Resuscitation on Asphyxiated Newborn

mts darmawan

Assess Breathing
Newborn crying? Yes No

Provide routine care

Chest is rising symmetrically Frequency >30 breaths/min.

Not breathing/ gasping Breathing < 30 or > 60 breaths/ min. Immediately start resuscitation

Provide routine care

Positioning the newborn to open the airway.

Overview

Persiapan Kelahiran Stabilisasi awal Ventilation - bag and mask : sungkup dan bagging Kompresi dada Obat-obatan

Asphyxia - The Basics

Apnea Tahapan-tahapan :
Napas cepat (takipnea) .. HR semakin jarang Apnea primer irregular gasping HR & drop TD Apnea sekunder

Apnea
Apnu primer Apnu sekunder

Frekuensi jantung

Tekanan darah

Asphyxia - The Basics

Mayoritas apnea primer membaik dg tindakan tepat Sekali apnea sekunder unresponsive utk distimulasi Apnea harus diperlakukan sbg apnea 2nd & dianggap tjd sejak intra uterin & resusitasi tak boleh ditunda

Asphyxia
Decreased oxygen supply Decreased blood supply in the blood

Oxygen Deficit End Organ

Organ injury

Pembersihan Cairan Paru

Napas pertama harus adekuat utk keluarkan cairan Tekanan utk buka pertama : 2-3 x > besar dari napas normal menangis Problem terjadi bila :

apnea Usaha napas pertama lemah cozd by:

prematuritas depression by asphyxia, maternal drugs or anaesthesia

Persiapan Kelahiran
Antisipasi Kebutuhan Resusitasi
1.

Ketahui riwayat antepartum & intrapartum

Antepartum Factors
Age > 35 years Maternal diabetes Pregnancy-induced hypertension Chronic hypertension Other maternal illness (e.g. CVS, thyroid, neuro) Drug therapy (e.g. magnesium, lithium adrenergic-blockers) No prenatal care Previous stillbirth Bleeding - 2nd/3rd trimester Hydramnios Oligohydramnios Multiple gestation Post-term gestation Small-for-dates fetus Fetal malformations

Intrapartum Factors
Abnormal presentation Operative delivery Premature Premature rupture of membranes Precipitous labour Prolonged labour Indices of fetal distress Maternal narcotics (within 4 hrs of delivery) General anaesthesia Meconium-stained fluid Prolapsed cord Placental abruption Placenta previa Uterine tetany

Personnel

Minimal 1 orang khusus penolong bayi yg menguasai resusitasi komplit.

Initial Stabilization
Cegah Kehilangan Panas
Hangat Alas : datar, keras : cegah konveksi Keringkan tubuh & kepala, isap lendir & cegah evaporasi Ini : merangsang timbulnya napas

Open the Airway

Supine ~ ekstensi ringan Hindari overekstensi or fleksi obs airway Trendelenburg ~ boleh Handuk terlipat (+ 2.5 cm) : di bawah pundah bila oksiput besar

Open the Airway 1st : mouth and then nose If nose 1st : may gasp & aspirate secretions Suction : batasi 5 detik & cek HR.
Suction

bila bradycardia mungkin krn terlalu dalam

Rangsang Taktil

Bila belum bernapas juga, lakukan:

Usap atau sentil telapak kaki Elus punggung dg gentel

Jangan boros waktu dg menyentil bila 10 - 15 detik tak berespon

Evaluate the Infant

1. Respirations ~ fungsi paru
Bayi merintih or apnea perlu VTP Bila napas adekuat & spontan go to next step.

Evaluate the Infant

2. Heart Rate ~ fungsi jantung Monitor apex jantung or dasar umbilicus Bila HR < 100 bpm VTP, bahkan sekali pun ada usaha bernapas HR > 100 bpm go to the next step

Evaluate heart rate.

