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ADVANCED RESUSCITATION, STABILISATION AND TRANSFER OF NEONATES BY: NICOLE STEVENS INTRODUCTION Revision of neonatal resuscitation Advanced resuscitation components Stabilisation of neonates for transfer Overview of conditions requiring transfer Nursing management and responsibilities Resuscitation: Check equipment Always check equipment, ensure it is in working order Become familiar with all equipment and ensure you know how it works Be prepared for a flat infant First evaluation Determines if intervention is required, is based upon the newly born infants: Response to stimulation Breathing Muscle tone First evaluation: colour? Newborn infants can take up to ten minutes of post natal age to look “pink” Look at the colour of the lips to judge central cyanosis Blue hands/feet is not a concern Assessment If baby is breathing, heart rate is > 100/min and beginning to look pink then give routine care and observations appropriate for gestation Leave them alone If not… Resucsitation needed… Start clock Place the infant supine on the warm resuscitaire Head towards you, in a neutral position Remove wet wraps Provide warmth Think ABC ABC A = Airway B = Breathing C = Circulation The initial priority in neonatal resuscitation is to ventilate the lungs with air/oxygen A = Airway Establish and maintain an airway Position to maintain patency (so called ‘sniffing’ position) Suctioning the mouth first and then the nares under vision only if indicated. (Suction should not be extended past the oro /naso pharynx) Suctioning Neonates are predominantly nose breathers Excessive suctioning can cause gag reflex/vomiting, vagal depression and bradycardia Measure the suction tubing from the infant’s mouth to ear. This distance is similar to that from mouth to pharynx. Breathing B = Breathing Stimulate to breathe – firm, but gentle, tactile stimulation. Most appropriate way to provide tactile stimulation is to dry the baby over with a warm towel/cloth nappy; enables you to assess muscle tone as you move over the limbs, and assists with temperature control by drying off the body. Assess respirations Provide PPV if the infant is not breathing &/or the heart rate is < 100 bmp Ventilation Commence ventilation with medical air at flow 10litre/min If no improvement after first few minutes of life reassess mask position, consider suction, consider higher inflation pressures If SaO2 monitoring is available and SaO2 are lower than normal for that stage in transition increase oxygen concentration on blender (no set rule, just continue to increase until SaO2 are normal) Ventilation Ventilate at a rate of 40 - 60 inflations per minute Count: “breathe- two- three, breathe- two- three”, inflating the lungs as you say “breathe” and allowing the infant to exhale on the “two - three” Effective ventilation The heart rate improves and increases to above 100 bpm The chest and upper abdomen rise with each inflation If these signs are not seen, then the technique of mask ventilation needs to be reassessed “When performed properly, positive pressure ventilation alone is effective for resuscitating almost all apnoeic or bradycardic newborn infants” (ILCOR, 2006) If response not satisfactory: Summon Help Call for additional help Activate hospital protocol Notify switchboard 94444 (For Ballarat Hospital) Know your hospital protocol and codes to call For BHS state: neonatal code blue, location If chest movement is not satisfactory: Ensure a good seal If chest movement is not satisfactory: Higher inflation pressures (> 30 cmH2O and even as high as 50 cmH2O) may be needed for the first few inflations, especially in a pre-term infant who has never made any respiratory effort Reduce the pressures once you have been able to expand the lungs and improve the situation. Remember the increase in pressures may only be needed for a few breaths. Neopuff Recommended Neopuff settings Gas flow at 10 L/min Maximum pressure valve set at 50 cm H2O PIP at 30 cm H2O PEEP 5 cm H20 Ventilate 60 breaths/min (1/3 of the time in inspiration, 2/3 in expiration) Laerdal bag and mask Circulation C = Circulation Assess heart rate and color Chest compressions are indicated whenever the heart rate remains below 60 bpm despite 30 seconds of EFFECTIVE positive pressure ventilation 3 compression to 1 breathe Rate 2 a second 120/min Cardiac compressions Place hands symmetrically around the neonates chest. Place one thumb on top of the other on the lower half of the sternum (just below the nipple line) Fingers encircle the chest and rest on the boney structure of the scapular Compress 1/3 chest wall Reassess every 30 seconds Person doing chest compressions stops, reassesses, and restarts if required; person managing airway continues 2 thumbs Place two fingers onto the lower third of the sternum, using the pads of the second and middle finger to compress the chest Compressions The person providing the chest compressions should verbalize (out loud): “One - two - three - and - breathe, one - two - three and - breathe” and so on. Essential Skill The