Cardiopulmonary resuscitation in newborns and children. Protocol for conducting primary resuscitation of newborns Algorithm for making a decision on the start of primary resuscitation measures
Currently, the Apgar score as a criterion for indications for resuscitation is subject to revision, however, it is quite acceptable to evaluate the effectiveness of resuscitation and the dynamics on this scale. The fact is that in order to obtain a quantitative assessment of the state of the newborn, one must wait a whole (!) Minute, while resuscitation should be started in the first 20 seconds, and by the end of the 1st minute Apgar score should be given. If it is less than 7 points, then in the future, an assessment should be made every 5 minutes until the condition is assessed at 8 points (G. M. Dementieva et al., 1999).
It should be noted that the algorithms for resuscitation remain basically the same as in adults. However, there are differences in the performance of individual techniques due to the anatomical and physiological characteristics of newborns. resuscitation measures ( principles A, B, C according to P. Safar) are as follows:
A - ensuring the patency of the respiratory tract;
B - restoration of breathing;
C - restoration and maintenance of hemodynamics.
When principle A is followed, the correct position of the newborn, suction of mucus or amniotic fluid from the oropharynx and trachea, and tracheal intubation are ensured.
The implementation of principle B involves various methods of tactile stimulation with a jet supply of oxygen through a mask, and artificial ventilation of the lungs.
The implementation of principle C involves indirect heart massage and drug stimulation.
Carrying out IVL necessary if the child does not respond to tactile stimulation, while maintaining bradycardia and pathological types of breathing. Positive pressure ventilation can be performed using special breathing bags (Ambu bag), masks or an endotracheal tube. A feature of the bags is the presence of a relief valve, usually at pressures exceeding 35-40 cm of water. Art. Breathing is carried out at a frequency of 40-60 per minute. It is important to provide the first 2-3 breaths with a pressure of 40 cm of water. Art. This should ensure good expansion of the lungs, reabsorption of the intraalveolar fluid by the lymphatic and circulatory systems. Further breaths can be taken with a peak pressure of 15-20 cm of water. Art.
When effective cardiac activity (>100 beats per minute) and spontaneous breathing are restored, ventilation can be turned off, leaving only oxygenation.
If spontaneous breathing is not restored, then ventilation should be continued. If the heart rate tends to increase (up to 100-120 per minute), then ventilation should be continued. The presence of persistent bradycardia (less than 80 per minute) is an indication for mechanical ventilation.
Given the possibility of overdistension by the oxygen-air mixture of the stomach, followed by aspiration, it is necessary to insert a gastric tube and keep it open.
The correct selection of the diameter of the endotracheal tube is very important for tracheal intubation. With body weight less than 1000 g - 2.5 mm; 1000-2000 g - 3.0 mm; 2000-3000 g - 3.5 mm; more than 3000 - 3.5-4 mm. The intubation itself should be as gentle as possible and be completed within 15-20 seconds. It should be remembered that manipulations in the vocal cords may be accompanied by unwanted vagal reflexes. In this case, we will not describe them, because. they are covered in detail in specific manuals.
Indirect cardiac massage carried out 15-30 seconds after the start of mechanical ventilation or oxygen inhalation, if the heart rate is 80 per minute. and less and has no tendency to normalize.
For heart massage, it is better to lay the child on a hard surface with a small roller under the shoulders to create a moderate extension position. The point of pressure on the sternum is located at the intersection of the inter-nipple line and the midline, but the fingers should be slightly lower, without covering the point found. The depth of immersion of the sternum is 1-2 cm. The frequency of chest compressions should be maintained within 120 per minute. The number of breaths should be 30-40 per minute, the ratio of breaths to the number of chest compressions is 1:3; 1:4.
For the implementation of indirect heart massage in newborns (and precisely in them), 2 methods have been proposed. In the first method, 2 fingers of the hand (usually index and middle) are placed on the pressure point, and the palm of the other hand is placed under the child's back, thus creating counter pressure.
The second way is that the thumbs of both hands are located side by side at the pressure point, and the remaining fingers of both hands are located on the back. This method is more preferable, as it causes less fatigue of the hands of the staff.
Every 30 seconds, the heart rate should be monitored and if it is less than 80 beats per minute, massage should be continued with the simultaneous administration of medications. If there is an increase in the frequency of contractions, then drug stimulation can be abandoned. Medical stimulation is also indicated in the absence of palpitations after 30 s of positive pressure ventilation with 100% oxygen.
For the introduction of drugs, the umbilical vein is used through a catheter and an endotracheal tube. It must be remembered that catheterization of the umbilical vein is a threatening risk factor for the development of septic complications.
Adrenaline is prepared at a dilution of 1:10,000 (1 mg / 10 ml), drawn into a 1 ml syringe and administered intravenously or through an endotracheal tube at a dose of 0.1-0.3 ml / kg. Typically, the dose injected into the endotracheal tube is increased by a factor of 3, while the volume is diluted with saline and quickly injected into the lumen of the tube.
If the heart rate after 30 seconds does not reach 100 beats per minute, then injections should be repeated every 5 minutes. If hypovolemia is suspected in a child, then within 5-10 minutes, drugs are administered that replenish the vascular bed: isotonic sodium chloride solution, Ringer's solution, 5% albumin in a total dose of up to 10 ml / kg of body weight. The lack of effect from these measures is an indication for the introduction of sodium bicarbonate at the rate of 1-2 mmol / kg (2-4 ml / kg of 4% solution) at a rate of 1 mmol / kg / min. If no effect is found, then immediately after the end of the infusion, the entire indicated volume of assistance should be repeated.
If there are suspicions of narcotic respiratory depression (administration of morphine-like drugs during anesthesia, drug addict mother who took drugs before childbirth), then the introduction of the antidote naloxone at a dose of 0.1 mg / kg of body weight is required. The child should be under monitor control due to the fact that after the end of the antidote (1-4 hours), repeated respiratory depression is possible.
Resuscitation measures end if within 20 minutes. failed to restore cardiac activity.
When carrying out resuscitation, special attention should be paid to maintaining the thermal regime, because even under normal thermal conditions in the delivery room (20-25°C), immediately after birth, the body temperature decreases by 0.3°C, and in the rectum - by 0.1°C per minute. Cooling can cause metabolic acidosis, hypoglycemia, respiratory disturbances, and delayed recovery even in full-term newborns.
Lysenkov S.P., Myasnikova V.V., Ponomarev V.V.
Emergency conditions and anesthesia in obstetrics. Clinical pathophysiology and pharmacotherapy
It should be in all medical institutions where childbirth can potentially occur. Work in the maternity ward should be organized in such a way that in cases where cardiopulmonary resuscitation begins, the employee who conducts it from the first minute can be assisted by at least two other medical workers.
Antenatal risk factors for neonatal asphyxia.
1. Diabetes
2. Preeclampsia
3. Hypertensive syndromes
4. Rh sensitization
5. History of stillbirth
6. Clinical signs of infection in the mother
7. Bleeding in the second and third trimester of pregnancy
8. Polyhydramnios
9. Low water
10. Multiple pregnancy
11. Fetal growth retardation
12. Maternal drug and alcohol use
13. The use of drugs that depress the breath of a newborn (promedol)
14. Presence of developmental anomalies
15. Abnormal CTG values before childbirth.
Intrapartum risk factors
1. Preterm birth before 37 weeks
2. Delayed delivery for more than 42 weeks
3. Caesarean
4. Placental abruption
5. Placenta previa
6. Prolapse of the umbilical cord
7. Pathological position of the fetus
8. General anesthesia
9. Anomaly of labor activity
10. The presence of myconium in the amniotic fluid
11. Violation of the fetal heart rhythm
12. Histocia of the shoulders
13. Instrumental delivery - forceps, vacuum extraction
In cases where the birth of a child is predicted in terms of up to 32 weeks of gestation, an intensive care team should be on duty in the delivery room. After the birth of a child, it is necessary to fix the time of his birth and proceed to the provision of resuscitation, regardless of the initial state of the newborn. Apgar score at the first and fifth minutes of life and at 10 minutes. The sum of 8 or more points is satisfactory. Comp, 4-7 moderate asphyxia
The protocol for conducting primary resuscitation of newborns includes
1. Initial measures - restoration of patency of the respiratory tract
2. Artificial ventilation
3. Indirect cardiac massage
4. Administration of medications
Assessment of the child's condition in the first minutes of life is carried out according to three criteria:
1. The presence and nature of spontaneous breathing
2. Heart rate
3. Skin color
The criteria for the effectiveness of ongoing resuscitation are:
1. Regular effective spontaneous breathing
2. Heart rate more than 100 beats / min.
Initial activities include:
1. Maintaining body temperature - drying children for more than 28 weeks is simply blotted with a diaper, if up to 28 weeks - it is placed wet in a plastic bag with a slot for the head.
2. Sanitation of the oropharynx is indicated only for those newborns who did not develop spontaneous breathing during the first 10 minutes of life or in the presence of a large amount of discharge.
3. Tactile stimulation - carried out either by slapping the feet or stroking the back.
4. Artificial ventilation of the lungs. Indications for mechanical ventilation: 1. Lack of breathing, 2. Irregular breathing, 3. Heart rate less than 100 beats / min.
Immediate inbation:
1. Children with suspected diaphragmatic hernia
2. Children born with an admixture of myconium in the amniotic fluid or with depressed spontaneous breathing
3. Children born before 27 weeks of age for the purpose of prophylactic administration of sulfoctant.
Evaluation of the effectiveness of ventilation through a face mask
The main criterion for effectiveness is a heart rate of more than 100. It must be assessed 30 seconds after the start. Heart rate evaluation lasts 6 seconds.
The heart rate is less than 60 - intubation is performed and IVL begins in turn. If in 20 seconds it is not possible to intubate, continue to breathe through the mask, then try to intubate again.
With persistent bradycardia, an indirect heart massage is started against the background of mechanical ventilation through a tube.