Evaluate the Infant

3. Colour ~ oksigenasi Sianosis sentral (+) : O2 belum cukup O2 100% 5 L/min sungkup rapat sampai kulit merah

Lepas

bertahap : frekuensinya !

Indikasi VTP :

Ventilating Procedure

apnea or napas merintih HR < 100 x/minute sianosis sentarl menetap meski O2 100%

Bag and mask the most important tool in newborn resuscitation

Ventilating Procedure
Frequency 40-60 x/minute Initial lung inflation : high pressure 30-40 cm H2O but subsequent should be 15-20 cm H2O Penilaian : Gerakan dinding dada and Auskultasi suara paru bilateral

Ventilating Procedure

Tidak adekuat ? Evaluasi :

Lihat seal sungkup reposisi kepala extensikan sedikit - reposisi handuk di bahu check for sekret - suction ! try ventilating with mouth slightly open - perhaps with an oral airway pressure to 20-40 cm H2O pasang ET

Ventilating Procedure
Stlh 15-30 detik VTP evaluasi HR Hemat waktu ~ HR : hitung 6 detik & kali 10 = 1-minute

LAHIR

Bersih dari mekonium? Bernapas atau menangis? Tonus otot baik Kulit kemerahan Cukup bulan?
Tidak

Ya
Perawatan rutin

30 detik

Berikan kehangatan Posisikan, bersihkan jalan napas* (bila perlu) Keringkan, rangsang, posisikan lagi Berikan oksigen (bila perlu) Nilai pernapasan, FJ, warna kulit
Apnu atau FJ < 100
Bernapas FJ < 100 & kemerahan

Perawatan supotif

30 detik

Berikan VTP* Berikan VTP* FJ < 60 FJ > 60

Bernapas FJ > 100 & kemerahan

30 detik

Berikan VTP* Berikan VTP* Lakukan kompresi dada Lakukan kompresi dada

Perawatan lanjut

FJ < 60
Berikan epinefrin* Berikan epinefrin*

The next step depends on HR HR

HR > 100 x HR < 60

Action
Bila napas spontan, bertahap VTP & rangsang taktil gentle Kompresi dada VTP adekuat 100% O2 Teruskan VTP Mulai kompresi dada

60 < HR < 80 (tdk naik) 60 < HR < 100 (naik)

Teruskan VTP

Initiate chest compressions if HR is less than 60 or is between 60 and 80 and is NOT increasing.

Evaluate heart rate: < 80 : continue chest compressions. > 80 stop compressions.

Kompresi Dada
Rationale
sirkulasi & transport O2 Harus selalu disertai VTP O2 100 %

Kompresi Dada
Rationale

Sternum compresses the heart

intrathoracic pressure

causing blood pumped into the arteries

Release of the sternal pressure venous return to the heart

Indikasi

Kapan memulai kompresi dada : Stlh 15-30 detik VTP dg 100% O2 HR < 60 bpm 60 < HR < 80 & tidak naik

Kapan stop kompresi dada:

HR > 80 bpm

Technique
1.

Lokasi 1/3 distal sternum, di bawah garis antara 2 papilla mammae

Jangan menekan pd xiphoid refleks

vagal (Goltz refleks) bisa fatal

Chest compressions - indication

Chest compressions should be performed if the HR < 60 beats/minute, despite adequate ventilation with 100% oxygen for 30 seconds. [ILCOR 1999 Advisory Statement],AHA- AAP 2000

Technique
2.

