UPDATE ON NEONATAL

RESUSCITATION PROGRAM
7TH EDITION

SETYA WANDITA
NEONATOLOGY DIVISION, DEPT. OF CHILD HEALTH
UNIVERSITAS GADJAH MADA/SARDJITO HOSPITAL, YOGYAKARTA

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BACKGROUND
Lain 6%

Cong. Anomaly
13%
Pneumonia 1
2
4% 3
4
Sepsis Preterm 5

11 45% 6

Asfiksia
21%

World Indonesia

2
UNICEF, 2014
BACKGROUND

Need resuscitation

AAP-AHA, 2011 3
BACKGROUND

NRP (AAP-AHA):
- Update every 5 years
7th edition

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AAP-AHA, 2016
ADAPTATION: CARDIORESPIRATORY

Intrauterine Extrauterine
Uterine contraction
Birth
Intermitten hypoxia

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ADAPTATION: RESPIRATION

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AAP-AHA, 2016
ADAPTATION:
CARDIOVASCUL
AR

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AAP-AHA, 2016
ADAPTATION
• Breathing term infants:
• 85%: 10-30 seconds
• 10%: tactil stimulation
• 3%: PPV
• 2%: intubation
• 0.1%: chest compression/epinephrine

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AAP-AHA, 2016
UPDATE NRP 7TH EDITION
• CIRCULATION journal, October and November 2015.
• 51 recommendations
• 19 new
• 13 update
• 19 no change

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 UPDATE NRP 7TH EDITION
• New recommendations • New recommendations
• 2 umbilical cord management • 2 PPV
• 2 thermoregulation in room • 3 Chest compression
delivery • 1 cooling therapy in limited
• 1 rewarming in hypothermic facility
neonate • 1 withholding/discontnuing
• 2 thermoregulation in limited
resuscitation
resources
• 2 training
• 1 heart rate assessment
• 2 oxygen for preterm
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ALUR RESUSITASI

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 INITIA
L STEP

Golden minute (60”):

initial step and PPV

(AAP-AHA, 2016) 12
LANGKAH AWAL
• Berikan kehangatan
• Posisikan
• Bersihkan jalan napas bila perlu
• Keringkan dan singkirkan kain basah
• Stimulasi
• Reposisi

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UMBILICAL CORD
• Delay Cord Clamping (DCC):
• Increase COP
• Increase blood pressure
• No increase:
• IVH
• Hyperbilirubinemia
• Death
• How long DCC in neonates who need resuscitation?
• Recent: cut imediattely
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UMBILICAL CORD

• Recommendation 2015:
• Preterm no need
resuscitation: DCC
• Not enough evidence to DCC
in preterm needing
resuscitation
• <28 weeks: no routine
umbilical cord milking  
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 THERMOREGULATION
• Keep the baby warm: resuscitation, stabilization.
• Hypothermia at admission:
• Increases mortality
• Increases morbidity: respiratory distress, metabolic, IVH,
EONS
• Dose response

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THERMOREGULATION

Avoid hypothermia
Axillar measurement

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(AAP-AHA, 2016)
 THERMOREGULATION
• Recommendation 2015:
• 36,5-37,5o C: birth to stabilization
• <32 weeks: combine intervention, room temperature,
warm blanket, plastic wrap, with out drying, cap, heat
mattress to reduce hypothermia (<36o C) at admission.
• Avoid >38o C
• >30 weeks in limited facility:
• No need resuscitation: plastic wrap or skin to skin contact

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REWARMING
• Recent practice:
• Slow rewarming
• Rapid rewarming: mortality, neurological outcome
(short/long term), hemorrhage, apnea episode,
hypoglycemia, respiratory distress, arrithmia.
• Not enough evidence to recommend
• Slow or rapid rewarming (>0,5 C/jam)

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 HEART RATE
ASSESSMENT
• Heart rate assessment
• After initial step.
• Sensitive indicator of improvement of
intervention.
• HRA: rapid, reliable, accurate.

Need time, lower, inaccurate in

first few minutes.
Auscultation: inaccurate Over intervention. (AAP-AHA, 2016)
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HEART RATE ASSESSMENT
• Recommendation 2015:
• 3 lead ECG, rapid and accurate
• Need time to put ECG lead

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(AAP-AHA, 2016)
OXYGEN
• Term infants:
• No change
• 21% FiO2
• Titrated as preductal target.
• Preterm infants? Low or high O2 FiO2?

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(AAP-AHA, 2016)
OXYGEN
• Recommendation:
• <35 weeks: 21-30%.
• Avoid side effects of excessive oxygen supplementation.
• No difference outcome low oxygen (21-30%) and high
(>65%).