The heart rate is more than 60 but less than 100 - IVL continues for another 30 seconds, then the heart rate is assessed if it is bad - intubation.
Heart rate greater than 100 - continue mechanical ventilation until spontaneous breathing is restored.
Indications for tracheal intubation
1. Children with suspected diaphragmatic hernia.
2. Children with meconium in the amniotic fluid in the absence of spontaneous breathing
3. Children born before 27 weeks for the purpose of professional administration of a suloctant.
4. If mask ventilation is ineffective when the heart rate is less than 60 for 30 seconds.
5. In case of insufficient effective mask ventilation, if from 60 - 100 for 60 seconds.
6. If necessary, an indirect heart massage.
Indirect cardiac massage
1. Ventilation rate to compressions 3:1.
2. After starting the massage, after 30 seconds, we evaluate the heart rate - if more than 60, then stop indirect heart massage, if below 60, then continue.
Drug therapy
Adrenaline if the frequency is less than 60 after 30 seconds of indirect massage. 0.3 ml per kg of body weight.
Saline solution - acute blood loss or hypovolumia - 10 ml per kg slowly.
sodium bicarbonate acidosis, no effect of the above. 4 ml per kg of 4% solution at a rate of 2 ml per kg per minute. End of resuscitation From the beginning of the activities carried out in 10 minutes if not effective.
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015
Unspecified birth asphyxia (P21.9), Moderate and moderate birth asphyxia (P21.1), Severe birth asphyxia (P21.0)
Neonatology, Pediatrics
general information
Short description
Expert Council
RSE on REM "Republican Center for Health Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
Protocol #10
I. INTRODUCTION
Protocol name: Resuscitation of premature babies.
Protocol code:
Code(s) according to ICD-10:
P21.0 Severe birth asphyxia
P21.1 Moderate and moderate birth asphyxia
P21.9 Unspecified birth asphyxia
Abbreviations used in the protocol:
BP blood pressure
IV intravenously
IVL artificial lung ventilation
MTR birth weight
NMS indirect heart massage;
BCC volume of circulating blood
FRC functional residual lung capacity
RR respiratory rate
HR heart rate
ETT endotracheal tube
FiO2 concentration of oxygen in the inspired gas mixture
ILCOR International Liaison Committee on Resuscitation
PIP positive inspiratory pressure (inspiratory pressure)
PEEP positive end expiratory pressure (positive end-expiratory pressure)
SpO2 oxygen saturation
CPAP continuous positive airway pressure (constant positive airway pressure)
Protocol development date: 2015
Protocol Users: neonatologists, resuscitators and obstetricians gynecologists of obstetric organizations.
Evidence assessment of the recommendations provided (Harmonized European Guidelines for the Treatment of Respiratory Distress Syndrome in Preterm Infants - Updated 2013).
Evidence level scale:
| Level I: | Evidence obtained from a systematic review of all eligible randomized controlled trials. |
| Level II: | Evidence obtained from at least one well-designed randomized controlled trial. |
| Level III-1: | Evidence obtained from a well-designed pseudo-randomized controlled trial (spare allocation or other method). |
| Level III-2: | Evidence obtained from comparative, non-randomised, parallel control and allocation studies (cohort studies), case-control studies, or from interrupted time series with controls. |
| Level III-3: | Evidence obtained from comparative studies with historical control, two or more uncontrolled studies, or interrupted time series without a parallel control group. |
| Level IV: | Evidence obtained from case series, either post-test or pre-test and post-test. |
| Recommendation grade | Description |
|
Grade A: Recommended Recommendations for class A treatment are given to those guidelines that are considered useful and should be used. |
|
|
Class B: Acceptable |
Diagnostics
Diagnostic measures: are carried out in the post-resuscitation period to identify the causes of pulmonary heart disorders at birth, i.e. to establish a clinical diagnosis.
Main activities
To determine the severity of asphyxia at birth, immediately after the birth of a child, blood is taken from the artery of the clamped umbilical cord to determine its gas composition.
. Markers of severe perinatal asphyxia (hypoxia) are:
- severe metabolic acidosis (in the arterial blood of the umbilical cord pH<7,0 и дефицит оснований ВЕ ≥ 12 ммоль/л);
- Apgar score 0-3 points at the 5th minute;
- clinical neurological disorders that manifest themselves in the early stages after birth (convulsions, hypotension, coma ─ hypoxic-ischemic encephalopathy);
- signs of multiple organ damage in the early stages after birth [LE - A].
Additional Research:
. monitoring of CBS to maintain normal performance within: pH 7.3-7.45; Ra O2 60-80 mm Hg; SpO2 90-95%); PaCO2 35-50 mm Hg;
. clinical blood test, platelet count to exclude or confirm the presence of a severe bacterial infection in the newborn (sepsis, pneumonia);
Heart rate, respiratory rate, body temperature, pulse oximetry, blood pressure monitoring to detect cardiopulmonary pathology, characterized by the development of hypotension, systemic secondary arterial hypoxemia against the background of increased pulmonary vascular resistance, leading to pathological blood shunting through fetal communications (OAP, LLC);
Control of diuresis, accounting for fluid balance and electrolyte levels in the blood serum (pronounced low levels of sodium, potassium and chlorides in the blood serum with a decrease in diuresis and excessive weight gain in the aggregate may indicate acute tubular necrosis of the kidneys or a syndrome of inappropriate secretion of antidiuretic hormone, especially for the first time 2-3 days of life; increased diuresis may indicate ongoing tubular damage and excess sodium excretion relative to water excretion);
The concentration of glucose in blood serum (glucose is the main energy substrate necessary for postnatal adaptation, brain nutrition; hypoglycemia can lead to apnea, convulsions).
Instrumental Research(preferably in the first days):
. Neurosonography to exclude / confirm IVH, ICH and other CNS pathologies;
. Ultrasound of the heart to exclude / confirm congenital heart disease, myocarditis;
. Echo KG to exclude/confirm UPU, PDA, LLC, etc.;
. Plain radiography to exclude / confirm the pathology of the respiratory organs, SUV, NEC;
. Other studies according to indications.
Expert advice: are carried out as necessary in the post-resuscitation period to confirm the identified pathology (neurologist, cardiologist, oculist, neonatal surgeon, neurosurgeon, etc.).
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Treatment
II. MEDICAL REHABILITATION ACTIVITIES
Purpose of resuscitation:
The purpose of resuscitation is the complete restoration of the vital functions of the body, the violation of which is due to perinatal hypoxia and asphyxia during childbirth.
Indications for medical rehabilitation: in accordance with international criteria in accordance with the Standard for organizing the provision of medical rehabilitation to the population of the Republic of Kazakhstan, approved by order of the Minister of Health of the Republic of Kazakhstan dated December 27, 2014 No. 759.
Indications for resuscitation:
. Premature newborns weighing 1000-1500 g need respiratory support immediately after birth in 25-50% of cases and those weighing less than 1000 g in 50-80% of cases (Class A).
. Such a frequent need for respiratory support is due to insufficient independent respiratory efforts in premature newborns and the inability to create and maintain functional residual capacity (FRC) of the lungs due to:
- lung immaturity, surfactant deficiency;
- weakness of the muscles of the chest; - immaturity of the central nervous system, which does not provide adequate stimulation of respiration.
. Within the framework of the Newborn Resuscitation Program, a “Primary Assessment Block” was singled out, which contains 3 questions that allow assessing the condition of the child at the time of birth and identifying the priority of actions:
- Is the baby full term?
- Breathing or screaming?
− Is the muscle tone good?
. If the answer to at least one of the above questions is “no”, the child should be transferred to a heated table (open resuscitation system) for resuscitation.
Contraindications for medical rehabilitation:
Contraindications for resuscitation:
In Kazakhstan, there is no law regulating the scope of the provision
Resuscitation care for newborns in the delivery room. However, the recommendations published by the International Resuscitation Consensus Committee, based on the American Heart Association Manual of Cardiopulmonary Resuscitation and Emergency Cardiovascular Therapy Part 15: Neonatal Resuscitation: 2010, and the 6th edition of the textbook "Resuscitation of the Newborn" indicate conditions under which resuscitation is not indicated:
. If gestational age, birth weight, or congenital malformations are associated with near-imminent death or unacceptably severe disability in surviving children, or:
. a confirmed gestational age of less than 23 weeks or a birth weight of less than 400 g;
. anencephaly;
. confirmed incompatible with life congenital malformations or genetic disease;
. the presence of data indicating an unacceptably high risk of death and disability.
Volumes of medical rehabilitation
The main stages of resuscitation:
Resuscitation of preterm infants follows the sequence recommended by ILCOR (International Conciliation Committee on Resuscitation) 2010 for all newborns [EL - A]:
A. Primary resuscitation measures (warming, releasing the airways, drying, tactile stimulation).
B. Positive pressure ventilation.
C. Indirect cardiac massage.
D. Introduction of adrenaline and/or solution to replenish the volume of circulating blood (volume expander therapy).
After each step of resuscitation, their effectiveness is evaluated, which is based on the heart rate, respiratory rate and oxygenation of the child (which is preferably assessed using a pulse oximeter).
. If heart rate, breathing and oxygenation do not improve, you should proceed to the next step (block) of actions.
Preparing for resuscitation
Assessment and intervention are simultaneous processes provided by the resuscitation team.
. The success and quality of resuscitation depends on the experience, readiness and skills of the staff, the availability of a full range of resuscitation equipment and medicines, which should always be available in the delivery room. [UD -A]
. In case of preterm birth, a team of doctors with experience in the neonatal intensive care unit is called to the delivery room, including employees who are well-versed in the skills of tracheal intubation and emergency umbilical vein catheterization. [AD A]
. In the case of expected preterm labor, it is necessary to increase the air temperature in the delivery room to ≥26°C and first turn on the radiant heat source to ensure a comfortable ambient temperature for the premature newborn. [UD -A]
Place an exothermic mattress under several layers of diapers on the resuscitation table.
