of the sternum that compresses the heart against the spine, increases the intrathoracic pressure and circulates blood to the vital organs.

·         Chest compressions must always be accompanied by ventilation with 100% oxygen to assure that the circulating blood is well-oxygenated.

Indications:

·         Heart rate less than 60b/min after bagging with 100% oxygen for 15-30 seconds.

·         Heart rate 60-80b/min and not increasing after bagging with 100%oxygen for 15-30 seconds.

Procedure:

Nursing Action	Rationale
Compress the chest by placing the hands around the newborn’s chest with the fingers under the back to the thumbs provide support and the thumbs over the lower third of the sternum or use two fingers of one hand to compress the chest and place the other hand under the back to provide support.	Correct hand position compresses the heart and avoids injury to the liver, spleen, fracture of the ribs and pneumothorax.
Compress the sternum to a depth of approximately one-third of the antero-posterior diameter of the chest and with sufficient force to cause a palpable pulse. The fingers should remain in contact with the chest between compressions.	The size of the newborn determines the depth of compressions to avoid injury.
Use 3 compressions followed by 1 ventilation for a combined rate of compressions and ventilations of 120 events each minute. This provides 90 compressions and 30 ventilations each minute. Pause for 0.5 second after every 3rd compression for ventilation.	Simultaneous compression and ventilation may interfere with adequate ventilation. The short pause allows air to enter the lungs.
Check the heart rate after 30 seconds. If it is 60b/min or more, discontinue compressions but continue ventilation until the heart rate is more than 100b/min and spontaneous breathing begins.	Periodic evaluation is necessary to ensure that treatment is appropriate to infant’s status

If cardiac compression fails, endotracheal intubation should be initiated.

ENDOTRACHEAL INTUBATION

Indications:

·         Heart rate below60b/min inspite of bagging and chest compressions.

·         Presence of meconium in the amniotic fluid.

Procedure:

Nursing Action	Rationale
Place infant with head slightly extended with a rolled towel under the shoulder.	Position makes the airway open.
Introduce laryngoscope over the baby’s tongue at the right corner of the mouth.
Advance 2-3 cm while rotating it to midline, until the epiglottis is seen. Elevation of the epiglottis with the tip of the laryngoscope reveals the vocal cords.
Suction secretions if needed.	Clears the airway.
Pass the endotracheal tube a distance of 1.5-2 cm into the trachea, hold it firmly but gently in place and withdraw the laryngoscope slowly.	Ensure adequate air into both lungs.
Attach the endotracheal tube to the adapter on the bag.
Ventilate with oxygen by bag. An assistant should check for adequate ventilation of both lungs with stethoscope.

Medications:

Medications should be administered if despite adequate ventilation with 100% oxygen and chest compressions the heart rate remains at 80b/min.

Recording:

Record the procedure in nurses’ record. Document the babies condition before and after procedure.

Chest compression: After every third chest compression, ventilation should be continued.

In one minute, 90 chest compressions and 30 PPVs should be carried out (3:1 ratio).

Medications:

Epinephrine: 0.1-0.3 ml/kg in 1:10000 dilution is given IV when there is persistent bradycardia. Intratracheal administration can also be given. It may be repeated every 5 minutes. Sodium bicarbonate to combat metabolic acidocis (pH <7.2) IV (4 ml/kg of 0.5mEq/ml, 4.2% solution) is given. Reversal of narcotic drugis needed when mother has been given pethidine or morphine within 3 hours of delivery. Naloxone 100mg/kg is given to the baby by IV, IM or endotracheal. Volume expansion is needed when blood pressure is low and tissue perfusion is poor. Whole blood, 5% albumin or packed red blood cells (10ml/kg) IV is given. Dopamine infusion may be given for hypotension.

Resuscitation protocol following American Heart Association and the American Academy of Pediatrics, recommended by the National Neonatology Forum (NNF), India.