Paediatric & Neonatal Week 3 Lecture Notes PDF

,Paediatric & Neonatal Week #3 - Neonatal Assessment & Resuscitation NRP = certification to be able to work in the NICU in hospital The single most important concept is ventilation of the baby’s lungs is the most important and effective action in neonatal resuscitation. Babies need to breathe in o...

,Paediatric & Neonatal Week #3 - Neonatal Assessment & Resuscitation NRP = certification to be able to work in the NICU in hospital The single most important concept is ventilation of the baby’s lungs is the most important and effective action in neonatal resuscitation. Babies need to breathe in order to move from fetal circulation to adult circulation changing from an increased PVR to a decreased PVR and a decreased SVR to an increased SVR. If the pressures do not flip the baby will stay in fetal circulation meaning their body is still trying to get blood flow and oxygen from the clamped umbilical cord. If we cannot feel a HR we use PPV for 30 seconds and it must be classified as ineffective before we do CPR. NRP Reference Regarding Transition 3 major changes occur immediately after birth: 1.​ The fluid in the alveoli is absorbed into the pulmonary lymphatics and replaced with air as long as the infant takes an effective first breath. -​ This allows oxygen to diffuse into the surrounding blood vessels. 2.​ The umbilical arteries constrict & the cord is clamped which removes the low pressure placental circuit resulting in an increase in the system blood pressure 3.​ The blood vessels in the lungs relax, decreasing resistance to blood flow because of the increased oxygen in the alveoli & less prostaglandin release. Decreased resistance to blood flow through the pulmonary vasculature together with the increased systemic blood pressure leads to a dramatic increase to pulmonary blood flow and a decrease in flow through the ductus arteriosus Room air is usually sufficient to initiate relaxation of the pulmonary blood vessels, and as blood levels of oxygen increase and pulmonary blood vessels relax, the ductus arteriosus begins to constrict, starting that functional closure??????????? The initial cries need to be strong enough to displace the fluid out of the alveoli and into the pulmonary lymphatics which is the reason we stimulate. Normal transition from fetal to adult circulation can take a minute, but may take days to be complete i.e. functional closure of the ductus arteriosus may not occur for 12-24 hours after birth & complete relaxation of pulmonary vasculature may not occur for months. What can go wrong during transition? If difficulty begins in utero or during labour (which would be evident by the fetal HR decreasing) the problem could be with uterine or placental blood flow. If this is the case we would give mom O2 or turn mom on her side. Repositioning the mother can help improve the baby's condition by enhancing blood and oxygen flow. Difficulties after birth are more likely to be due to the baby’s airway and/or lungs. Difficulties could be seen with any of the following circumstances: -​ inadequate ventilation The lungs may not fill with air on that baby’s initial first breath and this means the breath was not strong enough. If this is the case we do not get a switch from fetal to adult circulation and the SVR will not increase and PVR will not decrease. Due to this shunts will stay open causing the baby to stay in persistent pulmonary hypertension. -​ expected increase in BP may not occur This could be the case due to blood loss, neonatal hypoxia and ischemia. These can cause poor cardiac contractility or bradycardia leading to a low blood pressure. -​ pulmonary arterioles may remain constricted after birth This constriction of the pulmonary arteries prevents normal blood flow to the lungs and causes low gaseous distension. As a result blood bypasses the lungs through fetal shunts. This is also known as persistent pulmonary hypertension of the newborn (PPHN) and the newborn's oxygenation is compromised during or prior to a delivery. When normal transition does not occur, the oxygen supply to tissues is decreased and the blood vessels to the tissues may constrict so that O2 can continue to flow to the heart & the brain. A compromised baby may show any of the following signs: -​ decreased respiratory drive due to lack of oxygen to the brain With this we will see a diminished drive to breathe, 0 effort then they will go apneic. -​ poor muscle tone We will see them look like a rag doll where as in healthy babies they usually scrunch into a fetal position once they are born and are crying loudly. This indicates hypoxia. -​ bradycardia If the baby is not receiving enough oxygen, the body may slow the heart rate as a protective mechanism. This can occur during prolonged or severe hypoxia. -​ tachypnea When oxygen levels are low, the body attempts to increase oxygen intake by speeding up breathing. This is the body’s way of trying to meet oxygen demands and expel carbon dioxide. Conditions like meconium aspiration, pneumonia, or surfactant deficiency can impair gas exchange, leading to baby rapid breathing to compensate. -​ persistent cyanosis This is a visible sign that the tissues are not receiving enough oxygen. In conditions like Persistent Pulmonary Hypertension of the Newborn (PPHN), blood bypasses the lungs (through fetal shunts), preventing oxygenation and leading to cyanosis. There are two common types of cyanosis (central & peripheral). Peripheral cyanosis with neonates is referred to as acrocyanosis and is seen on the hands and feet. This is normal when they are born & can last up to 24 hrs. Central Cyanosis we worry about. -​ low BP In a compromised state, such as during sepsis or significant blood loss, the baby’s body may struggle to maintain adequate BP to ensure sufficient organ perfusion. If the heart is not pumping effectively due to hypoxia, acidosis, or congenital defects, blood pressure can drop. Apnea is a sign of perinatal compromise. There are two types: primary & secondary. Apnea is still considered 20 seconds for babies. Primary Apnea means they are born, brought to us on the warmer side and they are NOT breathing. The newborn’s HR will decrease during primary apnea and immediately respond to PPV. Secondary Apnea means baby came out crying then they stopped & went apneic. This could be from a mucous plug, or respiratory efforts were not enough due to lower O2 levels. There is some form of respiratory effort initially but then that effort is lost. This can also occur from suctioning due to the vasovagal stimulation leading to bradycardia. The longer the baby has been in secondary apnea the longer it will take for spontaneous breathing to resume. We need to be initiating PPV quickly!!!!!!! NRP (Neonatal Resuscitation Program) In the normal labour and delivery rooms there will be an intubation kit available, O2, medical air and a blender. In the resuscitation room there’s med carts, ventilators & warmers. 10% of all babies born will require some kind of assistance with breathing. Fewer than 1% require extensive resuscitation measures. Prep for delivery must include the following 3 things ALWAYS: -​ assembling of appropriate equipment We need oral suction (roughly a size 6-8 fr). We need an intubation kit, we normally use a miller blade because it holds the epiglottis up and out of the way. Our blade sizes are 00,0,1 etc. ETT sizes are going to range from 2.5-3.5 uncuffed (2 of each). We want uncuffed tubes because the trachea narrows below the glottis in neonates so when the tube goes in it seals itself due to the subglottic narrowing. We will be able to hear if we have a leak with our tube during passive exhalation. THIS IS WHEN WE NEED TO DECIDE IF TUBE SIZE IS ADEQUATE OR NOT. We need tapes, stylets (not always used), CO2 detectors (smaller to create less dead- space). We need stethoscope (sized for neonates), cardiac monitors, & saturation monitors. -​ assembling of appropriate staff We need to establish roles with the team for preparation. This includes role assignments such as who is going to drop up meds, provide PPV (US!), establish IV access, perform CPR, chart, assist with intubation etc. These roles are assigned after equipment is set up around the area. -​ providing warmth for the baby Warmth can be provided in a number of ways depending on the need for it: -​ drying the baby with warm dry linen immediately after birth -​ bringing the baby to a radiant heat warmer for assessment if necessary -​ pre-warming the delivery room A lot of the delivery rooms have their own thermostat. Generally we aim for 72-74°. -​ offering skin to skin contact with the mother and covering both with a blanket -​ placing the baby on a thermal warming mattress If baby is