. If a baby is expected to be born less than 28 weeks' gestation, prepare a heat-resistant plastic bag or plastic wrap for food or medical use and an exothermic mattress (warming bed). [UD - A]
. Warming and humidifying the gases used to stabilize the condition can also help maintain the newborn's body temperature. [UD - V]
. A pulse oximeter and a mixer connected to a source of oxygen and compressed air should always be available. [UD - S]
. It is important to have a prepared, pre-warmed transport incubator to maintain the body temperature of the newborn during transport to the intensive care unit after stabilization in the delivery room. [UD - A]
Block A.
Primary resuscitation ─ providing initial care to the newborn is reduced to ensuring minimal heat loss, debridement of the airway (if indicated), giving the child the correct position to ensure airway patency, tactile stimulation of breathing and re-positioning the newborn in the correct position, after which respiration and heart rate (HR) are assessed. [UD - V]
Prevention of heat loss:
. Preterm infants are particularly at risk for hypothermia, which can increase oxygen consumption and prevent effective resuscitation. This situation is most dangerous for newborns with extremely low (˂ 1000 g) and very low birth weight (˂ 1500 g). In order to prevent hypothermia, additional actions should be taken, which are not limited, as described above, to raising the air temperature in the delivery room to ≥26 ° C and in the area where resuscitation will be carried out, placing an exothermic mattress under several layers of diapers located on the recovery table. [LE C] When using an exothermic mattress, the manufacturer's instructions for activation should be strictly followed and the child placed on the appropriate side of the exothermic mattress.
Premature newborns with a gestational age of 29 weeks or less are placed immediately after birth (without drying) in a plastic bag or under a plastic diaper up to the neck on pre-warmed diapers on the resuscitation table under a source of radiant heat (Fig. 1). The surface of the child's head is additionally covered with a film or cap. The pulse oximeter sensor is attached to the child's right wrist before being placed in the bag. The bag or diaper should not be removed during resuscitation. [UD - A]
Picture 1
The child's temperature should be carefully monitored because sometimes, the use of methods aimed at preventing heat loss can lead to hyperthermia. [UD - V]
All resuscitation measures, including tracheal intubation, chest compressions, venous access, should be carried out while ensuring thermoregulation. [UD - S]
Respiratory sanitation:
Airway clearance has been shown to induce bradycardia during resuscitation, and tracheal evacuation in the absence of obvious nasal discharge in ventilated intubated neonates has been shown to reduce lung tissue plasticity and oxygenation, as well as reduced cerebral blood flow.
Therefore, airway debridement should be carried out only in those newborns who, during the first seconds of life, did not develop adequate spontaneous breathing due to obstruction by mucus and blood, and also, if mandatory positive pressure ventilation is required. [UD - S]
Giving the head of the newborn the correct position
A newborn in need of resuscitation should be gently placed on his back with his head slightly tilted back (correct position, Fig. 2). This position will allow you to place the back of the pharynx, larynx and trachea on the same line, provide maximum opening of the airways and unlimited air flow. [UD - V]
Figure 2:
If the back of the head is strongly protruding, a blanket or towel 2 cm thick placed under the shoulders can help in maintaining the correct position. [UD - A]
Tactile stimulation
. In many cases, correct positioning of the head and debridement of the airways (if indicated) are sufficient stimuli to start breathing. Drying the body and head of the newborn also provides stimulation of breathing with the correct position of the head.
. If the child does not have adequate respiratory movements, then additional tactile stimulation can be performed to stimulate breathing:
- gentle stroking along the back, torso or limbs (1-2 times), and then evaluate the effectiveness of primary resuscitation measures. [UD - A]
Evaluation of the effectiveness of Block A
. If a premature newborn does not breathe after initial care, or has gasping breathing, or a heart rate of less than 100 per 1 minute, this is indication to start positive pressure ventilation (go to Block B)
.
Block B. Positive pressure ventilation
Ensuring ventilation of the lungs
. Uncontrolled inspiratory volumes, both too large and too small, have a damaging effect on the immature lungs of preterm infants. That's why routine use of ventilation with a self-expanding Ambu bag and mask is not practical
. [UD - A]
. Apnea is not typical for most premature newborns, because. due to immaturity of the lungs and surfactant deficiency, natural ventilation of the lungs and the formation of functional residual lung capacity are hindered. Use of early CPAP in the presence of spontaneous breathing(including groaning, accompanied by retraction of compliant places of the chest) with the ability to provide controlled inflation, is currently the main way to ensure the safe stabilization of the condition of premature newborns immediately after birth, reducing the need for mechanical ventilation. [UD - A]
. To provide CPAP (constant positive airway pressure throughout the entire respiratory cycle, created due to the continuous flow of the gas mixture), a resuscitation device with a T-connector (Fig. 3) or a flow-filling bag with a resuscitation mask (Fig. 4) is used, as well as special equipment (CPAP machine, or neonatal ventilator with nasal cannulas or a mask). CPAP cannot be provided with a self-expanding bag. [UD - S].
Figure 3
Figure 4. Flow-fill bag: 
Continuous positive airway pressure (CPAP) is created by hermetically sealing a resuscitation mask attached to a T-system or flow-fill bag to the child's face. [UD - A].
Before applying the mask to the child's face, it is necessary to adjust the CPAP value by firmly pressing the mask to the hand of the resuscitator (Fig. 3). Check the pressure reading on the pressure gauge and adjust with the T-system PEEP valve or the flow control valve of the flow-fill bag until the pressure gauge reads at the desired initial pressure of 5 cmH2O [LE - A]
Then place the mask firmly on the child's face and make sure that the pressure remains at the selected level. If the pressure has decreased, the mask may not fit snugly against the child's face.
During CPAP, the neonate's lungs are constantly maintained in a slightly inflated state, and he does not make great efforts to refill the lungs with air during each exhalation. [UD - A]
Airtight contact between the mask and the child's face is the most important prerequisite for positive airway pressure. . [AD A]
When using the T-system, signs of an adequate mask position will be an audible exhalation sound and positive pressure readings on the pressure gauge (Fig. 5). [UD - A]
Figure 5.
If CPAP needs to be provided for a long time, it is more convenient to use special nasal prongs instead of a mask, since they are easier to fix in the desired position. [UD - A]
During CPAP, the child must breathe spontaneously, without additional mandatory breaths provided by a resuscitator bag or resuscitator with a T-connector (that is, this is not positive pressure mandatory ventilation!). [UD - A]
What concentration of oxygen in the breathing mixture should be used
Tissue damage during childbirth and the early neonatal adjustment period can be caused by inadequate blood circulation and limited oxygen delivery to body tissues. The restoration of these processes is an important task of resuscitation.
To start stabilizing the condition of a premature newborn, an oxygen concentration of 21-30% is advisable, and its increase or decrease is carried out based on the readings of a pulse oximeter attached to the wrist of the right hand from the moment of birth to obtain information on heart rate and saturation (SpO2). [UD - A]
After birth, saturation should increase gradually from about 60% to 80% over 5 minutes, reaching 85% and above by about 10 minutes. [UD - A]
Oximetry can identify newborns that are outside the specified range and help control the oxygen concentration in the mixture. The recommended preductal saturation targets after birth are as follows:
Target SpO2 after birth:
| 1 minute | 60-65% | 4 minute | 75-80% |
| 2 minute | 65—70% | 5 minute | 80-85% |
| 3 minute | 70-75% | 10 minute | 85-95% |
Initial CPAP parameters[UD - A]:
. CPAP is advisable to start with a pressure of 5 cm aq. Art. at FiO2 = 0.21-0.30 under saturation control. In the absence of improvement in oxygenation, gradually increase the pressure to 6 cm aq. Art.
. The optimal recommended pressure is 6 cm aq. Art. Using a higher pressure for CPAP is fraught with serious complications (pneumothorax).
. Increasing FiO2 should only be done after increasing the pressure.
. The pressure is provided by the flow rate (Flow), which is regulated by the apparatus. The flow-pressure nomogram shows the relationship between flow rate and generated pressure (Fig. 6).
Figure 6. Flow-pressure nomogram (CPAP). 
Indications for stopping CPAP:
. First of all, reduce FiO2, gradually to the level of 0.21 under the control of SaO2 88%. Then, slowly, 1-2 cm aq. Art. reduce airway pressure. When it is possible to bring the pressure up to 4 cm aq. Art. at Flow-7 L/min, FiO2-0.21, SpO2 -88% CPAP is stopped [LE - C]
. If spontaneous breathing is ineffective in a child, forced ventilation should be performed instead of CPAP.
. In this case, the optimal inspiratory pressure (PIP) during the first mandatory breaths is selected individually for a particular newborn until the heart rate is restored and chest excursion occurs.
. An initial inspiratory pressure (PIP) of 20 cmH2O is adequate for most preterm infants.
. Forced ventilation of the lungs should be carried out at a frequency of 40-60 breaths per 1 minute to restore and maintain a heart rate of ˃ 100 beats/min:
- Monitor blood oxygen saturation and adjust oxygen concentration to achieve SpO2 targets within the ranges shown in the Preductal SpO2 Targets After Birth table.
- insert an orogastric tube with continued ventilation of the lungs;
‒ reduce inspiratory pressure if the filling of the lungs with air seems excessive;
- During the entire time of mandatory ventilation, evaluate spontaneous breathing attempts, heart rate and blood oxygen saturation continuously or every 30 seconds.
