Special considerations Resuscitation of premature babies Ethics by vivi07

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									Special considerations Resuscitation of premature babies Ethics and Care at End of Life

Special considerations
Situations that may complicate resuscitation and cause ongoing problem  Post-resuscitation management  Resuscitation outside hospital or beyond time of birth
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Difficult situations
Not able to ventilate adequately  Cyanosis despite adequate ventilation  Bradycardia despite adequate ventilation  No spontaneous breathing despite adequate ventilation
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Not able to ventilate
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Mechanical blockage of airways
 Meconium

or mucus in pharynx or trachea Tracheal suction  Choanal atresia Pass small-caliber suction catheter, oral airway  Pharyngeal malformation (Robin syndrome) Prone, nasopharyngeal airway  Other rare conditions (laryngeal web) Emergency tracheostomy

Not able to ventilate
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Impaired lung functions
 Pneumothorax

Diminished air entry, transillumination, X-ray, drain  Congenital pleural effusion Hydrops, Drain  Congenital diaphragmatic hernia Intubate, orogastric tube  Pulmonary hypoplasia  Extreme prematurity High inflation pressure  Congenital pneumonia

Cyanosis/Bradycardia despite adequate ventilation
Cyanotic heart disease  Congenital heart block
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Ensure adequate ventilation

No spontaneous breathing despite adequate ventilation
Brain injury (HIE, severe acidosis, congenital neuromuscular disorder)  Sedation due to drugs given to mother (narcotic drugs, magnesium sulfate, general anesthesia, non-narcotic analgesics)
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Naloxone
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Indications
 Continued

respiratory depression after PPV has restored a normal heart rate and color AND  History of maternal narcotic administration within past 4 hours

Naloxone
Recommended concentration = 1.0 mg/ml  Route: IV preferred; IM acceptable but delayed onset of action; ET not recommended  Dose: 0.1 mg/kg  May require repeated administration
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Post-resuscitation care
Temperature control  Close monitoring of vital signs  Laboratory studies
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Post-resuscitation care
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Look for complications
 Pulmonary

hypertension  Pneumonia/other lung complications  Metabolic acidosis  Hypotension  Seizures  Apnea  Hypoglycemia  Feeding problem

Resuscitation outside hospital or beyond time of birth
Same principles (Restore adequate ventilation)  Alternative heat source (Skin-to-skin contact)  Clear airway (Bulb syringe, wipe with a cloth)  Ventilation (Mouth-to-mouth-and-nose)  Vascular access (Peripheral vein cannulation/intraosseus needle)
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Resuscitation and Prematurity
Thin skin, large surface area and ↓ fat  Oxygen toxicity  Weak muscles - difficulty in breathing  Immature nervous system –less respiratory drive  Immature lung  Fragile brain capillaries  Small blood volume
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Additional Resources Needed
 

Additional trained personnel Additional means of maintaining temperature
 Re

closable, food grade polyethylene bag  Portable warming pad  Transport incubator
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Additional means to control oxygenation
(in a hospital in which babies at <32 weeks gestation are born electively)
 Compressed

air source  Oxygen blender  Pulse oximeter

Keeping a premature baby warm
Increase temperature of the delivery room  Pre-heat the radiant warmer  Pre- warmed transport incubator
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Keeping a premature baby warm
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If baby is born at less than 28 weeks gestation, consider placing him below the neck in a re closable polyethylene bag without first drying the skin Avoid overheating

Oxygen in a premature baby
Connect a blender to compressed oxygen and air sources and to PPV device  Start somewhere between room air and 100% oxygen  Attach a pulse oximeter to baby’s foot or hand  Heart rate displayed by pulse oximeter should agree with heart rate that you palpate or hear
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Oxygen in a premature baby
Adjust oxygen concentration to achieve an oxygen saturation that gradually increases to 90%  Accept 70% to 80% if-heart rate is increasing and oxygen saturation is increasing  If saturation is less than 85% and not increasing, increase oxygen concentration  Decrease oxygen concentration of saturation rises above 95%
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Oxygen in a premature baby

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Resuscitation efforts not to be delayed while waiting for pulse oximeter to display a strong signal

Ventilation in a premature baby
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Consider giving CPAP if the baby Is breathing spontaneously and has a heart rate above 100 bpm but has
 Labored

breathing or  Is cyanotic or  Has low oxygen saturation
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By using flow-inflating bag or T-piece resuscitator

CPAP

Ventilation in a premature baby
Use lowest inflation pressure necessary to achieve adequate response  Initial inflation pressure of 20-25 cm H2O  May need higher pressure if no improvement in heart rate and no chest rise
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Ventilation in a premature baby
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Prophylactic surfactant as per your practice

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Baby should be fully resuscitated before surfactant is given

How to decrease chances of brain injury in a premature baby?
Gentle handling  No head-down position  Avoid excessive positive pressure or CPAP  Adjust ventilation and oxygen concentration gradually and appropriately (use pulse oximeter and blood gas)  Do not give rapid infusion of fluids  Avoid infusion of hypertonic solutions
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Post-resuscitation management of a premature baby
Monitor blood sugar  Monitor for apnea and bradycardia  Give and adjust ventilation and oxygen concentration gradually and appropriately  Give feeding slowly and cautiously  Increase suspicion of infection
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Ethics and neonatal resuscitation
Primary role in determining goals of care with parents  Informed consent based on complete and reliable information (may not be available before or immediately after delivery)
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Not to initiate resuscitation
Confirmed gestational age of less than 23 weeks or birth weight less than 400 gm  Anencephaly  Confirmed trisomy 13 or 18  If parents wish: confirmed gestational age of 24-25 weeks
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Based on your survival rates and local policy

Counseling parents before a high risk birth
Obstetrician and neonatologist perspectives may be different  Short and long term outcome of babies of different gestation in your hospital  Discuss resuscitation and level of care to be given to baby  Documentation
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When to stop resuscitation?
No heart rate after 10 minutes of complete and adequate resuscitation  No evidence of other causes of compromise
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