most important and effective action in neonatal resuscitation is to ventilate the infant’s lungs with air/oxygen. Deflate stomach During ventilation gas enters both the trachea and esophagus. Gas forced into the stomach interferes with ventilation. Bag mask ventilation for longer than a few minutes will usually require an orogastric tube to be inserted to deflate the stomach. The insertion of a oro/nasogastric tube should not interfer with ventilating a neonate. Stabilising the airway takes priority. Measuring for insertion of a gastric tube < 32 weeks – what do we do differently? If in a non-tertiary centre attempt to transfer out in utero If risk of delivery during transfer call PIPER to get them mobilised for retrieval Notify paediatric/medical staff and SCN staff (aim to have appropriately skilled team present at time of birth) Hat and plastic bag immediately following birth Neopuff settings are different: PIP 25 cm/H2O Commence resuscitation in FiO2 of 30% Placing into plastic bag when born Advanced resuscitation skills Intubation Size of tube 2.5 – 4.ocm (roughly based on gestational age/10). Eg 30wks, 30/10 = 3.0cm tube Length to insert: oral: 6cm + wt (kg), eg. 3.5kg baby 3.5 + 6 = 9.5cm at lip; nasal: 1.5 x wt + 6cm, eg. 3.5 kg baby 3.5 x 1.5 = 5.75 + 6 = 11.75cm at nare Pedicap to confirm position in lungs (gold is good) Taping of tube: protect skin on face with a thin hydrocolloid; different ways to tape; 2 tapes required; person who inserts the tube must maintain hold on it until adequately taped. CXR to check position Advanced resuscitation skills Gaining intravenous access: If a baby requires prolonged respiratory support and/or chest compressions it is a priority to gain intravenous access for fluid and drug administration Peripheral access: hands/arms or feet/lower legs are usual access points, if too shut down attempts may be made to access a scalp vein Umbilical access: be as sterile as possible, use umbilical catheter if available or a size 5 feeding tube; for both attach a 3 way tap to the end; tie the base of the umbi, cut it down to 1 – 2 cms above abdo and insert catheter length of cord plus a few extra cms. Secure using Htaping. This is a temporary measure. Advanced resuscitation skills Fluid resuscitation: for babies with hypovolaemia and/or metabolic acidosis: Normal saline or O neg PRBC at 10 – 20 mL/kg bolus; can be repeated. Draw up multiple 10mL syringes (these are easier to push than bigger syringes) Management of bradycardia or asystoli: Adrenaline 1 in 10,000 (0.1 – 0.3mL/kg IV or 0.5 – 1.0mL/kg via ETT); dose can be repeated every few minutes. LEVELS OF CARE Victorian public hospitals that have facilities to care for neonates are distinguished by the level of care that they can provide 4 intensive care units in Victoria: The Womens, The Royal Childrens, Mercy Hospital, Heidelberg and Monash Medical Centre Numerous metro and regional hospitals that provide the next level of care down (eg’s: Northern, Sunshine, Werribee, Box Hill, Frankston, Geelong, Bendigo, Ballarat) LEVELS OF CARE The next step down are the smaller, regional hospitals who can provide some care to neonates with higher needs, but it is limited (eg’s Horsham, Bacchus Marsh, Maryborough, Colac, Ararat) – generally limited by not having a midwife/nurse available 24/7 with skills required to safely manage more complex neonates or having a GP who is prepared to oversee the care of the neonate PIPER: Perinatal, Infant, paediatric emergency retrieval For infants has a retrieval and return service and education team Retrieval service generally involves a transport nurse and neonatal doctor coming to the referring hospital, taking over the stabilisation and preparation for transport and escorting the baby to one of the NICU facilities (via ambulance, light plane or helicopter) Return sevice: nurse escort of stable babies back to their local hospital for ongoing care Phone consults: also provide advice/support to nursing and medical staff when there are babies in the units who are unwell/more complex (but not necessarily requiring transfer) PIPER Based at The Royal Childrens Hospital Paediatric Emergency Transport Service: will retrieve children from emergency departments and childrens wards to take to Melbourne (RCH or MMC) Perinatal Emergency Referral Service: advice and consultation about pregnant women possibly requiring transfer to a higher level facility. Eg. 33wk gestation woman presents to Horsham hospital in labour – phone call to PIPER, PIPER should then coordinate transfer to a higher level facility such as BHS (if it is safe to do so, eg. Delivery not imminent). They will need to negotiate an obstetric bed and a neonatal bed in this case. Criteria for transfer up from a Level 2 facility Infants with birth weight < 1300g Infants with GA < 32 weeks Infants requiring intubation and ventilation Infants with O2 requirement > 60% Infants having seizures, or at risk or seizures Infants requiring cooling for management of HIE Infants with congenital abnormalities requiring tertiary care in the neonatal period