If there is no rapid increase in heart rate, check for visible chest excursion. If there is no chest excursion, check the tightness of the mask over the child's face and airway patency. If, after these measures, there is still no chest expansion, it is necessary to carefully increase the inspiratory pressure (every few forced breaths) until breath sounds begin to be heard over both lung fields, chest excursions appear with each forced breath. With the advent of chest excursion, heart rate and blood oxygen saturation will begin to increase. [UD - V]
Tracheal intubation in preterm infants
. Tracheal intubation in the delivery room is required for only a small number of preterm infants. It is used in infants who have not responded to face mask positive pressure ventilation, chest compressions, preterm infants less than 26 weeks' gestation for surfactant replacement, and children with congenital diaphragmatic hernia. [UD - V]
. If intubation is required, correct placement of the endotracheal tube (ETT) can be quickly checked using a colorimetric CO2 device (capnograph) before surfactant administration and mechanical ventilation behavior begins. If an ETT is inserted into the trachea, the capnograph indicator will show the presence of CO2 in the exhaled air. However, it should be noted that with a sharp decrease or absence of blood flow in the vessels of the lungs, the test results may be false negative, that is, CO2 is not detected, despite the correct introduction of ETT. [UD - V]
Therefore, along with a CO2 detector, clinical methods for correct ETT placement should be used: tube fogging, presence of chest excursions, listening to breath sounds on both sides of the chest, an increase in heart rate in response to positive pressure ventilation. [UD - S]
Surfactant therapy:
. Surfactant replacement administration directly in the delivery room is recommended for preterm infants up to 26 weeks' gestational age, and also in cases where the mother has not received antenatal steroids to prevent RDS in her newborn, or when intubation is necessary to stabilize the condition of the preterm infant. [UD - A]
In most clinical studies, the INSURE technique (INtubate-SURfactant-Extubate to CPAP) is recommended as the standard technique for administering surfactant. This technique has been shown in randomized trials to reduce the need for mechanical ventilation and the subsequent development of bronchopulmonary dysplasia (BPD) [LE-A]
Early therapeutic administration of a surfactant is recommended when CPAP is ineffective, with an increase in oxygen demand in newborns with a gestational age of less than 26 weeks, when FiO2 is ˃ 0.30, and for preterm infants with a gestational age of more than 26 weeks, when FiO2 is ˃ 0.40. [UD - A]
Evaluation of the effectiveness of block "B":
. The most important sign of effective positive pressure mandatory ventilation and an indication for its termination is an increase in heart rate to 100 beats / min or more, an increase in blood oxygen saturation (SpO2 corresponds to the target indicator in minutes) and the appearance of spontaneous breathing. [UD - A]
. If after 30 seconds of mandatory positive pressure ventilation:
- heart rate less than 100 beats/min in the absence of spontaneous breathing, continue mechanical ventilation until it appears and provide for the need for tracheal intubation;
- heart rate is 60-99 per 1 min, continue mechanical ventilation and provide for the need for tracheal intubation; [UD - A]
− Heart rate ˂60 in 1 min, start chest compressions, continue mechanical ventilation and provide for the need for tracheal intubation. [UD -A]
Block "C" Circulatory support with chest compressions
Indication for initiation of chest compressions(HMS) is a heart rate of less than 60 bpm despite adequate mandatory ventilation using supplemental oxygen for 30 seconds. [UD - A]
. NMS should be performed only against the background of adequate ventilation of the lungs with a supply of 100% oxygen. [UD - A]
An indirect heart massage is performed by pressing on the lower third of the sternum. It is located under the conditional line connecting the nipples. It is important not to press on the xiphoid process to prevent liver rupture. Two indirect massage techniques are used, according to which sternum compressions are performed:
1) pads of two thumbs - while the remaining fingers of both hands support the back (thumb method);
2) with the tips of two fingers of one hand (second and third or third and fourth) - while the second hand supports the back (two-finger method)
The depth of compressions should be one third of the anteroposterior diameter of the chest, and the frequency should be 90 per 1 min. After every three pressures on the sternum, ventilation is carried out, after which the pressures are repeated. For 2 sec. it is necessary to make 3 pressing on the sternum (90 in 1 min) and one ventilation (30 in 1 min). [UD - S]
Well-coordinated chest compressions and forced ventilation of the lungs are carried out for at least 45-60 seconds. A pulse oximeter and heart rate monitor can help determine heart rate without interrupting NMS [LE - M]
Evaluation of the effectiveness of block C:
- When the heart rate reaches more than 60 bpm. NMS should be stopped, but positive pressure forced ventilation should be continued at a frequency of 40-60 forced breaths per minute.
- As soon as the heart rate becomes more than 100 beats / min. and the child begins to breathe spontaneously, gradually reduce the frequency of forced breaths and reduce the ventilation pressure, and then transfer the child to the intensive care unit for post-resuscitation measures.
- If heart rate remains below 60 bpm despite continued chest compressions coordinated with positive pressure ventilation for 45-60 seconds, proceed to block D. [LE-C].
Block "D" Administration of epinephrine and/or circulating blood volume replacement solution
Administration of epinephrine while continuing positive pressure ventilation and chest compressions
. The recommended dose of adrenaline for intravenous (preferably) administration to newborns is 0.01-0.03 mg / kg. The intravenous dose should not be increased as this may lead to hypertension, myocardial dysfunction and neurological impairment.
. For endotracheal administration of the 1st dose of epinephrine, while the venous access is being prepared, it is recommended to always use a higher dose of 0.05 to 0.1 mg/kg. However, the effectiveness and safety of this practice has not been determined. Regardless of the method of administration, the concentration of adrenaline should be 1:10,000 (0.1 mg / ml). [UD - S]
Immediately after endotracheal administration of epinephrine, forced ventilation of the lungs with 100% oxygen should be continued for better distribution and absorption of the drug in the lungs. If epinephrine is injected intravenously through a catheter, then after it, 0.5-1.0 ml of saline must be injected as a bolus to ensure that the entire volume of the drug enters the bloodstream. [UD - V]
60 seconds after the administration of adrenaline (with endotracheal administration - after a longer period of time), the heart rate of the child should be assessed:
- If after the introduction of the 1st dose of adrenaline, the heart rate remains less than 60 beats / min, you can repeat the administration of the drug at the same dose after 3-5 minutes, but only if the minimum allowable dose was administered during the first administration of the drug, then with Subsequent injections should increase the dose to the maximum allowable. Any reintroduction of epinephrine must be administered intravenously. [UD - V]
You also need to make sure that:
- there is good air exchange, as evidenced by adequate chest excursion and listening to breath sounds over both lung fields; if tracheal intubation has not yet been performed, it should be done;
- ETT was not displaced during resuscitation;
- compressions are carried out to a depth of 1/3 of the anteroposterior diameter of the chest; they are well coordinated with mandatory ventilation.
Replenishment of circulating blood volume
. If the baby does not respond to resuscitation and has signs of hypovolemic shock (pallor, weak pulse, muffled heart sounds, positive white spot), or there are indications of placenta previa, vaginal bleeding, or blood loss from the umbilical vessels, consideration should be given to about replenishment of the volume of circulating blood (BCC). [LE - C] ●The drugs of choice that normalize BCC are 0.9% sodium chloride solution or Ringer's lactate solution. Emergency blood transfusion may be necessary to urgently replace significant blood loss.
In premature infants with a gestational age of less than 32 weeks, one should be aware of the structural features of the capillary network of the germinal matrix of the immature brain. Rapid administration of large volumes of fluid can lead to intraventricular hemorrhage. Therefore, the initial volume of fluid required to replenish the BCC is injected into the umbilical vein at a dose of 10 ml/kg in a slow stream over ≥10 minutes. If after the introduction of the first dose, the child's condition does not improve, it may be necessary to administer a second dose of the solution in the same volume (10 ml / kg). [UD - S]
After replenishment of the BCC, it is necessary to evaluate the obtained clinical effect.. The disappearance of pallor, the normalization of the capillary filling time (the “white spot” symptom is less than 2 seconds), the increase in heart rate over 60 beats / min, the normalization of the pulse, may indicate sufficient replenishment of the BCC. In this case, the administration of drugs and NMS should be stopped, while positive pressure ventilation is continued. [UD - S]
. As soon as the heart rate becomes more than 100 beats / min. and the child begins to breathe spontaneously, gradually reduce the frequency of mandatory breaths and reduce the ventilation pressure, and then transfer the child to the intensive care unit for post-resuscitation care. [UD - S]
. If the measures taken are ineffective and there is confidence that effective ventilation, chest compressions, and drug therapy are being adequately performed, mechanical reasons for the failure of resuscitation, such as airway abnormalities, pneumothorax, diaphragmatic hernia, or congenital heart disease, should be considered.
Termination of resuscitation
Resuscitation should be stopped if heartbeats are not detected within 10 minutes.
The decision to continue resuscitation after 10 minutes of no heartbeat should be based on the etiology of cardiac arrest, gestational age, presence or absence of complications, and parental judgment.
The available evidence suggests that neonatal resuscitation after 10 minutes of complete asystole usually ends in the infant's death or survival with severe disability. [UD - S].
Post-resuscitation period:
. Once adequate ventilation has been established and the heart rate restored, the newborn should be transferred in a pre-warmed transport incubator to the intensive care unit, where he will be examined and treated.
A premature baby has very little glycogen stores. In the process of resuscitation, its energy reserves are depleted, as a result of which hypoglycemia may develop. Hypoglycemia is a risk factor for brain damage and adverse outcomes in the presence of hypoxia or ischemia.
The level of glucose at which the risk of an adverse outcome is increased has not been determined, as well as its normal level. Therefore, to prevent the development of hypoglycemia, intravenous glucose should be administered in the first 12 hours of the post-resuscitation period with its level monitored every 3 hours. [UD - S].
. Premature babies may have short pauses between breaths. Prolonged apnea and severe bradycardia in the postresuscitation period may be the first clinical signs of temperature imbalance, blood oxygen saturation, decreased electrolyte and blood glucose levels, acidosis, and infection.
To prevent metabolic disorders, it is necessary to monitor and maintain within the following limits: - glucose level 2.6 - 5.5 mmol/l; − total calcium 1.75 - 2.73 mmol/l; − sodium 134 - 146 mEq/l; −potassium 3.0 - 7.0 mEq/l.
