Download advanced resuscitation, stabilisation and transfer of

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.