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CPAP
• Recent opinion:
• <32 weeks with respiratory distress: intubated + PPV
• CPAP in preterm: pneumothorax

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(AAP-AHA, 2016)
CPAP
• Recommendation 2015:
• <30 weeks with respiratory distress: CPAP better than
intubation + PPV
• CPAP
• <Intubation rate
• <Ventilator
• <Mortality
• <BPD
• = Air leak
• = IVH
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(AAP-AHA, 2016)
 SUSTAIN INFLATION (SI)
• Infant not breathing:
• PPV:
• Functional residual capacity
• Clear alveoli
• PEEP and Sustain Inflation may be help.
• European: SI 3 seconds.
• SI: not reduce mortality, BPD, air leak

http://ercguidelines.elsevierresource.com/european
-resuscitation-council-guidelines-resuscitation-2015-
section-7-resuscitation-and- 26
support#Newbornlifesupport
SUSTAIN INFLATION (SI)
• Recommendation:
• No SI routine (>5 seconds) in preterm not breathing
spontaneously.
• SI individual

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VENTILASI TEKANAN POSITIF

VTP efektif 30”

-15 detik: evaluasi DJ

* DJ naik: teruskan VTP 15”
* DJ tidak naik:
# lihat gerakan dada
+ dada mengembang: teruskan VTP 15”
+ dada tidak mengembang: SRIBTA
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PEEP VALVE
• PPV:
• Apneic infant
• Recommendation 2010 based on NICU practice. IDAI, 2014

• Increase PEEP:
• Not reduce mortality/chest compression/drugs/HR
improvement/intubation/air leak/CLD/Apgar score.
• Self inflating
• Bag mostly used
• No PEEP.
• Recommendation 2010: PEEP valve.
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PEEP VALVE

• Recommendation 2015:
• Preterm: PPV with PEEP
• Term: not enough evidence

PPV with self inflating bag + PEEP valve

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(AAP-AHA, 2016)
T-PIECE RESUSCITATOR AND
SELF INFLATING BAG
• PPV:
• T-piece resuscitator:
• CPAP, PEEP, PPV, gas pressure
• Flow inflating bag:
• PPEP, gas pressure, PPV
• Self inflating bag
• Reviewed in 2015

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(AAP-AHA, 2016)
T-PIECE RESUSCITATOR AND
SELF INFLATING BAG
• Review result 2015:
• T-piece resuscitator and flow inflating bag same.
• Used PPV
• PEEP 5 cm H2O

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(AAP-AHA, 2016)
RESPIRATORY ASSESSMENT
• PPV:
• Pressure >>  lung injury
• Pressure <<  ventilation <
• Need assessment: CO2 exhalation, volume, and pressure
• Suggestion:
• Not routinely use capnography, volume and pressure.
• Not enough evidence the use of these equipments
improve clinical outcome 
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LARYNGEAL MASK AIRWAY

• Intubation:
• Most difficult skill
• LMA is alternative for intubation
• Preterm >34 weeks/>2.0 kg
• PPV with LMA

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(AAP-AHA, 2016)
LARYNGEAL MASK AIRWAY

• Recommendation:
• LMA >34 weeks if PPV not effective
• LMA in chest compression and drugs not evaluated yet.

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 INTUBATION IN MECONIUM
STAINED AMNIOTIC FLUID
• MSAF:
• All MSAF
https://medicalfoxx.com/meconium-staining.html
• Not vigorous
• Controversy:
• MSAF not vigorous
intubation?

(AAP-AHA, 2016)
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http://learningradiology.com/archives04/COW%20089-Meconium%20aspiration/meconaspirationcorrect.htm
INTUBATION IN MECONIUM
STAINED AMNIOTIC FLUID
• Recommendation 2015:
• Clear AF, vigorous: No intubation (same with 2010)
• MSAF, not vigorous:
• Intubation not decrease death and MAS.
• Not routinely intubation
• Initial step
• Intubation: Postpone PPV, complication, repeating intubation
• Start PPV within first minute better than intubation

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KOMPRESI DADA

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CHEST COMPRESSION

Recommendation 2010
(AAP-AHA, 2016) 39
 CHEST COMPRESSION
• Evaluation:
• Thumb and index finger not superior other technics
• Same location and depth
• Thumb technics better position in preterm and term
• Superimpose tumb better than side by side:
higher blood pressure.
• Suggestion:
• Use superimpose thumb technic
• Better coronal perfusion, less fatique
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(AAP-AHA, 2016)
CHEST COMPRESSION AND
VENTILATION RATIO
• Recent practice:
• Rasio chest compression:ventilation: 3:1
• Focus of resuscitation: adequate ventilation
• Cardiac support secunder
• Asphyxia:
• collaps of CV caused by hypoxia
• ventilation – cardiac support
• Recommendation:
• Rasio 3:1, no. change ‘One & two & three &
• No evidence difference rasio is better breathe’
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(AAP-AHA, 2016)
OXYGEN IN CHEST COMPRESSION
• Rapid oxygentaion is focus of resuscitation
• Oxygen toxic
• Pulse oxymeter
• In chest compression: increase FiO2
• No human evidence
• Animal study: No benefit of 100% oxygen
• Recommendation:
• FiO2 100% in chest compression continued
• HR increase: oxygen decreased rapidly
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MEDICATION
• Drugs rarely used
• Bradycardia caused by hypoxemia
• Ventilation first
• Indication: HR <60x/minute after chest compression and PPV 100%
O2
• Recommendation 2015: Same
• Dose
• Route
• Indication

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TERIMA KASIH

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