To ensure adequate ventilation and adequate oxygen concentration, SpO2 should be monitored until the child's body can maintain normal oxygenation when breathing air.
If the child continues to require positive pressure ventilation or supplemental oxygen, blood gases should be measured regularly at intervals that optimize the amount of care required.
If the medical organization where the child was born does not specialize in providing care for premature newborns requiring prolonged mechanical ventilation, the transfer of the child to a medical institution of the appropriate profile (3rd level of perinatal care) should be arranged.
In infants with apnea, caffeine should be used to facilitate the cessation of mechanical ventilation (MV). [EL - A] Caffeine should also be considered in all infants at high risk of needing CF, eg, birth weight less than 1250 g, who are on non-invasive mechanical ventilation [EL C].
To facilitate extubation in infants who remain on CF for 1-2 weeks, consider a short course of low- or very-low-dose dexamethasone therapy with tapering [LE A]
Parenteral nutrition should be initiated on the first day to avoid growth retardation and increased rapidly, starting at 3.5 g/kg/day of protein and 3.0 g/kg/day of lipids, as tolerated [LE-C].
Minimal enteral nutrition should also be started on the first day [LE-B].
Low systemic blood flow and treatment of hypotension are important predictors of poor long-term outcome.
Decreased systemic blood flow and hypotension may be associated with hypovolemia, left-to-right shunting of blood through the ductus arteriosus or foramen ovale, or myocardial dysfunction. Establishing the cause will help choose the most appropriate treatment tactics. Early hypovolemia can be minimized by delaying cord ligation. [UD - S].
For hypovolemia confirmed by echocardiogram, and if the cause is not clearly established, consider increasing the blood volume by injecting 10-20 ml/kg of saline, but not colloid.
In the treatment of hypotension in preterm infants, dopamine is more effective than dobutamine in terms of short-term outcomes, but dobutamine may be a more rational choice for myocardial dysfunction and low systemic blood flow. If conventional treatment for hypotension fails, hydrocortisone may also be used.
Drugs used to treat arterial hypotension in premature babies
| A drug | Dose |
Profound changes occur in the cardiovascular and respiratory systems at birth. Violation of these changes can lead to death or damage to the CNS. Accordingly, at all births, a doctor who knows how to resuscitate newborns should be present. Wasting time looking for someone who can resuscitate a newborn can be disastrous for the child. This article discusses the causes and consequences of cardiorespiratory failure at birth and methods of resuscitation. Where possible, the recommendations of the American Academy of Pediatrics were followed.
Guidelines for neonatal resuscitation have been issued by many organizations, including the American Heart Association and the American Academy of Pediatrics. The recommendations are useful for remembering the sequence of resuscitation. Failure to follow the principles leads to bad results. However, thoughtlessly following the recommendations can also lead to poor results. Understanding the physiology of labor and birth is key to success.
Neonatal resuscitation requires training and hands-on experience. Unfortunately, there are few opportunities for most anesthesiologists to acquire and maintain neonatal resuscitation skills as few of their patients require resuscitation. Simulators can solve this problem. In the near future, neonatal resuscitators will need to train on a simulator and repeat this training several times a year to maintain certification.
Detecting potential problems and preparing to address them before birth increases the likelihood of successful resuscitation of patients. Fetal heart rate monitoring is a very reliable and widely used method for the early detection of serious fetal problems. Analysis of blood gases and fetal pH can be used to detect hypoxia and decide on the need for urgent premature removal of the fetus.
Asphyxia (ie, decreased PaO 2 and pHa and increased PaCO 2 ) occurs when gas exchange between the placenta (fetus) and lungs (newborn) is inadequate or when there is right-to-left shunting of blood to the heart or lungs after birth. It also occurs in myocardial dysfunction.
With fetal asphyxia, PaO 2 decreases from the normal 25-40 mm Hg. Art. to less than 5 mm Hg. Art. for about 2 minutes, followed by anaerobic metabolism. After five minutes of asphyxia, the pH drops to 6.90 or less, PaCO 2 increases to more than 100 mm Hg, and PaO 2 decreases to a level at which it is not detectable. Blood flow to the liver, kidneys, intestines, skin, and muscles decreases, while blood flow to the heart, brain, adrenal glands, and placenta remains unchanged or increases. The consumption of oxygen from the blood is greatly increased. Myocardial function is maintained by myocardial glycogen and lactic acid metabolism. Heart rate less than 100 beats / min significantly reduces cardiac output. Catecholamines are also important for survival after asphyxia. Asphyxia during childbirth can lead to hypervolemia or hypovolemia.
Fetal assessment at birth
The Apgar score, properly performed, is a simple, useful guide to the condition and need for resuscitation of the newborn, but it is only a guide. The 1-minute score correlates well with acidosis and survival. The 5-minute score predicts neurological outcome, but not always. To get an overall score, each parameter must be scored at 1 and 5 minutes. However, newborns with severe acidosis may have relatively normal Apgar values at 1 and 5 minutes due to peripheral vasoconstriction, which is manifested by pale skin with normal heart rate and blood pressure.
heart rate
In healthy fetuses and newborns, the heart rate ranges from 120 to 160 beats / min. When the heart rate is less than 100 bpm, cardiac output and tissue perfusion are reduced.
Breath
Respiration usually begins 30 seconds after birth and is maintained for 90 seconds. A few minutes after birth, the respiratory rate of healthy newborns is 30-60 per minute.
The absence of a pause between inhalation and exhalation helps to develop and maintain FRC. Apnea and bradypnea prolong expiration, decrease FRC, and cause hypoxia. Apnea and bradypnea can be caused by severe acidosis, asphyxia, maternal drugs, infections, and CNS damage. Tachypnea (>60 breaths/min) occurs due to:
hypoxemia;
hypovolemia;
metabolic and respiratory acidosis;
hemorrhage of the central nervous system;
air leakage syndrome;
lung disease (eg, hyaline membrane disease, aspiration syndromes, infections);
pulmonary edema;
drugs used by the mother (eg, drugs, alcohol, magnesium, barbiturates).
Resuscitation with 100% oxygen can be detrimental. Resuscitation of newborns with room air is as successful as resuscitation with oxygen. Animals resuscitated with air had less hydrogen peroxide in their brain tissue than those resuscitated with oxygen. Polymorphonuclear cells were less activated by room air. The supply of oxygen in excess of that in room air increases the likelihood of an inflammatory reaction. When possible, room air rather than oxygen should be used for neonatal resuscitation.
Muscle tone
Most newborns, including those born prematurely, are active immediately after birth and move their limbs in response to stimulation. Postponed asphyxia, CNS damage, congenital amyotonia and myasthenia gravis, as well as the appointment of maternal medications can contribute to a decrease in muscle tone in the newborn. Flexion contractures and the absence of skin folds in the joints are signs of intrauterine CNS damage.
reflex activity
A newborn child in a normal state reacts with motor activity in response to stimulation, and when a catheter is inserted into the nasal passage, it cries or shows a grimace of crying on its face. A newborn may not move in the event of hypoxia and acidosis, as well as in the presence of CNS damage, congenital muscle diseases, and when the mother is prescribed sedatives.
Color of the skin
In the first minutes after birth, all newborns have a bluish skin color. After 60 s, the skin turns pink in most children, except for the hands and feet, which are still cyanotic. If central cyanosis persists for more than 90 s, especially with ongoing oxygen therapy and controlled ventilation, then suspect asphyxia, low cardiac output syndrome, pulmonary edema, methemoglobinemia, polycythemia, congenital cardiovascular disease, arrhythmia, and lung disease (eg, respiratory distress syndrome, airway obstruction, pulmonary hypoplasia, diaphragmatic hernia).
Pale skin at birth is often observed in children in the case of asphyxia, hypovolemia, acidosis, or in the presence of a congenital malformation of the cardiovascular system. If a newborn has a pale skin color for more than 2 minutes, alcohol intoxication, hypermagnesemia, or alkalosis (pH> 7.50) should be suspected. Rubeosis of the skin is observed with polycythemia.
Resuscitation equipment
The resuscitation bed should be positioned so that the child's head is below the level of the lungs. This is necessary to ensure the drainage of lung fluid and prevent aspiration of gastric contents. In the absence of asphyxia, it is necessary to maintain the body temperature of the newborn at the level of 36-37°C. To do this, use an infrared heater with servo control. In the case of asphyxia, to ensure the protection of the brain, the child's body temperature must be reduced to 34-35 ° C. The resuscitation area should be equipped with a suction device with adjustable suction pressure; it is unacceptable to use pressure less than - 100 mm Hg. Art.
Tracheal intubation requires straight laryngoscope blades in sizes 00 and 0; pencil type laryngoscope; endotracheal tubes with an internal diameter of 2.5, 3.0 and 3.5 mm; suction catheters of the appropriate diameter.
The ventilator must be able to ventilate the lungs at a rate of up to 150 breaths/min and maintain PEEP. Be aware of the potential for “sticky” breathing circuit valves, especially when ventilating at high frequency and high gas flow. If the specialist has the appropriate training, modified Jackon-Rice or Eyre circuits can be used for ventilation. Overinflation of the lungs during ventilation with a large tidal volume causes lung damage and activation of the systemic inflammatory response, which can lead to the development of chronic lung disease. Careful ventilation of the lungs has less damaging effect. When performing assisted or controlled ventilation in a delivery room environment, peak inspiratory pressure should be constantly monitored and overpressure and high tidal volume ventilation should be avoided.
As in any critical situation, decision-making should be based on the information received. In this regard, it is mandatory to control the gas composition of the blood and the pH level, while the test results should be obtained within 10 minutes from the moment the blood was taken. It is convenient to use an arterial umbilical catheter to monitor blood pressure and take blood for research. In case of emergency, an infusion can be carried out through it.
Arterial blood saturation (SaO 2 ) in the first minutes after birth can be determined by attaching a pulse oximeter sensor to the palm or foot of the newborn. A pulse oximeter allows you to quickly detect changes in oxygenation or FiO. Normally, in newborns, SaO 2 is 87-95%, which corresponds to a PaO 2 of 55-70 mm Hg. Art.
