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

6/18/2014 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? 1

6/18/2014 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 2

6/18/2014 “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 3

6/18/2014 • 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 4

6/18/2014 “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? 5

6/18/2014 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 6

6/18/2014 “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 or gasping, prepare to administer positive pressure ventilation (PPV) via flow inflating bag or self inflating bag Flow Inflating Bag vs Self Inflating Bag 7

6/18/2014 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 8

6/18/2014 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 9

6/18/2014 If Chest is Not Rising Use of Pulse Oximetry in DR 48 Sp0 2 % 40 HR bpm Targeted Preductal SpO2 1 min 60 ‐ 65% Pulse Oximeter 2 min 65 ‐ 70% 3 min 70 ‐ 75% 4 min 75 ‐ 80% 5 min 80 ‐ 85% 10 min 85 ‐ 95% 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) 10

6/18/2014 Chest Compressions • If heart rate is <60 bpm after 30 seconds of 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 11

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6/18/2014 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 13

6/18/2014 • 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 14

6/18/2014 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 or prolonged resuscitation • pH < 7.0; Base Deficit ≥ 16 15

6/18/2014 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 16

6/18/2014 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 17