Updates in Newborn Care Elizabeth E. Rogers, MD Pediatric Hospital - - PDF document

6/18/2014 1

Updates in Newborn Care

Elizabeth E. Rogers, MD Pediatric Hospital Medicine Boot Camp 20 June 2014

Objectives

• Review initial steps in the resuscitation of a

compromised neonate

• Understand updates in the approach to

complicated delivery scenarios

– Neonatal encephalopathy – Preterm birth

2AM

• Just returned to the pediatric ward from a

STAT ED consult for eczema

• Debating going to sleep vs. getting a fresh

brewed latte from the nurses’ new Nespresso machine

• STAT page from the ED
• Eczema? Mosquito bite?

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2AM

• 19 yo G1P0 mom

– no prenatal care – abdominal pain – vaginal bleeding – no history of trauma

• Bedside U/S suggests 38 wks
• Agonal fetal bradycardia
• Stat C/S under general anesthesia

10% of newborns need some form of resuscitation at birth and 1% need extensive maneuvers to successfully transition to extra uterine life.

Kattwinkel J editor. Textbook of Neonatal Resuscitation. 6th ed. Elk Grove Village, Illinois: American Academy of Pediatrics; 2011.

Goals for Resuscitation:

• Establishment of effective respiratory

effort

• Cardiorespiratory stabilization
• Minimize heat loss and maintain

normothermia

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“Thick Meconium"

What do you do next?

• A. Intubate and suction for meconium
• B. Intubate and start PPV
• C. Place on mother’s chest to initiate breastfeeding

in the “sacred hour”

• D. Call the neonatology fellow and wait for them to

decide

“Thick Meconium"

What do you do next?

• A. Intubate and suction for meconium
• B. Intubate and start PPV
• C. Place on mother’s chest to initiate breastfeeding

in the “sacred hour”

• D. Call the neonatology fellow and wait for them to

decide

History of management of meconium stained fluid

• Gregory, Phibbs, Gooding, and Tooley from

UCSF in 1974 reported meconium staining of amniotic fluid in 9% of infants

– Meconium was present in 56% of tracheas

• From all those who became “sick,” meconium

was aspirated from the airway

• Hypothesized that clearing the airway of

meconium would reduce pulmonary disease

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• After 2000, AAP, AHA, ACOG no longer

recommended universal tracheal suctioning in MSAF (Wiswell et al., 2000)

• After 2006, no further recommendation for

suctioning on the perineum (Vain et al, 2004)

• Why are we still suctioning the tracheas of

nonvigorous newborns born through MSAF?

From the AAP

• “The only evidence that direct tracheal

suctioning of meconium may be of value was based on comparison of suctioned babies with historic controls… there was apparent selection bias in the group of intubated babies included in those studies.

• “In the absence of RCTs, there is insufficient

evidence to recommend a change in current practice.”

“Some meconium below the cords”

What would you do next?

• A. Intubate and suction again
• B. Let the heart rate determine the next move
• C. Leave the ETT in and start PPV through it
• D. Page the neonatology fellow again

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“Some meconium below the cords”

What would you do next?

• A. Intubate and suction again
• B. Let the heart rate determine your next move
• C. Leave the ETT in and start PPV through it
• D. Page the neonatology fellow again

The most important thing you can do for a neonate in distress is to establish respirations

In the absence of meconium: Assess

• Immediately dry the newborn, remove wet

linen

• Assess general appearance

– Respiratory effort: Is baby breathing or crying? – Check the newborn heart rate by palpating at the base of the umbilical cord and abdomen or by auscultation. – Does the baby have appropriate tone?

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What About Color?

HR > 100 bpm and infant is breathing

“Doctor, I can’t hear a heart rate!”

• You should
• A. Start cardiac compressions
• B. Quickly dry, position, stimulate, and reassess
• C. Initiate PPV
• D. Seriously, I hope that neonatal fellow is putting a

baby on ECMO

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“Doctor, I can’t hear a heart rate!”

• You should
• A. Start cardiac compressions
• B. Quickly dry, position, stimulate, and reassess
• C. Initiate PPV
• D. Seriously, I hope that neonatal fellow is putting a

baby on ECMO

HR < 100, no respiratory effort

• Briefly attempt to stimulate by rubbing

the back or flicking the soles of the feet

• If the baby does not respond, is apneic
• r gasping, prepare to administer

positive pressure ventilation (PPV) via flow inflating bag or self inflating bag

Flow Inflating Bag vs Self Inflating Bag

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If the Heart Rate is <100 and the Baby is Not Making Respiratory Effort…

• Clear airway with bulb syringe or suction

catheter

• Suction mouth first, then nose
• Deep suctioning is contraindicated, may induce a vagal

response

• Designate someone to call for help but do

not delay initiation of PPV

• Place infant supine with head closest to you
• Open airway with head in “sniffing”

position

“M Comes Before N”

Mouth Then Nose

“Sniffing” Position

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Administering PPV

• Administer 40‐60 breaths per minute

while watching for gentle chest rise

• Bilateral breath sounds should be heard

throughout the lung fields on auscultation

• Recheck heart rate after 30 seconds of

EFFECTIVE ventilation

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If Chest is Not Rising 48 40

Sp02% HR bpm

Pulse Oximeter

Targeted Preductal SpO2 1 min 60‐65% 2 min 65‐70% 3 min 70‐75% 4 min 75‐80% 5 min 80‐85% 10 min 85‐95%

Use of Pulse Oximetry in DR

Oxygen: To Use or Not To Use

• 21% is as efficient as 100% O2 in achieving

ROSC during CPR in asphyxiated newborn pigs (Solevag, 2010)