Pulmonary resuscitation
If the heart rate is less than 80 beats/min and SaO 2 is less than 85%, the need for tracheal intubation should be considered and mechanical ventilation should be started at a rate of 30-60 breaths/min. During the first minutes, the duration of each fifth breath should be 2 s. This increase in inspiratory time allows the atelectatic lungs to open and the lung fluid to be removed. PEEP is maintained at 3-5 cm H 2 O. Excessive peak inspiratory pressure should be avoided. In an experiment on preterm lambs, it has been shown that delivering just six overpressure rescue breaths significantly increases lung tissue damage and interferes with surfactant response. Excess tidal volume is also associated with inflammation and chronic lung disease. Airway pressure detection helps prevent overpressure and tidal volume ventilation.
Tracheal intubation
During mask ventilation and tracheal intubation, the child's head should be in the "sniffing" position. After visualization of the glottis, an endotracheal tube is inserted into the trachea to a depth of 1-2 cm below the level of the glottis, depending on the size of the child. This usually corresponds to a depth of 7, 8, 9, 10 cm from the anterior edge of the gums in a newborn weighing 1, 2, 3 and 4 kg, respectively. When ventilating with a peak pressure of 15-25 cm H 2 O, a small air leak should be heard on auscultation at the child's mouth. This is usually observed when using tubes with an internal diameter of 2.5 mm in children weighing less than 1.5 kg, tubes with a diameter of 3.0 mm in children weighing 1.5-2.5 kg and tubes with a diameter of 3, 5 mm in children weighing more than 2.5 kg. Confirmation of successful tracheal intubation is the visualization of the passage of the endotracheal tube behind the vocal cords, the movement of both halves of the chest with each artificial breath, the appearance of perspiration on the inner surface of the tube during each exhalation. Breath sounds should be louder on lung auscultation than on abdominal auscultation. Once positive pressure ventilation is initiated, skin color should improve, as should heart rate and SaO. At the time of exhalation, carbon dioxide should be determined (capnometry).
However, the small tidal volume and low pulmonary blood flow found in some infants at birth can make effective use of capnography difficult.
Adequate ventilation
During inspiration, both halves of the chest should move simultaneously and symmetrically, however, the expansion of the chest during artificial ventilation should not exceed the excursion during normal spontaneous breathing of the newborn. The presence of breath sounds on auscultation is not a reliable sign of ventilation adequacy, due to the possibility of breathing sounds from another lung in infants with a small chest. Asymmetric breath sounds on bilateral lung auscultation may indicate endobronchial intubation, pneumothorax, atelectasis, or congenital lung anomaly. The presence of loud breath sounds on auscultation in the epigastric region suggests esophageal intubation or tracheoesophageal fistula. In the case of adequate ventilation, the child turns pink, spontaneous breathing appears and the heart rate normalizes.
Because most suffocated neonates do not have lung disease, they can be effectively ventilated with a peak pressure of less than 25 mmHg. Art., including at the first breaths. Newborns with "tough" lungs (eg, fetal erythroblastosis, congenital pulmonary anomalies, pulmonary edema, severe meconium aspiration, diaphragmatic hernia) may require high peak inspiratory pressure ventilation, which increases the likelihood of air leak syndrome. It can be prevented by ventilating at a peak pressure of 15-20 cm H 2 O and a rate of 150-200 breaths/min. If low pressure (low volume) high frequency ventilation does not improve oxygenation, high pressure high tidal volume ventilation may be required. Ineffective ventilation at birth can exacerbate hypoxemia and lead to CNS damage and even death. With an increase in PaO 2 more than 70-80 mm Hg. Art. or SaO 2 more than 94%, the concentration of inhaled oxygen (if a breathing mixture with a high oxygen content was previously used) should be brought to a level at which SaO 2 and PaO 2 will be maintained at a normal age level. In children less than 34 weeks of gestation, oxygenation is maintained at the lower limit of normal to prevent the development of neonatal retinopathy. During tracheal intubation in a newborn in a state of hypoxia, there is a risk of arrhythmias, and therefore, the heart rate should be constantly monitored.
Routine tracheal sanitation
In the presence of an admixture of dense meconium in the amniotic fluid, as well as in the case of massive vaginal bleeding, ventilation of the lungs is started only after aspiration of the contents of the trachea. The description of the meconium aspirator is widely presented in the literature.
Meconium particulates must be removed from the lungs prior to ventilation. The mouth and throat must be sanitized immediately after the birth of the baby's head. After tracheal intubation, the endotracheal tube is connected to a special suction device and removed from the trachea at the time of aspiration. The laryngoscope is not removed. After aspiration of meconium, an endotracheal tube is inserted into the trachea, after which a second aspiration is performed. Then careful ventilation of the lungs is carried out. At the time of laryngoscopy and aspiration, it is necessary to constantly monitor the heart rate and insufflate 100% oxygen near the face of the newborn. Meconium should also be aspirated from the stomach to avoid regurgitation and aspiration. Newborns with an Apgar score of 9-10 do not require tracheal suctioning. Removal of liquid meconium from the trachea of a newborn at the time of birth does not have a positive effect, while removal of solid particles of meconium is effective.
Other causes of respiratory failure
Pneumothorax
Pneumothorax occurs in 1% of cases during vaginal delivery, in 10% of cases in the presence of meconium in the amniotic fluid, and in 2-3% of newborns who require mechanical ventilation in the delivery room. In the presence of unilateral pneumothorax, one half of the chest is overinflated and its respiratory excursion is limited. The cardiac impulse is shifted to the healthy side. Heart sounds may be muffled.
In the presence of pneumothorax, a glow of the affected part of the chest is observed when it is illuminated with a narrow beam of highly intense cold light. Elimination of pneumothorax is carried out by puncture or drainage of the pleural cavity.
Prescribing a surfactant
Administration of a surfactant resulted in a significant reduction in the incidence of air leak syndrome, including interstitial emphysema, as well as hyaline membrane disease, bronchopulmonary dysplasia (BPD), and mortality. Surfactant is administered intratracheally at a dose of 5 ml of solution per kilogram of body weight immediately at birth or within a short period of time after it. The introduction of a surfactant is accompanied by a short episode of desaturation. In most cases, SaO 2 rises rapidly in the future due to an increase in pulmonary compliance, which, in turn, can lead to hyperinflation of the lungs with subsequent damage to the lung tissue or the occurrence of an air leak syndrome, if a timely decrease in inspiratory pressure is not made.
Premature babies often require nasal CPAP after birth to reduce the chance of tracheal intubation and mechanical ventilation. However, this does not reduce the incidence of CNS hemorrhage and chronic lung disease. The duration of oxygen dependence and chronic lung disease does not change.
Vascular resuscitation
Vascular resuscitation is not a major aspect of neonatal resuscitation. If the condition of the newborn does not improve with ventilation, oxygenation (if necessary) and tactile stimulation, it is necessary to catheterize the umbilical artery in order to take blood for the study of the gas composition and pH level, and also for the purpose of carrying out infusion therapy if necessary.
Acidosis correction
Correction of respiratory acidosis is carried out with the help of artificial lung ventilation. To correct metabolic acidosis, sodium bicarbonate solution is introduced. Its osmolarity is 1800 mosmol/l, so rapid administration of this solution (>1 mmol/kg/min) in preterm infants may lead to intracranial bleeding. The interaction of hydrogen ions with 50 mmol of bicarbonate leads to the formation of 1250 ml of CO. If pulmonary ventilation is adequate, this does not lead to an increase in PaCO 2 ; with inadequate ventilation, a significant increase in PaCO 2 occurs, which can cause cardiac arrest and / or intracranial hemorrhage. Therefore, sodium bicarbonate solution should only be given to newborns with metabolic acidosis, provided there is adequate pulmonary ventilation. In hypovolaemic neonates, administration of sodium bicarbonate may cause hypotension by reversing the peripheral vasoconstriction caused by acidosis. Trisamine (THAM) is an alternative drug. Its appointment leads to a decrease in the level of PaCO.
If, despite tactile stimulation and ventilation, the Apgar score is 2 or less at 2 minutes or 5 or less at 5 minutes, administration of sodium bicarbonate at a dose of 2 mmol / kg may be required against the background of ongoing ventilation. If the pH is less than 7.0, PaCO 2 is less than 35 mm Hg. Art., and at the same time the blood volume is adequate, one-fourth of the base deficiency should be corrected. If the pH is more than 7.1, sodium bicarbonate is not administered, but pulmonary ventilation is continued. If the pH is more than 7.15, then only ventilation is performed. If, against this background, the pH decreases or remains at the same level, continue ventilation of the lungs and correct one-fourth of the deficiency of buffer bases by administering sodium bicarbonate or trisamine. No significant increase in PaO 2 was observed until the pH increased from 7.1 to 7.2, when Rudolph and Yuen found the most significant decrease in PVR.
Typically, metabolic acidosis develops as a result of reduced tissue perfusion as a consequence of hypovolemia or heart failure. Acidosis-induced heart failure usually occurs when the pH drops below. With an increase in pH over 7.15, cardiac output improves. In heart failure against the background of congenital bradycardia, isoproterenol is prescribed (at an initial dose of 0.05 μg / kg / min, with a further increase if necessary) or a transvenous pacemaker is installed. Hypoglycemia may be the cause of heart failure. Therefore, during resuscitation of a newborn, it is necessary to control the level of glucose in the blood.
Expansion of intravascular volume
If the umbilical cord is clamped early, or if the umbilical cord is tightly wrapped around the fetal neck, when the umbilical cord must be cut for the baby to be born, the baby may become hypovolemic. It is also observed with asphyxia in childbirth, abruption and placenta previa.