Infants with known, or suspected, bowel obstruction Infants requiring parenteral nutrition Infants requiring exchange transfusion Infants with significant issues in hypoglycaemia management; requiring central lines for management/higher than 12.5% dextrose solutions. < 1300g and/or < 32 weeks Intravenous access Respiratory support if required (? CPAP, ? Intubation, ? Surfactant) Thermoregulation vital Humidity management (keep in plastic bag until able to move to a humidified isolette) Fluid and drug administration Blood sugar monitoring Observations (? Need for inotropes) Intubated/ventilated infants IV access, drugs prior to intubation if able (not always necessary in an emergency) Taping, securing of tube Chest Xray to check placement NBM, fluid and blood glucose management Drugs to consider: morphine, pancuronium, antibiotics Central access (umbilical vein and umbilical artery) vein is used for fluid and drug administration, artery is used for blood sampling and invasive blood pressure monitoring Familiarise yourself with ventilator in your unit to reduce anxiety when you have to use it. Infants with high oxygen requirements Depends on facility as to what respiratory support can be offered High cot oxygen requirements, and/or significant respiratory distress, indicate respiratory support is required (eg CPAP, or possibly intubation if baby is tiring) CPAP (maximum of 8cm/H2O in non-tertiary hospitals), if still having high oxygen requirement baby likely needs intubation/surfactant administration Consider cardiac abnormalities if babies have ongoing hypoxia despite respiratory support At risk of, or having, seizures/HIE management Criteria for cooling (based on initial blood gases, apgars and behaviour) Have 6 hours post birth to commence active cooling (maintain at 33.5 degrees), in the meantime consider passive cooling (turn heaters off, don’t over wrap/nest) If exhibiting seizure activity will need IV access and administration of anticonvulsants (phenobarb loading then continuous infusion) Congenital abnormalities Not all congenital abnormalities will need time critical transfer to a tertiary hospital; but most will at least require connections made with RCH for long term follow up. Eg. Cleft lip/palate, downs syndrome, VSD or ASD not requiring immediate intervention. Examples of those that will need transfer out soon after birth: diaphragmatic hernia, cardiac abnormalities requiring surgery (eg. TGA, coarctation of aorta, HLHS, HRHS), pierre robin syndrome, inperforate anus, TOF’s Known, or suspected, bowel obstruction Neonatal emergency because of the risk of the bowel quickly becoming ischaemic then necrotic Abdominal Xray Gain IV access, fluid maintenance. NBM. Consider antibiotics Naso/orogastric on free drainage. NETS prefer a size 8 tube. Aspirate after initial insertion to empty stomach contents. Consider repeating aspiration every 2-4 hours if transfer delayed. Infants requiring parenteral nutrition At the moment Geelong SCN is the only nursery outside of Melbourne with capacity to give If preterm babies are too unwell to commence on feeds by day 2 – 3 need to consider transfer out for nutritional reasons If any babies become unwell (respiratory or gut issues) and need to have feeds significantly reduced or ceased may also need to transfer out Parenteral nutrition is a combination of 2 solutions: a glucose solution with amino acids and electrolytes and a fat/vitamin solution. Infants requiring exchange transfusion Rarely done these days. While waiting transfer maintain continuous phototherapy at the highest level possible, gain intravenous access and maintain hydration. Required in cases of extremely high bilirubin levels Usually ordered as a half exchange or full exchange Calculate babies blood volume (80mL x wt in kgs) Requires arterial and venous access Small volume will be taken from the artery, and same volume replaced in the vein. This process is repeated until exchange complete. Requires blood testing during the process to measure electrolytes so rapid access to results vital, electrolyte replacements may be required Phototherapy treatment will continue throughout Requires a lot of manpower (usually 3 – 4 personnel for several hours) Nursing responsibilities if transferring out Documentation, compiling of paperwork for transfer (copy drug charts, observations, notes) Commence child health record and have ready to go with baby Parent counselling Coordinate with multi disciplinary team (eg. Social work to assist parents with accommodation, support) Primary responsibility for drug administration, fluid administration, assistance with procedures (eg. Intubation, peripheral canulation, umbilical line insertion, chest drain insertion) Medical responsibilities Notify PIPER of need for transfer Liaise with neonatal doctors at PIPER regarding treatment Complete consent for transfer forms and PIPER referral paperwork Complete discharge summary Perform procedures necessary before PIPER team arrive Order drugs, fluids Handover to PIPER staff and stay to assist if required during the stabilisation.