• 100% O2 may have advantage for improved

recovery of cerebral perfusion (Solas, 2004)

• Moderate/Severe HIE is directly associated

with degree of hyperoxemia on NICU admission (Kapadia, 2013)

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Chest Compressions

• If heart rate is <60 bpm after 30 seconds
• f effective PPV, initiate chest

compressions

• This requires one person to administer

compressions and one to ventilate

• If you need to do compressions, increase

FiO2 to 100%

Chest Compressions

• Use ratio of 3:1 compressions to breaths
• “One and two and three and breathe”
• The two thumb technique is preferred
• Place thumbs on the lower third of the

sternum above the xiphoid process

• Depress one third the A/P diameter of

the chest

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Intubated, confirmed ETT, initiated chest compressions, still no HR

• The next most effective thing to do would be:
• A. Administer volume
• B. Administer endotracheal epinephrine
• C. Administer intravenous epinephrine
• D. Administer naloxone

Intubated, confirmed ETT, initiated chest compressions, still no HR

• The next most effective thing to do would be:
• A. Administer volume
• B. Administer endotracheal epinephrine
• C. Administer intravenous epinephrine
• D. Administer naloxone

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• After IV epi, HR > 60 and rising
• Chest compressions stopped
• PPV continued
• Obstetrician reports 50% abruption
• Neonatal Fellow finally shows up

– Asks for cord gases to be run – Notifies nearest cooling center

• Transfer infant to ICN, get blood gas and neuro

exam

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Therapeutic Hypothermia for Neonatal Encephalopathy

• 5 large RCTs of hypothermia with 18‐24 month

follow‐up

– Cool Cap Trial – Lancet 2005 – NICHD Trial – NEJM 2005 – TOBY Trial – NEJM 2009 – Neo.nEuro.network Trial – Pediatrics 2010 – ICE Trial – Arch Pediatric Adolescent Medicine 2011

Meta‐Analysis (n=979)

• Moderate whole body hypothermia or

selective head cooling are effective

• Decreased risk of death or moderate‐severe

disability

– RR 0.74, 95% CI 0.65, 0.83 – Number needed to treat = 7

• Improved secondary outcomes

– Mortality: RR 0.78 (0.65, 0.92) – Disability in Survivors: RR 0.67 (0.54, 0.84)

Which neonates should be treated?

• Inclusion criteria

should be similar to the RCTs

– Neonates ≥ 36 weeks GA – Evidence of perinatal asphyxia

• Apgar at 10 min < 5
• r prolonged

resuscitation

• pH < 7.0; Base

Deficit ≥ 16

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Moderate‐severe encephalopathy

• Abnormal level of consciousness (lethargy –

comatose)

• Spontaneous Activity – decreased to absent
• Tone – hypotonic or flaccid
• Primitive reflexes – weak or absent suck, gag,

moro

Hypothermia Treatment

• Initiate within 6 hours after birth
• Core temperature of 33.5°C, maintained for 72 hours

– Passive cooling initiated at referral center

• Brain Monitoring – with aEEG/cEEG

– Seizures are common (34 – 65%) – Many have subclinical seizures (45%) – Status epilepticus is common (10‐25%)

• Morphine to minimize shivering
• MRI at completion of treatment
• Discharged at 7‐15 days

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True Story: Baby B

• Woman presents to ED with abdominal pain,

vomiting, r/o AGE or bowel obstruction

• Urine collected for pregnancy test
• While awaiting results, goes to restroom
• Delivers infant in the toilet of the ED
• Call to on‐call pediatric hospitalist: “Dead

baby delivered in the ED‐ come STAT” Considerations for resuscitation of preterm infants:

Delayed cord clamping Thermoregulation Establishing adequate respirations

Delayed Cord Clamping

• 20 small RCTs, including 10 focused on

preterm, support delayed cord clamping for uncomplicated term and preterm birth

• 30‐180 seconds
• Improves BP
• Decreases IVH, anemia, and need for blood

transfusions

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Thermoregulation

• Cold Stress

– Increases apnea – Decreases surfactant function – Increases metabolic acidosis, lowers pH, may reduce pulmonary artery relaxation – Associated with increased mortality

Preterm Neonates are at High Risk for Hypothermia

• Immature epidermal barrier, high evaporative

heat loss

• Limited subcutaneous fat
• Increased surfact area/weight ratio
• Ineffective non‐shivering thermogenesis
• < 28 weeks: for every 1 °C decrease in

admission temp, odds of death  28% (Laptook, 2007)

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Avoid Hypothermia AND Hyperthermia

• Improve environmental temperature of the

delivery room

• Polythylene occlusive wrapping
• Thermal (sodium acetate) gel mattress
• Plastic poncho, plastic hat

Establish Respirations

• Prevent lung collapse: CPAP
• Oxygen use:

– Attach oximeter preductally – Blend O2 and air as needed – Must have oximeter, blender, and compressed air available

• Intubate as necessary for inadequate effort,

consider surfactant administration

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Baby B

• Estimated to be 28 weeks gestation to

coincide with mom’s, G1P0‐1 college student, spring break

• Intubated, received surfactant, extubated on

DOL 2 to CPAP

• Advanced on enteral feedings
• No IVH
• Discharged home off oxygen with normal

neuro exam at 39 weeks corrected gestational age

Thank you!

• Cynthia Jensen, RN, MS, CNS, UCSF ICN

Outreach Director

• Sonia Bonifacio, MD, UCSF NICN Director
• American Academy of Pediatrics, Neonatal

Resuscitation Program