Diagnosis of hypovolemia
Hypovolemia is determined by measuring blood pressure and physical examination (i.e., skin color, perfusion, capillary refill time, pulse refill, and extremity temperature). CVP measurements are useful in diagnosing hypovolemia and in determining the adequacy of fluid replacement. Venous pressure in healthy newborns is 2-8 cm H 2 O. If the CVP is less than 2 cm H 2 O, hypovolemia should be suspected.
Therapy for hypovolemia
To treat hypovolemia, it is required to replenish the intravascular volume with blood and crystalloids. Albumin can also be used, but the evidence for its effectiveness is limited. If a newborn is suspected to be hypovolemic at birth, then a bag of Rh-negative type 0 blood should be available in the delivery room before the baby is born.
Sometimes, in order to raise blood pressure to normal, huge amounts of blood and solutions are required. At times, more than 50% of the blood volume needs to be replaced (85 ml/kg in term newborns and 100 ml/kg in preterm infants), especially if placental abruption or trauma occurs during childbirth. In most cases, up to 10-20 ml / kg of solutions are required to restore the mean arterial pressure to normal.
Excessive intravascular volume expansion should be avoided because sudden systemic hypertension can rupture brain vessels, leading to intracranial hemorrhage, especially in preterm infants.
Other causes of hypotension
Hypoglycemia, hypocalcemia, and hypermagnesemia cause hypotension in neonates. Hypotension caused by alcohol or magnesium intoxication usually responds well to volume replacement or dopamine, or both. Neonatal hypermagnesaemia is usually treated with 100–200 mg/kg of calcium gluconate given over 5 minutes.
Heart massage
If, despite stimulation and ventilation, the heart rate at the 1st minute of life or earlier is less than 80 beats / min, it is necessary to intubate the trachea, carry out mechanical ventilation with oxygen and start a closed heart massage. Place both thumbs on the sternum and support the baby's back with the rest of your fingers. Squeeze the sternum 2-2.5 cm at a frequency of 100-120 per minute. There is no need to interrupt ventilation during cardiac massage. The effectiveness of heart massage is assessed by measuring blood gases and pH, created by blood pressure and examining the pupils, which should be in the middle position or constricted. If the pupils are dilated and no atropine has been used, then cerebral blood flow and oxygenation are inadequate.
Preparations for resuscitation
In severe acidosis (pH< 7,0) эффективность этих лекарств уменьшается. Т.е. необходимо как можно быстрее поднять рН выше. Все препараты необходимо вводить в минимальном объеме растворителя, чтобы снизить риск возникновения гиперволемии.
When to stop resuscitation
The decision to stop resuscitation is usually based on the experience of the doctor, the condition of the patient, and the wishes of the parents. If the chances of a productive, successful life are very low, then consideration should be given to stopping all revitalization efforts. Whether to resuscitate very premature babies is a big question, since the outcomes of nursing newborns born before 26 weeks of gestation are very deplorable. If possible, the situation should be discussed frankly with the family before the baby is born. If this is not done, then you need to start resuscitation and stop it after talking with the parents.
Relevance of the topic. According to WHO, approximately 5-10% of all newborns need medical care in the delivery room, and about 1% - in full resuscitation. Providing adequate care to newborns in the first minutes of life can reduce their mortality and/or morbidity by 6-42%. The degree of mastery of the medical personnel present at childbirth, methods of primary resuscitation of newborns has a positive effect not only on their survival, but also on their further development, the level of health in subsequent age periods.
Common goal: improve knowledge on the assessment of the condition of the newborn, determine the indications for resuscitation and their volume. Know your own; temporarily start resuscitation, master the skills of resuscitation of a newborn;
Specific Purpose: on the basis of the perinatal anamnesis, objective examination data, determine the main signs of an emergency, conduct a differential diagnosis, and provide the necessary assistance.
Theoretical questions
1. Preparation for the provision of resuscitation to the newborn in the delivery room or operating room.
2. Assessment of the condition of the newborn child, determination of the need for intervention.
3. Activities after the birth of a child. Providing airway patency, oxygen therapy, artificial ventilation of the lungs with a bag and mask, tracheal intubation, chest compressions, etc.
4. Algorithm for providing emergency care to newborns with clean amniotic fluid.
5. Algorithm for providing emergency care to newborns in case of contamination of amniotic fluid with meconium.
6. Medicines for primary resuscitation of newborns.
7. Indications for termination of resuscitation.
Indicative basis of activity
During preparation for the lesson, it is necessary to familiarize yourself with the main theoretical issues through the treatment algorithm (Fig. 1), literature sources.
Preparing to provide resuscitation care to a newborn in the delivery room
Staffing: 1 person who can provide resuscitation assistance; 2 people with these skills in high-risk deliveries that may require full resuscitation. In the case of multiple pregnancy, the presence of several resuscitation teams is necessary. Before each birth, it is necessary to assess the temperature in the room (not lower than 25 ° C), the absence of drafts, select, mount and check the functioning of resuscitation equipment:
1. Before delivery, turn on the source of radiant heat, heat the surface of the resuscitation table to 36-37 ° C and prepare warmed diapers.
2. Check the oxygen supply system: presence of oxygen, pressure, flow rate, presence of connecting tubes.
3. Roll up a roll under the shoulders from the diaper.
4. Prepare equipment for suctioning the contents of the upper respiratory tract (rubber balloon, adapter for connecting the endotracheal tube directly to the suction tube).
5. Prepare an 8F gastric tube, a 20 ml syringe for aspiration of gastric contents, adhesive tape, scissors.
6. Prepare equipment for artificial lung ventilation (ALV): resuscitation bag (volume no more than 75 ml) and mask. The oxygen flow rate must be at least 5 l/min. Check the operation of the control valve, the integrity of the bag, the presence of oxygen in the tank, it is desirable to have a pressure gauge.
7. Prepare an intubation kit.
Urgent care
Activities after the birth of a child
Immediately determine the need for resuscitation. Estimate:
— the presence of meconium contamination;
- breathing;
- muscle tone;
- color of the skin;
- determine the gestational age (full-term, premature).
Full-term active babies with adequate breathing, loud crying and normal motor activity do not require resuscitation. They are laid out on the mother's stomach, dried and covered with a dry diaper. Sanitation of the upper respiratory tract is carried out by wiping the mucous membranes of the mouth and nose of the child.
Indications for further assessment of the condition of the newborn and determination of the need for intervention:
1. Meconium contamination of the amniotic fluid or skin of the newborn.
2. Absence or decrease in the child's response to stimulation.
3. Persistent central (diffuse) cyanosis.
4. Premature birth.
If any of these signs are present, newborns require standard initial resuscitation steps and need constant monitoring.
If the newborn needs emergency care, while the amniotic fluid is clear and there is no meconium on the baby's skin, you must:
1. Place the baby under a radiant heat source on a warm diaper.
2. Ensure the patency of the airways: position on the back with the head moderately reclined back (roller under the shoulders).
3. Suck out the contents from the mouth, then from the nasal passages. In case of a significant amount of secretion, turn the child's head to one side.
4. Dry the skin and hair with a diaper with quick blotting movements.
5. Remove the wet diaper.
6. Again ensure the correct position of the child.
7. If there is no effective spontaneous breathing, perform one of the tactile stimulation techniques, which is repeated no more than two times (patting the soles, lightly hitting the heels, rubbing the skin along the spine)1.
8. If the skin of the trunk and mucous membranes remain cyanotic in the presence of spontaneous breathing, oxygen therapy should be carried out. Apply a free flow of 100% oxygen directed to the child's nose through the anesthesia bag and mask, or through an oxygen tube and a funnel-shaped palm, or using an oxygen mask.
After the cyanosis has been resolved, oxygen support should be gradually discontinued so that the child remains pink when breathing room air. The persistence of the pink color of the skin when the end of the tube is removed by 5 cm indicates that the child does not need high concentrations of oxygen.
In case of any contamination of amniotic fluid with meconium:
- it is necessary to assess the activity of the newborn, clamp and cut the umbilical cord, inform the mother about the child's breathing problems, without taking away the diaper and avoiding tactile stimulation;
- if the child is active - screams or breathes adequately, has satisfactory muscle tone and a heart rate (HR) of more than 100 beats per minute, it is laid out on the mother's stomach and observed for 15 minutes. A child at risk of meconium aspiration may require subsequent tracheal intubation, even if active after birth;
- in the absence of respiratory disorders, they provide standard medical care in accordance with the clinical protocol for medical observation of a healthy newborn child (Order No. 152 of the Ministry of Health of Ukraine of 04.04.2005);
- if the newborn has respiratory depression, reduced muscle tone, heart rate less than 100 beats per minute, immediately suck meconium from the trachea through the endotracheal tube. Aspiration of meconium is carried out under the control of heart rate. With an increase in bradycardia, stop repeated aspiration of meconium and start mechanical ventilation with a resuscitation bag through the endotracheal tube.
All measures for the primary treatment of a newborn are performed in 30 seconds. After that, the child's condition (respiration, heart rate and skin color) is assessed to decide whether further resuscitation is necessary2.
Breath assessment. Normally, the child has active chest excursions, and the frequency and depth of respiratory movements increases a few seconds after tactile stimulation. Convulsive respiratory movements are ineffective, and their presence in a newborn requires a complex of resuscitation measures, as in the complete absence of breathing.
Assessment of heart rate. The heart rate should exceed 100 beats per minute. Heart rate is calculated at the base of the umbilical cord, directly in the area of its attachment to the anterior abdominal wall. If there is no pulse at the umbilical cord, a heartbeat over the left side of the chest should be heard with a stethoscope. The heart rate is calculated for 6 seconds and the result is multiplied by 10.
Skin color assessment. The lips and torso of the child should be pink. After normalization of heart rate and ventilation, the child should not have diffuse cyanosis. Acrocyanosis usually does not indicate low oxygen levels in the blood. Only diffuse cyanosis requires intervention.
After eliminating heat loss, ensuring airway patency and stimulating spontaneous breathing the next step in resuscitation should be ventilation support.