Thumb Method:
Kedua tangan melingkar tubuh bayi & menekan sternum dg 2 jempol side-by-side Jari-jari melingkar ke punggung Pd bayi yg sangat kecil, kedua jempol bisa superimposed (menyilang) Cara ini > efektif > disukai

Technique
2. Thumb

Method:

Technique
3. Two-finger Method:

If tangan penolong terlalu kecil utk melingkar dada ~ punggung bayi If access to the umbilicus is necessary for medications Jari tengah & jari manis menekan sternum, tangan lain memegang punggung dr bawah

Technique

Pressure: - depress the sternum + 1.5 cm - release to allow the heart to fill

Rate: Utk HR normal, kompresi- release harus 120 x/ m (2 x per detik)

Technique

Cautions:
Jgn angkat jari dr dada bayi. Akibat : - habis waktu cari kembali lokasi kompresi salah area - risiko patah iga dg risiko lanjutan pneumothorax or laserasi hati
Agar sirkulasi adekuat, kecepatan & kedalaman kompresi konsisten

Chest compression
If:
HR < 60 after 30 seconds ventilation and stimulation Thumb technique: Place your thumbs side by side or, on a small baby, one over the other, immediately above xyphoid. The other fingers provide support needed for the back Pressure so that you depress the sternum to a depth of approximately 1/3 of the anterior/posterior diameter of the chest. Then release.

The downward stroke should be somewhat shorter than duration of the release. Your thumbs should remain in contact with the chest at all times 90 compressions + 30 breaths per min One and two and three and breath, and one and two and three and breath

VTP selama Kompresi Dada

VTP harus menyertai kompresi 2. Ratio kompresi : ventilasi = 3:1 3. Tiga kompresi diikuti 1 pause VTP 4. Kecepatan 120 /minute hasilkan 90 kompresi & 30 VTP / menit 5. VTP > mudah bila ET (+)
1.

Evaluating HR

Cek HR setelah 30 detik Selama cek, interupsi < 6 seconds Respon (+) : cek HR / 30 detik stop kompresi dada bila HR > 80 bpm VTP teruskan sampai HR > 100 bpm. Bila HR < 80 bpm minimal 30 detik lagi kompresi dada + VTP

Adverse effects of resuscitation with 100% O2

Clinical data

Prolonges time to first breath

Prolonges duration of positive pressure ventilation Elevates oxidative stress (at least 4 weeks) Increases neonatal mortality
3% in industrialised, 5% in developing countries

Associated with acute lymphatic leukemia Experimental data Inflammation in brain, myocardium and\lungs Increases neuronal damage? Poorer neurological outcome

Medications
Umbilical Vein: Jalan tersering selama resuscitation Perhatian utama adl pd insersi terlalu dalam dg risiko infus hipertonik & vasoaktif masuk hepar secara langsung

Medications
Drugs & Fluids The only "medication" : O2 100% by VTP Bbrp memerlukan kompresi dada (10 %) Sangat sedikit (1 %) yg memerlukan resusitasi lengkap

Medications
Epinephrine:

Indications:
HR < 80 HR = 0

Comments:

iv or ET, repeated tiap 3-5 mnt k/p

Medications
Obat Lain Sebagian besar resusitasi singkat Amat jarang pemakaian atropine, calcium & Na bicarbonate Bila arrest lama ~ metabolic acidosis, Na bicarbonate MUNGKIN bermanfaat Bila memberi Na bikarbonat (biknat) harus VTP efektif

Perawatan Pasca Resusitasi

Monitor ketat semua parameter Cairan cukup Hati-hati kejang Hati-2 hipoglikemia

Perawatan Pasca Resusitasi

Catat semua kejadian : TERTULIS. If the 5-minute APGAR < 7, assess every 5 minutes for up to 20 minutes or until 2x scores > 8

Although the APGAR score is not used as a decision-making tool, it has been of value in assessing the progress of the resuscitation.

Larangan dalam Rekam Medik

Tipp ex Dihapus Ditempel dengan kertas baru

Kesalahan Tulis dlm Status

Dicoret, sehinga tulisan lama masih bisa dibaca dengan jelas Bubuhkan tanda tangan atau paraf

Conclusion
Hal-hal
Skill

penting :

skill skill skill skill !!! Only by working through a simulated resuscitation can doing written guidelines into effective action (Hanya dengan MENGERJAKAN dengan simulasi, dapat mengerjakan pedoman dengan BENAR)

Terima Kasih