Artificial ventilation of the lungs with a bag and a mask
Indications for IVL:
- lack of breathing or its inefficiency (convulsive respiratory movements, etc.);
- bradycardia (less than 100 beats per minute), regardless of the presence of spontaneous breathing;
- Persistent central cyanosis with a free flow of 100% oxygen in a child who breathes independently and has a heart rate of more than 100 beats per minute.
The effectiveness of ventilation is determined: by the excursion of the chest; auscultation data; increase in heart rate; improving the color of the skin.
The first 2-3 breaths are performed by creating an inhalation pressure of 30-40 cm of water column, after which ventilation is continued with an inhalation pressure of 15-20 cm of water column and a frequency of 40-60 per minute. In the presence of pulmonary pathology, ventilation is carried out with an inspiratory pressure of 20-40 cm of water column. IVL for newborns is carried out with 100% humidified and warmed oxygen.
After 30 s of ventilation under positive pressure, the heart rate and the presence of spontaneous breathing are again determined. Further actions depend on the result obtained.
1. If the heart rate is more than 100 beats per 1 minute:
- in the presence of spontaneous breathing, mechanical ventilation is gradually stopped, reducing its pressure and frequency, a free flow of oxygen is supplied and skin color is assessed;
- in the absence of spontaneous breathing, continue mechanical ventilation until it appears.
2. If the heart rate is from 60 to 100 beats per 1 minute:
- continue IVL;
- if mechanical ventilation was carried out with room air, anticipate the transition to the use of 100% oxygen, the need for tracheal intubation.
3. Heart rate less than 60 beats per minute; chickpeas:
- begin an indirect heart massage with a frequency of 90 compressions per minute, continue mechanical ventilation with 100% oxygen at a frequency of 30 breaths per 1 minute and determine the need for tracheal intubation.
The heart rate is monitored every 30 seconds until it exceeds 100 beats per minute and spontaneous breathing is established.
Mechanical ventilation for several minutes requires the introduction of an orogastric tube (8F) in order to prevent gastric inflation with air and subsequent regurgitation of gastric contents.
Indirect cardiac massage indicated if heart rate is less than 60 beats per minute after 30 with effective ventilation with 100% oxygen.
An indirect heart massage is performed by pressing on the lower third of the sternum. It is below the conditional line that connects the nipples. It is important not to press on the xiphoid process to avoid rupture of the liver.
Two indirect massage techniques are used, according to which pressure is applied to the sternum:
the first - with two thumbs, while the remaining fingers of both hands support the back;
the second - with the tips of two fingers of one hand: II and III or III and IV; while the second hand supports the back.
The depth of pressure should be one third of the anteroposterior diameter of the chest.
The frequency of pressure is 90 per 1 minute.
It is important to coordinate chest compressions with mechanical ventilation, avoiding both procedures at the same time, and do not remove your fingers from the surface of the chest in the pause between pressures. After every three pressures on the sternum, a pause is made for ventilation, after which the pressures are repeated, etc. For 2 seconds, you need to do 3 pressures on the sternum (90 in 1 minute) and one ventilation (30 in 1 minute). Stop chest compressions if the heart rate is more than 60 beats per minute.
Tracheal intubation can be carried out at all stages of re-animation, in particular:
- if necessary, suck meconium from the trachea;
— if prolonged ventilation is required to increase its efficiency;
- to facilitate the coordination of chest compressions and ventilation;
- for the introduction of adrenaline;
- if a diaphragmatic hernia is suspected;
- with deep prematurity.
The use of medicines. The introduction of drugs is indicated if, despite adequate ventilation of the lungs with 100% oxygen and chest compressions for 30 seconds, the heart rate remains less than 60 beats per minute.
In the primary resuscitation of newborns, medicines are used: adrenaline; means that normalize the BCC; sodium bicarbonate, antagonists of narcotic drugs.
Adrenalin. Indications for use:
- Heart rate less than 60 beats per minute after at least 30 seconds of mechanical ventilation with 100% oxygen and chest compressions;
- the absence of heart contractions (asystole) at any time during resuscitation.
Adrenaline is administered as quickly as possible in / in or endotracheally at a dose of 0.1-0.3 ml / kg of a solution at a concentration of 1: 10,000. The concentration of the solution is 1: 10,000 (to 0.1 ml of a 0.1% solution of adrenaline hydrochloride or 0.9 ml of isotonic sodium chloride solution is added to 0.1 ml of a 0.18% solution of adrenaline hydrotartrate).
Endotracheally, epinephrine is administered from a syringe directly into the tube or through a probe inserted into the tube. In this case, a solution of adrenaline at a concentration of 1: 10,000 can be further diluted with isotonic saline to a final volume of 1 ml, or the endotracheal tube (probe) can be washed with isotonic sodium chloride solution (0.5-1.0 ml) after administration of an undiluted dose. In the case of endotracheal administration, it is always recommended to use a dose of 0.3-1.0 ml/kg. After the introduction of epinephrine into the trachea, it is important to immediately conduct several effective positive pressure ventilations.
In the absence of effect, the introduction of adrenaline is repeated every 3-5 minutes, repeated injections only in / in.
Large doses of intravenous epinephrine for resuscitation of newborns are not recommended, since their administration can cause damage to the brain and heart of the child.
Means that normalize the BCC: 0.9% sodium chloride solution; Ringer's lactate solution; in order to correct significant blood loss (with clinical signs of hemorrhagic shock) - transfusion of O (I) Rh (-) erythrocyte mass. Indications for use:
- lack of response of the child to resuscitation;
- signs of blood loss (pallor, pulse of weak filling, persistent tachycardia or bradycardia, no signs of improved blood circulation, despite all resuscitation measures).
With the development of hypovolemia, children whose condition does not improve during resuscitation are given intravenously slowly, over 5-10 minutes, up to 10 ml / kg of one of these solutions (isotonic sodium chloride solution is recommended). 3
sodium bicarbonate indicated for the development of severe metabolic acidosis during prolonged and ineffective resuscitation against the background of adequate mechanical ventilation. Enter into the vein of the umbilical cord slowly, no faster than 2 ml / kg / min 4.2% solution at a dose of 4 ml / kg or 2 meq / kg. The drug should not be administered until ventilation of the lungs of the newborn is established.
Narcotic drug antagonists (naloxone hydrochloride)
Indication for use: Persistent severe respiratory depression during positive pressure ventilation, with normal heart rate and skin color in a child whose mother was injected with narcotic drugs during the last 4 hours before delivery. Naloxone hydrochloride is administered at a concentration of 1.0 mg / ml solution, at a dose of 0.1 mg / kg IV. With intramuscular administration, the action of naloxone is slow, with endotracheal it is ineffective.
Naloxone should not be given to a child of a mother with suspected drug dependence or of a mother who is on long-term drug treatment. This can cause severe seizures. Other drugs administered to the mother (magnesium sulfate, non-narcotic analgesics, anesthetics) can also depress the child's breathing, but their effect will not be blocked by the administration of naloxone.
If the child's condition does not improve, despite effective mechanical ventilation and indirect heart massage, the introduction of drugs, exclude abnormalities in the development of the respiratory tract, pneumothorax, diaphragmatic hernia, congenital heart defects.
Resuscitation of the newborn is stopped if, despite the correct and complete implementation of all resuscitation measures, there is no cardiac activity for 10 minutes.
1 It is forbidden to pour cold or hot water on a child, direct a stream of oxygen to the face, squeeze the chest, hit the buttocks, and carry out any other activities that have not been proven safe for a newborn.
2 Apgar score characterizes the general condition of the newborn and the effectiveness of resuscitation and is not used to determine the need for resuscitation, its volume or the timing of resuscitation. Apgar scores should be taken at 1 and 5 minutes after birth. If the result of the assessment at the 5th minute is less than 7 points, it should be additionally carried out every 5 minutes until the 20th minute of life.
Literature
1. Decree of the Ministry of Health of Ukraine No. 437 dated 31.08.04 "On the approval of clinical protocols for the provision of medical assistance in emergency situations in children at the hospital and pre-hospital stages."
2. Ordinance of the Ministry of Health of Ukraine No. 152 dated 04.04.2005 “On the approval of the clinical protocol for medical supervision of a healthy newborn child”.
3. Ordinance of the Ministry of Health of Ukraine No. 312 dated 08.06.2007 “On the approval of the clinical protocol for primary resuscitation and post-reanimation care for new people”.
4. Inconsistencies in Pediatrics: Navch. posib. / Volosovets O.P., Marushko Yu.V., Tyazhka O.V. ta іnshi / For red. O.P. Volosovtsya and Yu.V. Marushko. - Kh. : Prapor, 2008. - 200 p.
5. Emergency conditions in children / Petrushina A.D., Malchenko L.A., Kretinina L.N. and others / Ed. HELL. Petrushina. - M .: LLC "Medical Information Agency", 2007. - 216 p.
6. Peshy M.M., Kryuchko T.O., Smyan O.I. Nevidkladna dopomoga in pediatric practice. - Poltava; Sumi, 2004. - 234 p.
7. Emergency medical care for children at the prehospital stage / G.I. Posternak, M.Yu. Tkacheva, L.M. Beletskaya, I.F. Volny / Ed. G.I. Belebeziev. - Lviv: Medicine of the world, 2004. - 186 p.
Additional
1. Aryaev M.L. Neonatology. - K .: ADEF - Ukraine, 2006. - 754 p.
2. Helper of neonatology: Per. from English / Ed. John Cleorty, Anne Stark. - K .: Fund for helping the children of Chornobil, 2002. - 722 p.
3. Shabalov N.P. Neonatology: Textbook for students and residents of pediatric faculties of medical institutes. — Second edition, revised and enlarged. - St. Petersburg: Special Literature, 1997. - T. 1. - 496 p.
4. Resuscitation of the new people: Podruchnik / For red. J. Kavintela: Translated from English. - Lviv: Spolom, 2004. - 268 p.
